Wearables in epilepsy and Parkinson's disease-A focus group study.

OBJECTIVES: Wearable sensors that measure movement and physiological variables are attractive for clinical evaluation of neurological diseases such as epilepsy and Parkinson's disease (PD). The aim of this study was to explore perceptions regarding the use of wearable technology in disease monitoring and management as reported by individuals with epilepsy and Parkinson's disease as well as health professionals working with these patient groups. MATERIALS AND METHODS: Six patient groups (n=25) and two groups with health professionals (n=15) participated in this qualitative, descriptive study with focus group interviews. A manifest qualitative content analysis was used. RESULTS: Four categories and nine subcategories emerged from the analysis. Participants saw possible benefits for improved treatment effect and valued this benefit more than possible inconvenience of wearing the sensors. Discrete design and simplicity were considered as facilitators for improved usability. They emphasized the importance of interactive information between patients and health professionals. However, they were concerned about unclear information and inconclusive recordings and some fears about personal integrity were at odds with the expectations on interactivity. CONCLUSIONS: Patients need to feel well informed and find an added value in using wearables. Wearables need to be user-friendly, have an attractive design, and show clinical efficacy in improving disease management. Variations in perceptions regarding integrity, benefits, and effectiveness of monitoring indicate possible conflicts of expectations among participants. The engagement of end users, patients, and health professionals, in the design and implementation process, is crucial for the development of wearable devices that enhance and facilitate neurological rehabilitation practice.

Parenchymal lesions in pharmacoresistant temporal lobe epilepsy: dual and multiple pathology.

OBJECTIVES: Dual pathology is reported in 5-30% of temporal lobe resections performed in pharmacoresistant epilepsy. Dual pathology may be of importance for surgical planning and also for the understanding of the pathogenesis of epilepsy. We describe the frequency of dual or multiple pathology, i.e. more than one histopathological diagnosis, in adults with temporal lobe resections. MATERIAL AND METHODS: Surgical specimens from 33 consecutive patients with resections including mesial as well as neocortical temporal structures were reviewed. All histopathological findings were recorded. Post-mortem specimens from 11 control subjects were also reviewed. RESULTS: Dual or multiple pathology was found in almost half of the epilepsy patients (48%). Hippocampal sclerosis was found in 25 patients (76%), malformations of cortical development in 15 (46%), of which 12 (36%) were microdysgenesis, and low-grade tumours in seven (21%). Apart from mild gliosis, there were no histopathological changes in the control specimens. CONCLUSION: Dual or multiple pathology was a common finding in this group of adults with temporal lobe resections. In order to increase our understanding of how aetiological factors may combine in the development of seizures, we consider it relevant and important to report all histopathological findings in epilepsy surgery series.

Microdysgenesis in epilepsy.

Microdysgenesis is a microscopic malformation of cortical development characterized by heterotopic neurones and abnormal cortical architecture. It has been described in primary generalized and partial epilepsy. Its significance in epileptogenesis is controversial, partly due to lack of consensus of diagnostic criteria. Different terms have also been used for the malformation. Several quantitative studies have been performed of the histopathological aberrations associated with microdysgenesis. A majority of the studies have revealed an increased number of heterotopic neurones in specimens from epilepsy patients. However, the quantitative values given for abnormal numbers of white matter neurones vary greatly between studies and there is no consensus yet on quantitative criteria for microdysgenesis. There have also been conflicting results from studies correlating microdysgenesis with clinical data. Both favourable and worse outcome after epilepsy surgery have been reported in patients with increased numbers of white matter neurones and microdysgenesis. While some studies have shown earlier seizure onset and increased frequency of mental retardation in patients with microdysgenesis, others have not. Differences in inclusion criteria and definition might contribute to the contradictory results. There is some evidence that microdysgenesis could be important in epileptogenesis, but the mechanisms involved remain unknown and difficult to investigate. A consensus on what histopathological criteria to use for the diagnosis of microdysgenesis is needed to explore this further and enable comparisons between centres. There are advantages and disadvantages both with quantitative stereological and with qualitative assessments. It is necessary to evaluate these in the decision on diagnostic criteria, if possible taking both qualitative and quantitative aspects into account.

Visual field defects after temporal lobectomy -- comparing methods and analysing resection size.

OBJECTIVES: The frequency of visual field defects (VFD) after temporal lobe resections (TLR) was compared for two types of TLR and VFD frequency was correlated to resection size. METHODS: Pre- and post-operative perimetry results were analysed for 50 patients with TLR for medically intractable epilepsy. Thirty-three patients had a classical TLR and 17 had a TLR with less lateral extension. Post-operative MRIs were studied in 34 patients by scoring resection size in 12 compartments in the temporal lobe. RESULTS: Twenty-five patients developed a VFD. In the classical TLR group, 16 of 33 developed a VFD, compared with nine of 17 in the other group. The resection points were higher for the VFD group in the most anterior compartment studied, in the superior temporal gyrus. CONCLUSIONS: There was no clearcut difference in VFD frequency between the surgical methods studied. However, the compartmentalized analysis disclosed a relation between the extent of resection in the anterior part of the superior temporal gyrus and VFD frequency.

Guidelines for the use of EEG methodology in the diagnosis of epilepsy. International League Against Epilepsy: commission report. Commission on European Affairs: Subcommission on European Guidelines.

The Commission of European Affairs of the International League Against Epilepsy published 'Appropriate Standards for Epilepsy Care Across Europe' which contained recommendations for the use of electroencephalography (EEG) in the diagnosis of epilepsy (Brodie et al. Epilepsia 1997; 38:1245). The need for a more specific basic document of EEG methodology was recognized and the Subcommission on European Affairs was asked to produce more detailed guidelines to be used across Europe recognizing the range of practices in EEG laboratories. There are many general guidelines published on EEG methodology but this document focuses on the diagnosis of epilepsy. Details from previously published guidelines are included in references and in an appendix. These guidelines are not meant to be used as minimal standards but recommendations that can be applied to all EEG laboratories despite variations in equipment.

Widespread microdysgenesis in therapy-resistant epilepsy--a case report on post-mortem findings.

Microdysgenesis is a subtle malformation, which is often found in specimens from epilepsy surgery. It is, however, not clear whether the changes are focal or diffuse. A recent autopsy case offered an opportunity to investigate whether microdysgenesis found after temporal lobe surgery was focal or widespread in the brain. The entire brain of a 20-year-old patient who died suddenly and unexpectedly was examined histologically. Microdysgenesis had previously been diagnosed after a left temporal lobectomy performed because of therapy-resistant seizures. A light microscopic examination was performed on specimens stained with Luxol-fast blue-cresyl violet and polyclonal antibodies to glial fibrillary acidic protein. Widespread microdysgenesis with irregular nerve cell distribution in the cortex and an increased number of nerve cells in cortical layer I and in the white matter was found in the right temporal and parietal lobes and bilaterally in the frontal and occipital lobes. The post-mortem examination confirmed the previous diagnosis of microdysgenesis and showed that the changes were widespread in a patient who was operated on because of focal epilepsy.

Nonorganic and Organic Psychiatric Disorders in Patients after Epilepsy Surgery.

This study aimed at describing preoperative psychiatric morbidity in a consecutive series of 70 epilepsy patients who were surgically treated and to analyze postoperative psychiatric morbidity and predisposing factors. Nonorganic (DSM-III-R) and organic (Lindqvist-Malmgren diagnostic system) psychiatric morbidity was prospectively assessed preoperatively and during the first two postoperative years. At presurgical evaluation 44.3% of the patients had a psychiatric diagnosis (nonorganic in 14.3%, organic in 38.6%). The most common nonorganic diagnosis was major depression; the most common organic diagnosis was Astheno-Emotional disorder (AE disorder). During the first two postoperative years 68.1% of the patients received some psychiatric diagnosis. The most common nonorganic diagnoses were anxiety and depressive disorders (AD disorders) in 36.2%; the most common organic diagnosis was AE disorder in 52.2%. Patients with a preoperative history of AD disorders or AE disorder had a significantly higher risk of postoperative AD disorders (P < 0.01 and P < 0.001 respectively). Laterality, type of resection, histopathological diagnosis, or outcome were not significantly related to postoperative psychiatric morbidity. The importance of psychiatric assessment, including organic psychiatric disorders, is emphasized.

Lateralisation with magnetic resonance spectroscopic imaging in temporal lobe epilepsy: an evaluation of visual and region-of-interest analysis of metabolite concentration images.

We carried out spectroscopic imaging (MRSI) on nine consecutive patients with temporal lobe epilepsy being assessed for epilepsy surgery, and nine neurologically healthy, age-matched volunteers. A volume of interest (VOI) was angled along the temporal horns on axial and sagittal images, and symmetrically over the temporal lobes on coronal images. Images showing the concentrations of N-acetylaspartate (NAA) and of choline-containing compounds plus creatine and phosphocreatine (Cho + Cr) were used for lateralisation. We compared assessment by visual inspection and by signal analysis from regions of interest (ROI) in different positions, where side-to-side differences in NAA/(Cho + Cr) ratio were used for lateralisation. The NAA/ (Cho + Cr) ratio from the different ROI was also compared with that in the brain stem to assess if the latter could be used as an internal reference, e. g., for identification of bilateral changes. The metabolite concentration images were found useful for lateralisation of temporal lobe abnormalities related to epilepsy. Visual analysis can, with high accuracy, be used routinely. ROI analysis is useful for quantifying changes, giving more quantitative information about spatial distribution and the degree of signal loss. There was a large variation in NAA/ (Cho + Cr) values in both patients and volunteers. The brain stem may be used as a reference for identification of bilateral changes.

Pre--and postoperative general neurocognitive status and memory in 70 epilepsy surgery patients.

PURPOSE: To describe cognitive function preoperatively and cognitive change 2 years postoperatively in 70 consecutive adults in the Göteborg epilepsy surgery series. METHODS: Analysis of general neurocognitive status and memory for the total group and for three subgroups: 26 patients with seizure onset in dominant temporal lobe, 28 patients with onset in non-dominant temporal lobe and 12 with frontal lobe onset. Preoperative performance was compared with a control group (n=30). RESULTS: Preoperatively, patients were more impaired in general neurocognitive status than controls. Patients in the temporal lobe subgroups performed worse than controls in two memory variables. No postoperative negative change was found at group level. There was a small increase in Full Scale IQ and Performance IQ for the total patient group, and in Performance IQ for the frontal lobe subgroup. At individual level, many patients suffered losses or obtained gains in a number of memory variables without any consistent intra-pattern. CONCLUSIONS: Cognitive stability was the main postoperative result. The importance of considering inter- and intra-individual variability of negative as well as positive change is emphasized.

Vigabatrin visual toxicity: evolution and dose dependence.

PURPOSE: To investigate the prevalence and prognosis of visual field defects (VFDs) in epilepsy patients with and without vigabatrin (VGB) treatment; to investigate the possible relationship between VFDs and cumulative VGB dose, and to characterise the evolution of VFDs. METHODS: A cohort of 155 presurgical candidates who had undergone full-field Goldmann perimetry (GP) was studied, 99 (64%) of whom had been treated with VGB. All GPs were reevaluated in 1998 by one experienced examiner, blinded to medication. Duration of treatment and total VGB dose were related to perimetric results. RESULTS: Twenty-five (16%) of the 155 patients had VFDs: Nineteen (19%) of the 99 VGB-treated patients, and six (11%) of the 56 patients unexposed to VGB. VGB-treated patients with VFDs had been treated significantly longer than those without VFDs. Cumulative VGB dose could be calculated for 84 patients. The prevalence of VFDs increased significantly with increasing total VGB-dose, from 4% in the 51 patients who had been exposed to

Gabapentin versus vigabatrin as first add-on for patients with partial seizures that failed to respond to monotherapy: a randomized, double-blind, dose titration study. GREAT Study Investigators Group. Gabapentin in Refractory Epilepsy Add-on Treatment.

PURPOSE: Our objective was to compare the efficacy and safety of gabapentin and vigabatrin as first-line add-on treatment in patients with partial epilepsy. METHODS: This was a multicenter, double-blind, randomized dose titration study. After baseline assessment and randomization, the dose could be increased if seizures persisted and reduced if side effects occurred. Health-related quality of life was assessed at baseline and at the end of the study. By a protocol amendment post hoc, all randomized patients were offered a standardized perimetry examination at the end of the study. Improvement rate was the proportion of patients with a reduction of seizure frequency of at least 50% during an 8-week period without any adverse events causing withdrawal. RESULTS: One hundred two patients were randomized and analyzed on an intent-to-treat basis. The improvement rate was 48% in the gabapentin group and 56% in the vigabatrin group. The improvement rate, when per protocol criteria were fulfilled, was 57% in the gabapentin group and 59% in the vigabatrin group. The proportion of seizure-free patients was 31% in the gabapentin group and 39% in the vigabatrin group. There was no difference in quality-of-life scores between the groups. Perimetry after termination of the study on 64 patients showed abnormal results in 3 of 32 patients in the vigabatrin group. CONCLUSION: Approximately one third of the patients in both groups became seizure-free. Although no major differences were seen in terms of the improvement rate between the groups, equivalence between the two drugs was not found.

[Goals of epilepsy treatment--a multidimensional model. The description of goals as a basis for efficiency measurement]. / Epilepsivårdens mål--en mångdimensionell modell. Målbeskrivning grund för effektmätning.

Review of relevant literature suggests at least seven distinct goals of epilepsy treatment to exist: to reduce seizure frequency and severity, to improve function, to enhance quality of life, to promote coping, to improve external circumstances, to prevent premature death, and (in children) to promote growth and development. However, these goals are subject to certain qualifications. For example, seizure frequency and severity is not to be reduced under all conditions, but only when such reduction can be expected to have beneficial effects on quality of life or on life expectancy (the two ultimate goals). The different qualifications suggest that the proposed goals can not, and should not be considered in isolation, but incorporated in a multidimensional model.

Microdysgenesis in surgical specimens from patients with epilepsy: occurrence and clinical correlations.

Malformations of cortical development are commonly associated with epilepsy. In the first 139 consecutive patients in the Göteborg epilepsy surgery series, parenchymal malformations were found in 56. 1% of the children and in 23.1% of the adults. Microdysgenesis (MDG), which was the most common parenchymal malformation, was found in 35. 1% of the children and in 16.7% of the adults. The aim of this study was to identify clinical characteristics of patients with MDG. Mental retardation was found to be significantly more common in patients with major parenchymal malformations and in patients with MDG compared with patients without parenchymal malformations. Patients with major parenchymal malformations as well as patients with MDG also had a significantly earlier onset of seizures than patients without parenchymal malformations, also when adjusting for mental retardation. Patients with MDG were in these clinical aspects shown to closely resemble patients with major malformations. These findings suggest that MDG is a pathoanatomical entity of clinical relevance, with implications both in mental retardation and in epileptogenesis.

Cross-cultural adaptation and use of the epilepsy psychosocial effects scale: comparison between the psychosocial effects of chronic epilepsy in Sweden and the United Kingdom.

PURPOSE: To establish Swedish weightings for the Epilepsy Psycho-Social Effects Scale (EPSES) and examine differences between Sweden and the U.K. in attitudes toward chronic epilepsy. METHODS: After translation and back-translation of the EPSES into Swedish, weightings were established through a paired comparison study in which 24 epilepsy professionals participated. The EPSES was then given to a hospital-based sample of 57 patients with chronic epilepsy and the results compared with a British sample matched for age, sex, and frequency of seizures. RESULTS: In the professional judgments of the EPSES statements, there were statistically significant differences in only four of 42 statements. Attitudes to employment, to medication, and to fear of seizures were considered more serious in the U.K., whereas social isolation was considered more a problem in Sweden. Patient attitudes to chronic epilepsy were found to be largely similar in the U.K. and Sweden; however, attitudes to employment, to the future, and to fear of seizures were significantly more a problem for patients in the U.K. CONCLUSIONS: The results indicate a great similarity in the interpretation of problems as measured by the EPSES in the U.K. and in Sweden. The differences in attitudes found are discussed in relation to economic and legislative differences between the two countries. Social as well as cultural differences should be taken into account when using standardized questionnaires. It is suggested that culturally specific weightings should be calculated and that these should be reevaluated at regular intervals.

Surgical treatment of epilepsy--clinical, radiological and histopathological findings in 139 children and adults.

The present study relates clinical and radiological data to histopathological diagnoses in the first 139 patients (children and adults) in the Göteborg Epilepsy Surgery series. Temporal lobe resections were most common (54.0%) followed by frontal lobe (18.0%) and multilobar resections (11.5%). All histopathological specimens were re-evaluated in connection with this study. Parenchymal malformations and atrophic-gliotic lesions were the most common histopathological findings. Microdysgenesis was more common than major malformations (24.5% versus 11.5%). When the MRI scans were blindly re-evaluated the MRI findings correlated with histopathological diagnosis in all of the vascular malformations, in 77.8% of the tumours, in 76.5% of the cases with hippocampal sclerosis but only in 28.6% of the major cortical development malformations. Hemispherectomies carried the best seizure outcome prognosis followed by temporal lobe resections (75.0% versus 57.3% seizure free 2 years after surgery). Vascular malformations carried the best, and microdysgenesis the worst prognosis (76.9% versus 39.4% seizure free).

LD and delinquency: rethinking the "link".

Longitudinal data from a 7-year prospective study was examined to investigate whether the presence of learning disabilities (LD) increases a youth's risk of becoming a juvenile delinquent. The sample included 515 students enrolled in the fifth grade in the fall of 1985, 51 (9.9%) of whom were youth with LD. Self-report data on delinquent activity were collected in the spring of 1993. Official court records were obtained for the years 1985 through 1992. Hierarchical multiple regression analyses were performed using a block of three demographic variables (gender, ethnicity, and socioeconomic status) as predictors in the first step and including LD status in a second step. Seven separate analyses were performed, using different measures of delinquency as criterion variables. In no case did LD status account for a significant portion of unique variance in the delinquency variables when the demographic variables were controlled for. The results of this study did not confirm the presence of a direct relationship between LD and delinquency and suggest that the finding of a direct relationship in other studies may have been due to confounding of the LD status with age, ethnicity, or socioeconomic status.

Stimulation of forward locomotion by SCH-23390 and raclopride in d-amphetamine-treated rats.

In d-amphetamine-treated (4.0 mg kg(-1) s.c.) rats the selective dopamine D1 and D2/3 receptor antagonists SCH-23390 (2.5-20.0 microg kg(-1) s.c.) and raclopride (12.5-100.0 microg kg(-1) s.c.), respectively, produced a biphasic pattern of effects on forward locomotion, as observed in an open-field arena (approximately 0.5 m2). Thus, at the low doses of SCH-23390 (2.5-10.0 microg kg(-1)) or raclopride (12.5-50.0 microg kg(-1)), there was a statistically significant increase in forward locomotion, followed by suppression of the behavior at the higher doses. The SCH-23390-induced (5.0 microg kg(-1)) stimulation of forward locomotion was partially antagonized by concomitant raclopride treatment (12.5-25.0 microg kg(-1)) and the corresponding raclopride-induced (12.5 microg kg(-1)) stimulation was fully antagonized by treatment with SCH-23390 (2.5-5.0 microg kg(-1)). Furthermore, the SCH-23390- or raclopride-induced stimulation of forward locomotion was also antagonized by treatment with the alpha1-adrenoceptor antagonist prazosin (1.0 mg kg(-1) s.c.). These observations suggest that under conditions of an increased general tone at brain dopamine receptors, there is a mutual inhibitory synergy between dopamine D1 and D2/3 receptors.