The cost of everything and the value of nothing

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 nursewarm 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.

Epilepsy and the ovary (cutting out the hysteria)

This review touches on the historical links between epilepsy, seizures and the uterus and ovaries which have fascinated and misled physicians since Greco-Roman times. It then examines present knowledge of ovarian function and its effect on epileptic activity and vice versa before exploring the modern controversy about polycystic ovaries and the polycystic ovary syndrome, epilepsy and anticonvulsant medication. Based on present evidence, women with epilepsy are more prone to develop polycystic (polyfollicular) ovaries than other women due to the epilepsy itself. But women with epilepsy related polycystic (polyfollicular) ovaries are vulnerable to the effects of sodium valproate (possibly particularly during adolescence) and may develop the polycystic ovary syndrome: this is reversible if the valproate is withdrawn. Lamotrigine and carbamazepine seem to prevent the development of the syndrome.

Epilepsy--doctor's dilemma, lawyer's delight? Medico-legal consequences of practising in the field of epilepsy report of an International League Against Epilepsy British Branch meeting--Edinburgh, April 2000

Six cases are described where the medical management of a person's epilepsy was brought under legal scrutiny. Lessons learnt from this educational exercise include improving doctor patient communication, the function of a Coroner's Court, when is misdiagnosis negligent, the vagaries of expert witnesses, should failure to diagnose a tumour be blamed on the physician or the service when facilities are inadequate, is failure to recognise a rare drug interaction, failure to warn against an interaction, or failure to take a proper history, negligent? The conference also examined the legal ramifications of the nurse/doctor relationship in epilepsy care, the place of epilepsy guidelines and, due to its interactive nature, reflected on the audience's epilepsy knowledge, which, in places seemed significantly deficient. It was a gripping educational exercise.

A multifilamented electrode in the middle cardiac vein reduces energy requirements for defibrillation in the pig

OBJECTIVE

To compare the defibrillation efficacy of a novel lead system placed in the middle cardiac vein with a conventional non-thoracotomy lead system.

METHODS

In eight pigs (weighing 35-71 kg), an electrode was advanced transvenously to the right ventricular apex (RV), with the proximal electrode in the superior caval vein (SCV). Middle cardiac vein (MCV) angiography was used to delineate the anatomy before a three electrode system (length 2 x 25 mm + 1 x 50 mm) was positioned in the vein. An active housing (AH) electrode was implanted in the left pectoral region. Ventricular fibrillation was induced and biphasic shocks were delivered by an external defibrillator. The defibrillation threshold was measured and the electrode configurations randomised to: RV-->AH, RV+MCV-->AH, MCV-->AH, and RV-->SCV+AH.

RESULTS

For these configurations, mean (SD) defibrillation thresholds were 27.3 (9.6) J, 11.9 (2.9) J, 15.2 (4.3) J, and 21.8 (9.3) J, respectively. Both electrode configurations incorporating the MCV had defibrillation thresholds that were significantly less than those observed with the RV-->AH (p < 0.001) and RV-->SCV+AH (p < 0.05) configurations. Necropsy dissection showed that the MCV drained into the coronary sinus at a location close to its orifice (mean distance = 2.7 (2.2) mm). The MCV bifurcated into two main branches that drained the right and left ventricles, the left branch being the dominant vessel in the majority (6/7) of cases.

CONCLUSIONS

Placement of specialised defibrillation electrodes within the middle cardiac vein provides more effective defibrillation than a conventional tight ventricular lead.

Reduction in defibrillation threshold using an auxiliary shock delivered in the middle cardiac vein

Defibrillation in the middle cardiac vein (MCV) has been shown to reduce ventricular defibrillation thresholds (DFTs). Low amplitude auxiliary shock (AS) from an electrode sutured to the left ventricle at thoracotomy have also been shown to reduce DFT if delivered immediately prior to a biphasic shock (between the ventricular RV and superior vena caval (SVC) electrodes). This study investigates the impact on DFT of an AS shock from a transvenously placed MCV lead system. A standard defibrillation electrode was positioned in the RV in eight anesthetized pigs (35-43 kg). A 50 x 1.8-mm electrode was inserted in the MCV through an 8 Fr angioplasty guide catheter. A 150-V (leading edge) monophasic AS was delivered (95 microF capacitor) from the MCV-->Can with three different pulse widths (3, 5, 7 ms). A primary biphasic shock (PS) (95 microF capacitor, phase 1: 44% tilt, 1.6-ms extension and phase 2: 2.5-ms fixed duration) was delivered from the RV-->Can +/- AS. The four configurations were randomized and DFTs (PS + AS) assessed using a modified binary search. Ventricular fibrillation (VF) was induced with 60 Hz AC followed 10 seconds later by the test shock. The DFTs were compared using repeated measures analysis of variance (ANOVA). All configurations incorporating AS produced significant (P < 0.05) reduction in the DFT compared to no AS (13.8 +/- 7.4 J). There was no difference in the efficacy of differing pulse widths (P > 0.05); 3 ms (11.0 +/- 5.4 J), 5 ms (11.5 +/- 6.0), and 7 ms (10.6 +/- 5.3 J). In conclusion, delivering an AS from a transvenous lead system deployed in the MCV reduces the DFT by 23% compared to a conventional RV-->Can shock alone.

Psychiatric symptoms after therapy with new antiepileptic drugs: psychopathological and seizure related variables

The purpose of this paper is to understand the association between antiepileptic drugs (AEDs), patient characteristics, changes in seizure pattern and emergent psychiatric disorder, i.e. psychosis or affective disorder. To this end we carried out a retrospective casenote study on 89 patients who developed psychiatric symptoms during treatment with topiramate, vigabatrin or tiagabine. The psychiatric problem was either an affective or a psychotic disorder (not including affective psychoses). It was discovered that 99% of the patients suffered from complex partial seizures with or without secondary generalization. More than half were on polytherapy with two or more other AEDs. Nearly two-thirds had a previous psychiatric history. There was a strong association between the type of previous psychiatric illness and the type of emerging psychiatric problem, both for psychoses and for affective disorders. Patients on vigabatrin had an earlier onset of epilepsy and more neurological abnormalities than those on topiramate. Those patients on lower doses had a shorter interval between the start of the AED therapy and the onset of the psychiatric problem. A seizure-free period was observed in more than half of the patients before they developed the psychiatric symptoms, and of these more were likely to develop a psychosis rather than an affective disorder. There seemed to be an association of suppression of right-sided seizures and the onset of the psychiatric problem. The conclusions drawn were that patients with a previous history of psychosis or affective disorder tended to develop the same psychiatric problem with new AEDs. Those with a seizure-free period before the onset of the psychiatric problem were more likely to develop a psychosis than an affective disorder.

Increased defibrillation threshold with right-sided active pectoral can

The aim of this study was to identify the optimal position on the chest wall to place an implant able cardioverter defibrillator in a two-electrode system, consisting of a right ventricular electrode and active can.

METHODS AND RESULTS

Defibrillation thresholds (DFT) were measured in 10 anaesthetised pigs (weight 33-45 kg). An Angeflextrade mark lead was introduced transvenously to the right ventricular apex. The test-can (43 cc) was implanted submuscularly in each of four locations: left pectoral (LP), right pectoral (RP), left lateral (LL) and apex (A). The sequence in which the four locations were tested was randomized. Ventricular fibrillation (VF) was induced using 60 Hz alternating current. Rectangular biphasic shocks were delivered 10 seconds after VF induction. The DFT was measured using a modified four-reversal binary search. The results of the four configurations were: LP, 14.6+/- 4.0 J; RP, 18.8+/- 4.2 J; LL, 14.7+/- 4.1 J; A, 14.9+/- 3.1 J. Repeated measures analysis of variance showed that the DFT of RP was significantly higher than LP, LL and A (p < 0.05).

CONCLUSIONS

Implanting an active can in the RP position increases the DFT by 29% compared to LP, LL and A sites. The can position on the left thorax does not appear to have a significant influence on DFT.

A multicentre, double-blind, randomized, parallel group study to evaluate the tolerability and efficacy of two oral doses of levetiracetam, 2000 mg daily and 4000 mg daily, without titration in patients with refractory epilepsy

The aim of this study was to determine the tolerability and efficacy of two oral regimens of levetiracetam, 1000 mg and 2000 mg twice daily, as add-on treatment without titration in patients with refractory epilepsy. After a 1- to 4-week baseline, 119 patients were randomized to receive levetiracetam 2000 mg daily, 4000 mg daily, or placebo for a 24-week double-blind period, then levetiracetam 4000 mg daily in a 24-week open-label phase. Somnolence was the most common reason for discontinuation, and along with asthenia, occurred more frequently with levetiracetam than placebo. Responder rates were higher with levetiracetam 2000 mg and 4000 mg daily (48.1% [P < 0.05] and 28.6% [NS], respectively) than placebo (16.1%). In the open-label phase, the overall responder rate was 43.0%. Switching from placebo to levetiracetam increased the overall responder rate from 16.7% to 44.0%. No such increase was observed with patients initiated on levetiracetam 2000 mg daily. Levetiracetam initiated at doses of 2000 mg or 4000 mg daily without titration is well-tolerated and effective as add-on therapy in patients with partial and/or generalized seizures. The higher dose may be related to an increased incidence of somnolence and is not necessarily more effective than the lower dose.

How much risk does a woman with active epilepsy pose to her newborn child in the puerperium? A pilot study

Much attention in the literature has recently been paid to women's issues in epilepsy but most of the literature stops in the delivery room or at the first moment of suckling. Although it is commonly supposed that a woman who continues to have active epilepsy during the puerperium will pose a risk to her child, little assessment of how great a risk this is has been carried out. We present an audit of the puerperal experiences of 187 women with epilepsy counselled before birth in our women's clinic and contrast this with a number of women with epilepsy seen for the first time in the puerperium (and therefore uncounselled). The audit suggests that in counselled women the risk is very low (women with Juvenile Myoclonic Epilepsy may be particularly at risk, as may women with tonic-clonic seizures that occur without warning, plus those with automatisms or who have prolonged post-ictal confusion). Some women with controlled epilepsy prior to conception may lose that control during the puerperium so even women with well controlled epilepsy should adopt precautions in the puerperium. The only baby to die (or be seriously injured) in the puerperium born to a woman with epilepsy was killed in the mother's first seizure.

Proactive pre-conception counselling for women with epilepsy-is it effective?

We describe the development of a proactive pre-conception counselling service for women with epilepsy based on complete re-investigation of the woman's epilepsy, a policy of withdrawing antiepileptic drugs (AEDs) thought to carry an increased risk of foetal abnormality (and substitution, where indicated, of AEDs thought to carry a lesser risk) and the exhibition of folic acid 5 mg daily plus fulfilment of the woman's educational needs and exploration of her and her partner's wishes. The outcome of the assessment of 90 such women is compared with the outcome of 59 women presenting to our service already pregnant. An audit of the outcomes in the two groups suggests that re-investigation of women pre-conceptually is worthwhile (some women turn out not to have epilepsy or have cerebral lesions best managed before pregnancy) and that foetal morbidity may be reduced by judicious rationalization of medication: folic acid taken before conception may also be protective for the foetus. Proactive pre-conception counselling, however, only works if the woman is prepared to wait (sometimes up to a year) for necessary drug changes to be instituted and is using reliable contraception.

Best practice guidelines for the management of women with epilepsy. The Women with Epilepsy Guidelines Development Group

Clinical guidelines for the treatment of epilepsy have been published. A statement on management issues for women with epilepsy has recently been produced by the American Academy of Neurology which has raised awareness of the issues facing women with epilepsy. The communication presented here aims to review current literature on specific issues relating to women with epilepsy, and proposes graded recommendations for its management within a UK health care framework.

Epilepsy needs revisited: a revised epilepsy needs document for the UK

We revisit epilepsy needs in the United Kingdom, and update our previous publication to take into account new epidemiological data, changes in investigation and treatment and trends in the organization of health and other caring agencies. This document attempts to define and quantify the scope, content and standards of services required, from primary care settings to specialized centres. Reference is also made to the role of other agencies.

A note on a phrase in Shakespeare's play King Lear: 'a plague upon your epileptic visage'

In Shakespeare's play King Lear the word 'epileptic' appears (used in a derogatory manner). This is held to be the first appearance of the word in the English language (although we have found earlier English references to the word which Shakespeare may have read). Textual analysis of the lines following the use of 'epileptic' suggests that it is actually a reference to the pock-marks of syphilis, endemic in Elizabethan England, and is not actually a reference to epilepsy itself.

John Hall and his epileptic patients--epilepsy management in early 17th century England

John Hall, a physician, practised in Stratford in the early 17th century and was the son-in-law of William Shakespeare. During his career he kept records of his patients (in Latin) which he may have been preparing for publication when he died. Despite his instruction for them to be destroyed some were later translated into English and published by another physician. The case records were popular and have recently been reprinted with a commentaryl. We have searched the case records for descriptions of epilepsy and examined the treatments offered (and the attitudes to) this condition in early 17th century England. Treatment consisted of standard remedies ('fumes' of hartshorn and extracts of peony) related to the Galenic system of medicine, plus individual remedies. Interestingly, there is no evidence that the condition was stigmatized.

Learning disability and epilepsy. 2, a review of available outcome measures and position statement on development priorities

People with epilepsy plus learning disabilities pose a challenge in terms of clinical management and research investigation, and, to date, the measurement of outcomes in this population has been limited. There have been uncertainties concerning both the 'what' and the 'how' of assessment. This paper presents a comprehensive review of available outcome measures across nine domains, i.e. relating to seizures, drugs, cognitive function, behaviour, social functioning, carer functioning, attitudes, motivation and 'quality of life'. This last domain reflects more global measures designed to encompass several assessment strands. The uses and limitations of each scale is discussed and, where data are available, psychometric properties are also presented. The paper concludes with suggestions for the further development of outcome measures in this population.

Learning disabilities: moving forward--a focus on epilepsy, Birmingham, England, 29 June 1996

On 29 June 1996 a conference was held in Birmingham to highlight the status of epilepsy in people with learning disabilities. The conference consisted both of seminars and workshops. Dr Tim Betts, Birmingham; Dr Greg O'Brien, Northumberland; and Dr Mike Kerr addressed issues of assessment, diagnosis and drug treatment of epilepsy in this population. This meeting report summarizes the proceedings of the conference.