Development of a novel scale to assess life fulfillment as part of the further refinement of a quality-of-life model for epilepsy

An observational time-series study on the behavioral effects of adjunctive artisanal cannabidiol use by adults with treatment resistant epilepsies

BACKGROUND

For approximately 30% of people with epilepsy, seizures are not well-controlled by anti-seizure medication (ASM). This condition, called treatment resistant epilepsy (TRE), is associated with increased morbidity and mortality, and substantially impacts the quality of life of both the individual and their family. Non-responsiveness to ASMs leads many people with TRE to seek alternative therapies, such as cannabinoid-based medication, particularly cannabidiol (CBD), with or without medical or professional advice. This is due in part to widespread reporting in the media about the benefits of CBD for seizures in some forms of epilepsy.

METHODS

Adults with TRE, opting to add CBD to their existing treatment regime, completed this prospective, observational, longitudinal, quasi-experimental, time-series study. We hypothesized that adjunctive CBD use would positively impact participants' quality of life and psychological well-being in comparison to a baseline period without CBD use. Participants were followed for a period of approximately six months - for approximately one month of baseline prior to the initiation of CBD use and approximately five months after the initiation of CBD use. Participants provided urine samples and completed behavioral questionnaires that assessed quality of life, anxiety/depression, and adverse events during baseline and at two times during CBD use.

RESULTS

Complete case analyses (n = 10) showed a statistically significant improvement in quality of life, a statistically significant decrease in anxiety symptoms, and a statistically significant decrease in the experience of adverse events over time (p < 0.05). Improvements noted in the experience of depression symptoms did not reach statistical significance. Urinalysis revealed the majority of participants had no CBD/metabolites in their system at the beginning of the study, and confirmed the presence of CBD/metabolites in participants' urine after CBD was added to their treatment regime. Analysis of missing data using multiple imputation supported the findings of the complete case analysis.

INTERPRETATION

For a small group of individuals with TRE of varying etiologies, adjunctive use of artisanal CBD was associated with improvements in the behavioral and psychological symptoms of TRE, as well as improved medication tolerability.

Non-discontinuation of antiseizure medication in seizure-free epilepsy patients

BACKGROUND AND PURPOSE

In patients with epilepsy and sustained seizure freedom, guidelines recommend considering discontinuation of antiseizure medication (ASM) based on shared decision-making. This study aims to identify factors associated with non-discontinuation of ASM in seizure-free patients.

METHODS

Retrospective data from three sites of an academic outpatient clinic were analyzed. Adult patients with epilepsy who have been seizure-free for ≥24 months on ASM monotherapy were included. The primary end-point was non-discontinuation of ASM, defined as no discontinuation or no dose reduction of ≥25% at the last outpatient clinic visit in the ultimate seizure-free interval. Secondary end-points included frequency of discussion on discontinuation attempts between patients and physicians, adherence to ASM discontinuation decisions, and post-discontinuation seizure outcomes.

RESULTS

Out of 338 included patients, 81.7% did not discontinue ASM and did not reduce its dose, 11.5% discontinued ASM and 6.8% had a significant dose reduction. Factors independently associated with non-discontinuation of ASM were history of focal to bilateral or generalized tonic-clonic seizures (odds ratio [OR] 2.33, 95% confidence interval [CI] 1.08-5.06), history of breakthrough seizures (OR 3.32, 95% CI 1.10-10.04), history of failed attempts to discontinue or reduce the ASM dose (OR 4.67, 95% CI 1.03-21.11) and higher ASM load at the index visit (OR 6.10, 95% CI 2.09-17.78). Discontinuation attempts were made during the entire period of seizure freedom and were most commonly undertaken ≥10 years after the last seizure.

CONCLUSIONS

This study provides insights into factors associated with the shared decision-making process regarding ASM discontinuation in seizure-free patients and highlights the importance of considering individual patient characteristics and seizure history.

Clinical outcome assessment in patients with epilepsy: The value of health-related quality of life measurements

This narrative review provides an overview of the current knowledge on health-related quality of life (HRQOL), a relevant clinical outcome in patients with epilepsy. It shows that the most important factor determining HRQOL in this patient group is seizure frequency. In particular, seizure-freedom is associated with better HRQOL scores. Many other factors may impact perceived HRQOL aspects, but their interrelation is complex and requires further research. Novel analytical approaches, such as hierarchical cluster and symptom network analyses might shed further light on this, and may result in recommendations for interventions on the most 'central' factors influencing different aspects of HRQOL in patients with epilepsy. Next, an overview of the HRQOL tools and analytical methods currently used in epilepsy care, with a focus on clinical trials, is provided. The QOLIE-31 is the most frequently applied and best validated tool. Several other questionnaires focusing on specific aspects of HRQOL (e.g., mood, social impact) are less frequently used. We show some pitfalls that should be taken into account when designing study protocols including HRQOL endpoints. This includes standardized statistical analysis approaches and predefined reporting methods for HRQOL in epilepsy populations. It has been shown in other patient groups that the lack of such standardisation negatively impacts the quality and comparability of results. We conclude with a number of recommendations for future research.

Onset of Inattention and Hyperactivity in Children and Adolescents With Epilepsy 6 months After the Diagnosis

OBJECTIVE

Complete or major symptoms of ADHD are often present in epilepsy. This study evaluated inattention and hyperactivity symptoms over the first 6 months in newly diagnosed pediatric epilepsy without comorbid ADHD.

METHOD

Children and adolescents with newly diagnosed epilepsy were followed for 6 months after starting antiseizure medications. The Nisonger Child Behavior Rating Form (NCBRF), Adverse Event Profile (AEP), and the Revised Wechsler Intelligence Scale for Children were used.

RESULTS

There was a marked increase in attention difficulties while a moderate increase in hyperactivity levels. AEP scores, changes in non-verbal aspects of intelligence, levels of hyperactivity at the follow-up, and attention at baseline were significant predictors for inattention. In contrast, only levels of hyperactivity at the baseline and inattention at the follow-up were significant predictors for hyperactivity.

CONCLUSION

Significant inattention and hyperactivity levels originated 6 months after the diagnosis of epilepsy and starting antiseizure medication.

Patient reported outcomes for phosphomannomutase 2 congenital disorder of glycosylation (PMM2-CDG): listening to what matters for the patients and health professionals

Background

Congenital disorders of glycosylation (CDG) are a growing group of rare genetic disorders. The most common CDG is phosphomannomutase 2 (PMM2)-CDG which often has a severe clinical presentation and life-limiting consequences. There are no approved therapies for this condition. Also, there are no validated disease-specific quality of life (QoL) scales to assess the heterogeneous clinical burden of PMM2-CDG which presents a challenge for the assessment of the disease severity and the impact of a certain treatment on the course of the disease.

Aim and methods

This study aimed to identify the most impactful clinical signs and symptoms of PMM2-CDG, and specific patient and observer reported outcome measures (PROMs and ObsROMs, respectively) that can adequately measure such impact on patients’ QoL. The most burdensome signs and symptoms were identified through input from the CDG community using a survey targeting PMM2-CDG families and experts, followed by family interviews to understand the real burden of these symptoms in daily life. The list of signs and symptoms was then verified and refined by patient representatives and medical experts in the field. Finally, a literature search for PROMs and ObsROMs used in other rare or common diseases with similar signs and symptoms to those of PMM2-CDG was performed.

Results

Twenty-four signs/symptoms were identified as the most impactful throughout PMM2-CDG patients’ lifetime. We found 239 articles that included tools to measure those community-selected PMM2-CDG symptoms. Among them, we identified 80 QoL scales that address those signs and symptoms and, subsequently, their psychometric quality was analysed. These scales could be applied directly to the PMM2-CDG population or adapted to create the first PMM2-CDG-specific QoL questionnaire.

Conclusion

Identifying the impactful clinical manifestations of PMM2-CDG, along with the collection of PROMs/ObsROMs assessing QoL using a creative and community-centric methodology are the first step towards the development of a new, tailored, and specific PMM2-CDG QoL questionnaire. These findings can be used to fill a gap in PMM2-CDG clinical development. Importantly, this methodology is transferable to other CDG and rare diseases with multiple signs and symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02551-y.

State of the Art of Patient-reported Outcomes in Acromegaly or GH Deficiency: A Systematic Review and Meta-analysis

CONTEXT

Insight into the current landscape of patient-reported outcome (PRO) measures (PROM) and differences between PROs and conventional biochemical outcomes is pivotal for future implementation of PROs in research and clinical practice. Therefore, in studies among patients with acromegaly and growth hormone deficiency (GHD), we evaluated (1) used PROMs, (2) their validity, (3) quality of PRO reporting, (4) agreement between PROs and biochemical outcomes, and (5) determinants of discrepancies.

EVIDENCE ACQUISITION

We searched 8 electronic databases for prospective studies describing both PROs and biochemical outcomes in acromegaly and GHD patients. Quality of PRO reporting was assessed using the International Society for Quality of Life Research (ISOQOL) criteria. Logistic regression analysis was used to evaluate determinants.

EVIDENCE SYNTHESIS

Ninety studies were included (acromegaly: n = 53; GHD: n = 37). Besides nonvalidated symptom lists (used in 37% of studies), 36 formal PROMs were used [predominantly Acromegaly Quality of Life Questionnaire in acromegaly (43%) and Quality of Life-Assessment of Growth Hormone Deficiency in Adults in GHD (43%)]. Reporting of PROs was poor, with a median of 37% to 47% of ISOQOL items being reported per study. Eighteen (34%) acromegaly studies and 12 (32%) GHD studies reported discrepancies between PROs and biochemical outcomes, most often improvement in biochemical outcomes without change in PROs.

CONCLUSIONS

Prospective studies among patients with acromegaly and GHD use a multitude of PROMs, often poorly reported. Since a substantial proportion of studies report discrepancies between PROs and biochemical outcomes, PROMs are pivotal in the evaluation of disease activity. Therefore, harmonization of PROs in clinical practice and research by development of core outcome sets is an important unmet need.

Valproic acid use in fertile women with genetic generalized epilepsies

OBJECTIVES

In genetic generalized epilepsies (GGE), valproic acid (VPA) is the most efficacious compound. However, due to teratogenicity and increased risk for impaired cognitive development after intrauterine exposure, its use in women of fertile age is strictly regulated but sometimes unavoidable.

METHODS

All patients with GGE treated at the outpatient clinic of a tertiary epilepsy center with at least one visit between January 2015 and April 2020 were included in this retrospective study. The rate of women aged 18 to 49 years taking VPA was compared to that of men of the same age group and to women > 49 years. Furthermore, in each group, clinical variables associated with VPA use were sought.

RESULTS

Twenty-eight out of 125 women of fertile age (22%) were treated with VPA, compared to 28 out of 56 men ≤ 49 years (50%; p = .002) and to 22 out of 40 female patients > 49 years (55%; p < .001). VPA dose was lower in fertile women compared to men, with no difference in seizure freedom rates. In women ≤ 49 years, multivariate analysis demonstrated age as the only variable independently associated with VPA use (OR 1.095; 95% CI 1.036-1.159). In the other two groups, no associated variables were identified.

CONCLUSIONS

Despite warnings with respect to teratogenicity and impaired cognitive development with VPA, from 2015 to 2020, almost every fourth women of fertile age with GGE received this compound. Inevitably lower VPA doses in these women seem sufficient for favorable seizure freedom rates.

Costs of Epilepsy in Austria: Unemployment as a primary driving factor

PURPOSE

Epilepsy is one of the most common chronic neurological disorders, and long-term treatment with antiseizure medication is often central to its management. The costs of antiseizure medication are more evident than other disease-related costs; thus, we assessed the direct and indirect costs of epilepsy focusing on both drug expenditure and other cost-driving factors.

METHODS

Outpatient records and questionnaires applied in a tertiary epilepsy centre in Vienna were used in this bottom-up cost-of-illness study to evaluate disease duration, age at onset, epilepsy syndrome, seizure frequency, sex, healthcare utilisation, diagnostic evaluations, antiseizure medication, and occupation. Cost data were clustered in a histogram-based data analysis, and multivariate regressions were performed to identify cost drivers.

RESULTS

The average annual costs of 273 patients amounted to €9,256 ($10,459): €4,486 ($5,069) direct costs and €4,770 ($5,390) indirect costs. A histogram of semi-annual costs revealed distinct groups with low costs (< €2,500 = $2,825) and high costs (> €2,500 = $2,825). Seizure-free patients were clustered in the group with low costs; patients with ongoing seizures appeared more frequently in the group with high costs. Working patients were more often found in the group with low costs, whereas unemployed patients were more prevalent in the group with high costs. The regression analysis confirmed worklessness as the main cost driver.

CONCLUSION

Non-productivity and poorly controlled disease with ongoing seizures are associated with higher costs in epilepsy. Providing high-level care and optimal drug treatment that enables patients to remain in work may help reduce the economic burden of epilepsy.

A feasibility assessment of functioning and quality-of-life patient-reported outcome measures in adult epilepsy clinics: A systematic review

OBJECTIVE

The objective of the study was to identify functioning and quality-of-life (QOL) patient-reported outcome measurements (PROMs) feasible for use in the waiting room of adult epilepsy clinics.

MATERIAL AND METHODS

We searched PubMed and Web of Science for articles on in English, Spanish, Portuguese, Italian, and French published by the end of February 15th, 2019. We screened retrieved titles and abstracts looking for publications that reported the use of PROMs to measure functioning and QOL in epilepsy. The authors, clinical experts, and patient advocates from the Epilepsy Foundation of America conceptualized a set of desirable feasibility attributes for PROMs implementation in the waiting room of adult epilepsy clinics. These attributes included brief time for completion (i.e., ≤3 min), free cost, coverage of four minimum QOL domains and respective facets, and good evidence of psychometric properties. We defined QOL domains according to the World Health Organization's classification and created psychometric appraisal criteria based on the Food and Drug Administration's (FDA) Guidance.

RESULTS

Eighteen candidate instruments were identified and compared with respect to desirable attributes for use in adult epilepsy clinics. We found that the Quality-of-life in epilepsy (QOLIE)-10 and Patient-Reported Outcome Measurement Information System-10 (PROMIS-10) were the most feasible PROMs for implementation in adult epilepsy clinics based on our criteria. The QOLIE-10 and PROMIS-10 still lack ideal evidence of responsiveness in people with epilepsy.

CONCLUSION

This is the first systematic review that aimed to assess feasibility properties of available functioning and QOL PROMs. The QOLIE-10 and PROMIS-10 are potentially feasible instruments for implementation in the waiting room of adult epilepsy clinics. Further studies assessing the responsiveness of these PROMs are needed and will contribute to the selection of the most appropriate instrument for longitudinal use in adult epilepsy clinical practice.

Validity of the Liverpool Adverse Events Profile as a Screening Tool for Detecting Comorbid Depression or Anxiety Disorder in People with Epilepsy

Background and Purpose

The Liverpool adverse events profile (LAEP) is useful for detecting and monitoring the adverse effects of antiepileptic drugs (AEDs) and contains items related to symptoms of depression or anxiety. This study evaluated the usefulness of the LAEP for detecting comorbid depression or anxiety disorder in people with epilepsy (PWE).

Methods

PWE, aged from 18 to 70 years and who took AEDs for at least 1 year, were included. They completed the Korean version of the LAEP (K-LAEP) to detect the adverse effects of AEDs and the mini international neuropsychiatric interview-plus version 5.0.0 (MINI) to identify major depressive disorder (MDD) and generalized anxiety disorder (GAD). We validated the K-LAEP as a screening tool for coexisting MDD or GAD in PWE. Receiver operating character (ROC) curve analyses were used to measure the appropriateness of cutoff scores for the total and item K-LAEP scores for detecting MDD or GAD.

Results

The study enrolled 150 PWE. According to the MINI, 30 PWE (20.0%) had MDD and 26 (17.3%) had GAD. Cronbach's α coefficient of the K-LAEP was 0.939. For the total K-LAEP score, cutoff scores of 40 and 43 could detect MDD and GAD, respectively. For the K-LAEP item score, a cutoff of five could detect MDD or GAD.

Conclusions

The K-LAEP is a valid screening tool for detecting MDD and GAD in PWE. A high LAEP score suggests comorbid psychiatric disorders, which need further specific evaluation.

Wordless intervention for people with epilepsy and learning disabilities (WIELD): a randomised controlled feasibility trial

OBJECTIVE

To investigate the feasibility of a full-scale randomised controlled trial of a picture booklet to improve quality of life for people with epilepsy and learning disabilities.

TRIAL DESIGN

A randomised controlled feasibility trial. Randomisation was not blinded and was conducted using a centralised secure database and a blocked 1:1 allocation ratio.

SETTING

Epilepsy clinics in 1 English National Health Service (NHS) Trust.

PARTICIPANTS

Patients with learning disabilities and epilepsy who had: a seizure within the past 12 months, meaningful communication and a carer with sufficient proficiency in English.

INTERVENTION

Participants in the intervention group used a picture booklet with a trained researcher, and a carer present. These participants kept the booklet, and were asked to use it at least twice more over 20 weeks. The control group received treatment as usual, and were provided with a booklet at the end of the study.

OUTCOME MEASURES

7 feasibility criteria were used relating to recruitment, data collection, attrition, potential effect on epilepsy-related quality of life (Epilepsy and Learning Disabilities Quality of Life Scale, ELDQOL) at 4-week, 12-week and 20-week follow-ups, feasibility of methodology, acceptability of the intervention and potential to calculate cost-effectiveness.

OUTCOME

The recruitment rate of eligible patients was 34% and the target of 40 participants was reached. There was minimal missing data and attrition. An intention-to-treat analysis was performed; data from the outcome measures suggest a benefit from the intervention on the ELDQOL behaviour and mood subscales at 4 and 20 weeks follow-up. The booklet and study methods were positively received, and no adverse events were reported. There was a positive indication of the potential for a cost-effectiveness analysis.

CONCLUSIONS

All feasibility criteria were fully or partially met, therefore confirming feasibility of a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN80067039.

The effects of lacosamide on cognition, quality-of-life measures, and quality of life in patients with refractory partial epilepsy

OBJECTIVE

The objective of this study was to examine cognitive and quality-of-life measures/quality of life outcomes with adjunctive lacosamide therapy in patients with treatment-resistant partial epilepsy.

METHODS

This was a prospective, open-label, nonblinded, adjunctive therapy test-retest (within subjects) study of patients with treatment-resistant partial epilepsy in which outcome (cognitive functioning and mood/quality of life) was measured in the same subject before and after adjunctive lacosamide administration for 24weeks. The cognitive assessment included the following: Controlled Oral Word Association Test, Buschke Selective Reminding Test, Brief Visuospatial Memory Test-Revised, Stroop Color Word Test, Symbol Digit Modalities Test, Digit Span, Digit Cancellation, and Trails A and B. The quality-of-life measures/quality-of-life assessment included the following: Beck Depression Inventory-II, Profile of Mood States, and Quality of Life Inventory-89. Lacosamide was started at 100mg (50mg twice daily) and could be titrated as needed up to 400mg/day (200mg twice daily). Baseline concomitant AEDs were kept constant. Composite scores were calculated for a pre-post difference score for the cognitive and mood/quality-of-life measures separately and used in regression analyses to correct for the effects of age, education, seizure frequency, seizure severity, dose of lacosamide, and number of AEDs at baseline.

RESULTS

Thirty-four patients were enrolled (13 males, 21 females). Mean age was 38.8±2.43years. Mean seizure frequency decreased significantly from 2.0±2.55 seizures per week at baseline to 1.02±1.72 seizures per week at posttreatment (t=4.59, p<.0001) with a 50% responder rate seen in 18 patients (52.9%). No significant differences were found on the composite scores of the cognitive or the mood/quality-of-life measures after 6months of lacosamide.

SIGNIFICANCE

Lacosamide appeared to have low risks of significant changes in cognition or mood/quality of life. In addition, the present study supports prior studies that have proven lacosamide as an effective adjunctive therapy for the treatment of resistant partial epilepsy.

Specific adverse effects of antiepileptic drugs--A true-to-life monotherapy study

BACKGROUND

In patients taking antiepileptic drugs (AEDs) for epilepsy, adverse effects (AEs) often lead to unfavorable quality of life, impaired adherence, and, eventually, discontinuation of pharmacological treatment. In a true-to-life sample of subjects from our academic epilepsy outpatient clinic, we aimed to identify predictors for overall high AE burden and for specific AEs focusing on patients on monotherapy.

METHODS

All patients ≥16years of age with epilepsy for ≥12months were routinely asked to complete the Liverpool Adverse Event Profile (LAEP) just before their appointment. Demographic, epilepsy, and treatment variables were derived from our comprehensive outpatient database.

RESULTS

Out of 841 patients, 438 (61% female, mean age: 44.7±17.1years) on monotherapy were included in this study. Levetiracetam (n=151), lamotrigine (n=167), valproic acid (n=73), or controlled-release carbamazepine (n=47) were the most commonly used antiepileptic drugs (AEDs). Independent predictors for general high AE burden (LAEP score≥45) were duration of epilepsy, lack of 12-month seizure freedom, and partial epilepsy, but none of the four individual AEDs. The most frequent LAEP-defined specific AEs were sleepiness, difficulty concentrating, tiredness, and memory problems. The three most frequent independent predictors for each of the 19 AEs were lack of 12-month seizure freedom (13/19 AEs), individual AED (7/19 AEs), and partial epilepsy (6/19 AEs). Levetiracetam was independently associated with anger/aggression, nervousness/agitation, upset stomach, depression, and sleep disturbance; lamotrigine with nervousness/agitation, upset stomach, and difficulty concentrating; and valproic acid with upset stomach and shaky hands.

CONCLUSION

Individual AEDs independently predicted some specific AEs, but not overall high AE burden. Our findings may help to characterize patients with epilepsy who are at high risk for specific AEs. Dose reduction or change to another AED may reduce LAEP score and potential nonadherence.

Comparison of tolerability and adverse symptoms in oxcarbazepine and carbamazepine in the treatment of trigeminal neuralgia and neuralgiform headaches using the Liverpool Adverse Events Profile (AEP)

Background

Adverse effects of drugs are poorly reported in the literature . The aim of this study was to examine the frequency of the adverse events of antiepileptic drugs (AEDs), in particular carbamazepine (CBZ) and oxcarbazepine (OXC) in patients with neuralgiform pain using the psychometrically tested Liverpool Adverse Events Profile (AEP) and provide clinicians with guidance as to when to change management.

Methods

The study was conducted as a clinical prospective observational exploratory survey of 161 patients with idiopathic trigeminal neuralgia and its variants of whom 79 were on montherapy who attended a specialist clinic in a London teaching hospital over a period of 2 years. At each consultation they completed the AEP questionnaire which provides scores of 19–76 with toxic levels being considered as scores >45.

Results

The most common significant side effects were: tiredness 31.3 %, sleepiness 18.2 %, memory problems 22.7 %, disturbed sleep 14.1 %, difficulty concentrating and unsteadiness 11.6 %. Females reported significantly more side effects than males. Potential toxic dose for females is approximately 1200 mg of OXC and 800 mg of CBZ and1800mg of OXC and 1200 mg of CBZ for males.

Conclusions

CBZ and OXC are associated with cognitive impairment. Pharmacokinetic and pharmacodynamic differences are likely to be the reason for gender differences in reporting side effects. Potentially, females need to be prescribed lower dosages in view of their tendency to reach toxic levels at lower dosages.

Side effects associated with AED could be a major reason for changing drugs or to consider a referral for surgical management.

Children with epilepsy and anxiety: Subcortical and cortical differences

OBJECTIVE

Using a hypothesis-driven approach, subcortical and cortical regions implicated in anxiety disorders in the general population were examined in children with recent-onset epilepsy with versus without anxiety compared to controls. This study reports frequency of anxiety disorders while examining familial, clinical, and demographic variables associated with anxiety in children with epilepsy.

METHOD

Participants included 88 children with epilepsy aged 8-18 years: 25 with a current anxiety disorder and 63 children with epilepsy and no current anxiety disorder. Forty-nine controls without anxiety disorders were included. T1 volumetric magnetic resonance imaging (MRI) scans were collected; subcortical volumes and cortical thickness were computed using the FreeSurfer image analysis suite. Analyses focused on adjusted measures of subcortical volumes and cortical thickness.

RESULTS

Relative to controls, larger left amygdala volumes were found in the Epilepsy with Anxiety group compared to the Epilepsy without Anxiety group (p = 0.027). In the hippocampus, there were no significant differences between groups. Examination of cortical thickness demonstrated that the Epilepsy with Anxiety group showed thinning in left medial orbitofrontal (p = 0.001), right lateral orbitofrontal (p = 0.017), and right frontal pole (p = 0.009). There were no differences between groups in age, sex, IQ, age of onset, medications, or duration of epilepsy. There were more family members with a history of anxiety disorders in the Epilepsy with Anxiety group compared to the Epilepsy without Anxiety group (p = 0.005).

SIGNIFICANCE

Anxiety is a common psychiatric comorbidity in children with recent-onset epilepsy with volumetric enlargement of the amygdala and thinner cortex in orbital and other regions of prefrontal cortex, suggesting structural abnormalities in brain regions that are part of the dysfunctional networks reported in individuals with anxiety disorders in the general population. These findings are evident early in the course of epilepsy, are not related to chronicity of seizures, and may be linked to a family history of anxiety and depressive disorders.

Wordless intervention for epilepsy in learning disabilities (WIELD): study protocol for a randomized controlled feasibility trial

BACKGROUND

Epilepsy is the most common neurological problem that affects people with learning disabilities. The high seizure frequency, resistance to treatments, associated skills deficit and co-morbidities make the management of epilepsy particularly challenging for people with learning disabilities. The Books Beyond Words booklet for epilepsy uses images to help people with learning disabilities manage their condition and improve quality of life. Our aim is to conduct a randomized controlled feasibility trial exploring key methodological, design and acceptability issues, in order to subsequently undertake a large-scale randomized controlled trial of the Books Beyond Words booklet for epilepsy.

METHODS/DESIGN

We will use a two-arm, single-centre randomized controlled feasibility design, over a 20-month period, across five epilepsy clinics in Hertfordshire, United Kingdom. We will recruit 40 eligible adults with learning disabilities and a confirmed diagnosis of epilepsy and will randomize them to use either the Books Beyond Words booklet plus usual care (intervention group) or to receive routine information and services (control group). We will collect quantitative data about the number of eligible participants, number of recruited participants, demographic data, discontinuation rates, variability of the primary outcome measure (quality of life: Epilepsy and Learning Disabilities Quality of Life scale), seizure severity, seizure control, intervention's patterns of use, use of other epilepsy-related information, resource use and the EQ-5D-5L health questionnaire. We will also gather qualitative data about the feasibility and acceptability of the study procedures and the Books Beyond Words booklet. Ethical approval for this study was granted on 28 April 2014, by the Wales Research Ethics Committee 5. Recruitment began on 1 July 2014.

DISCUSSION

The outcomes of this feasibility study will be used to inform the design and methodology of a definitive study, adequately powered to determine the impact of the Books Beyond Words intervention to improve the management of epilepsy in people with learning disabilities.

TRIAL REGISTRATION

http://ISRCTN80067039 (Date of ISRCTN assignation: 23 April 2014).

Tools for assessing quality of life in epilepsy patients

In this review, we attempt to bring the reader up to date with recent developments in the area of assessment of quality of life (QOL) of patients with epilepsy, in both the research and clinical contexts. We present evidence from recent publications on the major and most commonly used QOL instruments for both adults and children with epilepsy, including both strengths and limitations. We discuss both generic measures and ones that have been developed specifically for use in the epilepsy population. We draw attention to some of the broader issues that render the QOL assessment endeavor a somewhat complex one - in particular, that epilepsy is not a single condition, with a common clinical trajectory; and that QOL measures as currently configured almost universally focus on its negative impacts, largely neglecting the possibility of those affected being able to retain reasonable social adjustment and life satisfaction. Finally, we suggest that further work needs to focus on plugging the current evidence gaps in relation to psychometric and cross-cultural applicability issues; and on the value of QOL instruments in the clinical care setting. We conclude by highlighting a number of issues from the QOL literature that will, in our view, be the focus of increasing research interest in the next few years.

Comparing drug treatments in epilepsy

The great majority of randomised controlled trials (RCTs) that compare antiepileptic drugs are industry sponsored and have the objective of obtaining a monotherapy license for a drug. Such trials do not inform everyday clinical practice as they tend to be too short and to depart from clinical practice by restricting clinicians in their choice of actions. The data that exists provides evidence that drugs with actions on voltage-gated sodium channels provide best seizure control for localised onset seizures and epilepsy syndromes, while valproate provides best seizure control for generalised epilepsy and unclassified syndromes. Drugs do, however, vary in their tolerability over the short term and in their risk for rare serious idiosyncratic adverse events, chronic toxicity and teratogenicity; issues that cannot be examined within the scope of RCTs.

Epilepsy and employment: literature review

OBJECTIVE

The aim of this review is to increase understanding of the factors that affect the regular employment positions of people with epilepsy by means of the World Health Organization International Classification of Functioning, Disability, and Health (ICF) model.

METHOD

Thirty-four primary research articles describing factors associated with employment for people with epilepsy are reviewed.

RESULTS

People with epilepsy may face a number of complex and interacting problems in finding and maintaining employment. Stigma, seizure severity, and psychosocial variables such as low self-esteem, passive coping style, and low self-efficacy have been implicated as factors that play an important role in predicting employment. Findings demonstrate the need for specific employment training programs.

CONCLUSION

We recommend specific training interventions that focus on increasing the self-efficacy and coping skills of people with epilepsy so that these individuals will be able to accept their disorder and make personal and health-related choices that help them to achieve better employment positions in society.

Improvement in quality of life after initiation of lamotrigine therapy in patients with epilepsy in a naturalistic treatment setting

Quality of life is impaired in patients with epilepsy and can be improved by effective therapy. Randomised clinical trials have shown that lamotrigine treatment is associated with improved quality of life. However, little information is available on quality of life or treatment effects in patients with epilepsy in the general population. The objective of this study was to estimate the impact of lamotrigine on quality of life in a naturalistic treatment setting. The study included adult patients with epilepsy in whom lamotrigine therapy was initiated. Each subject completed the Quality of Life in Epilepsy Inventory (QOLIE)-31 quality of life questionnaire at inclusion and at a follow-up visit in the next 4 months. Demographic information and medical history were provided by the investigator. These were evaluated as potential determinants of change in quality of life using logistic regression. Three hundred and forty-one patients were evaluated, 192 starting lamotrigine in combination with another drug, 90 as a first-line monotherapy, 45 as a switch from another drug and 14 as a reduction to monotherapy from a previous combination. Baseline scores on the QOLIE-31 ranged from 53.8 in the combination group to 69.5 in the first-line group. 34.6% of patients were considered to be responders, with no significant differences between treatment regimen. Most improvement was seen for the energy-fatigue and medication effects subscales and, for the first-line group, seizure worry. Seizure type was the only determinant of improvement of quality of life identified. In conclusion, lamotrigine treatment is associated with improved quality of life, regardless of treatment regimen.

Factors influencing on quality of life in people with epilepsy

OBJECTIVES

To assess the influence of different factors on health-related QOL in adults with epilepsy in Moscow, Russia.

METHOD

We evaluated quality of life in 242 patients (98 de novo and 144 previously inadequately treated) by using QOLIE-31. Partial cryptogenic or symptomatic epilepsy was diagnosed in 214 patients, in 28-idiopathic generalized epilepsy. Stepwise regression analysis was performed to assess the influence of different factors on QOL.

RESULTS

In patients with epilepsy in Russia the total score of QOLIE-31 was rather low-42.13+/-4.14. Relationship of quality of life (total score) and frequency of seizures and duration of disease was analyzed. Frequency of seizures was the most significant parameter related to QOL (R=0.46 with total score). Duration of disease also correlated with QOL score (R=0.24 with total score). Significant but rather weak association (link) between frequency of seizures and almost all of subscales of quality of life was noticed. Duration of epilepsy correlated with less number of subscales: Energy/fatigue, Medication effects, Social functioning, Overall QOL subscales. When factors influencing on QOL were separately analyzed in newly diagnosed and previously treated patients frequency of seizures was the most important parameter in both groups.

CONCLUSIONS

Frequency of seizures is the most important factor influencing on QOL in adults with epilepsy (newly diagnosed and previously treated).

Improved quality of life in patients with partial seizures after conversion to oxcarbazepine monotherapy

OBJECTIVE

Quality of life (QOL) was assessed in patients who switched to oxcarbazepine monotherapy because of the lack of efficacy or poor tolerability of their current antiepileptic drug (AED).

METHOD

This open-label, single-arm study consisted of patients aged 12 >or= years with partial onset seizures. Oxcarbazepine (8-10mg/kg/day for children, 600 mg/day for adults) was titrated up over 4 weeks while the existing AED was tapered off. QOL was evaluated at baseline and end of study (Week 16) using the validated-in-epilepsy QOLIE-31 questionnaire.

RESULTS

For all patients who completed the QOLIE-31 at baseline and completion, a statistically significant improvement was noted for both the composite and multi-item subscale QOL scores (P<0.05 vs baseline). Statistically significant mean percentage improvements of >or=10% from baseline (range=10.8-50.1%) were also noted. Significant improvements were seen in health-related QOL for patients who experienced seizure freedom or >or=50% reductions in seizure frequency with oxcarbazepine monotherapy.

CONCLUSIONS

Patients with partial seizures who switched to oxcarbazepine monotherapy showed statistically significant, clinically relevant improvements in QOL.

The contribution of spirituality to quality of life in focal epilepsy

People with epilepsy of comparable severity may differ widely in quality of life (QOL), suggesting a role for unexplored individual aspects. This study considered the possible role of spirituality. Thirty-two patients with focal epilepsy completed scales for QOL (World Heath Organization QOL, WHOQOL 100), spirituality (WHO Spirituality, Religiousness, and Personal Beliefs), depression, anxiety, and cognitive efficiency, as well as neuropsychological testing. The QOL and spirituality scales exhibited satisfactory internal consistency. Factor analyses of the scale and test scores yielded separate spiritual (Personal Meaning, Inner Energy, Awe and Transcendence, and Openness), affective (Mood), and cognitive (Cognition, Memory, and Perceived Cognitive Efficiency) factors. The total WHOQOL 100 score was significantly predicted by the Awe and Transcendence and Mood factors. The spiritual, Mood, and Cognition factors significantly predicted single QOL domains. These preliminary results highlight the contribution of spirituality to QOL in epilepsy, encouraging future studies. This could influence the conceptualization and assessment of QOL in these patients.

Development of a measure to assess the impact of epilepsy on people with an intellectual disability: the Glasgow Epilepsy Outcome Scale - Client version (GEOS-C)

BACKGROUND

Epilepsy is common in people with intellectual disability, yet clinicians and researchers seldom obtain information directly from the client. The development and preliminary validation of a novel measure for use with people with mild to moderate intellectual disabilities is described.

METHODS

Focus group methods (6 groups; 24 participants) identified issues of concern, and qualitative analysis (NUD*IST) was applied to derive items and themes for a draft scale. Psychometric scale development techniques were then used in a pilot study and subsequent field-testing to investigate validity and reliability (n = 46).

RESULTS

A total of 148 issues of concern was reduced initially to 52 and then to 42 items using these methods. The derived scale comprised sub-scales reflecting (1) concerns about having seizures; (2) about injury; (3) about issues during; and (4) after seizures; (5) about medication; (6) about what people think; and (7) about daily life. Cronbach alpha for the Glasgow Epilepsy Outcome Scale - Client version (GEOS-C) was 0.92, and ranged from 0.64-0.81 for the sub-scales. Relatively weak associations (r <or= 0.40), between client and family carer, staff carer or clinician views, suggests that proxy reports are not good predictors of how people with epilepsy themselves are feeling. Preliminary validation suggests that the GEOS-C can discriminate on variables of clinical importance.

CONCLUSIONS

The GEOS-C complements existing GEOS measures, can be completed in 5-15 min depending upon the level of support required, and may provide a valuable clinical and research tool. Further validational work and appraisal of sensitivity are required.

A randomized, double-blind, placebo-controlled trial of topiramate in adults with epilepsy and intellectual disability: impact on seizures, severity, and quality of life

This randomized, double-blind, placebo-controlled UK trial evaluated the effect of topiramate as add-on therapy on seizure frequency, seizure severity, and quality of life in patients with epilepsy and intellectual disability. There were three phases: 4 weeks baseline, 18 weeks titration to 200-400 mg topiramate/day (adults) or 5-9 mg/kg/day (children), 12 weeks maintenance. Recruitment was low (88/120); analyses were underpowered. Seizure frequency varied enormously (median 17.7, maximum 1706.2). There was no significant difference in reduction in mean total seizure frequency or number of responders between the groups. Topiramate reduced seizure frequency by >30% from baseline (placebo 1%); post hoc analyses showed a trend toward significance (R ratio, P=0.052). There were no significant differences between the groups with respect to mean seizure severity or other outcome measures. Topiramate was generally well tolerated; body weight (P=0.015) and systolic blood pressure (P=0.043) were reduced. The study suggests that topiramate reduces seizure frequency in patients with epilepsy and intellectual disability without the added burden of behavior effects, and was potentially advantageous to physical well-being.

Validity and reliability of the Italian version of the Quality-of-Life in Epilepsy Inventory (QOLIE-31)

PURPOSE

To develop an Italian adaptation of the shortened version of the Quality-of-Life in Epilepsy Inventory (QOLIE-31).

METHODS

The study population comprised 503 consecutive ambulatory patients with epilepsy from 44 centers. Internal validity was tested by factor analysis, to detect similarities to and differences from the original version, and by multitrait/multi-item analysis, to assess item convergent and discriminant validity. External validity testing included correlation to the SF-36 Inventory, to check the properties of the epilepsy-specific dimensions. Validity testing was completed by analysis of variance (ANOVA) of QOLIE-31 dimension scores against demographic and clinical variables, including age, sex, seizure frequency and number of drugs.

RESULTS

The domains showing the highest internal consistency and the best discriminant validity were Medication effect, and Seizure worry. Social functioning had the lower discriminant validity. With reference to the SF-36 scores, the study patients were slightly but constantly below the population values, mostly for General health and Role physical domains. All QOLIE-31 dimensions were sensitive to almost any demographic and clinical variable, except for Medication effects (sensitive to number of drugs) and Energy-fatigue (sensitive to age).

CONCLUSIONS

Except for Social functioning, the psychometric properties of the Italian adaptation of the QOLIE-31 Inventory are fairly good and similar to the American version and the Spanish translation. Social functioning scale suffers shortcomings because of life constraints caused by epilepsy (with missing values for regular job and driving license).

Development and validation of a health related quality of life questionnaire for Brazilian children with epilepsy: preliminary findings

PURPOSE: To construct a multidimensional questionnaire that analyses the epileptic child quality of life from the parental point of view. METHOD: The pilot questionnaire was composed of 157 questions distributed in several dimensions. Fifty-one epileptic children's parents answered the questionnaire. The instrument was tested in its diverse properties: frequency of endorsement, homogeneity (Cronbach alpha), criterion and face validity, and later it was reduced. RESULTS: Endorsement frequency excluded 65 questions that did not attain a minimum of 5% response per item. Cronbach alpha was as follows: physical (0.93), psychological (0.91), social (0.91), familiar (0.70), cognitive (0.92), medical (0.30) and economical (0.37). Patient groups, in relation to seizure control, significantly differed only in physical domain and total score, although there was a trend to differences in other domains. The final questionnaire (QVCE50) has 50 items, with good homogeneity in the physical, psychological and cognitive domains. CONCLUSION: QVCE-50 is a promissing Brazilian HRQL questionnaire for children with epilepsy.It needs to be applied in a larger population to confirm its psychometric properties.

Quality of Life of People with Epilepsy in Iran, the Gulf, and Near East

PURPOSE

To study the impact of epilepsy and its treatment on the quality of life of people living in Iran and in countries in the Gulf and Near East.

METHODS

Clinical, demographic, and psychosocial details were collected through the use of a self-completed questionnaire distributed to patients attending hospital outpatient clinics.

RESULTS

Data were collected from 3,889 people with epilepsy from 10 countries. More than 40% of all respondents had frequent seizures, and reported levels of side effects from medication were high, the most commonly reported being nervousness, headaches, and tiredness. A significant number of respondents reported changing their medications because of side effects or poor seizure control. Respondents reported that epilepsy and its treatment had a significant impact on a number of different aspects of their daily lives. A significant number of respondents felt stigmatized by their epilepsy. Reported health status was reduced when compared with that of people without epilepsy, particularly for physical and social functioning and energy and vitality, as assessed by using a generic health status measure, the SF-36.

CONCLUSIONS

This is the largest study to date documenting the impact of epilepsy and its treatment in Iran, the Gulf, and Near East regions. Differences were found between the quality-of-life profiles of respondents in this study and those who participated in an earlier parallel study in Europe.

Assessment of adverse events and quality of life in epilepsy: design of a new community-based trial

Improving health-related quality of life (HRQOL) has become recognized as an essential component of treating patients with epilepsy. In recent years, several rating scales have been developed that focus on both common adverse effects and various aspects of HRQOL that are more relevant to this patient population. Increasingly, such assessments are being incorporated into clinical trials, as it becomes clear that improvements in overall quality of life are an important feature of drug therapy. Here we present the design of a large, community-based trial evaluating the effects of switching from immediate-release carbamazepine to twice-daily, beaded, extended-release carbamazepine (Carbatrol). As this trial involves switching formulations of the same compound, we expect to find only small differences in efficacy but significant differences in tolerability and quality-of-life measures. To identify appropriate instruments that could measure these factors, here we review several epilepsy-specific scales used to monitor adverse events and HRQOL and discuss their potential utility in the context of the proposed trial.

Patient-validated content of a Greek version of the Quality of Life in Epilepsy Inventory (QOLIE-89) combined with individualized measures

PURPOSE

The goal of this study was to determine the content validity of a Greek version of the Quality of Life in Epilepsy Inventory (QOLIE-89) and to investigate whether it can be developed in combination with individualized measures to assess the health-related needs of the individual patient with epilepsy in Cyprus.

METHODS

The QOLIE-89 was translated into Greek and combined with individualized validation measures. The instrument was administered to 44 adult outpatients receiving medication for epilepsy. They were asked to evaluate the clarity and appropriateness of the QOLIE-89 content and the accuracy of their scores, and to report their quality-of-life-related concerns. Reported concerns were compared with the QOLIE-89 scores and content.

RESULTS

The majority of participants (92.9%) endorsed the representativeness of the assessment. Quality-of-life (QoL) overall scores correlated significantly with satisfaction with QoL. Twenty-seven (30.3%) QOLIE-89 items were deemed unclear or difficult to answer and 13 items (14.6%) were deemed not relevant or inappropriate by > or =7.1% (N = 3) of patients. At least 7.1% of participants disagreed that their scores were representative of their self-perceived QoL, on 23 items (25.8%). Participants reported 33 QoL-related concerns, of which nearly a quarter were not addressed in the original QOLIE-89. Correlations of QOLIE-89 domains with content-related concerns ranged from phi = 0.43 to phi = 0.85 ( P < 0.01), lower correlations coinciding with the scale content that was criticized.

CONCLUSIONS

Patients were able to use superimposed measures to evaluate the content of QOLIE-89 and identified areas that could be incorporated into an instrument for the determination of patients' individual QoL-related concerns.

Tackling the needs of the homeless: a controlled trial of health advocacy

The objective of the present study was to assess the effectiveness of a health advocate's casework with homeless people in a primary care setting in terms of improvements in health-related quality of life (QoL). The impact of the health advocacy intervention was assessed in a quasi-experimental, three-armed controlled trial. Homeless people moving into hostels or other temporary accommodation in the Liverpool 8 area of the UK and patients registering at an inner-city health centre as temporary residents were allocated in alternating periods to health advocacy (with or without outreach registration) or 'usual care' over a total intake period of 3 years. Health-related QoL outcomes were assessed using three independent self-report measures: the Life Fulfilment Scale; the Delighted-Terrible Faces Scale; and the Nottingham Health Profile. Out of the 326 homeless people who were given baseline questionnaires at registration, 222 (68%) returned usable questionnaires. Out of these individuals, 171 (77.0%) were traceable at follow-up, and 117 (68.4%) follow-up questionnaires were returned. The majority of respondents (n = 117) were women (72%) who were under 30 years of age (74%), white British (91%), and single (63%) or separated (23%), many of whom were living with their children (41%) in either women's refuges (30%) or family hostels (25%). Improvements in health-related QoL were greatest in people recruited and supported by a health advocate early in their stay in temporary housing, in comparison with those in the control group given 'usual care' at the health centre. The model of streamlined care for patients with complex psycho-social needs is shown to be a worthwhile and effective option for primary healthcare providers.

Psychopathology in people with epilepsy and intellectual disability; an investigation of potential explanatory variables

OBJECTIVES

There are few studies on epilepsy and psychopathology in people with intellectual disability (mental retardation) despite epilepsy prevalence rates that are thirty times higher than in the general population. The aims of this study, therefore, were to identify reliable, epilepsy-specific predictors of psychiatric and behavioural disorder in these patients, and to investigate reliable predictors of carer stress.

METHODS

A database of 685 patients was compiled, from which 250 were randomly selected. Structured interviews were completed on 186 of these 250 patients (74%) (108 men, 78 women; mean age (SD) 35.5 (10.1)) comprising descriptive, clinical and functional components, and validated measures of psychopathology for which comparative data were available. Logistic and linear regression methods were used to identify predictors.

RESULTS

One-third of patients with epilepsy and intellectual disability met criteria for possible psychiatric disorder, particularly affective/neurotic disorder; twice the comparison rates for intellectual disability alone. Behavioural problem levels, however, were lower than population norms. Regression models explaining modest amounts of variance (R(2)< or =24%) suggested certain seizure phenomena (greater seizure severity, more seizures in past month, lesser tendency to loss of consciousness during seizures) as particular risk factors for psychiatric disorder. General disability factors such as level of intellectual, sensory or motor disability and side effects of medication, however, contributed more to explaining behavioural problems. Around half of the family carers reported significant stress, and one-third exhibited clinically significant anxiety symptoms. Younger carers were more stressed, and side effects from patients' medication also contributed to carer stress.

CONCLUSIONS

Although epilepsy in itself may be a risk factor for psychopathology in a minority of people with intellectual disability, some epilepsy-specific factors may predict psychiatric disorder. Behavioural problems need to be considered separately from psychiatric disorder because general factors, more closely associated with disability, are stronger predictors of their occurrence.

The impact of epilepsy on quality of life: a qualitative analysis

The assessment and understanding of epilepsy's impact on an individual's quality of life (QOL) is increasingly being recognized as an important component of clinical care. Because the impact of epilepsy can span a range of clinically important functional and psychosocial domains, QOL as a model for understanding epilepsy's impact should be inclusive of the many life domains that are important to the individual. In this study a community-based sample of 46 adults with epilepsy were surveyed to identify the QOL domains that are important to persons with epilepsy, the factors that contribute to and detract from QOL, and the ways that epilepsy is perceived to impact QOL. A multidomain structure of quality of life emerged from the qualitative data analysis. Epilepsy was seen as having both a direct and an indirect impact on QOL, by directly affecting QOL domains and by affecting those factors that contribute to QOL.

Health-related quality of life in children with epilepsy: development and validation of self-report and parent proxy measures

PURPOSE

To answer a need to include and measure accurately the impact and burden of epilepsy as outcomes of interventions with affected children, we developed and validated self-report and parent-proxy respondent health-related quality of life (HRQL) instruments for preadolescent children with epilepsy.

METHODS

We combined qualitative and quantitative research methods. Items were extracted from focus group discussions involving children with epilepsy and their parents. We created scales formatted with alternative paired options of forced responses and used factor analysis to generate relevant subscales and reduce the number of items. We checked internal consistency, assessed test-retest reliability 10-14 days apart, and documented construct validity.

RESULTS

A sample of 381 children with epilepsy, age 6-15 years, and their parents independently completed a 67-item questionnaire, from which we chose five items for each subscale. The measures share four subscales, but each measure has an additional distinct subscale. The children and parents could discern differences and report differentially between the various aspects of the HRQL. Internal consistency measured with Cronbach's alpha was acceptable for all subscales; construct validity has been demonstrated from the testing of several hypotheses. Test-retest reliability examined with the intraclass correlation coefficient was satisfactory for the parents and for children age 8 years and older. The correlations between the mothers' and children's responses was poor to moderate.

CONCLUSIONS

The data demonstrate sound psychometric properties for both related measures, which are easy to administer for children with epilepsy who are 8 years and older and their parents. The subscales encompass HRQL dimensions judged most important by children with epilepsy for the self-report measure and by parents for the proxy response measure. The parent-proxy measure should be useful as a complement to the child self-report measure in evaluating the validity of parental assessment of the child's health status; in longitudinal outcome research; and in HRQL assessment of children who are unable to respond independently.

Effects of a 1.5-day multidisciplinary outpatient treatment program for fibromyalgia: a pilot study

OBJECTIVE

The purpose of this pilot study was to determine the effect of a 1.5-day multidisciplinary fibromyalgia treatment program on impact of illness, depression, and life fulfillment.

DESIGN

A sample of 100 consecutive enrollees in a 1.5-day multidisciplinary group outpatient fibromyalgia treatment program between February 14, 2000, and May 9, 2000, in a tertiary medical center was used for this study. The Fibromyalgia Impact Questionnaire, the Life Fulfillment and Satisfaction Scales, and the Center for Epidemiologic Studies Depression Scale were administered to subjects immediately preceding the treatment program and by mail 1 mo after completing the program.

RESULTS

The 78 subjects who returned their surveys 1 mo after treatment demonstrated significant improvement in the area of the impact of illness as measured by the Fibromyalgia Impact Questionnaire total score (51.3-44.7, P < 0.002). There was no significant improvement in depressive symptoms (P < 0.056) or the level of life fulfillment (P < 0.53). Subjects with depression improved on the Fibromyalgia Impact Questionnaire to the same degree as those without depression. The 22 nonresponders did not differ significantly from the responders in the variables of sex, age, pretreatment Fibromyalgia Impact Questionnaire score, marital status, educational level, family income, duration of symptoms, or history of depression.

CONCLUSIONS

These results suggest that a 1.5-day multidisciplinary fibromyalgia treatment program does have a significant positive effect on the impact of illness among patients with fibromyalgia with or without concomitant depression and may be a cost-effective model for the treatment of these patients.

Elderly people with hypothalamic-pituitary disease and untreated GH deficiency: clinical outcome, body composition, lipid profiles and quality of life after 2 years compared to controls

OBJECTIVE

Elderly patients with GH deficiency (GHD) have significant impairments in multiple aspects of quality of life (QOL) but similar lipid profiles compared to age-matched control subjects. There are, however, no data on changes in these parameters with time. This study assessed the impact of untreated GHD over a period of 2 years in a group of elderly patients with hypothalamic-pituitary disease in relation to new illnesses and differences in body composition, circulating lipid profile levels and QOL. Control subjects were also followed for 2 years.

SUBJECTS

Twenty-seven elderly patients (> 65 years) with hypothalamic-pituitary disorders and GHD (mean peak stimulated GH response 1.6 mIU/l, range 0.6--5.0) were studied initially. Two years later 21 (13 males) agreed to attend for reassessment. Mean age was then 72.7 +/- 5.04 years (range 67--85). Eighteen patients had pituitary tumours, three had craniopharyngiomas. Twenty-seven control subjects were studied at baseline and 17 (7 males) agreed to attend for reassessment. Mean age was then 75.9 +/- 6.97 years (range 67--88).

METHODS

Weight, body mass index (BMI), total fat mass (FM) (bioelectrical impedance), serum IGF-1 and fasting lipid profile (total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol) were measured. QOL was assessed in both groups using five interviewer-administered self-rating questionnaires: the Nottingham Health Profile, Short Form-36, Hospital Anxiety and Depression Scale, Mental Fatigue Questionnaire and Life Fulfillment Scale. The GHD group also completed the Disease Impact Scale.

RESULTS

Two of the 27 patients with GHD died during the 2-year follow-up (myocardial infarction and probable cerebrovascular accident). Four controls could not be traced but there were no deaths in the other 23. In the 21 GHD patients after 2 years, mean serum IGF-1 and BMI were unchanged (12.6 +/- 5.8 vs. 13.3 +/- 5.1 nmol/l, P = 0.5 and 28.3 +/- 4.3 vs. 29.1 +/- 4.2, P = 0.5, respectively) at the 2-year follow-up and there were no significant changes in the lipid profiles. However, there was a significant reduction in fat mass (31.7 +/- 11.2 vs. 28.5 +/- 10.9%, P = 0.04). In the 17 control subjects after 2 years, serum IGF-1 levels (17.2 +/- 4.0 vs. 15.7 +/- 5.6 nmol/l, P = 0.4), BMI and fat mass were unchanged. However, there was a significant fall in total cholesterol levels over the 2-year follow-up (6.3 +/- 0.9 vs. 5.7 +/- 0.9 mmol/l, P < 0.0001), although LDL cholesterol, triglycerides and HDL cholesterol were unchanged. Analysing the QOL data, the GHD patients had less energy (P < 0.05), more depression (P < 0.05), more pain (P < 0.05) and lower life fulfillment scores (P < 0.01) after 2 years. However, the control subjects also had less energy (P < 0.05), less vitality (P < 0.05) and lower self-esteem (P < 0.05), more depression (P < 0.05), worse mental health (P < 0.05), life fulfillment personal (P < 0.01), life fulfillment material (P < 0.02), physical functioning and role physical functioning (P < 0.05) after 2 years. Comparing the patients and controls at baseline, there were significant differences in IGF-1, BMI, FM, LDL cholesterol, personal life fulfillment, mental fatigue, general health and mental health. However, after 2 years, only BMI and depression scores were significantly different.

CONCLUSION

These patients with untreated GHD did not have deterioration of body composition or lipid profiles when reassessed after a period of 2 years. In fact, fat mass fell. The control subjects did have a significant decrease in total cholesterol but no change in other lipids or body composition. Some quality of life domains did deteriorate in the patients with GHD. However, the control subjects also had worse quality of life scores after 2 years which were then little different from the GHD patients. These results raise doubts about the benefits of GH replacement in elderly people with GHD.

Development and validation of the Glasgow Epilepsy Outcome Scale (GEOS): a new instrument for measuring concerns about epilepsy in people with mental retardation

PURPOSE

To develop a measure for use with adults with epilepsy and mental retardation, capable of assessing both clinical and care concerns and of quantifying treatment outcomes.

METHODS

Extensive validational and other psychometric evaluation was undertaken, comprising initial scale development work with 48 carers and 46 health practitioners, followed by formal field testing on a sample of 186 patients, using 384 respondents (160 clinicians, 141 staff, 83 family). Recognised qualitative methods were applied to identify central themes, and psychometric procedures generated data on validity, reliability, and component structure.

RESULTS

A total of 1,007 items of concern was generated, which was reduced systematically to a representative set of 90 items. The GEOS-90 comprises four subscales: concerns about "seizures," "treatment," "caring," and "social impact," each explaining approximately 70% of variance. Subscales and factor scales had strong internal consistency (alpha > or = 0.82). Stepwise linear regression was applied to derive a short-form version with similar structure. Thirty-five items were retained (GEOS-35; alpha > or = 0.89). Both scales discriminated moderately on clinical variables (number of seizure types, mono- vs. polytherapy, seizure frequency; all values of p < 0.05) and demonstrated concurrent validity with interview ratings from the ELDQOL (p < 0.05).

CONCLUSIONS

The GEOS scales appear valid and reliable for use with clinical populations of people with mental retardation.

Health outcomes in persons with epilepsy

Epilepsy is a common disorder that effects millions of persons worldwide and costs billions of dollars for direct medical care. Despite the importance of epilepsy from a public health perspective, the physiological and psychosocial outcomes from epilepsy are incompletely understood and are in some ways controversial. The paroxysmal nature and the immense social stigma of the disorder have contributed to misunderstanding of its associated health outcomes. This article reviews the issues surrounding the assessment of health outcomes from the epilepsies and the interventions used to treat recurrent seizures.

Quality of life self-assessment as a function of lateralization of lesion in candidates for epilepsy surgery

PURPOSE

This prospective study aimed to investigate the relationship(s) of the laterality of the epileptogenic lesion to personality factors, emotional processing, and the subjective experience of quality-of-life (QOL) self-assessment in candidates for epilepsy surgery.

METHODS

Patients who were candidates for epilepsy surgery were studied. Eighteen of them (aged 19-61 years) had localization-related epilepsy in the right temporal lobe (RTLE), 18 (aged 21-50 years) had localization-related epilepsy in the left temporal lobe (LTLE), and 20 were demographically matched normal subjects. The Spielberger Trait/State Anxiety questionnaire and the QOLIE-31 questionnaire for self-assessment of quality of life were used. One-way analysis of variance, Pearson correlations, and linear regression analyses were performed on group and anxiety levels and QOLIE variables.

RESULTS

LTLE patients systematically showed higher levels of anxiety and lower self-estimates of the quality of their lives when compared with RTLE patients. All anxiety measures were highly correlated with Total QOL in LTLE (p < 0.05) but not in RTLE patients; however, different parameters of QOL showed different relationships with measures of anxiety. Results of multiple regression analyses suggested that the level of anxiety was relatively stable and less affected by QOL factors in LTLE as compared with RTLE patients (p = 0.03).

CONCLUSIONS

A high level of anxiety shown by LTLE patients may represent a personality trait and cause a response bias in overreporting of negative symptoms and a decreased self-assessment of QOL. It may also present a presurgical risk factor, particularly for patients with LTLE lesions. Appropriate patient counseling is advised.

Parent- and patient-validated content for pediatric epilepsy quality-of-life assessment

PURPOSE

The purpose of this study was to assess the parent-and patient-validated content of quality-of-life measurement for use in children with epilepsy.

METHODS

We asked the parents of 80 consecutive children and adolescents with epilepsy to list in order of importance their concerns about living with or caring for their children with epilepsy. Patients were 3 months to 18 years of age (mean, 10 years) and identified at the outpatient clinic or during hospital stay. To minimize investigator bias, parents and children listed their concerns in a private setting without staff involvement.

RESULTS

Twenty-six distinct domains were generated by the parents and children. Concerns listed by more than 20 of parents included medication adverse effects (58), cognitive effects of epilepsy (46), prospects for the future (41), safety (35), independence (31), and brain damage caused by seizures (30). Concerns ranked by parents as most important included safety (18), brain damage from seizures (12), enigma of epilepsy (12), cognitive effects of epilepsy (11), and prospects for the future (10). Concerns listed by more than 20 of children included social problems (35), cognitive effects of epilepsy (29), driving (29), sports (27), medication adverse effects (25), and schooling (21). Concerns ranked by children as most important included issues related to medication adverse effects (13), cognitive effects of epilepsy (10), hatred of epilepsy (8), social embarrassment (6), fear of seizures (6), injury (6), and dislike of hospital visits (6).

CONCLUSION

The effect of epilepsy on health-related quality of life in pediatric patients is defined by a limited number of domains. A 20-item inventory was chosen from the 26 domains generated by the parents and children. Our study provides insight into parents' and children's perception of seizures and the impact of epilepsy on everyday life.

Elderly people with hypothalamic-pituitary disease and growth hormone deficiency: lipid profiles, body composition and quality of life compared with control subjects

OBJECTIVE

In healthy adults the secretion of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) declines with ageing and body composition alters, particularly with an increase in total body fat. In elderly people, hypothalamic-pituitary disease can cause GH deficiency (GHD), compared with age matched controls. This study aimed to clarify whether GHD in the elderly is associated with differences in body composition, circulating lipid levels and quality of life (QOL) compared with control subjects.

SUBJECTS

Twenty-seven elderly patients (14 males, mean age 71 years, range 65-83) with hypothalamic-pituitary disorders (23 pituitary tumours) and GHD (mean (SD) peak stimulated GH response 1.6 mIU/l (1.03) range 0.6-5) were studied. Twenty-five patients had been treated surgically (six cranial surgery, 19 transsphenoidal) and eight patients had received external cranial irradiation. Twenty-seven control subjects (14 males, mean age 72 years, range 65-86) were also studied.

METHODS

Weight, body mass index (BMI), total fat mass (FM, bioelectrical impedance), waist to hip ratio (WHR), serum IGF-1, fasting blood glucose and lipid profile were measured. QOL was assessed in both groups using five interviewer administered self-rating questionnaires: The Nottingham Health Profile, Short-Form 36, Hospital Anxiety and Depression Scale, Mental Fatigue Questionnaire and Life Fulfilment Scale. The GHD group also completed the Disease Impact Scale.

RESULTS

The data (mean (SD)) from males and females were analyzed separately. The male patients had a higher BMI than controls, 28.9(4.5) vs. 25.2(2.3) kg/m2 (P = 0.01) but the BMI in the female patients and controls was similar. In the female patients compared with the controls, FM was higher 39. 4(6) vs. 33.1(8.3) % (P = 0.02), WHR was also higher 0.9(0.08) vs. 0. 83(0.09) (P = 0.03) and serum IGF-1 levels were lower 10.8(6.4) vs. 18.2(6.5) nmol/l (P = 0.01). However, in the male patients, FM, WHR and IGF-1 levels were similar to the controls. Fasting blood glucose was similar in both male and female patients and the controls. Two female patients and one male control subject were taking lipid-lowering agents and were therefore excluded from the analysis of lipid profiles. Total cholesterol, triglyceride, LDL cholesterol, HDL cholesterol and total cholesterol/HDL cholesterol ratio were not significantly different for both male and female patients compared with the controls. The 27 patients with GHD reported significantly less energy (P < 0.05), mobility (P < 0.05) and personal life fulfillment (P < 0.01) than the 27 controls. There were significantly more problems with emotional reaction (P < 0.01), social isolation (P < 0.05) and mental fatigue (P < 0.05). Additionally the GHD group reported more impairment in areas of social functioning (P < 0.05), general health (P < 0.05) and mental health (P < 0.05). The GHD group reported a modest degree of disease impact (mean score of 14.1). There were no significant differences in the domains of material life fulfillment, pain, sleep, physical functioning, vitality, anxiety, depression, self-esteem or role physical functioning compared with the controls.

CONCLUSION

Compared with control subjects, the elderly female patients with hypothalamic-pituitary disease and GHD had a significantly higher total fat mass, with the WHR indicating a more central fat distribution and lower female serum IGF-1 levels. In contrast, elderly male patients had similar total fat mass, WHR and IGF-1 levels compared to the controls. There were no significant differences in the lipid profiles between male or female patients compared to controls. However, many of the male patients were receiving androgen replacement which might have influenced these results. Low HDL cholesterol concentrations are probably a better predictor of future cardiovascular disease than raised LDL cholesterol levels in the elderly population and these were similar in patients and controls for both

Epilepsy in our world: an ethnographic view

This paper describes how epilepsy is viewed according to biomedicine and the scientific literature and argues that the subjective experience of people dealing with illness is often overlooked by focusing solely on this approach. A review of the pertinent literature from a social science perspective, mainly anthropology and sociology, illustrates the richness of the lived experience of epilepsy that can be uncovered by using ethnographic and other qualitative methods, including narrative studies, in the interest of informing medical practice and leading to a better understanding and treatment of people with this disorder.

Characteristics of severely mentally ill patients in and out of contact with community mental health services

Community mental health nurses have been criticized for failing to prioritize work with people with a severe or enduring mental illness, many of whom have no contact with specialist mental health services and rely entirely on their general practitioner and primary care team. It is important to ensure that those in contact with specialist services actually need this level of input but, conversely, that those in contact with only primary care receive a service that is equipped to meet their needs. This study examines the differences between these two groups of patients. A sample of 253 community-based patients with a severe or enduring mental illness was divided into those with mental health service contact and those without. Differences in the demographic characteristics of the two groups were assessed and further, more detailed, comparisons were made with a sub-sample of 49 individuals randomly drawn from this larger sample. Instruments adopted for these purposes comprised the Camberwell Assessment of Need and the Life Fulfilment Scale. It was found that patients with a psychotic disorder were more likely than those with neurosis to be in contact with mental health services and patients with schizophrenia were significantly more likely to be on the active caseload of a community mental health nurse than those from all other diagnostic groups. However, patients' levels of need, unmet need and quality of life did not differ in relation to their service contact. Whilst the study provides limited evidence that community mental health nurses are targeting people with the most serious disorders, questions remain about the large proportion not receiving specialist care. Because primary care plays a significant role in the care of severely mentally ill people living in the community, the further mental health training of general practitioners and practice nurses is becoming increasingly important.