Myocardial infarction after epilepsy onset: A population-based retrospective cohort study.

INTRODUCTION: Cardiovascular comorbidities of epilepsy such as hypertension, hyperlipidemia, and diabetes are associated with myocardial infarction (MI). Little data on the development of subsequent cardiovascular disease (CVD) in persons with epilepsy (PWE) are available, with inconsistent findings regarding the association between epilepsy and subsequent MI. A higher risk of MI among adults (without prior MI) following epilepsy diagnosis compared with that among controls was hypothesized. METHODS: This retrospective cohort study used statewide hospital and emergency department (ED) encounter data from 2000-2013 for South Carolina residents aged >18 years without prior MI at the onset of epilepsy, or the first encounter for controls. Persons with epilepsy were compared with 1) persons with migraine (PWM), whose neurological condition has characteristics similar to epilepsy; and 2) persons with isolated lower extremity fracture (PWLF). Subsequent MI was defined as a diagnosis of MI after the first clinical encounter for epilepsy, migraine, or lower extremity fracture (LEF); the association was evaluated with Cox proportional hazard modeling methods. RESULTS: In this study, 2.2% of PWE, 0.6% of PWM, and 1.2% of PWLF had a subsequent MI. Persons with epilepsy were significantly more likely to be non-Hispanic Black (NHB), be covered by Medicaid, and reside in a rural or low income area compared with PWM and PWLF. Specific cardiovascular disease risk factors were more prevalent in PWE than in PWM and PWLF. After adjustment, the hazard of subsequent MI in PWE was 48% higher than in PWM (hazard ratio (HR) = 1.48; 95% confidence intervals (CI) = 1.31-1.67) and 24% higher than in PWLF (HR = 1.24; 95% CI = 1.10-1.39). The hazard of MI increased with increasing age and number of additional comorbidities and was higher in males, those living in rural areas, and those with specific cardiovascular risk factors. CONCLUSION: Persons with epilepsy had moderately elevated risk of subsequent MI compared with PWM or PWLF. The association between epilepsy and MI needs to be further investigated, and clinical care of PWE should include evaluation and management of risk factors for MI.

Population-based comparative analysis of risk of death in children and adolescents with epilepsy and migraine.

OBJECTIVE: Follow-up studies of children and adolescents with epilepsy (CAW-E) have revealed higher risk of mortality than children in the general population. The mortality experience of CAW-E relative to patients with other common neurologic disorders in the pediatric age group is yet undetermined. The objectives of this study are the following: (1) to compare the causes and the adjusted risk of death in CAW-E with that of children and adolescents with migraine (CAW-M) in reference to children and adolescents with lower extremity fracture (CAW-LEF), and children and adolescents in the general population; (2) to evaluate if disparate mortality risks exist by demographic characteristics. METHODS: This retrospective cohort study included 56,781 children and adolescents 0-18 years of age hospitalized or treated in an emergency or outpatient department from 2000 to 2011 for epilepsy, migraine, or lower extremity fracture from all nonfederal health care facilities. Data on deaths were acquired from linked multiple causes of death data file using person-specific unique identifiers. Time of follow-up was from initial clinical encounter to time of death or censoring date of December 31, 2011. The association of risk characteristics with mortality was examined with Cox proportional hazard model after adjusting for potential confounders. RESULTS: Four hundred forty-seven CAW-E and 125 CAW-M died yielding mortality rates of 8.71 and 1.36 per 1,000 person-years, respectively. The 5-year risk of death was 4.38% for CAW-E, 0.68% for CAW-M, and 0.71% for CAW-LEF. Adjusted hazard ratios (HRs) were 3.81 (95% confidence interval [CI] 3.08-3.72) in CAW-E and 1.14 (95% CI 0.94-1.34) in CAW-M relative to CAW-LEF. Risk of death from neurodevelopmental comorbidities was 5.86 (95% CI 4.24-8.08) times greater than those without in the model that compared epilepsy with LEF. SIGNIFICANCE: There is an elevated risk of death in CAW-E with neurodevelopmental comorbidities that remains to be proven.

Stroke after adult-onset epilepsy: a population-based retrospective cohort study.

BACKGROUND: Earlier studies indicate a higher risk of subsequent stroke in PWE aged ≥60. However, little is known of the incidence of subsequent stroke in people with epilepsy (PWE) aged 35 through 60. We determined the risk factors that increase the incidence of stroke following adult-onset epilepsy in a large statewide population over a 10-year period. METHODS: South Carolina hospital discharge and emergency department (ED) data from 2000 to 2011 were used. The study was limited to persons aged ≥35years without prior stroke. Cases included patients diagnosed with epilepsy who were hospitalized or visited the ED. Controls were people with an isolated fracture of the lower extremity without any history of epilepsy or seizure disorders, presumed to approximate the health status of the general population. Epilepsy, fracture, stroke, and comorbid conditions were ascertained by diagnostic codes from health-care encounters. Only persons having stroke occurring ≥6months after the onset of epilepsy or after the first clinical encounter for controls were included. Cox proportional hazards modeling was performed to determine the risk of stroke. RESULTS: There were 21,035 cases with epilepsy and 16,638 controls who met the inclusion criteria. Stroke incidence was 2.5 times higher following adult-onset epilepsy (6.3%) compared with controls (2.5%). After adjusting for comorbidities and other factors, cases with epilepsy showed a 60% higher risk of stroke (HR=1.6; 95% CI: 1.42-1.80) compared with controls. Nearly half of the strokes in cases with epilepsy occurred in those with first diagnosis between ages 35 and 55. Somatic comorbidities associated with increased risk of stroke were more prevalent in cases with epilepsy than controls yet similar in both groups with stroke. Risk of stroke increased with increasing age in both groups. However, the risk of stroke in cases with epilepsy increased faster and was similar to that in controls who were ≥10years older. CONCLUSION: Adult-onset epilepsy at age 35 and older warrants consideration for occult cerebrovascular disease as an etiology of the epilepsy, which may also increase the risk of subsequent stroke. Somatic comorbidities frequently associated with epilepsy include comorbid conditions that share the same underlying pathology with stroke (i.e., hypertension, hyperlipidemia, myocardial infarction, diabetes, and arteriosclerosis). This increased risk of stroke in patients with adult-onset epilepsy should dictate the evaluation and management of stroke risk factors to prevent stroke.

A population-based study of risk of epilepsy after hospitalization for traumatic brain injury.

PURPOSE: This study was undertaken to determine the risk of developing posttraumatic epilepsy (PTE) within 3 years after discharge among a population-based sample of older adolescents and adults hospitalized with traumatic brain injury (TBI) in South Carolina. It also identifies characteristics related to development of PTE within this population. METHODS: A stratified random sample of persons aged 15 and older with TBI was selected from the South Carolina nonfederal hospital discharge dataset for four consecutive years. Medical records of recruits were reviewed, and they participated in up to three yearly follow-up telephone interviews. RESULTS: The cumulative incidence of PTE in the first 3 years after discharge, after adjusting for loss to follow-up, was 4.4 per 100 persons over 3 years for hospitalized mild TBI, 7.6 for moderate, and 13.6 for severe. Those with severe TBI, posttraumatic seizures prior to discharge, and a history of depression were most at risk for PTE. This higher risk group also included persons with three or more chronic medical conditions at discharge. DISCUSSION: These results raise the possibility that although some of the characteristics related to development of PTE are nonmodifiable, other factors, such as depression, might be altered with intervention. Further research into factors associated with developing PTE could lead to risk-reducing treatments.

Caregiver perceptions of seizure severity in pediatric epilepsy.

PURPOSE: Seizure severity has been investigated using multiple tools over the years, and its defining features continue to be debated. Severity ratings are necessary for medical, psychological, and epidemiologic investigations. Adults with epilepsy have been evaluated more than youth with epilepsy. METHODS: Seizure severity was evaluated as part of a larger study that included youth and caregiver self-report measures of the emotional and social variables that occur in epilepsy. RESULTS: The results indicate that a longer recovery time from the last seizure and a longer duration of seizure influence how severe a caregiver judges seizures. The usual elements such as type of epilepsy, frequency of seizures, and most recent seizure were not significantly related to severity rating. Behavior ratings were also not related to severity rating. DISCUSSION: Clinicians often rely heavily on caregiver information during clinic visits to help inform treatment decisions; therefore, a standard measure of seizure severity from the caregivers' perception has clinical utility. Rather than assuming what makes a seizure severe to a parent, more research should be conducted on what elements contribute to severity, as judged by both the parent and youth.

Psychosocial factors associated with stigma in adults with epilepsy.

Living Well with Epilepsy II called for further attention to stigma and its impact on people with epilepsy. In response, the South Carolina Health Outcomes Project on Epilepsy (SC HOPE) is examining the relationship between socioeconomic status, epilepsy severity, health care utilization, and quality of life in persons diagnosed with epilepsy. The current analysis quantifies perceived stigma reported by adults with epilepsy in relation to demographic, seizure-related, health, and psychosocial factors. It was found that reported levels of stigma were associated with interactions of seizure worry and employment status, self-efficacy and social support, and quality care and age at seizure onset. This information may be used to target and develop evidence-based interventions for adults with epilepsy at high risk for perceived stigma, as well as to inform epilepsy research in self-management.

Prevalence of self-reported epilepsy, health care access, and health behaviors among adults in South Carolina.

Behavioral Risk Factor Surveillance System data from South Carolina for 2003-2005 were used to determine epilepsy prevalence and prevalence variation by demographic subgroups, and to compare health insurance coverage, health care visits, and health-related behaviors among persons with epilepsy and the general population. Two percent of respondents reported they had ever been told by a doctor that they had epilepsy, and 1% reported active epilepsy. Almost half of those with active epilepsy reported a seizure in the prior 3 months. More than one-third of respondents with active epilepsy reported that there was a time in the past 12 months when they needed to see a doctor but could not because of cost. Persons with epilepsy were more likely to smoke and have less physical activity. Persons with epilepsy need better access to health care, as well as interventions focused on smoking cessation and increased physical activity.

Mortality in people with epilepsy: A statewide retrospective cohort study.

RATIONALE: People with epilepsy (PWE) have a higher risk of mortality than the general population, because of disparities in the receipt of appropriate epilepsy care, which may be affected by socioeconomic status, race/ethnicity and insurance coverage. Increased epilepsy prevalence has been associated with black race, low educational attainment, unemployment, and low income levels. Rural/urban residence may affect health through individual or environmental factors. Health disparities seen in rural residents are likely amplified in rural PWE because of limited access to specialized care. This analysis aims to examine the risk of mortality attributable to rural residence in the statewide population of South Carolina (SC) after adjusting for potential confounders. METHODS: This statewide retrospective cohort study of PWE seen in SC non-federal hospitals and emergency departments from 2000 to 2013 describes the hazard of mortality by rural/urban residential status in addition to other demographic and clinical characteristics. Differences in proportions were assessed by comparison of 95% confidence intervals. The association of rural/urban residence with mortality was further evaluated with Cox proportional hazard regression controlling for demographic and clinical covariables. RESULTS: 62,794 PWE were identified, of whom 21,451 (25.7%) had died. Deceased PWE were more likely to be rural residents, black, older than age 45, Medicare insured, in the middle income group, and have 5 or more comorbid conditions compared with living PWE. After adjustment for all other covariables, the risk of mortality did not differ by rural/urban residence. Blacks had a weak but significantly higher risk than whites (hazard ratio (HR)=1.14; 95% confidence interval (CI)=1.11, 1.18) while PWE of other races had a slightly lower risk of mortality (HR=0.79; 95% CI=0.67, 0.93). Male PWE had higher hazard as did Medicare, Medicaid or commercially insured PWE, those living in zip codes with annual median incomes less than $36,000, and those with 2 or more comorbid conditions. CONCLUSIONS: While other covariables were more strongly associated with mortality after adjustment (older age, insurance coverage, income level of zip code, and number of comorbidities), the finding of a higher hazard in black PWE than white PWE after adjustment for rural/urban residence and other demographic and clinical covariables is a concern. Further, the increased risk of mortality with higher numbers of comorbid conditions warrants regular management of these conditions.

Mortality following status epilepticus in persons with and without epilepsy.

PURPOSE: Incidence of status epilepticus (SE) ranges from 6.8 to 41.0 per 100,000 population. Although SE is associated with significant morbidity and mortality, the temporal relationship between SE, epilepsy, and mortality is less clear. The risk of all-cause mortality following SE with and without prior epilepsy was investigated. METHOD: This study identified hospitalizations and emergency department visits for persons with SE and persons with epilepsy between 2000 and 2013. Excluded were those with epilepsy subsequent to SE, epilepsia partialis continua, less than 90days follow-up, and less than 2 years of data prior to first diagnosis. The cohort was grouped into: 1) SE only, 2) post-epilepsy SE (PES), and 3) epilepsy only. The risk of mortality was estimated using Cox proportional hazard models adjusting for potential confounders. RESULTS: The cohort (N=82,331) consisted of 1296 SE only cases (1.6%); 2136 PES cases (2.6%); and 78,899 epilepsy only controls (95.8%) with 24.9%, 29.2% and 20.0% mortality, respectively. Compared with controls, the hazard of mortality was increased for those with SE only (hazard ratio [HR]=1.61, 95% CI=1.41-1.82) and PES (HR=1.16, 95% CI=1.07-1.25) after adjustment for demographic and clinical factors. Prior stroke, central nervous system infection, and brain tumor increased the mortality hazard. CONCLUSION: There is a statistically significant increased risk of all-cause mortality with SE. The risk is stronger in those with no prior epilepsy. Specific etiologies increase mortality risk in those with SE warranting further investigation of the complex associations between these etiologies and SE.

Epilepsy beyond seizure: a population-based study of comorbidities.

Comorbid conditions may affect the quality of life in persons with epilepsy (PWE) more than seizures. Using legally mandated healthcare encounter data, somatic, psychiatric, and neurodevelopmental comorbidities in a large population-based cohort of PWE, were compared to persons with migraine (PWM), a similar neurologic condition, and lower extremity fracture (PWLF), otherwise healthy controls. 64,188 PWE, 121,990 PWM, and 89,808 PWLF were identified from inpatient, outpatient, and emergency department from 2000 to 2011. Epilepsy was ascertained with ICD-9-CM code 345; migraine with 346; fracture of the tibia, fibula, and ankle with 823 and 824. Common comorbidities of epilepsy were identified from the literature. Differences in prevalence among PWE, PWM, and PWLF were assessed by comparison of 95% confidence intervals (CI) constructed under the assumption of independence and normal approximation. The association of the comorbid conditions with epilepsy and migraine, compared to lower extremity fracture, were evaluated with polytomous logistic regression controlling for demographic and mortality covariables. PWE had significantly elevated prevalence of comorbidities compared with PWM and PWLF. Compared with PWLF, the adjusted odds ratios (OR) of having both somatic and psychiatric/neurodevelopmental comorbidities were 5.44 (95% CI=5.25-5.63) and 2.49 (95% CI=2.42-2.55) in PWE and PWM, respectively. The association with epilepsy was the strongest for cognitive dysfunction (OR=28.1; 95% CI=23.3-33.8); autism spectrum disorders (OR=22.2; 95% CI=16.8-29.3); intellectual disability (OR=12.9; 95% CI=11.6-14.3); and stroke (OR=4.2; 95% CI=4.1-4.4). The absolute risk increase in PWE compared with PWM for any somatic or psychiatric/neurodevelopmental comorbidity was 58.8% and 94.3%, respectively. Identifying comorbidities that are strongly and consistently associated with seizures, particularly disorders with shared underlying pathophysiology, is critical in identifying specific research and practice goals that may ultimately improve the quality of life for PWE. This study contributes to that effort by providing population-based comorbidity data for PWE compared with PWM and PWLF.