Socio-occupational and employment profile of patients with epilepsy.

OBJECTIVE: Epilepsy has a significant impact on quality of life. Many studies have observed higher unemployment rates among patients with epilepsy. However, unemployment rates vary according to the clinical conditions, country, and group studied. METHODS: Between October 2007 and February 2008, we performed a cross-sectional multicenter epidemiological study to evaluate the socio-occupational and employment profiles of 872 adult patients with epilepsy followed in outpatient epilepsy clinics in Spain. RESULTS: Fifty-eight percent of the patients were employed at the time of the survey, 10.9% of the patients were unemployed, and 12.5% were occupationally incapacitated. CONCLUSION: Patients with epilepsy had employment rates similar to those of the general population, and slightly higher levels of unemployment. The main factors associated with unemployment and incapacity were the presence of refractory epilepsy, the occurrence of a seizure in the last 12 months, level of education, and polytherapy.

Self-reported memory problems in everyday activities in patients with epilepsy treated with antiepileptic drugs.

OBJECTIVE: The goal of this study was to assess everyday memory complaints in a large cohort of patients with epilepsy treated with antiepileptic drugs and to determine demographic, clinical, and emotional state factors associated with patients' self-perception of memory disturbances. METHODS: This cross-sectional epidemiological study was carried out in routine clinical practice using the Questionnaire of Memory Efficiency (QME) and the Hospital Anxiety and Depression Scale (HADS). RESULTS: Six hundred sixty-one patients were recruited. The time since epilepsy diagnosis was 17.3 years (SD=12.5); the number of seizures in the past year 13.8 (SD=4.8); the proportion of patients free of seizures in the last year 42.5%; the proportion of patients with partial seizures 73.2%; and the proportion of patients on monotherapy 56.3%. Total QME score was 110.0 (SD=18.6). Depression and anxiety scores and polytherapy explained 38.7% of the QME variance. CONCLUSIONS: Subjective memory functioning in this cohort of patients with epilepsy was relatively good. Complaints expressed by these patients are explained mainly by the presence of depressive and anxiety symptoms.

Strategies to detect adverse effects of antiepileptic drugs in clinical practice.

OBJECTIVE: The aim was to study the frequency and types of adverse effects (AEs) in patients treated with antiepileptic drugs (AEDs) according to the strategies used by the neurologist to detect them. METHOD: This cross-sectional epidemiological study was carried out in standard clinical practice. Two strategies were used to detect AEs: spontaneous reporting by the patient, and a checklist of possible treatment-related adverse reactions completed by the patient. RESULTS: A total of 579 patients were recruited for the study. Roughly a third (33.7%) reported AEs spontaneously, and 65.2% did so when administered the checklist. The main reason for changing medication was lack of efficacy, but significant side effects were also an important reason for modifying treatment in those patients who reported higher levels of discomfort. CONCLUSIONS: The use of an active approach is recommended for detection of AEs of AED treatment. AEs appear to have a key effect on the decision to change treatment.

Reliability and clinical usefulness of the short-forms of the Wechsler memory scale (revised) in patients with epilepsy.

PURPOSE: The Wechsler Memory Scale-R (WMS-R) is often used for the evaluation of patients with epilepsy, but is time consuming. Two shortened forms of the WMS-R have been published in an effort to reduce the time involved in the test. The purpose of this study is to cross-validate these abbreviated forms in patients with epilepsy. METHODS: We assessed 103 consecutive patients with drug-resistant partial epilepsy being treated in our epilepsy unit. The WMS-R was administered to all patients. The reliability of two shortened versions of the WMS-R were evaluated. The appraisal was performed taking into account the side of the epileptogenic region. The statistical analyses were carried out with the Pearson's correlation and with the intraclass correlation coefficient. RESULTS: Both shortened formulas showed good reliability coefficients for predicting the General Memory and Delayed Recall Indices. In the overall accuracy of the predictions by both short forms no significant differences were found among the three study. groups (right, left or bilateral). However, when considering the predictive error only the three-subtest formulas comprising logical memory, verbal paired associates and visual reproduction efficiently predicted performance, regardless of the side of the epileptogenic region. Of the predicted scores in the overall sample, 92 and 97% fell below the standard error of measurement for general and delayed memory index, respectively. Both short forms correctly classified 89-94% of the performances at the average or impaired level. CONCLUSIONS: The short form of the M-MS-R using three subtests (logical memory, verbal paired associates and visual reproduction) is reliable and time-efficient for estimating the General and Delayed Recall Memory indexes in patients with drug-resistant partial epilepsy.

[Is drug resistant partial epilepsy progressive?]. / Es progresiva la epilepsia parcial farmacorresistente?

OBJECTIVES: Approximately one third of the patients with epilepsy are drug resistant. For decades it has been speculated whether repetition of the seizures might potentially lead to progression of the disorder. DEVELOPMENT: In recent years four levels of evidence (experimental, imaging, epidemiological and neuropsychological) suggest that in at least some types of epilepsy the disorder may progress. In various experimental models of epilepsy it has been shown that the persistence of seizures led to biochemical, structural and cellular changes which are persistent and progressive. However, it is difficult to extrapolate these results to human epilepsy. Studies using magnetic resonance volume measurements and spectroscopy have shown that in temporal lobe epilepsy the lesion seems to progress over the years. However, epidemiological and clinical studies do not consistently show a worsening pattern of seizures over the years of epilepsy duration. In fact, recent evidence has shown that drug resistance may occur from the beginning of the disorder. CONCLUSIONS: Neuropsychological studies in patients with drug resistant epilepsy, especially in those with mesial temporal lobe epilepsy, show deterioration of certain cognitive aspects (mainly memory) in relation to the duration and frequency of the partial and secondarily generalized seizures. In case progression of a epilepsy syndrome might be anticipated, this would undoubtedly lead to relevant consequences. If this is so, the therapeutic approach should be more aggressive than at present and might offer early curative treatment, such as epilepsy surgery or neuroprotective drugs, which might halt the progress of the disorder.

[Drug resistant partial seizures. therapeutic strategies in adults]. / Epilepsias parciales farmacorresistentes. Estrategias terapéuticas en el adulto.

INTRODUCTION: Epilepsy affects 6.6 of every 1,000 inhabitants of the developed world. A third of these patients do not achieve satisfactory control of their condition with currently available antiepileptic drugs. Medical treatment of drug resistant epilepsy is complicated owing to the need to evaluate the clinical progress of the different types of epilepsy and to deal with many antiepileptic drugs. DEVELOPMENT AND CONCLUSIONS: We review the basic principles of satisfactory treatment of a patient with drug resistant epilepsy. We particularly emphasize the use of the new antiepileptic drugs, and evaluation of their efficacy and side effects. We also analyze the use of additional treatment of these patients and assess the pharmacokinetic and pharmacodynamic interactions of the drugs which are essential to determine which is the drug of choice in a particular patient. Finally, we consider the most suitable strategies for correct treatment of a patient with epilepsy which is difficult to control.

[Epilepsy surgery in a reference centre]. / Cirugía de la epilepsia en un centro de referencia.

INTRODUCTION: Patients with drug resistant epilepsy are potential candidates for surgery. The pre surgical study of these patients involves a multidisciplinary approach. PATIENTS AND METHODS: We included patients who had been submitted to EEG video monitoring in our centre (a tertiary university hospital) between April 1995 and May 2000. The evaluation protocol included magnetic resonance (MR) brain scan (according to a specific protocol), neuropsychological and psychiatric evaluation, and ictal/interictal SPECT, when possible. Patients who underwent surgery were followed up at regular intervals until at least two years after surgery. RESULTS: Of the 299 patients with EEG video monitoring, 87 had been submitted to surgery up to June 2000. Nine of these patients required invasive subdural studies or studies of the foramen ovale using electrodes. Of the patients who underwent surgery, 44.8% had sclerosis of the hippocampus in the MR and in 10% it was found to be normal. The results of pathological anatomy revealed: 49.3% with sclerosis of the hippocampus, 15.1% with benign tumours, 13.7% with gliosis, 4.1% heterotopias and 4.1% cavernomas. Just one patient has been submitted to surgery again because of badly controlled seizures. Eight patients have presented post surgical complications (four with permanent morbidity). Of the 73 patients who were followed up for at least a year, 83.6% are in Engel class I, 9.6% in class II, 2.7% in class III and 4.1% in class IV. Among patients who underwent a temporal resection, 88.7% were in class I and 0% in class IV. CONCLUSIONS: Epilepsy surgery, in selected patients, has a very low morbidity/mortality rate and the chances that seizures will disappear or greatly improve are high.

Does neuroticism influence cognitive self-assessment after epilepsy surgery?

PURPOSE: To examine how cognitive, personality, and seizure outcome variables influence the subjective cognitive functioning of patients with refractory temporal lobe seizures after epilepsy surgery. METHODS: Thirty-three consecutive patients with drug-resistant partial epilepsy who underwent surgical treatment at a tertiary referral university epilepsy center were tested before surgery and 1 year after surgery. Objective cognitive and subjective cognitive functioning tests were used, and personality was assessed. Seizure control was operationalized as a dichotomous variable. RESULTS: A significant inverse relationship was found between neuroticism and subjective cognitive functioning. None of the other pre- and postoperative cognitive and surgery outcome variables were significant predictors of subjective cognitive functioning, even after controlling for the effect of neuroticism. CONCLUSIONS: Subjective and objective memory functioning are independent in patients with epilepsy after surgical treatment. Subjective memory functioning appears to be related not to seizure relief but to neuroticism. These data suggest that psychological factors such as personality traits predisposing to emotional distress should be taken into consideration in the clinical management and counseling of patients undergoing epilepsy surgery.

Blood pressure and functional recovery in acute ischemic stroke.

BACKGROUND AND PURPOSE: The relevance of elevated blood pressure in acute ischemic stroke and its most appropriate management are unresolved. We aimed to evaluate the rate of functional recovery with relation to early blood pressure management in patients with ischemic stroke. METHODS: Four hundred eighty-one consecutive ischemic stroke patients were admitted to the Neurology Service within 20.9+/-10.5 hours of symptoms onset as part of the Barcelona Downtown Stroke Registry, including 235 patients who received oral antihypertensive agents within <24 hours after stroke onset. Demographic, clinical (Mathew scale), and CT scan findings were collected prospectively. Mean arterial pressure (MAP) was recorded before hospital arrival and at 7 AM on days 1, 2, and 7 of hospitalization. The primary end point was complete functional recovery at day 7 defined as a score of 0 to 1 on the modified Rankin scale. RESULTS: Two hundred fifty-two patients achieved complete recovery on day 7. Using logistic regression, independent predictors of complete recovery included mild impairment at stroke presentation, lack of history of hypertension, and absence of brain edema on CT scan. Also, a 20% to 30% drop in MAP on day 2 after stroke onset almost tripled the odds of full recovery (odds ratio, 2.9; 95% CI, 1.3 to 6.3). MAP tended to normalize after stroke in all subjects, more rapidly if hypotensive agents were administered. Brain edema was also less frequent in patients with a greater drop in blood pressure. Despite the fact that a drop in MAP >30% from baseline was observed in 49 patients, this preceded worsening stroke in only 4 patients. Conversely, worsening stroke occurred in 51 patients despite stable blood pressure. CONCLUSIONS: These results suggest that complete recovery in ischemic stroke is facilitated by a moderate blood pressure reduction when brain edema develops, most likely as the result of a more adequate cerebral perfusion pressure. Conversely, stroke worsening due to pharmacological hypoperfusion is exceptional.

¿Es progresiva la epilepsia parcial farmacorresistente? / Is drug-resistant partial epilepsy progressive?

Introducción. Aproximadamente un tercio de los pacientes con epilepsia son farmacorresistentes. Durante décadas se ha especulado si la repetición de las crisis pudiera potencialmente provocar progresión de la enfermedad. Desarrollo. En los últimos años, cuatro niveles de evidencia (experimental, de imagen, epidemiológico y neuropsicológico) han sugerido que, al menos en ciertos tipos de epilepsia, puede haber progresión. En diversos modelos experimentales de epilepsia se ha evidenciado que la persistencia de crisis produce alteraciones bioquímicas, estructurales y celulares persistentes y progresivas. Sin embargo, es difícil de trasladar estos resultados experimentales a la epilepsia humana. Estudios con volumetría o espectroscopia por resonancia magnética han mostrado que en la epilepsia parcial del lóbulo temporal parece haber una progresión de la lesión con los años. Por otra parte, los estudios epidemiológicos o clínicos no parecen señalar de forma consistente un deterioro del patrón de crisis a lo largo de años de evolución de la epilepsia. De hecho, reciente evidencia ha mostrado que la farmacorresistencia podría estar presente desde el inicio de la enfermedad. Conclusiones. Los estudios neuropsicológicos en pacientes con epilepsias farmacorresistentes, especialmente en la epilepsia mesial temporal, muestran un deterioro de ciertos aspectos cognitivos (principalmente en la memoria) en relación con la duración y la frecuencia de crisis parciales y secundariamente generalizadas. Determinar con seguridad si una epilepsia va a ser progresiva tiene indudablemente consecuencias relevantes. De confirmarse, la conducta terapéutica debería ser más agresiva que la actual ofreciendo muy tempranamente terapias `curativas' como la cirugía de epilepsia o fármacos neuroprotectores que pudiesen detener el curso de la enfermedad (AU)

Epilepsias parciales farmacorresistentes. Estrategias terapéuticas en el adulto / Drug resistant partial seizures. Therapeutic strategies in adults

Introducción. La epilepsia afecta a 6,6 de cada 1.000 habitantes en los países desarrollados. De estos pacientes, un tercio no llegarán a alcanzar un control adecuado con la medicación antiepiléptica actualmente disponible. El tratamiento médico de los pacientes con epilepsia farmacorresistente es complejo debido a la necesidad de valorar la evolución clínica de los distintos tipos de epilepsia y de manejar múltiples medicaciones antiepilépticas. Desarrollo y conclusiones. Se revisan los principios básicos para el tratamiento adecuado de un paciente con epilepsia farmacorresistente. Se hace especial énfasis en la utilización de los nuevos fármacos antiepilépticos y de la valoración de su eficacia y perfil de efectos adversos. Se analiza, asimismo, el uso de terapia añadida en estos pacientes y se valoran las interacciones farmacocinéticas y farmacodinámicas de los fármacos, esenciales para poder determinar qué fármaco es de elección en un determinado paciente. Finalmente, se examinan las estrategias más adecuadas (AU)

Cirugía de la epilepsia en un centro de referencia / Epilepsy surgery in a reference centre

Introducción. Los pacientes con epilepsia farmacorresistente son potencialmente candidatos a cirugía. El estudio prequirúrgico de estos pacientes implica un abordaje multidisciplinario. Pacientes y métodos. Se incluyeron los pacientes a los que realizamos en nuestro centro (hospital universitario terciario) registro vídeo-EEG, entre abril de 1995 y mayo de 2000. El protocolo de evaluación incluyó resonancia magnética (RM) craneal (según un protocolo específico), evaluación neuropsicológica, valoración psiquiátrica y SPECT ictal/interictal, cuando fue posible. Aquellos pacientes intervenidos se siguieron a intervalos regulares, hasta como mínimo dos años tras la cirugía. Resultados. De los 299 pacientes con registro vídeo-EEG, 87 se han intervenido hasta junio de 2000. Nueve de estos pacientes precisaron estudios invasivos con electrodos de foramen ovale o subdurales. De los pacientes intervenidos, 44,8 por ciento tenían esclerosis del hipocampo en la RM y en el 10 por ciento ésta fue normal. Los resultados de anatomía patológica mostraron: 49,3 por ciento con esclerosis del hipocampo, 15,1 por ciento con tumores benignos, 13,7 por ciento con gliosis, 4,1 por ciento heterotopías y 4,1 por ciento de cavernomas. Un sólo paciente se ha reintervenido por mal control de sus crisis. Ocho pacientes han presentado complicaciones posquirúrgicas (cuatro con morbilidad permanente). De los 73 pacientes con seguimiento mínimo de un año, 83,6 por ciento están en clase I de Engel, 9,6 por ciento en clase II, 2,7 por ciento en clase III y 4,1 por ciento en clase IV. Entre los pacientes intervenidos con resección temporal, 88,7 por ciento están en clase I y 0 por ciento en clase IV. Conclusiones. La cirugía de la epilepsia, en pacientes seleccionados, tiene una morbimortalidad mínima y ofrece una elevada esperanza de desaparición o mejoría importante de las crisis (AU)