Clinical characteristics and surgical outcomes of epilepsy associated with temporal encephalocele: A systematic review.

Temporal encephaloceles (TE) are an under-identified, potentially intervenable cause of epilepsy. This systematic review consolidates the current data to identify the major clinical, neuroimaging, and EEG features and surgical outcomes of epilepsy associated with TE. Literature searches were carried out using MEDLINE, Embase, PsycINFO, Scopus, and Cochrane Library databases from inception to December 7, 2023. Studies were included if they described clinical, neuroimaging, EEG, or surgical data in ≥5 patients with TE and epilepsy. Of 562 studies identified in the search, 24 met the eligibility criteria, reporting 423 unique patients with both epilepsy and TE. Compared to epilepsy patients without TE, those with TE had a higher mean age of seizure onset and were less likely to have a history of febrile seizures. Seizure semiologies were variable, but primarily mirrored temporal lobe onset patterns. Epilepsy patients with TE had a higher likelihood of having clinical or radiographic features of idiopathic intracranial hypertension (IIH) than those without. Brain MRI may show ipsilateral mesial temporal sclerosis (16 %). CT scans of the skull base usually revealed bony defects near the TE (90 %). Brain PET scans primarily showed ipsilateral temporal lobe hypometabolism (80 %), mostly in the anterior temporal lobe (67 %). Scalp EEG mostly lateralized ipsilateral to the implicated TE (92 % seizure onset) and localized to the temporal lobe (96 %). Intracranial EEG revealed seizure onset near the TE (11 of 12 cases including TE-adjacent electrodes) with variable timing of spread to the ipsilateral hippocampus. After surgical treatment of the TE, the rate of Engel I or ILAE 1 outcomes at one year was 75 % for lesionectomy, 85 % for anterior temporal lobectomy (ATL), and 80 % for ATL with amygdalohippocampectomy. Further studies are needed to better elucidate the relationship between IIH, TE, and epilepsy, improve the identification of TE, and optimize surgical interventions.

Identification of patients with drug-resistant epilepsy in electronic medical record data using the Observational Medical Outcomes Partnership Common Data Model.

OBJECTIVE: More than one third of appropriately treated patients with epilepsy have continued seizures despite two or more medication trials, meeting criteria for drug-resistant epilepsy (DRE). Accurate and reliable identification of patients with DRE in observational data would enable large-scale, real-world comparative effectiveness research and improve access to specialized epilepsy care. In the present study, we aim to develop and compare the performance of computable phenotypes for DRE using the Observational Medical Outcomes Partnership (OMOP) Common Data Model. METHODS: We randomly sampled 600 patients from our academic medical center's electronic health record (EHR)-derived OMOP database meeting previously validated criteria for epilepsy (January 2015-August 2021). Two reviewers manually classified patients as having DRE, drug-responsive epilepsy, undefined drug responsiveness, or no epilepsy as of the last EHR encounter in the study period based on consensus definitions. Demographic characteristics and codes for diagnoses, antiseizure medications (ASMs), and procedures were tested for association with DRE. Algorithms combining permutations of these factors were applied to calculate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for DRE. The F1 score was used to compare overall performance. RESULTS: Among 412 patients with source record-confirmed epilepsy, 62 (15.0%) had DRE, 163 (39.6%) had drug-responsive epilepsy, 124 (30.0%) had undefined drug responsiveness, and 63 (15.3%) had insufficient records. The best performing phenotype for DRE in terms of the F1 score was the presence of ≥1 intractable epilepsy code and ≥2 unique non-gabapentinoid ASM exposures each with ≥90-day drug era (sensitivity = .661, specificity = .937, PPV = .594, NPV = .952, F1 score = .626). Several phenotypes achieved higher sensitivity at the expense of specificity and vice versa. SIGNIFICANCE: OMOP algorithms can identify DRE in EHR-derived data with varying tradeoffs between sensitivity and specificity. These computable phenotypes can be applied across the largest international network of standardized clinical databases for further validation, reproducible observational research, and improving access to appropriate care.

Epilepsy Care in Transgender Patients.

PURPOSE OF REVIEW: The goal of this review is to outline the main considerations when treating transgender patients with epilepsy. Points to be addressed include the gender affirming hormone therapy regimens and how they interact with anti-seizure medications and seizure control, as well as common co-morbidities in the transgender epilepsy population. RECENT FINDINGS: Gender affirming hormone therapy (GAHT) may affect seizure control directly, due to proconvulsant or anticonvulsant properties. GAHT may interact with anti-seizure medications; most notably, estrogen will decrease serum concentration of lamotrigine. Enzyme-inducing anti-seizure medications may decrease hormone levels, potentially interfering with goals of GAHT. Transgender epilepsy patients are at risk for co-morbidities such as decreased bone mineral density and depression. There are minimal direct studies on treatment or outcomes in the transgender epilepsy population. Providers must be knowledgeable about the bi-directional interactions between gender affirming hormone therapy and anti-seizure medications, as well as direct hormonal influences on seizure control. Future research should directly evaluate outcomes in transgender epilepsy patients with regard to seizure control, success of hormone therapy, and management of co-morbidities, to further educate providers and patients how to best manage their healthcare.

Patient characteristics and antiseizure medication pathways in newly diagnosed epilepsy: Feasibility and pilot results using the common data model in a single-center electronic medical record database.

INTRODUCTION: Efforts to characterize variability in epilepsy treatment pathways are limited by the large number of possible antiseizure medication (ASM) regimens and sequences, heterogeneity of patients, and challenges of measuring confounding variables and outcomes across institutions. The Observational Health Data Science and Informatics (OHDSI) collaborative is an international data network representing over 1 billion patient records using common data standards. However, few studies have applied OHDSI's Common Data Model (CDM) to the population with epilepsy and none have validated relevant concepts. The goals of this study were to demonstrate the feasibility of characterizing adult patients with epilepsy and ASM treatment pathways using the CDM in an electronic health record (EHR)-derived database. METHODS: We validated a phenotype algorithm for epilepsy in adults using the CDM in an EHR-derived database (2001-2020) against source records and a prospectively maintained database of patients with confirmed epilepsy. We obtained the frequency of all antecedent conditions and procedures for patients meeting the epilepsy phenotype criteria and characterized ASM exposure sequences over time and by age and sex. RESULTS: The phenotype algorithm identified epilepsy with 73.0-85.0% positive predictive value and 86.3% sensitivity. Many patients had neurologic conditions and diagnoses antecedent to meeting epilepsy criteria. Levetiracetam incrementally replaced phenytoin as the most common first-line agent, but significant heterogeneity remained, particularly in second-line and subsequent agents. Drug sequences included up to 8 unique ingredients and a total of 1,235 unique pathways were observed. CONCLUSIONS: Despite the availability of additional ASMs in the last 2 decades and accumulated guidelines and evidence, ASM use varies significantly in practice, particularly for second-line and subsequent agents. Multi-center OHDSI studies have the potential to better characterize the full extent of variability and support observational comparative effectiveness research, but additional work is needed to validate covariates and outcomes.

Effects of robot-guided passive stretching and active movement training of ankle and mobility impairments in stroke.

OBJECTIVES: To investigate the effects of controlled passive stretching and active movement training using a portable rehabilitation robot on stroke survivors with ankle and mobility impairment. METHODS: Twenty-four patients at least 3 months post stroke were assigned to receive 6 week training using the portable robot in a research laboratory (robot group) or an instructed exercise program at home (control group). All patients underwent clinical and biomechanical evaluations in the laboratory at pre-evaluation, post-evaluation, and 6-week follow-up. RESULTS: Subjects in the robot group improved significantly more than that in the control group in reduction in spasticity measured by modified Ashworth scale, mobility by Stroke Rehabilitation Assessment of Movement (STREAM), the balance by Berg balance score, dorsiflexion passive range of motion, dorsiflexion strength, and load bearing on the affected limb during gait after 6-week training. Both groups improved in the STREAM, dorsiflexion active range of motion and dorsiflexor strength after the training, which were retained in the follow-up evaluation. CONCLUSION: Robot-assisted passive stretching and active movement training is effective in improving motor function and mobility post stroke.

Smoking cessation counseling by pediatricians in an inner-city setting.

OBJECTIVE: To assess mothers' perceptions of pediatrician-provided smoking cessation counseling. DESIGN: Cross-sectional, descriptive study. SETTING: Waiting rooms of five ambulatory pediatric clinics in the Bronx, NY. PARTICIPANTS: Convenience sample of 115 mothers. MAIN OUTCOME MEASURES: A structured questionnaire assessed the smoking history of the subject, presence or absence of environmental tobacco smoke(ETS)-related conditions in the subject's youngest child, and extent of smoking cessation counseling by the pediatrician. Subjects were asked whether they had been 1) asked about smoking; 2) advised about the risks of ETS exposure; 3) assisted in smoking cessation; and 4) arranged for a follow-up appointment to discuss smoking cessation. RESULTS: Overall, 73% of mothers reported being asked about smoking by their child's pediatrician, and 50% reported being advised about the effects of ETS exposure. Of the 26 smokers in the sample, only two reported being assisted in smoking cessation. None reported being arranged for a follow-up appointment. Mothers of children with ETS-related conditions reported a higher rate of assessment for smoking status (ask: 85% vs. 63%, p =.01; advise: 57% vs. 43%, p =.19). CONCLUSIONS: Mothers in our setting report a high level of inquiry into their tobacco use, especially when they have children with ETS-related conditions. While they also report receiving advice about the risks of ETS exposure, smokers are very infrequently assisted in smoking cessation.