Epidemiology and pathophysiology of autonomic seizures: a systematic review.

PURPOSE: To review the epidemiology and pathophysiology of autonomic symptoms and signs during epileptic seizures. METHODS: We performed a systematic literature search on the following autonomic symptoms and signs during epileptic seizures: cardiovascular changes, respiratory manifestations, gastrointestinal symptoms, cutaneous manifestations, sexual and genital manifestations, and urinary symptoms. RESULTS: Autonomic symptoms and signs can represent the predominant symptom at the onset of a focal seizure, which would then lead to the seizure being classified as a focal onset autonomic seizure. Conversely, clinically relevant autonomic symptoms and signs frequently accompany seizures of focal, generalized, and/or unknown onset, but the seizure is regardless classified according to other, more relevant features. Autonomic symptoms and signs do not represent mere reactions to motor activity or other behavioral seizure manifestations, but rather they are generated by epileptic discharges affecting the central autonomic network. We have reviewed the localizing and lateralizing information currently available on the seizure onset zone and on seizure propagation pathways as provided by systematic analysis of specific autonomic seizure symptoms and signs. We present data on how autonomic seizure symptoms and signs are useful for gaining a better understanding of the anatomical and functional organization of the central autonomic network. Finally, we discuss the differential diagnosis of focal autonomic seizures with autonomic symptoms and signs representing the sole seizure manifestation versus various non-epileptic conditions. CONCLUSIONS: Autonomic seizure symptoms and signs are relevant in clinical epileptology and open a unique window on the functional organization and pathophysiology of the central autonomic network.

Surveillance colonoscopy in Austria: Are we following the guidelines?

BACKGROUND AND STUDY AIM: The European guidelines for quality assurance in colorectal cancer screening and diagnosis contain postpolypectomy surveillance recommendations. They recommend follow-up intervals depending on the findings at index colonoscopy, and divide patients into a low-, intermediate- or high-risk group. The aim of this study was to assess the adherence of Austrian endoscopists to the European guidelines and to determine whether sending a reminder letter resulted in better adherence. METHODS: A single reminder letter containing the guidelines was sent to all endoscopists who participated in the Certificate of Quality for Screening Colonoscopy program in Austria. Adherence was assessed before and after the letter had been sent. Factors associated with adherence were investigated. RESULTS: We found poor baseline adherence to the guidelines. After the reminder letter, the adherence slightly improved in the low-risk group, but did not change in the intermediate-risk or high-risk groups. An adenoma detection rate of at least 20 % was associated with higher adherence rates. Generally, internists and hospitals showed better adherence compared with surgeons and private practices, respectively, both before and after the reminder letter. CONCLUSION: A single reminder letter was not enough to improve the poor adherence to the European postpolypectomy surveillance guidelines. Thus, future studies are required to identify and eliminate all factors responsible for nonadherence to postpolypectomy guidelines in order to reach the goal of a safe, effective, and cost-effective colorectal cancer prevention tool in the near future.

Risk factors cannot explain the higher prevalence rates of precancerous colorectal lesions in men.

BACKGROUND: Prevalence of (pre)cancerous colorectal lesions are higher in men than in women, although transition rates from advanced lesions to cancer is similar in both sexes. Our aim was to investigate whether the sex-specific difference in incidence of premalignant colorectal lesions might be explained by the impact of risk factors. METHODS: A cross-sectional study analysing health check-up examinations and screening colonoscopies performed within a national quality assurance program. RESULTS: A total of 25 409 patients were included in this study, 50.8% were women. Median age for both sexes was 60 years (interquartile range (IQR) 54-67). A multivariable model showed that risk factors mediated only 0.6 of the 10.4% gender gap in adenoma and 0.47 of the 3.2% gender gap in advanced adenoma detection rate. Smoking was the only independent risk factor with a varying sex-specific effect (men OR 1.46, CI 1.29, 1.64, women OR 1.76, CI 1.53, 2.06) and advanced adenomas (men OR 1.06, CI 0.80-1.42; women OR 2.08, CI 1.52-2.83). Independent risk factors for adenomas were BMI (OR 1.35 per IQR, CI 1.25-1.47) and triglyceride level (OR 1.03 per IQR, CI 1.00-1.06); for advanced adenomas physical activity (none vs regular: OR 1.54, CI 1.18-2.00, occasional vs regular: OR 1.17, CI 1.00-1.38), cholesterol level (OR 1.13 per IQR, CI 1.02-1.25), blood glucose level (OR 1.05 per IQR, CI 1.01-1.09) and alcohol score (OR 1.09 per IQR, CI 1.01-1.18). CONCLUSIONS: Risk factors cannot explain higher prevalence rates in men. Results of this study strongly underline the need for sex-specific screening recommendations.

Trends in quality of screening colonoscopy in Austria.

Background and study aim: Screening colonoscopy only effectively prevents colorectal cancer if performed with high quality. The aim of this study was to analyze the detection rates of premalignant colorectal lesions in screening colonoscopies performed within a nationwide quality control program for screening colonoscopy in Austria. Methods: Data from electronic records of the screening program from its implementation in 2007 until December 2014 were analyzed in order to calculate detection rates for adenomas, advanced adenomas, polyps, and proximal lesions, and rates of cecal intubation, sedation, complications, and adequate bowel preparation. Results were evaluated to identify trends and changes in quality parameters over the 8-year study period. Results: During the study period, 301 endoscopists provided data from 159 246 screening colonoscopies. Mean age of screened individuals was 61.1 years, and 49.1 % were women. Significant increases over time were found for age- and sex-adjusted adenoma detection rates (ADRs), which increased from a mean of 22.2 % (SD 10.7 %) in 2007/2008 to 24.2 % (SD 11.6 %) in 2013/2014. On average, each endoscopist increased their individual ADR by + 1.5 percentage points per 2-year period (95 % confidence interval [CI] 0.9 - 2.2 percentage points; P < 0.01). Similarly, detection rates for proximal lesions rose from 15.8 % (SD 9.8 %) to 21.7 % (SD 13.3 %  + 2.5 percentage points per 2-year period, 95 %CI 1.9 - 3.1 percentage points; P < 0.01). ADR in men increased from 27.6 % in 2007/2008 (SD 11.1 %) to 29.2 % in 2013/2014 (SD 12.7 %; P < 0.01); ADR in women increased from 14.2 % (SD 7.1 %) in 2007/2008 to 19.0 % (SD 10.5 %) in 2013/2014 (P < 0.01). Advanced adenoma detection rates decreased during the study period, from 11.4 % (SD 9.0 %) in 2007/2008 to 7.6 % (SD 5.4 %) in 2013/2014 (P = 0.06) in men, and from 5.5 % (SD 5.3 %) in 2007/2008 to 4.0 % (SD 4.1 %) in 2013/2014 in women (P = 0.21). Conclusions: This study showed an improvement in the quality of screening colonoscopies performed within a quality assurance program in Austria between 2007 and 2014. Although, overall ADR increased significantly during the study period, there was a decrease in the rate of advanced adenoma detection.

A greater proportion of liver transplant candidates have colorectal neoplasia than in the healthy screening population.

BACKGROUND & AIMS: Various types of liver disease are associated with an increased prevalence of colorectal adenomas. We investigated whether cirrhosis is a risk factor for colorectal neoplasia by analyzing colonoscopy findings from 2 cohorts of patients awaiting liver transplantation. METHODS: We performed a retrospective analysis to compare findings from colorectal cancer screenings of 567 adult patients with cirrhosis placed on the waitlist for liver transplantation with those from controls (matched for age, sex, body mass index, smoking, and diabetes). Rates of adenoma and advanced adenoma detection were adjusted owing to differences in rates of polypectomies performed in the 2 cohorts. RESULTS: Adenomas were detected in a significantly higher percentage of patients with cirrhosis (29.3%) than in controls (21.5%) (P = .0057; relative risk [RR], 1.36; 95% confidence interval [CI], 1.09-1.69); and patients with cirrhosis had a higher rate of advanced adenoma detection than controls (13.9% vs 7.7%; P = .0015; relative risk, 1.82; 95% CI, 1.25-2.64). A greater percentage of patients with alcoholic cirrhosis had neoplasias (34.3%) than controls (25.3%; P = .0350; RR, 1.36), and rates of advanced adenoma detection were 16.7% vs 10.2% (P = .0409; RR, 1.63). Adenomas were detected in 27.8% of patients with viral cirrhosis vs 15.9% of controls (P = .0061; RR, 1.74), with rates of advanced adenoma detection of 13.6% vs 5.0% (P = .0041; RR, 2.73). Similar proportions of patients with cirrhosis of other etiologies and controls were found to have colorectal neoplasias. CONCLUSIONS: Based on a retrospective analysis of colonoscopy findings from patients awaiting liver transplantation, those with alcoholic or viral cirrhosis are at higher risk of developing colorectal neoplasia and should be considered for earlier colonoscopy examination.

High quality of screening colonoscopy in Austria is not dependent on endoscopist specialty or setting.

BACKGROUND AND STUDY AIM: International studies have shown differences in the outcome of screening colonoscopies related to the endoscopist's specialty and setting of colonoscopy. The aim of this study was to investigate the impact of these two factors on quality parameters for screening colonoscopy in a quality-assured screening program. METHODS: Adenoma detection rate (ADR), cecal intubation rate (CIR), polypectomy rate, flat polyp detection rate, carcinoma detection rate, sedation rate, complication rates, and other parameters of 59 901 screening colonoscopies performed by 178 endoscopists were analyzed in relation to specialty (35 gastroenterologists: 10 066 colonoscopies [16.8 %]; 84 nongastroenterologists: 26 271 colonoscopies [43.9 %]; 59 surgeons: 23 564 [39.3 %]), and setting (hospital: 12 580 [21.6 %] colonoscopies; office: 45 781 [78.4 %] colonoscopies). RESULTS: The overall ADR was 20.5 % and the CIR was 95.6 %. The ADR did not show any statistical significance, either in relation to specialty or to setting. A significant difference in the CIR was found between hospital-based and office-based internists (98.5 % vs. 96.8 %, respectively; P  = 0.0005; odds ratio [OR] 2.2, 95 % confidence interval [CI] 1.4 - 3.4). Hospital-based internists had a significantly higher flat polyp detection rate (7.5 % vs. 4.1 %; P  = 0.02; OR 1.9, 95 %CI 1.1 - 3.2) and a significantly lower carcinoma detection rate (0.4 % vs. 0.6 %; P  = 0.03; OR 0.7, 95 %CI 0.5 - 1.0) compared with office-based internists. Complication rates were significantly lower among surgeons than among internists (0.1 % vs. 0.2 %; P  = 0.03; OR 0.5, 95 %CI 0.3 - 1.0). CONCLUSION: Endoscopists participating in the Austrian quality assurance program offered high quality screening colonoscopy regardless of their specialty and setting. The implementation of a standardized quality program is therefore a decisive factor in quality improvement of screening colonoscopy.

Forceps versus snare polypectomies in colorectal cancer screening: are we adhering to the guidelines?

BACKGROUND AND STUDY AIMS: European guidelines for quality assurance in colorectal cancer screening recommend snare resection for polyps > 5 mm. The aim of this study was to investigate polypectomy technique according to lesion size and shape, and to assess adherence of endoscopists enrolled in the national quality assurance program to the European guidelines. PATIENTS AND METHODS: This cohort study included screening colonoscopies performed between 2007 and 2013 within a quality assurance program in Austria. Resection technique was analyzed according to lesion characteristics and endoscopy facility (private practices, hospitals, outpatient clinics) before publication of the EU guidelines (2007 - 2010) and adherence to the guidelines after publication (2011 - 2013). All surveillance colonoscopies and examinations with missing data were excluded. RESULTS: A total of 128 969 screening colonoscopies performed by 278 endoscopy units were included. The polyp detection rate was 39.6 % (n = 47 797) and 95.6 % of polyps were resected. Of polyps ≥ 5 mm, 46.0 % were resected using forceps and were therefore not treated in accordance with the guidelines. Forceps polypectomy of lesions 5 - 10 mm and > 10 mm decreased significantly in hospitals after implementation of the guidelines (both P < 0.0001). In private practices, there was no difference in forceps usage for polyps of 5 - 10 mm (P = 0.41) before and after the guidelines, and for polyps > 10 mm forceps usage even increased (P < 0.0001). Endoscopists' forceps removal rates for polyps ≥ 5 mm correlated significantly with respective adenoma detection rates (P = 0.0007, r p  - 0.187) and cecal intubation rates (P = 0.0001, r p  - 0.303). Among endoscopists in private practices, internists had slightly lower forceps removal rates for polyps ≥ 5 mm than surgeons, both before (47.2 % vs. 50.7 %; P = 0.014) and after publication of the guidelines (51.9 % vs. 53.5 %; P = 0.161). CONCLUSIONS: This study confirmed the importance of the European guidelines. The inclusion of adequate resection technique as a quality indicator in colorectal cancer screening programs is recommended.

Endoscopists with low adenoma detection rates benefit from high-definition endoscopy.

BACKGROUND: An endoscopists adenoma detection rate (ADR) of less than 20 % correlates with high risk for occurrence of interval cancer. The impact of high-definition (HD) imaging on the ADR is discussed controversially. We aimed to investigate whether detection rates of individual endoscopists increase within 1 year before and 1 year after the switch from standard to HD endoscopy. METHODS: This cohort study analyzed 6,330 screening colonoscopies (2,968 with standard and 3,362 with HD) performed by 42 endoscopists between November 2007 and March 2013 within a nationwide quality assurance program for screening colonoscopy. RESULTS: The ADR of endoscopists with a low ADR (<20 %) increased significantly higher (from 11.8 to 18.1 %, p = 0.003) than of those with a high ADR (≥ 20 %) (from 28.6 to 30.7 %, p = 0.439) after switch from standard to HD colonoscopes (p = 0.0076). The proportion of endoscopists with an ADR < 20 % decreased from 45 to 42.9 % (p = 0.593). There was no significant increase in age- and sex-adjusted detection rates of adenomas (20.2 vs 23.7 %; p = 0.089), advanced adenomas (4.7 vs 5.5 %; p = 0.479), flat adenomas (2.7 vs 3.1 %; p = 0.515), polyps (38.8 vs 41.5 %; p = 0.305), proximal polyps (18.5 vs 20 %; p = 0.469) and hyperplastic polyps (15 vs 17.2 %; p = 0.243) of endoscopists after switch to HD colonoscopes. There was no difference in detection rates of flat polyps (5.5 vs 5.5 %; p = 0.987). CONCLUSIONS: The use of HD scopes is associated with marginal improvement in adenoma detection rates limited to those endoscopists with low adenoma detection rates prior to its introduction.

Presurgical epilepsy evaluation and epilepsy surgery.

With a prevalence of 0.8 to 1.2%, epilepsy represents one of the most frequent chronic neurological disorders; 30 to 40% of patients suffer from drug-resistant epilepsy (that is, seizures cannot be controlled adequately with antiepileptic drugs). Epilepsy surgery represents a valuable treatment option for 10 to 50% of these patients. Epilepsy surgery aims to control seizures by resection of the epileptogenic tissue while avoiding neuropsychological and other neurological deficits by sparing essential brain areas. The most common histopathological findings in epilepsy surgery specimens are hippocampal sclerosis in adults and focal cortical dysplasia in children. Whereas presurgical evaluations and surgeries in patients with mesial temporal sclerosis and benign tumors recently decreased in most centers, non-lesional patients, patients requiring intracranial recordings, and neocortical resections increased. Recent developments in neurophysiological techniques (high-density electroencephalography [EEG], magnetoencephalography, electrical and magnetic source imaging, EEG-functional magnetic resonance imaging [EEG-fMRI], and recording of pathological high-frequency oscillations), structural magnetic resonance imaging (MRI) (ultra-high-field imaging at 7 Tesla, novel imaging acquisition protocols, and advanced image analysis [post-processing] techniques), functional imaging (positron emission tomography and single-photon emission computed tomography co-registered to MRI), and fMRI significantly improved non-invasive presurgical evaluation and have opened the option of epilepsy surgery to patients previously not considered surgical candidates. Technical improvements of resective surgery techniques facilitate successful and safe operations in highly delicate brain areas like the perisylvian area in operculoinsular epilepsy. Novel less-invasive surgical techniques include stereotactic radiosurgery, MR-guided laser interstitial thermal therapy, and stereotactic intracerebral EEG-guided radiofrequency thermocoagulation.

Sex is a stronger predictor of colorectal adenoma and advanced adenoma than fecal occult blood test.

Due to high costs and limited availability of screening colonoscopy, some screening programs require a positive fecal occult blood test (FOBT) before screening colonoscopy is remunerated. As male sex is a strong predictor of adenoma and advanced adenoma, we evaluated whether a positive FOBT or male sex is a stronger risk factor for adenoma and advanced adenoma. FOBT and screening colonoscopy results from 18.665 consecutive patients participating in a "national health check program" between 2009 and 2011 were included in this cohort study. Age-corrected adenoma detection rates (ADR), advanced adenoma detection rates (AADR) and carcinoma detection rates were calculated for men and women according to FOBT result separately. ADR and AADR in FOBT-positive men (34.6 and 11.8 %) and FOBT-negative men (29.1 and 7.6 %) were higher than ADR and AADR in FOBT-positive women (20 and 6.9 %) and in FOBT-negative women (17.6 and 4.4 %), (p = 0.0003). Men with negative FOBT were at higher risk of having an adenoma and advanced adenoma than women with positive FOBT (p < 0.0001). Odds ratios of a positive FOBT for ADR and AADR were 1.3 (1.1-1.5) (p = 0.0047) and 1.6 (1.2-2.1) (p < 0.0001), respectively. Odds ratios of male sex to predict ADR and AADR were significantly higher with 1.9 (1.8-2.1) and 1.8 (1.6-2), respectively (p < 0.001). Male sex is a stronger predictor for colorectal adenoma and advanced adenoma than positive FOBT. These results should be taken into account analyzing FOBT-based screening programs.