Adverse antiepileptic drug effects in new-onset seizures: a case-control study.

OBJECTIVE: Adverse effects (AEs) are a major concern when starting antiepileptic drug (AED) treatment. This study quantified the extent to which AE reporting in people with new-onset seizures started on AEDs is attributable to the medication per se, and investigated variables contributing to AE reporting. METHODS: We pooled data from 2 large prospective studies, the Multicenter Study of Early Epilepsy and Single Seizures and the Northern Manhattan Study of incident unprovoked seizures, and compared adverse event profile (AEP) total and factor scores between adult cases prescribed AEDs for new-onset seizures and untreated controls, adjusting for several demographic and clinical variables. Differences in AEP scores were also tested across different AED monotherapies and controls, and between cases and controls grouped by number of seizures. RESULTS: A total of 212 cases and 206 controls were identified. Most cases (94.2%) were taking low AED doses. AEP scores did not differ significantly between the 2 groups. Depression, female gender, symptomatic etiology, younger seizure onset age, ≥2 seizures, and history of febrile seizures were associated with higher AEP scores. There were no significant differences in AEP scores across different monotherapies and controls. AEP scores increased in both cases and controls with increasing number of seizures, the increment being more pronounced in cases. CONCLUSIONS: When AED treatment is started at low doses following new-onset seizures, AE reporting does not differ from untreated individuals. Targeting specific factors affecting AE reporting could lead to improved tolerability of epilepsy treatment.

How common are the "common" neurologic disorders?

OBJECTIVE: To estimate the current incidence and prevalence in the United States of 12 neurologic disorders. METHODS: We summarize the strongest evidence available, using data from the United States or from other developed countries when US data were insufficient. RESULTS: For some disorders, prevalence is a better descriptor of impact; for others, incidence is preferable. Per 1,000 children, estimated prevalence was 5.8 for autism spectrum disorder and 2.4 for cerebral palsy; for Tourette syndrome, the data were insufficient. In the general population, per 1,000, the 1-year prevalence for migraine was 121, 7.1 for epilepsy, and 0.9 for multiple sclerosis. Among the elderly, the prevalence of Alzheimer disease was 67 and that of Parkinson disease was 9.5. For diseases best described by annual incidence per 100,000, the rate for stroke was 183, 101 for major traumatic brain injury, 4.5 for spinal cord injury, and 1.6 for ALS. CONCLUSIONS: Using the best available data, our survey of a limited number of disorders shows that the burden of neurologic illness affects many millions of people in the United States.

Emergency department visits associated with traumatic brain injury: United States, 1995-1996.

The purposes of this study were to provide a national estimate of the incidence of traumatic brain injuries (TBIs) seen in emergency departments (EDs), but not requiring hospitalization and to determine the causes of these injuries. Using the Centers for Disease Control and Prevention case definition of TBI, ED data was analysed from the National Hospital Ambulatory Medical Care Survey (1995-1996). The average overall incidence rate of TBI-related ED visits for persons who were not hospitalized was 392/100,000 population per year, or 1,027,000 visits to hospital EDs in the US each year. This estimate is nearly twice (392 vs. 216) the previously estimated incidence rate, which was based on data from the 1991 National Health Interview Survey Injury Supplement. It was found that the highest incidence rate occurred among children aged 0-14 years, the rate for males was higher than for females, and the primary reported causes of these injuries were 'falls', motor vehicle-related causes, and 'struck by an object'. Although often considered 'mild' TBIs, these injuries can lead to significant cognitive and emotional impairment. Thus, continued surveillance of TBI-related ED visits is an important part of a comprehensive TBI prevention strategy.

Traumatic brain injury in the United States: A public health perspective.

Traumatic brain injury (TBI) is a leading cause of death and disability among persons in the United States. Each year, an estimated 1.5 million Americans sustain a TBI. As a result of these injuries, 50,000 people die, 230,000 people are hospitalized and survive, and an estimated 80,000-90,000 people experience the onset of long-term disability. Rates of TBI-related hospitalization have declined nearly 50% since 1980, a phenomenon that may be attributed, in part, to successes in injury prevention and also to changes in hospital admission practices that shift the care of persons with less severe TBI from inpatient to outpatient settings. The magnitude of TBI in the United States requires public health measures to prevent these injuries and to improve their consequences. State surveillance systems can provide reliable data on injury causes and risk factors, identify trends in TBI incidence, enable the development of cause-specific prevention strategies focused on populations at greatest risk, and monitor the effectiveness of such programs. State follow-up registries, built on surveillance systems, can provide more information regarding the frequency and nature of disabilities associated with TBI. This information can help states and communities to design, implement, and evaluate cost-effective programs for people living with TBI and for their families, addressing acute care, rehabilitation, and vocational, school, and community support.

The epidemiology of sports-related traumatic brain injuries in the United States: recent developments.

We examined recent population-based data from the National Health Interview Survey, Consumer Product Safety Commission, and state-based traumatic brain injury (TBI) surveillance programs that provide estimates of the overall incidence of sports-related TBI in the United States. Available data indicate that sports-related TBI is an important public health problem because of the large number of people who incur these injuries each year (approximately 300,000), the generally young age of patients at the time of injury (with possible long-term disability), and the potential cumulative effects of repeated injuries. The importance of this problem indicates the need for more effective prevention measures. The public health approach can guide efforts in injury prevention and control. The steps in this approach are (1) identifying the problem, (2) identifying risk factors, (3) developing and testing interventions, and (4) implementing programs and evaluating outcomes. Each of these steps requires adequate data. This article examines the limitations of current sports-related TBI data and suggests ways to improve data in order to develop more effective injury prevention strategies. The impact of sports-related TBI on the public indicates that this task deserves a high priority.

Surveillance of traumatic brain injuries in Utah.

From 1990 through 1992 we conducted surveillance of cases requiring hospital admission and of fatal cases of traumatic brain injury among residents of Utah and found an annual incidence rate of 108.8 per 100,000 population. The greatest number of injuries occurred among men and persons aged 15 to 24 years. Motor vehicles were the leading cause of injury, followed by falls and assaults. The incidence rate we found is substantially lower than previously published rates of traumatic brain injury. This may be the result of a decrease in the incidence of these injuries in the decade since earlier studies were done, as well as changing hospital admission criteria that serve to exclude less severe cases of injury. Despite the apparent decline in rates, our findings indicate the continued importance of traumatic brain injury as a public health problem and the need to develop more effective prevention strategies that will address the major causes of these injuries.

Incidence of mild and moderate brain injury in the United States, 1991.

The 1991 National Health Interview Survey was analysed to describe the incidence of mild and moderate brain injury in the United States. Data were collected from 46 761 households and weighted to reflect all non-institutionalized civilians. The report of one or more occurrences of head injury resulting in loss of consciousness in the previous 12 months was the main outcome measure. Each year an estimated 1.5 million non-institutionalized US civilians sustain a non-fatal brain injury that does not result in institutionalization, a rate of 618 per 100,000 person-years. Motor vehicles were involved in 28% of the brain injuries, sports and physical activity were responsible for 20%, and assaults were responsible for 9%. Medical care was sought by 75% of those with brain injury; 14% were treated in clinics or offices, 35% were treated in emergency departments, and 25% were hospitalized. The risk of medically attended brain injury was highest among three subgroups: teens and young adults, males, and persons with low income who lived alone. The incidence of mild and moderate brain injury in the United States is substantial. The National Health Interview Survey is an important national source of current outpatient brain-injury data.

Risk factors and mechanisms of occurrence in motor vehicle-related spinal cord injuries: Utah.

The purpose of this paper is to describe the incidence, risk factors, and crash factors of motor-vehicle-related spinal cord injuries in Utah. The Utah Department of Health established a statewide registry of spinal cord injuries (SCIs) occurring in 1989-1991, analyzing data from hospital medical records and police reports. Forty-nine percent of all SCIs involved motor vehicles, including injuries arising from motor vehicle collisions with bicyclists and pedestrians. Adolescent and young adult males were at highest risk of injury. Among occupants of automobiles and trucks with SCI, 70% were involved in a vehicle rollover, while 39% were ejected from the vehicle. Only 25% reported using seatbelts. SCIs were much more likely to be associated with rollover compared with other types of motor vehicle-occupant injuries. These findings suggest areas in which SCI prevention programs and research should be focused.

Surveillance of spinal cord injuries in Utah, USA.

From 1989 through 1991, we conducted surveillance of spinal cord injury (SCI) among residents of Utah. We found an annual incidence rate of 4.3 per 100,000, with the highest rates occurring among males 15-24 years of age. Motor vehicles were the leading cause of injury, followed by falls, and sports and recreation. We also examined the accuracy and completeness of reporting in this surveillance system. We found the predictive value positive of SCI diagnoses reported in hospital discharge data to be only 61%. When we considered only patients who received acute hospital care in-state, we found that the sensitivity of hospital discharge data 89%. These findings indicate serious problems in the reporting of spinal cord injury diagnoses in hospital discharge data and the need to verify case reports based on these data. There is also a need to study this problem in other jurisdictions to determine if overreporting is widespread.

Submersion injuries in children younger than 5 years in urban Utah.

Submersion injuries of children younger than 5 years in 4 urban Utah counties from 1984 through 1988 were studied retrospectively to identify associated risk factors. Infants younger than 1 year had the highest rates of both submersion injuries and deaths. The incidence of bathtub drownings was 2 to 3 times higher than reported national rates. All bathtub drownings occurred while the victim was bathing with a young sibling (10 months to 7 years of age) without adult supervision. All drownings in pools and moving bodies of water (rivers, irrigation ditches) resulted from unintentional falls into the water rather than from swimming and wading activities. Drowning prevention strategies should focus on educating parents about the risk of young children bathing with siblings in the absence of adult supervision and fencing regulations for pools and open bodies of moving water.

A community-wide outbreak of hepatitis A in a religious community: impact of mass administration of immune globulin.

Community-wide outbreaks of hepatitis A are frequently prolonged and difficult to control. An extensive outbreak of hepatitis A in a religious community provided an opportunity to assess the effect of mass administration of immune globulin on the course of the outbreak. Between July 1, 1988 and May 30, 1989, 204 cases occurred among 3,500 residents (58/1,000), with persons aged 5-19 years having the highest attack rate. It was found that 89% of persons older than age 19, but no persons under age 20, had evidence of prior hepatitis A infection. During a 5-day campaign, immune globulin (0.02 ml/kg) was administered to 2,287 (65%) of the 3,500 residents. The cost of vaccine and syringes was less than $3,500. New cases among immune globulin recipients virtually stopped 2 weeks after the campaign, and the incidence of hepatitis in the community decreased from 9.6/week to 1.9/week. Among persons younger than age 20 years, the efficacy of immune globulin was 88.9% (95% confidence interval 77.9-94.5) for seven months. Although the authors cannot be sure that the outbreak will not recur, they believe that mass administration of immune globulin appears to have been partially effective at controlling this community-wide outbreak.

EMG and histochemical findings in neurogenic atrophy with electrode localisation.

A new technique permitting electromyographic electrode localisation during open muscle biopsy is described. Using this technique recordings were made from biceps brachii from 22 normal subjects and 19 patients with neurogenic atrophy. Motor unit potential duration and onset interspike interval were the best predictors of histochemical evidence for atrophy. Of patients with neurogenic atrophy, polyphasic potentials and increased rise time of the major spike were found in 18 and 10 cases respectively. Abnormal motor unit potentials were always associated with findings of atrophy. However, normal duration, amplitude, and recruitment intervals occurred in 36%, 58% and 50% respectively of subjects with neurogenic atrophy in the region of the recording.

Clinical phenomena and their correlation to angiographic findings in cerebrovascular disease.

Seventy-one patients who had cerebral angiography because of clinical evidence of focal ischemic cerebrovascular disease were studied. Seventy-seven per cent of these patients had an arterial lesion in the distribution appropriate to the symptoms. However, the degree of dissemination of the atherosclerotic lesions, lesion morphology and severity of stenosis could not be predicted from the clinical manifestations. The presence of atherosclerotic cerebrovascular disease can usually be predicted by analysis of the symptoms and signs, but the nature and extent of the lesions can only be determined using cerebral angiography.

The angiographic ocular choroidal crescent: distortion with intraorbital and remote intracranial pathology.

The ocular choroidal plexus can be identified on virtually all normal internal or common carotid angiograms. Posterior flattening of the choroid is often seen with retrobulbar tumors. This angiographic appearance can also be observed in some patients with papilledema and increased intracranial pressure. In these patients, ampulliform dilatation of the dura and subarachnoid space just posterior to the globe produces a retrobulbar mass effect that can mimic true retrobulbar tumor. Enlargement of the ocular choroid crescent is an unusual angiographic finding and can be seen with intraocular expansile lesions such as unilateral axial high myopia with posterior staphyloma. An abnormally small, shrunken choroidal blush can be seen with microphthalmia, extreme degrees of hyperopia, and in the phthisical eye.