Ictal consciousness in epilepsy and nonepileptic attack disorder.

Exploration of subjective experiences during seizures may enhance knowledge of the differing natures of epilepsy and nonepileptic attack disorder (NEAD). We performed a quantitative evaluation of both the general level of awareness and the specific contents of consciousness during seizures using the Ictal Consciousness Inventory (ICI). Ninety-five adult outpatients attending general neuropsychiatry and epilepsy clinics with established diagnoses of either epilepsy (n = 66) or NEAD (n = 29) completed one ICI for each witnessed seizure recalled. Patients with a dubious/dual diagnosis were excluded. ICI Level (ICI-L) and ICI Content (ICI-L) scores were calculated for the 167 questionnaires generated by patients with epilepsy (n = 119, of which 58 from patients with temporal lobe epilepsy, 14 frontal lobe epilepsy, and 47 idiopathic 30 generalized epilepsy) and patients with NEAD (n = 48). Mann-Whitney U tests revealed statistically significant higher ICI-L and ICI-C scores for patients with NEAD (both P = 0.01). Subjective reports of consciousness experiences varied between epilepsy and NEAD, with patients with NEAD reporting significantly greater levels of general awareness/responsiveness and more vivid subjective experiences during attacks. The ICI is proposed as a potentially useful self-report instrument to supplement clinical and instrumental tests for the differential diagnosis of epilepsy and NEAD.

The cost of everything and the value of nothing: nursing case histories.

A series of three nursing case histories related to epilepsy care are presented to demonstrate the range of clinical nursing activity in an epilepsy clinic and to pose the question whether any of these activities, deemed essential by both clinician and nurse, would be thought appropriate if cost effectiveness of nursing care was merely measured by a significant reduction in seizure frequency. The conclusion drawn is that a specialist epilepsy nurse in an epilepsy clinic is an invaluable member of the team, who frees the medical member of the team to concentrate on those duties which need medical input: but, using currently applied outcome criteria, it would be difficult to justify the nurse's cost effectiveness. Measures that do this accurately and fairly must be developed.

The epilepsy nurse specialist--expendable handmaiden or essential colleague?

The benefits of a specialist epilepsy nurse in the management of people with epilepsy are still in question. Evidence from controlled clinical trials suggests that patients supported by a nurse specialist are well informed and have a high degree of satisfaction. However, no significant effect on health status or the number of seizures has been yet demonstrated, although this is not the primary function of most epilepsy specialist nurses. The recent International League Against Epilepsy (ILAE) British Branch meeting in Liverpool (April 2001) dedicated a one-day symposium to epilepsy nursing including a debate on the effectiveness of 'the epilepsy specialist nurse--warm fuzzy feeling or evidence based?'. Although it was agreed that evidence-based research is limited, the case studies and data presented, throughout the symposium, highlighted the varying role of the epilepsy specialist nurse in supporting both the specialist physician in epilepsy care, the non-specialist physician and the primary care physician in patient communication. This paper provides an overview of the presentations given at the symposium, including those on nursing research and publishing.

Clinical experience of marketed Levetiracetam in an epilepsy clinic-a one year follow up study.

Levetiracetam is a new anti-convulsant with impressive pivotal trial credentials. We examined its effectiveness in refractory clinic patients with epilepsy with a year's follow up. Six months after initiation 32% of the patients were seizure free, and 26% at one year. By the end of the 12 months follow up 77% of patients were still taking the drug, having gained benefit from it: 23% had dropped out due to intolerable side effects, seizure increase or lack of efficacy. There is evidence that the drug is broad spectrum and as effective in primary generalised epilepsy as in partial onset epilepsy. Our audit of its use and effectiveness has led us to position it as our first choice add-on drug if the initial monotherapy drug fails.

A study of anticonvulsant medication on ovarian function in a group of women with epilepsy who have only ever taken one anticonvulsant compared with a group of women without epilepsy.

A group of 105 women (54 of whom were, and had only ever been, taking valproate for at least a year, and 51 who had only ever taken either lamotrigine or carbamazepine, for at least a year) were compared with a group of 50 women who did not have epilepsy: any oral contraceptive taken at the time of testing was recorded and blood levels of follicle stimulating hormone (FSH), luteinising hormone (LH), testosterone and prolactin were estimated from days 2 to 6 of the menstrual cycle (day 1 being the first day of bleeding) and an MRI scan made of their pelvis. Women with epilepsy in general were significantly more likely to exhibit evidence on MRI scanning, of polycystic ovaries (PCO): women taking valproate but not an oral contraceptive were significantly more likely to have clinical biochemical evidence of the polycystic ovarian syndrome (PCOS) with raised LH and/or testosterone levels between days 2 and 6 of their menstrual cycle than women who did not have epilepsy: this was not so for women taking lamotrigine or carbamazepine. Since the polycystic ovary syndrome has potentially serious consequences it is suggested that, where possible, valproate is avoided in women of child bearing potential.

Effects of monitoring strategies on seizures in pregnant women on lamotrigine: a meta-analysis.

OBJECTIVES: Pregnant women with epilepsy have a significantly increased risk of mortality and morbidity compared to non-pregnant women. At least one in 250 pregnancies is exposed to anti-epileptic drugs (AED). Seizure deterioration occurs in up to a third of pregnant women. AED levels fall in most pregnant women, although it is uncertain that this is responsible for seizure deterioration rather than a hormonal effect. Current practice of AED monitoring is either therapeutic drug monitoring (TDM) or clinical features monitoring (CFM) to adjust the AED dose. We have systematically reviewed the effectiveness of the two monitoring regimens for AEDs, especially lamotrigine, the most commonly used AED in pregnancy on maternal and fetal outcomes. STUDY DESIGN: We searched MEDLINE (1966-2012), EMBASE (1980-2012) and Cochrane, for relevant citations on the effectiveness of different monitoring strategies on seizure deterioration in pregnant women with epilepsy on lamotrigine. Study selection, quality assessment and data extraction were carried out by two independent reviewers. We calculated the rates of deterioration in seizures with the two strategies and pooled the estimates with random effects meta-analysis. RESULTS: Six observational studies (n=132) evaluated the effectiveness of the two monitoring strategies on pregnant women with epilepsy on lamotrigine. There were no randomised controlled trials. The rate of seizure deterioration was 0.30 (95% CI 0.21-0.41) in women monitored by therapeutic drug monitoring (TDM) compared to 0.73 (95% CI 0.56-0.86) in those receiving clinical feature monitoring (CFM) alone. CONCLUSION: Evidence based on observational data suggests that monitoring of AED levels in pregnancy reduces seizure deterioration, although the included studies have numerous sources of bias. There is paucity of evidence to make firm recommendations on optimal monitoring of AED drugs in pregnancy. Further research is needed to advise on the best clinical practice in managing AED in pregnancy.