Dual diagnosis of epilepsy and dissociative seizures: Prescription patterns, feasibility and safety of rationalising antiseizure medication.

BACKGROUND: Patients with a dual-diagnosis of epilepsy and dissociative seizures (DS) have received far less attention than those with single pathology. Anti-seizure medication (ASM) prescription patterns and safety of rationalisation have not been reviewed. METHODS: We undertook a retrospective cohort study of all patients with a dual-diagnosis admitted to the Scottish Epilepsy Centre between 2012-2020. ASM frequencies were compared across admission, discharge and follow-up and emergency hospital attendances compared a year before and after admission. Demographic data, seizure characteristics and mortality data were also reviewed. RESULTS: Across the 139 patients included in our study, ASM frequency at follow-up was significantly lower than on admission (mean 2.51 vs 2.14, Z = -2.11 p = 0.035, r = -0.215). Total hospital attendances in the year following admission were significantly lower than in the year before (mean 1.27 vs 0.77, Z = 2.306, p = 0.021, r = -0.262). Those with inactive epilepsy had their medications reduced to a greater extent that those with active epilepsy. 44 patients had their ASM frequency reduced during admission with a similar trend of reduced hospital attendances (mean 1.29 vs 0.43 Z = -3.162 p = 0.002). There was one epilepsy related death. CONCLUSIONS: Clinicians should consider the development of co-morbid DS in patients with epilepsy not responding to an escalation of ASM, especially if presenting with a new seizure type. Patients with a dual-diagnosis of epilepsy and DS, particularly those with well controlled epilepsy, are likely overtreated with ASM. Medication review in a tertiary epilepsy centre allows for safe rationalisation of ASM and likely contributes to the need for fewer hospital attendances.

Anti-cholinergic drug burden in patients with dementia increases after hospital admission: a multicentre cross-sectional study.

BACKGROUND: Anticholinergic medications are drugs that block cholinergic transmission, either as their primary therapeutic action or as a secondary effect. Patients with dementia may be particularly sensitive to the central effects of anticholinergic drugs. Anticholinergics also antagonise the effects of the main dementia treatment, cholinesterase inhibitors. Our study aimed to investigate anticholinergic prescribing for dementia patients in UK acute hospitals before and after admission. METHODS: We included 352 patients with dementia from 17 UK hospital sites in 2019. They were all inpatients on surgical, medical or Care of the Elderly wards. Information about each patient's medications were collected using a standardised form, and the anticholinergic drug burden of each patient was calculated with an evidence-based online calculator. Wilcoxon's rank test was used to look at the correlation between two subgroups upon admission and discharge. RESULTS: On admission to hospital, 37.8% of patients had an anticholinergic burden score ≥ 1 and 5.68% ≥3. On discharge, 43.2% of patients with an anticholinergic burden score ≥ 1 and 9.1% ≥3. The increase in scores was statistically significant (p = 0.001). Psychotropics were the most common group of anticholinergic medications prescribed at discharge. Of those patients taking cholinesterase inhibitors, 44.9% were also prescribed anticholinergic medications. CONCLUSIONS: Our cross-sectional, multicentre study found that people with dementia are commonly prescribed anticholinergic medications, even if concurrently taking cholinesterase inhibitors, and are significantly more likely to be discharged from hospital with a higher anticholinergic burden than on admission.

Validation of electronic visual acuity (EVA) measurement against standardised ETDRS charts in patients with visual field loss from inherited retinal degenerations.

BACKGROUND: With the increase in clinical trials testing therapy for retinal disease, there is a need to ensure that outcome measures are both accurate and standardised. The US Food and Drug Administration favours the use of visual acuity measured using ETDRS logMAR charts. The loss of visual field can interfere with visual tracking across the charts, leading to increased variability of measurements. Electronic visual acuity (EVA) presents the optotype on the centre of a screen, thereby removing the tracking element of the task, and may provide a more precise measurement. METHODS: Visual acuity was measured twice using ETDRS charts, EVA automated single letter (E-ETDRS) and EVA single line (EVA-SL) presentation (EMMES). Patients underwent microperimetry (MAIA; Centervue) to determine visual field. We tested 65 patients with rod-cone dystrophies and 41 healthy volunteers. RESULTS: Both participant groups read 2-3 letters more on average on the electronic charts compared with ETDRS. Limits of agreement using a modified Bland-Altman analysis account for replicates were wider in eyes with foveal defects (-9 to 18) compared with eyes without foveal defects (-11 to 15). Electronic charts in the presence of foveal defects reduced the range (-11 to 13). CONCLUSION: EVA may provide more accurate measures of visual acuity than traditional ETDRS charts in patients when the visual field loss encroached on the central vision. Electronic presentation with a single line of letters was the favoured style reported by patients and should be considered in future interventional clinical trials.