Examining the prevalence of epilepsy and delivery of epilepsy care in Ireland

Neurosurgery for intractable epilepsy in pregnancy: A case report

We describe the management of a 39-year-old woman with intractable focal epilepsy whose condition deteriorated during pregnancy and who required emergency neurosurgery. A literature search did not identify any previous reports of epilepsy surgery in pregnancy. To our knowledge, this is the first time surgery was planned and executed in rapid order with a successful outcome, without obstetrical or surgical complications and seizure freedom achieved. The value of rapid communication between established women's health advanced nurse practitioner clinics, the multidisciplinary Epilepsy Surgery Group and specialist Obstetrical Epilepsy service is highlighted. A care cycle for pregnant women with refractory epilepsy is proposed.

Association between social deprivation and incidence of first seizures and epilepsy: a prospective population based cohort

OBJECTIVE

Epidemiologic studies have investigated whether social deprivation is associated with a higher incidence of epilepsy and results are conflicting, especially in children. The mechanisms underlying a potential association are unclear. This study examines whether there is an association between social deprivation and the incidence of first seizures (unprovoked and provoked) and new diagnosis of epilepsy by comparing incidence across an area-level measure of deprivation in a population-based cohort.

METHODS

Multiple methods of case identification followed by individual case validation and classification were carried out in a defined geographical area (population 542,868) to identify all incident cases of first provoked and first unprovoked seizures and new diagnosis of epilepsy presenting during the calendar year 2017. An area-level relative deprivation index, based on ten indicators from census data, was assigned to each patient according to registered address and categorised into quintiles from most to least deprived.

RESULTS

The annual incidence of first unprovoked seizures (n=372), first provoked seizures (n=189) and new diagnosis of epilepsy (n=336) was highest in the most deprived areas compared to the least deprived areas (incidence ratios of 1·79 (95%CI 1·26, 2·52), 1·55 (95%CI 1·04, 2·32) and 1·83 (95%CI 1·28, 2·62), respectively). This finding was evident in both adults and children and in those with structural and unknown aetiologies of epilepsy.

SIGNIFICANCE

The incidence of first seizures and new diagnosis of epilepsy is associated with more social deprivation. The reason for this higher incidence is likely multifactorial.

Estimating the prevalence and incidence of treated type 2 diabetes using prescription data as a proxy: A stepwise approach on Iranian data

AIMS

Type 2 diabetes is a serious health challenge, and large-scale studies on its prevalence in Iran are lacking. In pharmacoepidemiology, case-finding can be done by reviewing the prescription databases for specific drug(s) prescribed for a disease. We aimed to determine the prevalence and incidence of type 2 diabetes in Fars province, Iran, using prescription data and a stepwise approach to ascertain the results.

METHODS

A dataset of 3,113 insured individuals aged ≥35 years were selected. Their Prescription Data Centre records were reviewed for all drugs frequently used in controlling type 2 diabetes available in the Iranian pharmacopeia. Then we used a stepwise method for case-finding. In step one, each individual with a positive drug history for type 2 diabetes was labeled as an individual with diabetes. The next two steps were implemented for ascertainment of step one estimations.

RESULTS

Prevalence of type 2 diabetes based on prescription, internist opinion, and phone call verification in 2015 and 2016 was 9.3% and 10.3%, 8.5% and 9.8%, and 7.2% and 8.7%, respectively. An incidence of 1.9% was determined for 2016.

CONCLUSIONS

We obtained a realistic estimation of prevalence and incidence of treated type 2 diabetes, using prescription data which are large-scale, low cost, and real-time.

Coproducing health and well-being in partnership with patients, families, and healthcare providers: A qualitative study exploring the role of an epilepsy patient portal

BACKGROUND

Coproduced epilepsy care sees people with epilepsy (PwE), their care-proxies, and healthcare providers (HCPs), working together as partners to build strong relationships, improve communication, trust, and share decision-making. Coproduction underpins good quality patient- and family-centered care (PFCC) that is responsive to individual patient needs, preferences, and values. By facilitating information sharing and exchange between partners, electronic patient portals (ePortal) can enable coproduction. This paper explores what HCPs, PwE, and their care-proxies value from their user experience of PiSCES, the Irish epilepsy ePortal.

METHODS

A purposeful sample of actors involved in the receipt and delivery of epilepsy care and services were recruited via adult epilepsy centers at St James's and Beaumont Hospitals in Dublin. Interactive codesign sessions, surveys, and focus groups were used to elicit perspectives from PwE, care-proxies, and HCPs to understand their perception of how PiSCES could enhance or inhibit the epilepsy care process.

RESULTS

Results illustrate that participants welcome the role PiSCES can play in: empowering PwE/care-proxies, strengthening confidence in the healthcare system; aiding memory; advancing health literacy, motivating PwE to understand their condition better; acting as a passport of care between different clinical settings; and creating a foundation for stronger coproduction partnerships. PiSCES was generally embraced; however, some HCPs expressed plausible concerns about how clinical implementation might impact their work practices.

CONCLUSION

"Nothing about me without me" is a core value of the PiSCES initiative, recognizing that people need to be included in the planning of their own treatment and care. Our data show that PwE, their care-proxies, and HCPs value PiSCES potential, particularly in bolstering healthcare partnerships that foster inclusion, confidence, and trust.

LoVE in a time of CoVID: Clinician and patient experience using telemedicine for chronic epilepsy management

As part of our ongoing interest in patient- and family-centered care in epilepsy, we began, before the onset of the CoVID-19 pandemic, to evaluate the concerns and preferences of those delivering and receiving care via telemedicine. CoVID-19 arrived and acted as an unexpected experiment in nature, catalyzing telemedicine's widespread implementation across many disciplines of medicine. The arrival of CoVID-19 in Ireland gave us the opportunity to record these perceptions pre- and post-CoVID. Data were extracted from the National Epilepsy Electronic Patient Record (EEPR). Power BI Analytics collated data from two epilepsy centers in Dublin. Analysis of data on reasons for using the telephone support line was conducted. A subset of patients and clinicians who attended virtual encounters over both periods were asked for their perception of telemedicine care through a mixed methods survey. Between 23rd December 2019 and 23rd March 2020 (pre-CoVID era), a total of 1180 patients were seen in 1653 clinical encounters. As part of a telemedicine pilot study, 50 of these encounters were scheduled virtual telephone appointments. Twenty eight surveys were completed by clinicians and 18 by patients during that period. From 24th March 2020 to 24th June 2020, 1164 patients were seen in 1693 encounters of which 729 (63%) patients were seen in 748 scheduled virtual encounters. 118 clinician impressions were captured through an online survey and 75 patients or carers completed a telephone survey during the post-CoVID era. There was no backlog of appointments or loss of care continuity forced by the pandemic. Clinicians expressed strong levels of satisfaction, but some doubted the suitability of new patients to the service or candidates for surgery receiving care via telemedicine. Patients reported positive experiences surrounding telephone appointments comparing them favorably to face-to-face encounters. The availability of a shared EEPR demonstrated no loss of care contact for patients with epilepsy. The survey showed that telemedicine is seen as an effective and satisfactory method of delivering chronic outpatient care.

Analysis of the aetiology of epilepsy in 3,216 adult patients attending a tertiary referral center enabled by an electronic patient record

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Large scale studies examining the aetiologies of the epilepsies in existence worldwide are few.

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Assigning causation in epilepsy is a dynamic and evolving diagnostic process owing to continuous advances in science and technology.

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Electronic patient records offer immense clinical and research opportunities to clinicians.

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The data acquisition process used in this study utilised a bespoke extant dynamic clinically utilised electronic heath record.

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This is the first robust large analysis of aetiology following the publication of updated ILAE 2017 classification system.

Purpose

The aim of this study was to review the causes of the epilepsies in our institution, an adult tertiary referral center for neurology and neurosurgery in Dublin, Ireland. Data was obtained from a bespoke epilepsy electronic patient record (EPR).

Methods

Predetermined search parameters of well-established broad categories of epilepsy aetiology were used to identify patients with a diagnosis of epilepsy attending Beaumont Hospital, Dublin. There were 3216 patients that met the inclusion criteria for this study. We included living patients with epilepsy attending our institution. We then excluded patients with a diagnosis of pure non-epileptic attack disorder and patients found to have idiopathic generalised epilepsy (IGE) (n = 382) from our final cohort. We excluded IGE due to the complex polygenic basis underlying this patient group.

Results

An aetiology was identified in 54.3 % (n = 1747) of the total number of patients studied. Of the symptomatic epilepsies, 41.08 % (n = 1321) were acquired and 13.3 % (n = 426) were predominantly of genetic or developmental aetiology. The most common causes of the acquired epilepsies were hippocampal sclerosis (n = 380; 28.75 %), cerebral tumor (n = 279; 21.06 %), traumatic brain injury (n = 248; 18.77 %), stroke and cerebrovascular disease (n = 151; 11.43 %) and perinatal causes (n = 138; 10.45 %). The leading causes in the genetic / developmental category included cavernous haemangiomas (n = 62, 22.22 %), arteriovenous malformations (n = 59; 21.15 %) and cortical dysplasia (n = 55; 19.71 %). The aetiology of a patient’s epilepsy was undetermined in 45.68 % (n = 1469) of individuals.

Conclusion

This study emphasizes the clinical utility of the ILAE’s 2017 revised classification of the epilepsies and highlights the evolving dynamic nature of attributing causality in epilepsy. This is the largest single centre analysis of the aetiology of the epilepsies described in the literature. It is also the first large scale study examining aetiology utilising a bespoke electronic patient record in epilepsy.

Seizure and Sudden Unexpected Death in Epilepsy (SUDEP) characteristics in an urban UK intellectual disability service

PURPOSE

This study identifies epilepsy-related characteristics and SUDEP risk factors in people with epilepsy (PWE) attending an urban community ID service in the UK where managing epilepsy is not part of the service remit, to understand the care provided to this vulnerable population.

METHODS

An electronic database search in a north London community ID service (catchment population approx. 290,000) identified relevant ID/epilepsy characteristics in PWE to compare those with mild ID to moderate-profound ID. The SUDEP and Seizure Safety Checklist ("Checklist"), was administered to patients and families/carers. Risk management data was compared to similar data from Cornwall UK where PWE are supported within the ID service and the Checklist is used annually.

RESULTS

One fifth (137/697) of people attending the service had epilepsy. Over 3/4 had moderate-profound ID. Neurodevelopmental disorders were coexistent in 2/3, psychiatric conditions in 1/3 (1/4 of which was psychosis). The mean number of anti-seizure drugs was 1.45 ± 0.98, and 1/4 were taking psychotropic medications. Over a third did not have an epilepsy care plan. None contacted (n = 103) had SUDEP awareness. The median number of Checklist risk factors was seven (IQR 4.5-9). A third had experienced seizures lasting >5 min or status epilepticus. In comparison to the Cornish ID data significant differences were evident in four of seven modifiable risk factors.

CONCLUSIONS

This real world study highlights the complexity and risks among PWE and ID. The lack of a "joined up" approach can undermine the safety of this vulnerable population. Person-centred risk communication and care plans are easily achievable and essential.

A survey of general practitioner's opinion on the proposal to introduce 'treat and referral' into the Irish emergency medical service

BACKGROUND

The introduction of treat and referral by ambulance practitioners is under active consideration in Ireland. The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call to an emergency department. The introduction of treat and referral will present a significant care pathway change.

AIMS

To engage GPs in relation to the proposed introduction of treat and referral.

METHODS

A postal survey of 50 general practices in the southeast of Ireland was completed in 2019 to identify their opinion on the introduction of treat and referral. Descriptive statistics were calculated, and Pearson's chi-square tests were used to identify statistically significant differences among GP cohorts.

RESULTS

A 78% response rate was achieved. Respondents indicated that informal treat and referral was practised by 40% of GPs. A significant majority of GPs indicated that their patients with diabetes or epilepsy would benefit from treat and referral and were happy for paramedics to make appointments posthypoglycaemia or seizure. There was no clear consensus in relation to confining treat and referral to adults only. Barriers to the implementation of treat and referral were a significant issue for GPs.

CONCLUSIONS

GPs are in the main supportive of the introduction of treat and referral; however, they have identified several barriers that may inhibit successful introduction. Importantly, a GP appointment within 48 h does not appear to be a barrier. The adequacy of the working relationships between GPs and the ambulance service and its practitioners appears to have reduced since 2006, which is concerning.

An estimation of global volume of surgically treatable epilepsy based on a systematic review and meta-analysis of epilepsy

OBJECTIVEEpilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation.METHODSThe authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence.RESULTSThis systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources.CONCLUSIONSUnderstanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.

Seizures in HIV: The case for special consideration

Purpose

This study aimed to determine the rate, cause and management of seizures in the context of potential ART–ASD interactions in a cohort of HIV + individuals.

Methods

Records of 604 HIV + patients were reviewed and those reporting epilepsy/seizure diagnosis were further evaluated.

Results

This cohort exhibited a seizure rate of 2.4%. HIV + patients treated for epilepsy displayed low serum ASD levels and failed to achieve seizure control. They were more likely to disengage from Neurology follow-up.

Conclusion

For HIV + patients presenting with seizures/epilepsy the ASD prescription and the provision of supplementary support services needs to be carefully considered.

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ID and Neurology services should be involved in the evaluation and treatment of seizures in the context of HIV infection.

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ART-ASD interactions could have been the cause of ineffective treatment and other poor outcomes in this small cohort.

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In this group of patients it is important to apply published guidelines when it comes to making treatment decisions.

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Counseling and supportive services need to be provided to ensure engagement with services and adherence to treatment.

The Temple Star Transitional Model of Care for epilepsy; the outcome of a quality improvement project

OBJECTIVE

The aim and objective of this study was to assess the knowledge and views of parents on transitional and adolescent care in young adults with epilepsy, and to develop a transitional and adolescent program for epilepsy.

METHODS

Data were collected from questionnaires completed by parents during focus groups exploring transitional care and inherent issues for young adults, aged 12-18years, with epilepsy. The questionnaire assessed the current knowledge and views of parents of children with epilepsy on transitional care, and following a presentation on "Transition in Epilepsy" (including themes such as self-advocacy, independent healthcare behavior, sexual health, psychosocial support, educational and vocational planning, health and lifestyle issues) assessed feedback on the proposed model of care in transitional and adolescent care.

RESULTS

Data were collected from 34 parents; the majority of parents, 74% (n=25), wish their children to be transitioned and transferred over to the adult epilepsy sites at the age of 18years. Over 82% (n=28) of parents believe the concept of transition should be introduced between the ages of 12-16years.

CONCLUSION

This quality improvement initiative identified the need for transitional care to begin at an early age. This study engaged parents in a process to improve adolescent and transitional care for adolescents with epilepsy. This study also highlights the importance of introducing a detailed preparatory phase for a transitional and adolescent care in epilepsy.

Moving evidence based guidelines for seizures into practice in the emergency department: What's stopping us?

PURPOSE

To identify barriers to implementation of an evidence based integrated care pathway (ICP) for seizure management in the Emergency Department (ED).

METHODS

A site specific bespoke questionnaire was designed to solicit anonymous responses from all grades of ED medical and nursing staff to a series of questions regarding utility, feasibility, significance and implementation of a locally designed and championed ICP for seizure management and onward referral.

RESULTS

While 95% of respondents agreed that the pathway ensured patients were treated according to best practice, a number of human factors were identified as barriers to use. These fell into three categories 1) environmental 2) pathway design/process and 3) user related issues.

CONCLUSIONS

Most respondents understood and endorsed the evidence based utility of the pathway. Barriers to use, however, are broad with interactions involving many complex human factors. Nevertheless, solutions can be relatively easily formulated but departmental-wide effort is required to comprehensively address all issues.

Becoming comfortable with "my" epilepsy: Strategies that patients use in the journey from diagnosis to acceptance and disclosure

OBJECTIVE

Proponents of resilience theory have highlighted the importance of understanding the processes of resilience. The objective of the study was to explore how people with epilepsy reach a stage of being comfortable with their epilepsy. Identifying the processes used is important to developing effective self-management for people who are newly diagnosed with epilepsy.

METHOD

A grounded theory approach involving forty-nine consenting adult people with epilepsy (18 years and over), was used to explore their first-hand experiences of coming to terms with their epilepsy. Data were collected using one-to-one interview to elicit in-depth personal accounts of people with epilepsy's experiences of adjusting to their diagnosis of epilepsy. Using grounded theory's systematic inductive-deductive process data of analysis, the core findings that emerged from the open coding and inductive phase were analyzed independently by two researchers to ensure that findings were verified and validated across the interview dataset.

FINDINGS

Three core categories emerged as central to the journey that people experience after receiving their diagnosis of epilepsy towards becoming comfortable with their epilepsy. These were: i) meaning of "my" epilepsy diagnosis, to capture people with epilepsy's feelings, reactions and concerns after being diagnosed with epilepsy, ii) useful strategies, to identify what people with epilepsy did to become comfortable with their diagnosis, and iii) being comfortable with my epilepsy, to account for the frame of mind of people with epilepsy when they reach a point of accepting their diagnosis.

DISCUSSION

The findings provide important insights into the personal experiences of people with epilepsy after receiving their diagnosis and identifies a range of strategies they find useful in helping them reach a position of acceptance and being 'comfortable with my epilepsy'.

Experiences of university students disclosing epilepsy to peers: ‘It's a shared thing now’

Introduction

While disclosure of concealable conditions like epilepsy can create social support, it may cause relationships to disintegrate. Friendship in young adulthood is pivotal in the transition to emotional autonomy, yet little is known about peer disclosure by university students with epilepsy. This qualitative study aimed to map key features in the process of epilepsy disclosure.

Method

Semi-structured interviews were completed with eight young adults (aged 18–25 years) with epilepsy enrolled in or recently graduated from Irish universities.

Findings

Thematic analysis yielded four main themes: (1) Assessing the disclosure recipient; (2) Managing the presentation of epilepsy; (3) Forging alliances; and (4) Feeling more positive. The process of disclosure centred on enlisting the support of allies deemed trustworthy by participants. Disclosure messages presented epilepsy neutrally to bolster allies' commitment to the role. Although participants viewed disclosure as beneficial to wellbeing, concern was expressed about acquiring a stigmatised social identity.

Conclusion

Occupational therapists are well placed to support young adults through the process of disclosure. Promoting a positive collective identity through peer mentorship promises to disrupt stigma. More broadly, partnerships between occupational therapists and epilepsy organisations or disability support services in third level education could establish an academic culture where supports are readily available to people with concealable illnesses.

To tell or not to tell: A systematic review of the disclosure practices of children living with epilepsy and their parents

Disclosing an epilepsy diagnosis to others is complex due to the condition's largely invisible nature and associated stigma. Despite this, little has been documented in terms of what this process involves for children living with epilepsy (CWE) and their parents. A systematic review was conducted to examine and synthesize evidence pertaining to: (i) the disclosure practices of CWE and their parents, (ii) enablers and barriers for disclosure, (iii) the impact of disclosure practices, and (iv) the relationship between disclosure management and other variables. The electronic databases PsycINFO, PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched systematically. Any empirical, peer-reviewed journal articles with findings reported regarding the self- or proxy-reported disclosure practices of children aged 0-18years with any type of epilepsy and/or their parents were deemed eligible for inclusion. Two review authors completed all stages of screening, data extraction, and quality assessment independently with two additional review authors resolving any discrepancies. A total of 32 articles were included in the review. Only one dated study examined disclosure as a primary focus; in the remaining studies, disclosure was a subfocus of larger studies or pertinent qualitative themes/subthemes incidentally emerged. The limited evidence suggests that: 1) CWE and parents adopt varying disclosure management strategies - from concealment to voluntary disclosure; 2) disclosure decisions are challenging for CWE and parents; 3) many barriers to disclosure exist (e.g., fear of stigmatization and rejection); 4) only a limited number of factors that enable disclosure are known (e.g., openness by others to engage with and learn about epilepsy); 5) disclosure management is significantly related to a number of variables (e.g., child/maternal perceived stigma and seizure control); and 6) there are varying outcomes for CWE and/or their parents in accordance with the adoption of specific disclosure management strategies (e.g., disclosure resulting in greater acceptance and the receipt of support or evoking anxiety/fear in others; and concealment resulting in misunderstandings, embarrassment, and stigma-coaching), but the evidence remains inconclusive in terms of which disclosure management strategy is optimal. While some preliminary work has been conducted, disclosure of epilepsy is a topic that has been largely neglected to date. This is despite the fact that disclosure is a significant source of concern for CWE and parent populations. Future studies should focus on elucidating the unique contextual factors that inform disclosure decisions in order to develop a theoretical framework that can explain the epilepsy disclosure decision-making process.

Family communication in the context of pediatric epilepsy: A systematic review

In childhood chronic illness, family communication can impact the child's and parents' psychosocial well-being. However, little is known about family communication in the context of epilepsy in childhood. The aim of this systematic review was to identify the existing evidence available on communication strategies adopted by families living with childhood epilepsy, including; the facilitators, barriers and challenges experienced by families when choosing to communicate, or not, about epilepsy; and the consequences of this communication. Papers published in the English language prior to March 2015 were identified following a search of six electronic databases: PubMed, MEDLINE, Web of Science, PsycINFO, CINAHL, and Scopus. Studies were included if they involved a sample of parents of children with epilepsy or children/young people with epilepsy (0-18years of age) and used qualitative, quantitative, or mixed methods. Following a comprehensive search and screening process, 26 studies were identified as eligible for inclusion in the review. No studies identified specific communication strategies adopted by families living with childhood epilepsy. Some studies found that talking about epilepsy with family members had positive consequences (e.g., communication as an effective coping strategy), with no negative consequences reported in any of the studies. The main barrier to communication for parents was an unwillingness to use the word "epilepsy" because of the perceived negative social connotations associated with the health condition. For children with epilepsy, barriers were as follows: parental desire to keep epilepsy a secret, parents' tendency to deny that the child had epilepsy, parental overprotection, and parents' tendency to impose greater restrictions on the child with epilepsy than on siblings without epilepsy. Future research investigating the communication strategies of families living with epilepsy is needed in order to create effective communication-based interventions for discussing epilepsy within the home.

Benzodiazepine prescribing guideline adherence and misuse potential in Irish minors

BACKGROUND

The Good Prescribing Practice for Clinicians guidelines were published in 2002 in Ireland to guide General Practitioners about prescribing benzodiazepines. There has been no research to-date to measure compliance by General Practitioners. Inappropriate prescribing to minors may result in increased use or misuse of benzodiazepines.

OBJECTIVE

The purpose of this study was to evaluate the prescribing of benzodiazepines to minors in Ireland against the Good Prescribing Practice for Clinicians guidelines.

METHOD

Data for medicines dispensed between January 2009 and December 2012 from the Health Intelligence Ireland database were accessed and analysed. This database contains information about government-subsidised community-pharmacy-dispensed medicines.

RESULTS

Benzodiazepine prescribing to minors increased by 10.2% between 2009 and 2012. Almost 15% of patients (n = 2193) were prescribed benzodiazepines for greater than four weeks; which contravenes the guidelines. Approximately half (51.4%) of prescribers who contravened this guideline, prescribed all their benzodiazepines in quantities of greater than one week, against the recommendations of the guidelines.

CONCLUSION

The consequences of prescribing against National Guidelines can result in patients who become long-term benzodiazepine users and thus place an increased burden upon the healthcare system. The reasons for non-compliance by GPs should be investigated to find solutions.

Prevalence of epilepsy among people with intellectual disabilities: A systematic review

PURPOSE

Epilepsy is more common in people with intellectual disabilities than in the general population. However, reported prevalence rates vary widely between studies. This systematic review aimed to provide a summary of prevalence studies and estimates of prevalence based on meta-analyses.

METHOD

Studies were identified via electronic searches using Medline, Cinahl and PsycINFO and cross-citations. Information extracted from studies was tabulated. Prevalence rate estimates were pooled using random effects meta-analyses and subgroup analyses were conducted.

RESULTS

A total of 48 studies were included in the tabulation and 46 studies were included in meta-analyses. In general samples of people with intellectual disabilities, the pooled estimate from 38 studies was 22.2% (95% CI 19.6-25.1). Prevalence increased with increasing level of intellectual disability. For samples of people with Down syndrome, the pooled estimate from data in 13 studies was 12.4% (95% CI 9.1-16.7), decreasing to 10.3% (95% CI 8.4-12.6) following removal of two studies focusing on older people. Prevalence increased with age in people with Down syndrome and was particularly prevalent in those with Alzheimer's/dementia.

CONCLUSION

Epilepsy is highly prevalent in people with intellectual disabilities. Services must be equipped with the skills and information needed to manage this condition.

The economic cost of nonepileptic attack disorder in Ireland

The present study endeavored to calculate a conservative estimate of both incidence- and prevalence-based costs of nonepileptic attack disorder (NEAD) in Ireland by applying previously identified prevalence figures to Irish population figures. Variables related to the economic cost of NEAD were identified based on a retrospective chart review of patients diagnosed with NEAD at Beaumont Hospital, Dublin. The annual cost per patient of undiagnosed NEAD was calculated as €20,995.30. The combined cost of diagnosis and psychological treatment of NEAD was estimated at €8728. Although it is difficult to determine precise economic costings, early diagnosis and intervention would result in a significant economic saving to the exchequer, a reduction in hospital waiting-list times, and a better prognosis for patients.

A Survey Examining the Impact of Driving Cessation on People with Epilepsy in Ireland

Introduction:

Driving is a job, a hobby and a form of transport that enables occupation. This research investigated the impact of the inability to drive due to epilepsy on community mobility and occupational participation, and compared both men and women's perceptions of the impact of driving cessation on romantic relationships and family involvement.

Method:

By means of an internet-based survey, data were collected concerning community mobility, personal impact of driving cessation, previous driving practices, epilepsy and demographics. Statistical analysis was performed on quantitative data and content analysis was used with responses to open questions. The survey received 95 eligible participants.

Findings:

Participants used public transport more than the general population; however, when unable to drive, being driving by friends or relatives was the main mode of transport. As a result, people experienced restricted access to the community, had to give up activities, had a reduced quality of life and a lowered self-esteem. Significantly more men than women felt that driving cessation had a negative impact on romantic relationships (p = 0.024) yet men and women did not differ significantly in their feelings about the impact of driving cessation on family involvement (p = 0.58).

Conclusion:

Independent access to the community is often dependent on the ability to drive.

Prevalence and clinical characteristics of epilepsy in the South of Spain

PURPOSE

Epilepsy is a common neurological disorder found in all societies. There are extensive epidemiologic studies of different European areas. However, not much information about the South-West of Europe exists. In Málaga, Health Care is free and there are only two public hospitals with Neurological Services that assist Eastern or Western areas depending on the case. The purpose is to estimate the epidemiology in Málaga through a hospital-based study and compare it to the other European studies.

METHODS

Review on the hospital data base and gathering of consecutive patients with a diagnosis of active epilepsy served by the Epilepsy outpatient clinic in Virgen de la Victoria Hospital throughout a year.

RESULTS

2 281 patients fulfilled the criteria and 515 patients were recruited in order to study the epidemiologic characteristics. Male gender and focal onset seizures predominate (75.5%). Medium age 40. 58% of patients have been seizure-free in the last year. Known etiology in half of the patients. 54% of patients are treated with monotherapy. Valproic acid is the commonest drug. Other epidemiologic and demographic important data are provided. Data are analysed and compared to other European studies.

CONCLUSIONS

Prevalence rate in Western Málaga is 4.79 cases/1000 inhabitants. Characteristics of the sample are similar to those of other European studies. Although this is a hospital-based study, the particular characteristics of the Health Care System in our region enable us to gather real data concerning epidemiology and prevalence.

A seizure care pathway in the emergency department: preliminary quality and safety improvements

Aim. To evaluate the utility of a seizure care pathway for seizure presentations to the emergency department (ED) in order to safely avoid unnecessary admission and to provide early diagnostic and therapeutic guidance and minimize length of stay in those admitted. Methods. 3 studies were conducted, 2 baseline audits and a 12-month intervention study and prospective data was collected over a 12-month period (Nov 2008-09). Results. Use of the Pathway resulted in a reduction in the number of epilepsy related admissions from 341 in 2004 to 276 in 2009 (P = 0.0006); a reduction in the median length of stay of those admittedfrom 4-5 days in the baseline audits to 2 days in the intervention study (P ≤ 0.001); an improvement in time to diagnostic investigations such as CT brain, MRI brain and Electroencephalography (P ≤ 0.001, P ≤ 0.048, P ≤ 0.001); a reduction in readmission rates from 45.1% to 8.9% (P ≤ 0.001); and an improvement in follow-up times from a median of 16 weeks to 5 weeks (P < 0.001). From a safety perspective there were no deaths in the early discharged group after 12 months follow-up. Conclusion. The burden of seizure related admissions through the ED can be improved in a safe and effective manner by the provision of a seizure care pathway.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Future directions for epidemiology in epilepsy

Epidemiology continues to be an important research tool in the study of epilepsy and related disorders, providing a better understanding of the frequency, causes and natural history of the disorder. But, beyond risk factors and seizure prognosis, epidemiological studies advance knowledge of many other aspects of epilepsy. Epidemiological studies are being conducted in a new environment in which high quality neuroimaging and fast through-put genomic technologies have become routine tools in clinical diagnosis and therapeutics. Epilepsy is currently understood, not as a single, homogeneous disorder, but a multitude of different clinical syndromes and disease, each with its own cause(s), natural history, and treatment implications. That is why; the comorbidites of epilepsy represent an important area, amenable to study, as they may ultimately have a greater impact on quality of life than epilepsy itself. In this document we share our thoughts on what we think are the future directions for epidemiology in epilepsy.

Primary care doctors' management behavior with respect to epilepsy in Kerala, southern India

Although a majority of persons with epilepsy in developing countries are diagnosed, treated, and followed up by primary care doctors, few efforts have been made to examine their understanding with respect to epilepsy management. Through a questionnaire survey, we gathered information about the epilepsy management behavior of 500 primary care doctors distributed across the south Indian state of Kerala. Very few of them ever had diagnosed focal seizures, and the majority of them overutilize EEGs, prescribe continuous antiepileptic drug (AED) prophylaxis for febrile convulsions, use relatively expensive AEDs often in combination and in suboptimal doses, and did not know about alternate management options for AED-resistant epilepsies. A substantial proportion of the current large treatment gap in epilepsy in developing countries could be minimized by educating the primary care physicians about the diagnosis of epileptic seizures, cost-effective AED treatment, and need-based referral for specialized care.

Psychiatric and medical admissions observed among elderly patients with new-onset epilepsy

BACKGROUND

Inpatient utilization associated with incidence of geriatric new-onset epilepsy has not been characterized in any large study, despite recognized high levels of risk factors (comorbidity).

METHODS

Retrospective study using administrative data (Oct '01-Sep '05) from the Veterans Health Administration from a nationwide sample of 824,483 patients over age 66 in the retrospective observational Treatment In Geriatric Epilepsy Research (TIGER) study. Psychiatric and medical hospital admissions were analyzed as a function of patient demographics, comorbid psychiatric, neurological, and other medical conditions, and new-onset epilepsy.

RESULTS

Elderly patients experienced a 15% hospitalization rate in FY00 overall, but the subset of new-onset epilepsy patients (n = 1,610) had a 52% hospitalization rate. New-onset epilepsy was associated with three-fold increased relative odds of psychiatric admission and nearly five-fold increased relative odds of medical admission. Among new-onset epilepsy patients, alcohol dependence was most strongly associated with psychiatric admission during the first year after epilepsy onset (odds ratio = 5.2; 95% confidence interval 2.6-10.0), while for medical admissions the strongest factor was myocardial infarction (odds ratio = 4.7; 95% confidence interval 2.7-8.3).

CONCLUSION

From the patient point of view, new-onset epilepsy was associated with an increased risk of medical admission as well as of psychiatric admission. From an analytic perspective, omitting epilepsy and other neurological conditions may lead to overestimation of the risk of admission attributable solely to psychiatric conditions. Finally, from a health systems perspective, the emerging picture of the epilepsy patient with considerable comorbidity and demand for healthcare resources may merit development of practice guidelines to improve coordinated delivery of care.

The health care journeys experienced by people with epilepsy in Ireland: what are the implications for future service reform and development?

Opportunities exist to significantly improve the quality and efficiency of epilepsy care in Ireland. Historically, epilepsy research has focused on quantitative methodologies that often fail to capture the invaluable insight of patient experiences as they negotiate their health care needs. Using a phenomenological approach, we conducted one-to-one interviews with people with epilepsy, reporting on their understanding of their health care journey from onset of symptoms through to their first interaction with specialist epilepsy services. Following analysis of the data, five major themes emerged: delayed access to specialist epilepsy review; uncertainty regarding the competency and function of primary care services; significant unmet needs for female patients with epilepsy; disorganization of existing epilepsy services; and unmet patient information needs. The findings reveal important insights into the challenges experienced by people with epilepsy in Ireland and identify the opportunities for future service reorganization to improve the quality and efficiency of care provided.