Socioeconomic status and self-management in epilepsy: comparison of diverse clinical populations in Houston, Texas

We compared the scores on self-management and associated psychosocial scales of patients with epilepsy at two clinics in Houston, TX, USA, to determine if there were systematic differences associated with socioeconomic status (SES). Patients of low SES reported higher scores on overall, information, and safety management (P<0.03) and no differences on medication, seizure, and lifestyle management. The two groups were similar with respect to the pattern of high and low scores. Reported levels of self-efficacy, depression, social support, stigma, desire for control, and outcome expectations were higher for those of high SES (P<0.01). Knowledge of epilepsy and satisfaction with care were lower (P<0.01). Again, the patterns of high and low scores were similar. Tests of association between psychosocial factors and self-management revealed that people with higher levels of self-efficacy and social support also reported higher self-management (P<0.01) regardless of demographics, seizure frequency, and SES (P<0.05). These findings provide little support for SES-related disparities in self-management and suggest that the focus of strategies to improve self-management may be similar across diverse populations.

A Literature Review of Subtle-Obvious Items on the MMPI

This article chronologically reviews the literature relating to subtle and obvious items of the Minnesota Multiphasic Personality Inventory. Wiener's original development of subtle and obvious subscales, Seeman's support for the concept of subtlety, and Duffs arguments concerning empirical versus face validity are discussed. Later research exploring demand characteristics are then reviewed, such as the paradoxical relationships under differing instruction sets and population issues. The work from Auburn University researchers on the development of a 5-point subtlety scale, the interaction with personality factors, and individual scale research is critiqued.

Sociodemographic disparities in epilepsy care: Results from the Houston/New York City health care use and outcomes study

PURPOSE

The purpose of this study was to identify sociodemographic disparities in health care use among epilepsy patients receiving care at different sites and the extent to which the disparities persisted after adjusting for patient characteristics and site of care.

METHODS

Three months of health care use data were obtained from baseline interviews of approximately 560 patients at four sites. One-half of the patients were from a Houston site and two NYC sites that serve predominantly low-income, minority, publicly insured, or uninsured patients. The other half were at the remaining site in Houston that serves a more balanced racial/ethnic and higher sociodemographic population. Differences in general and specialist visits, hospital emergency room (ER) care, and hospitalizations were associated with race/ethnicity, income, and coverage. Logistic regression was used to assess the extent to which the differences persisted when adjusting for individual patient characteristics and site of care.

RESULTS

Compared to whites, blacks and Hispanics had higher rates of generalist visits [odds ratio (OR) = 5.3 and 4.9, p < 0.05), ER care (OR = 3.1 and 2.9, p < 0.05) and hospitalizations (OR = 5.4 and 6.2, p < 0.05), and lower rates of specialist visits (OR = 0.3 and 0.4, p < 0.05). A similar pattern was found related to patient income and coverage. The magnitude and significance of the disparities persisted when adjusting for individual characteristics but decreased substantially or were eliminated when site of care was added to the model.

DISCUSSION

There are sociodemographic disparities in health care for people with epilepsy that are largely explained by differences in where patients receive care.

Zonisamide monotherapy in a multi-group clinic

OBJECTIVE

Reports on zonisamide monotherapy are limited despite favourable preliminary data, and typically restricted to tertiary referral centres. The goal of this study is to report clinical experience with zonisamide monotherapy in a large, multi-group clinic setting.

METHODS

We reviewed the charts of patients treated with zonisamide monotherapy in the Neurology Department of the Kelsey-Seybold Clinic (Houston, Texas) during an 18-month period. We analysed subgroups of patients who were naive to antiepileptic drug (AED) therapy (Group 1) and those who had previous exposure to AEDs (Group 2).

RESULTS

The study included 54 paediatric and adult patients with a variety of seizure types: 15 patients in Group 1 and 39 patients in Group 2. Mean maintenance zonisamide dosages in the two groups were similar (193 mg/day in Group 1 vs. 218 mg/day in Group 2). Thirty-eight patients (70.4%) continued zonisamide monotherapy, with 7 patients (13.0%) adding a second AED and 9 patients (16.7%) switching to a different drug. Of the 24 patients who became seizure free on zonisamide monotherapy, 11 were on the 100-mg initial dosage. Zonisamide monotherapy was well tolerated.

CONCLUSIONS

Zonisamide monotherapy is safe and effective for a variety of seizure types and may be appropriate as first-line therapy in some cases.

Improved neutron detection by gamma-ray spectroscopy

Most high-efficiency interactions for neutron detection are with thermal neutrons, and the detection of the prompt gamma radiation emitted as a result of thermal neutron absorption in specific materials was sometimes used. These materials are named converters, the most widespread being 10B, 113Cd or 73Ge (the last two materials are detector materials themselves for CdZnTe and HPGe detectors). However, for these materials, the main gamma-ray energies are relatively low (in the region 473-600 keV), and there are interferences from other gamma rays present in background. Different combinations of moderator-converter-detector systems were employed to optimise the system efficiency and signal-to-background ratio, using B, Cd, Gd and Cl converters and HPGe, NaI(Tl) and BGO detectors. When using a Cl converter, the 1164.7 keV peak seems to be a good choice when a HPGe spectrometer is used. A very practical material containing chlorine is PVC.

On the determination of the post-irradiation time from the glow curve of TLD-100

The ratio of peak 3 to the sum of peaks 4 + 5 in TLD-100 was measured for various pre-irradiation and post-irradiation time periods, under conditions characteristic of routine personal dosimetry. It was confirmed that the value of this ratio depends only on the elapsed time between the prior readout and the present one, independent of the moment when the irradiation took place during the total time interval (storage time). This effect indicates that fading of peak 3 seems to be due mainly to changes in the unoccupied traps, and not to decay of trapped charges, being almost independent of the presence of electrons or holes in the traps. This observation leads to the conclusion that the suggestions in the past to use the decay of peak 3 in TLD-100 for the measurement of the elapsed time between irradiation and readout may have been wrong. On the other hand, the decay of peak 2 can be used to measure the elapsed time from irradiation, since the rate of decay is different when related to pre-irradiation and post-irradiation times, indicating a much higher decay rate of the trapped charges (Randall-Wilkins decay). However, because of the fast decay rate of peak 2, its use for determination of the elapsed time since irradiation is of little practical significance.

The cost of epilepsy in the United States: an estimate from population-based clinical and survey data

PURPOSE

To provide 1995 estimates of the lifetime and annual cost of epilepsy in the United States using data from patients with epilepsy, and adjusting for the effects of comorbidities and socioeconomic conditions.

METHODS

Direct treatment-related costs of epilepsy from onset through 6 years were derived from billing and medical chart data for 608 population-based incident cases at two sites in different regions of the country. Indirect productivity-related costs were derived from a survey of 1,168 adult patients visiting regional treatment centers. Direct costs separate the effects of epilepsy and comorbidity conditions. Indirect costs account for the effects of other disabilities and socioeconomic conditions on foregone earnings and household activity. The estimates were applied to 1995 population figures to derive national projections of the lifetime and annual costs of the disorder.

RESULTS

The lifetime cost of epilepsy for an estimated 181,000 people with onset in 1995 is projected at $11.1 billion, and the annual cost for the estimated 2.3 million prevalent cases is estimated at $12.5 billion. Indirect costs account for 85% of the total and, with direct costs, are concentrated in people with intractable epilepsy.

CONCLUSIONS

Direct costs attributable to epilepsy are below previous estimates. Indirect costs adjusted for the socioeconomic conditions of patients are above previous estimates. Findings indicate that epilepsy is unique in the large proportion of costs that are productivity-related, justifying further investment in the development of effective interventions.

The incidence of epilepsy and unprovoked seizures in multiethnic, urban health maintenance organizations

PURPOSE

Studies of the incidence of epilepsy are limited to a few populations in which new cases can be ascertained. Health maintenance organization (HmO) populations were studied to determine the incidence in a multiethnic, urban United States population.

METHODS

Cases of initial unprovoked seizure disorder or epilepsy while enrolled in an HMO between 1988 and 1994 were ascertained. Ethnicity was obtained from the medical records and was part of a nested case-control study.

RESULTS

There were 197 incidence cases of epilepsy and 275 of initial unprovoked seizure diagnosis. The incidence rate in the age range 0-64 years was 35.5 per 100,000 for epilepsy and 50.9 for initial unprovoked seizure. When compared with population-based studies, rates were slightly higher in children younger than 15, similar for the 15- to 24-year age group, but lower for ages 25-64 years. The ethnicity-specific odds ratios for initial unprovoked seizure, by using non-Hispanic white as the referent, were 1.04 (0.73-1.49) for African-American, 0.97 (0.64-1.48) for Hispanic, and 0.25 (0.08-0.84) for Asian-American.

CONCLUSIONS

The lower rate in the HMO population is presumably due to a healthy-worker effect. The ethnicity-specific incidence rates do not differ in this population.