Quality of care of epilepsy in Italy: multi-hospital survey of diagnosis and treatment of 1104 epileptic patients

Overtreatment in adults with epilepsy

Overtreatment of epilepsy patients is traditionally associated with the use of polytherapy, i.e. use of more than one antiepileptic drug (AED). Although monotherapy is now being used in 70% of patients with epilepsy, these patients are also at risk at being overtreated. Ten to 20% of patients withdraw from their first drug because of adverse effects. This is partly related to high starting dosages and fast titration rates. The conventional AEDs are still first choice monotherapy drugs, although they potentially have more adverse effects, especially in the elderly. Other problems are the random selection of second or third choice drugs and the uncertainty about when to switch to polytherapy. Several authors have suggested that patients with progressive forms of epilepsy, such as patients with mesiotemporal sclerosis, should be treated adequately as soon as possible and that epilepsy surgery should be considered for them in a much earlier stage. Overtreatment in polytherapy is still a large threat, due to several reasons: drug loads are much higher, and thus more adverse effects are likely to develop; drug combinations are selected randomly, as evidence about effective combinations has been scarce; the constant choice between continuing the existing treatment (which is suboptimal) and trying new drugs (which may disturb a patient's equilibrium); the long-term use of benzodiazepines.

Anti-epileptic therapy and behaviour disturbances in children

In order to evaluate the effects on behaviour of some anti-epileptic drugs, we studied 300 children treated with phenobarbital and other drugs; their age ranged from 3.1 months to 15.9 years. The children were divided into two groups: group A: 197 (116 male and 81 female) children, mean age +/- SD 5.3 +/- 2.8 years, treated with phenobarbital; group B: 103 (66 male and 37 female) children, mean age 6.4 +/- 3.1 years, treated with anti-epileptic drugs other than phenobarbital. In all patients hyperactivity, irritability, disturbances of sleep, and drowsiness were investigated. The parents of patients completed a questionnaire with seven items. In group A, 150 (76.1%) children showed one or more behaviour disturbances, while in Group B a smaller number of patients 32 (31%) had such disorders. There was a significant difference between the two groups (P < 0.0001). The most frequent disorder was hyperactivity. The results of this study suggest that anti-epileptic drugs, in particular phenobarbital, can cause behaviour disturbances.

Epilepsy treatment in The Netherlands. Comparison of two medical centres

In order to test if it is feasible to compare epilepsy treatment policies, a secondary (University Hospital) and a tertiary referral care centre (i.e. an Epilepsy Centre) were compared with respect to their characteristics, the treatment approaches, and the outcome of treatment using clinimetric indexes. At the Epilepsy Centre a greater variety of seizure types was seen than at the University Hospital. At the University Hospital more patients were treated with monotherapy (62.5%) than at the Epilepsy Centre (28.0%). The Composite Index of Impairments (CII), which reflects all treatment related impairments i.e. seizures and adverse events, was significantly higher at the Epilepsy Centre than at the University Hospital. No difference was seen in the groups of patients with a high score of the CII (> 100). Further analysis is needed to obtain an answer as to why differences between the two groups exist.

Epilepsy in an Italian community as assessed by a survey for prescriptions of antiepileptic drugs: epidemiology and patterns of care

The prescriptions of antiepileptic drugs in the years 1985 and 1986 were used to identify all possible cases of epilepsy in a population of about 50,000 people. The general practitioners of the study area filled out a questionnaire for each user of antiepileptic drugs registered as a patient of theirs. This information was integrated using data obtained by local specialist services or directly collected by visits and/or phone interviews. Two-hundred and fifty-six of the 417 antiepileptic drug users proved to be active epileptics with a prevalence rate of 5.2/1000, the annual incidence rate for 1986 being 51.8/100,000. The main patterns of the disease appeared to be consistent with those of the literature while the prior history of seizures in the previous five years was generally lower. The health care of epileptic patients involved a wide range of specialists. The general practitioners were responsible for the final diagnosis of epilepsy in 10% of patients and for the management of the disease in 22%, most of the patients being over 50 years old. The calculated mean prescribed daily doses of the antiepileptic drugs suggested that many epileptics were taking therapeutic schedules lower than those of the literature.

The role of the EEG in epilepsy of long duration

Although the electroencephalogram's (EEG's) relevance in the initial work-up of individuals with epilepsy is well-defined, its role in epilepsy of long duration remains uncertain. A literature survey revealed eight studies that had evaluated epileptiform patterns (EPs) in series of patients but none of these were derived from outpatients presenting for regular follow-up. Such EEG results are crucial for determining disability benefits that are often denied to people with normal records. We therefore randomly surveyed 100 adult outpatients attending the seizure follow-up clinic at Cook County Hospital. An EP was detected in 33 patients, 36 had normal records, and 31 had non-EP abnormalities. The presence of an EP was significantly related to an etiology of head injury, duration of epilepsy, age of onset before age 20 years, and receiving more than one antiepileptic drug (AED). The presence of an EP did not correlate with seizure frequency, seizure type, or presence of a neurological deficit. A prior EEG increased the proportion with an EP only to 41%. The relatively low proportion of people who demonstrated an EP suggests that (a) the presence of an EP on an EEG should not be a factor in deciding about disability benefits for individuals with epilepsy, and (b) that use of an EP as an eligibility criterion for entry into a research series is likely to generate a select group of patients, thus making it difficult to generalize results.

Prevalence of the epilepsies in Nigerian Africans: a community-based study

A door-to-door survey to detect commonly occurring neurologic diseases was carried out in Igbo-Ora, a large Nigerian town with a population of approximately 20,000. Effective health care facilities have been operating in the community since 1963. Primary health care workers and nondoctor personnel administered a complete census, a screening questionnaire, and a simple screening neurologic examination. The pretested screening questionnaire had been shown in a pilot study to have a sensitivity of 95% for identifying those with epilepsy. Individuals positive on the screening phase of the survey were evaluated by neurologists and neurosurgeons, who used well-defined criteria to make the diagnosis. There were 101 (48 males and 53 females) who suffered from active epilepsy (5.3 cases/1,000) on prevalence day. The highest age-specific prevalence ratios occurred in those below age 20. The most common of the identifiable seizure types was complex partial seizures (52 cases). The prevalence ratio of epilepsy in this Nigerian town (with an effective health care system) is similar to that reported in some developed countries and several times lower than figures derived from studies in developing countries. These data suggest that an improved health care system would probably reduce the prevalence and burden of epilepsy in developing countries.

Adverse reactions to antiepileptic drugs: a multicenter survey of clinical practice. Collaborative Group for Epidemiology of Epilepsy

A multicenter survey of adverse drug reactions (ADR) to anticonvulsants was conducted in 15 university and hospital departments, including six epilepsy centers in Italy. Five hundred and nine patients undergoing chronic anticonvulsant therapy (greater than 3 months) were admitted to the study. Details of the main characteristics of the underlying disease, drug schedules, and ADR (including date of onset, type, involved tissue or organ, severity, duration, acceptability by the patient, clinical significance, referral pattern, and clinical implications) were provided. One or more ADR were recorded in 157 cases (31%), with a wide range of referrals among centers (6-79%). Of the 232 recorded ADR, 109 were definite, 84 were possible, and 26 were doubtful. In 54.5% of the cases ADR were reported by the patient, 52.5% were clinically important, 49.5% were permanent, and 67% were tolerable. In 53% of patients having ADR no decisions had been taken. Plasma levels of anticonvulsants were determined in 47% of cases and for 49% of the prescribed drugs. The proportion of cases with ADR was 22% in patients receiving monotherapy, 34.2% in patients treated with two drugs, and 44.4% in patients receiving three or more drugs. Thirty-three percent of patients taking phenytoin as the only drug had ADR as compared with 23, 15, and 12% of patients treated with phenobarbital, carbamazepine, and sodium valproate or depamide. Somnolence was the commonest complaint (51 cases), followed by gingival hyperplasia (34 cases), nystagmus (23 cases), and ataxia (16 cases). These findings provide a real-life profile of the ADR to anticonvulsants, with inclusion of the factors likely to influence the behavior of the practicing physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

Antiepileptic drug toxicity: definition and mechanism of action

A detailed review of the adverse reactions of anticonvulsants is given, focusing on the definitions of drug toxicity, sources of information, patterns of drug utilization, pharmacokinetic variables and different mechanisms of action. The information available in the literature provides a wide spectrum of drug toxicity with no attempt at a practical definition of the reported events. This favors uncertainty among practising physicians, who are led to use the individual items with different attitudes. Suggestions are given for the evaluation, prevention and treatment of anticonvulsant drug toxicity.

A descriptive study of epilepsy in the district of Copparo, Italy, 1964-1978

Worldwide investigation of the epidemiology of epilepsy has suggested wide variations in the frequency of convulsive disorders. However, descriptive studies in general populations cannot be completely comparable because of a remarkable methodological dishomogeneity in definition of epilepsy, classification of seizures, and ascertainment, collection, and selection of the cases. The position with regard to the Mediterranean people was still little known, and the few studies presently available from Italy offer underestimates of epilepsy frequency owing to incompleteness in case-collection practices and lack of information about the incidence of the disease. Therefore, to verify the true frequency of epilepsy in our country, we performed a community-based epidemiologic study of convulsive disorders in the district of Copparo (population 45,153) in northern Italy. Based on 278 accepted cases with "active" epilepsy, the prevalence per 1,000 population on December 31, 1978, was 6.2 (6.4 if standardized to the Italian population). The average annual incidence for the period 1964 through 1978 was 33.1 per 100,000 (38.3 if standardized). These results, similar to those found in other Western countries, support the view that the frequency of epilepsy in Italy as a whole is higher than that indicated by the Italian studies previously published, and suggest that epilepsy is evenly distributed in Europe and the United States. Antecedents which could be considered potential causes of epilepsy were found in 39.6%, and in 39.1% of the prevalence and incidence cases, respectively; for both prevalence and incidence groups, perinatal brain injuries were the most frequent event. This high proportion of epileptic cases with underlying causes emphasizes the urgency of planning precautionary measures in Italy to improve prenatal and perinatal medical care.