Approach to the patient with epilepsy in the outpatient department

Comparing Companion Involvement in Clinical Telephone and Face-To-Face Consultations About Seizures

Companions (i.e., friends, family members, and other accompanying persons) play an important role in seizure clinic consultations, providing information that patients cannot. The COVID-19 pandemic has seen an increase in these consultations being conducted via telephone. Little is known, however, about how this shift might affect companion participation. Using conversation analysis applied to a set of recorded telephone neurologist-patient-companion consultations (n = 9) and comparable moments drawn from a set of face-to-face consultations (n = 37) (both collected in the UK), we aimed to explore this impact and to identify communication methods that clinicians can use to manage companion participation during telephone consultations. We identified four ways in which participation was observably affected by the telephone. Telephone consultations could make it unclear whether a companion was present and make it difficult for the companion to communicate directly with the neurologist. Passing the floor from one speaker to another was more complex remotely, which could also restrict the patient's own participation once the companion had the floor. These issues are rooted in the limitations of the telephone as a communication medium. Based on the issues identified, we conclude our analysis by highlighting some of the ways in which neurologists and other health professionals can manage companion participation in telephone consultations. These include encouraging the use of speakerphone, checking whether a companion is present throughout the call, keeping track of who can hear what throughout the call, and directing questions using given names to avoid ambiguity.

Characterization and quantification of epilepsy patients with hospital episodes in Portugal: A multicenter retrospective study from Liga Portuguesa Contra a Epilepsia

INTRODUCTION

Epilepsy affects around 50 million people worldwide and is associated with lower quality of life scores, an increased risk of premature death, and significant socio-economic implications. The lack of updated evidence on current epidemiology and patient characterization creates considerable uncertainty regarding the epilepsy burden in Portugal. The study aims to characterize and quantify the epilepsy patients who have been hospitalized, with medical or surgical procedures involved, and to analyze their associated comorbidities and mortality rates.

METHODS

A multicenter retrospective study was conducted using hospital production data of epilepsy patients. The study included all patients diagnosed with epilepsy-related International Classification of Diseases-9/10 codes between 2015 and 2018 in 57 Portuguese National Health Service (NHS) hospitals (n = 57 institutions). Patient characterization and quantification were done for all patients with an epilepsy diagnosis, with specific analyses focusing on those whose primary diagnosis was epilepsy. Baseline, demographic, and clinical characteristics were analyzed using descriptive statistics.

RESULTS

Between 2015 and 2018, a total of 80,494 hospital episodes (i.e., patient visit that generates hospitalization and procedures) were recorded, with 18 % to 19 % directly related to epilepsy. Among these epilepsy-related hospital episodes, 13.0 % led to short term hospitalizations (less than 24 h). Additionally, the average length of stay for all these epilepsy-related episodes was 8 days. A total of 49,481 patients were identified with epilepsy based on ICD-9/10 codes. The median age of patients was 64 years (min: 0; max: 104), with a distribution of 4.8 patients per 1,000 inhabitants. From the total of deaths (9,606) between 2015 and 2018, 14% were associated with patients whose primary diagnosis was epilepsy, with 545 of these being epilepsy-related deaths. Among patients with a primary diagnosis of epilepsy, the most common comorbidities were hypertension (24%) and psychiatric-related or similar comorbidities (15%), such as alcohol dependance, depressive and major depressive disorders, dementia and other convulsions.

CONCLUSION

This study showed similar results to other European countries. However, due to methodological limitations, a prospective epidemiological study is needed to support this observation. Furthermore, the present study provides a comprehensive picture of hospitalized epilepsy patients in Portugal, their comorbidities, mortality, and hospital procedures.

Impact of COVID-19 pandemic on caregivers of persons with epilepsy - A systematic review

PURPOSE

To describe the impact of COVID-19 pandemic on caregivers of persons with epilepsy.

METHODS

This systematic literature review was conducted according to the Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA) guidelines. The PECO (Patient, Exposure, Comparison, Outcome) framework criteria were as follows: caregivers of persons with epilepsy; exposed to the COVID-19 pandemic; and outcomes, evaluated under 4 domains- Difficulties faced by caregivers during the COVID-19 pandemic, physical, emotional and behavioural impacts, diagnosed health conditions, and impact on clinical management and follow-up). Literature was searched in PubMed, Google Scholar, CINAHL, Medline, and Cochrane Library Databases. Appraisal tool for Cross-Sectional Studies (AXIS) was used to assess the methodological quality of studies.

RESULTS

Data were extracted from 21 eligible articles from 199 and included 5810 caregivers of persons with epilepsy. In the domain of difficulties faced by caregivers during the COVID-19 pandemic, the most significant effect was related to difficulties in obtaining and affording anti-seizure medications. Appointment cancellations also affected most caregivers (4/7 studies). Seizure exacerbation was not a major concern to them. Anxiety, reported by most caregivers in 5/7 studies, depression in 2/5 studies, stress by majority of caregivers in 4/6 studies, and increased substance use in one study were other significant bad experiences. Social isolation increased for the majority in 2/7 studies. Financial difficulties were described in two studies. Under caregivers' health conditions, there was only one study to review. Emotional issues affected majority in 3/7 studies, physical issues in 2/4 studies, and worsened behavior in one. With regards to clinical management and follow-up, most caregivers (4/5 studies) adopted self-management strategies, but 3/8 studies reported difficulties in accessing medications and healthcare services. Additionally, 4/8 studies highlighted communication and coordination difficulties with healthcare providers. Caregivers' attitude towards telemedicine varied across studies.

SIGNIFICANCE

COVID-19 pandemic had a profound impact on caregivers of persons with epilepsy, affecting their emotional, physical, and behavioral health. It limited their access to healthcare and impacted financial stability. Caregivers of persons with epilepsy need comprehensive support and resources during crisis situations.

COVID-19 pandemic influence on epilepsy course in pediatric patients

INTRODUCTION

In 2020, Coronavirus Disease 2019 (COVID-19) was declared as a global pandemic. Self-reported stress, anxiety, and insomnia, which are believed to be common triggers for epilepsy, are more likely to occur. We aimed to establish the influence of COVID-19 pandemic itself on changes in the daily life routine related to pandemic on epilepsy course in pediatric patients. The unique form of clinical care which is telemedicine was also taken into consideration. We wanted to evaluate patients' satisfaction with telemedicine and if changing stationary visits into telemedicine influenced epilepsy course in our patients.

METHODS

Patients, who attended developmental neurology outpatient clinic in the period March-December 2020 were collected. As patients were minors, legal guardians were asked to fill out the questionnaire. Patients were divided according to the outcome into three groups: those with a worsened, stable, or improved course of epilepsy during the pandemic. Appropriate statistical tests for two-group and multi-group comparisons have been implemented. Post hoc p values were also calculated.

RESULTS

Four hundred and two questionnaires were collected. Most of the patients had a stable course of epilepsy during the pandemic; in 13% of participants an improvement has been observed, worsening of the disease was seen in 16% of patients. Age, sex, type of epilepsy, number of seizure incidents before pandemic, and duration of the disease had no statistically significant connection with changes in the course of the disease. Behavioral changes and altered sleep patterns were found to be more common in the worsened group. Fifty-eight percent of patients were satisfied with telemedicine. Poorer satisfaction was connected with less frequent visits, cancellation of scheduled appointments, and lack of help in case of need in an emergency situation.

CONCLUSION

Epilepsy course in pediatric patients seems to be stable during COVID-19 pandemic. Sleep disturbances and changes in a child's behavior may be related to increase in seizure frequency. Telemedicine is an effective tool for supervising children with epilepsy. Patients should be informed about possible ways of getting help in urgent cases.

Evidence-based practice among epilepsy specialist nurses in the Republic of Ireland: Findings from the SENsE study

AIM

To describe how epilepsy specialist nurses in Ireland enact the evidence-based practice dimension of their role.

BACKGROUND

The importance of epilepsy specialist nurses (ESNs) delivering evidence-based care to people experiencing epilepsy is unquestionable, yet research into this aspect of the role is relatively sparse.

METHODS

A qualitative design was used, involving 12 epilepsy specialist nurses working in five units in Ireland, 24 multidisciplinary team members working with them and 35 people with epilepsy and their family members. Data were collected using individual and focus group interviews, observation and documentary analysis.

RESULTS

These ESNs were active in accumulating, translating, applying, generating and disseminating evidence. All were actively involved in, or leading audit and service evaluations, and used findings to improve practice. Their research activity mainly consisted of small-scale unfunded research projects.

CONCLUSIONS

These ESNs acted as opinion leaders and role models in relation to evidence-based practice, including the generation of new knowledge through audit and research.

IMPLICATIONS FOR NURSING MANAGEMENT

Organisations and managers need to support ESNs by ensuring that they have the necessary resources and competencies to accumulate, translate, apply, generate and disseminate relevant evidence. Future research should explore the impact of ESNs' evidence-based practice on patient outcomes.

The social space of empowerment within epilepsy services: The map is not the terrain

Empowerment is now seen as an integral component of holistic practice and service design in healthcare, particularly as it relates to the improvement of quality of life for people with epilepsy. However, the literature suggests that empowerment is a neglected and poorly understood concept by service users and providers alike within epilepsy services. Conceptual ambiguity is a further impediment to its understanding and implementation. Bearing this in mind, a clear definition of empowerment is needed in order to realistically recognize, encourage, and prioritize empowerment as a service design philosophy. Therefore, this paper undertakes a concept analysis of empowerment with reference to epilepsy services. Results indicate that empowerment demands a transformation of consciousness and a readiness to act on this transformation in order to allow people to gain personal power and autonomy over their own life, including the self-management of their condition. With this in mind, a critical reflection on the 'micro' and 'macro' levels of power that exist within epilepsy services is warranted with reference to theoretical principles. In this context although the map is not the terrain, we argue that an educational intervention guided by critical social theory principles has the potential to encourage an understanding of empowerment and 'holds the key' to future advances for its implementation within epilepsy services.

The potential of critical social theory as an educational framework for people with epilepsy

Effective education can support people with epilepsy to develop the attributes and skills required to function as equal partners with clinical service providers, make informed decisions, and competently self-manage their healthcare. However, despite knowledge deficits, unmet information needs, and a poor sense of empowerment, the study of education for people with epilepsy is often neglected and is a poorly understood component of holistic practice within epilepsy healthcare. Historically, the only debate with regard to education and people with epilepsy has been guided either within a positivist or within a constructivist philosophy. We argue that new pedagogies are warranted, recognizing the views of people with epilepsy regarding their illness. Therefore, this paper explores the potential of an educational framework for people with epilepsy based upon critical social theory (CST). By utilizing a CST approach for education, people with epilepsy are engaged with as active 'participants'. This is a key difference that distinguishes CST from other metatheoretical frameworks. It has the potential to support people with epilepsy to acquire the skills and confidence to manage the biopsychosocial challenges associated with their condition.

Epilepsy services in Ireland: 'A survey of people with epilepsy in relation to satisfaction, preferences and information provision'

BACKGROUND

A challenge facing modern health care systems is to develop and implement new models of service that deliver increased capacity while providing a higher-quality, more cost-effective service within resource constraints. Incorporating the experience of people with epilepsy must be seen as central to the effectiveness of service design and delivery. This paper, therefore, reports the views of people with epilepsy with regards to health service delivery in Ireland.

METHOD

A cross-sectional descriptive survey design involving both quantitative and qualitative items was administered to a convenience sample of one hundred and two people with epilepsy (n=102) attending an epilepsy specialist centre.

RESULTS

Despite high levels of satisfaction with hospital and primary care, participants offered several suggestions to improve healthcare delivery, such as: less delay in accessing specialist care and hospital appointments; better communication; and easier access to investigatory services. Findings demonstrate that for people with epilepsy the burden of the disorder is substantial and complex encompassing social, psychological and structural difficulties. Poor information provision particularly among women is reported. Furthermore, a lack of empowerment in people with epilepsy is highlighted.

CONCLUSION

This study has implications for the reform and development of epilepsy services in relation to practice, education and research. It provides a basis for an evaluation of current practice and identifies opportunities for future service reorganization to improve the quality and efficiency of healthcare provision.

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.

Initial experience with a rapid access blackouts triage clinic

Transient loss of consciousness (T-LOC), or blackout, is common in acute medicine. Clinical skills are not done well, with at least 74,000 patients misdiagnosed and mistreated for epilepsy in England alone. The aim of this study was to provide a rapid, structured assessment and an electrocardiogram (ECG) for patients with blackouts, aiming to identify high risk, reduce misdiagnoses, reduce hospital admission rates for low-risk patients, diagnose and treat where appropriate, and also provide onward specialist referral. The majority of patients had syncope, and very few had epilepsy. A high proportion had an abnormal ECG. A specialist-nurse-led rapid access blackouts triage clinic (RABTC) provided rapid effective triage for risk, a comprehensive assessment format, direct treatment for many patients, and otherwise a prompt appropriate onward referral. Rapid assessment through a RABTC reduced re-admissions with blackouts. Widespread use of the web-based blackouts tool could provide the NHS with a performance map. The U.K. has low rates of pacing compared to Western Europe, which RABTCs might help correct. The RABTC sits between first responders and specialist referral, providing clinical assessment and ECG in all cases, and referral where appropriate.

Seizures in people with cancer

CASE STUDY

Ms. S is a 52-year-old woman who was diagnosed with infiltrating ductal breast carcinoma two years prior. She was treated with mastectomy followed by focal radiation and FAC (5-fluorouracil, adriamycin, and cyclophosphamide). One year ago, she began experiencing headaches. A magnetic resonance imaging scan with gadolinium revealed a 2 cm enhancing mass in the left temporal lobe, and she received whole-brain irradiation.

How to avoid a misdiagnosis in patients presenting with transient loss of consciousness

Daily in the UK, frontline medical and paramedical staff are required to manage patients with "collapse ?cause". This universal colloquialism refers to patients who have had an abrupt loss of postural tone. Some of these patients would have had a "blackout" or a transient loss of consciousness (T-LOC). The three most important causes of T-LOC are syncope, epilepsy and psychogenic blackouts. Determining the correct cause is an important challenge; if the initial clinical diagnosis is wrong, investigations may be misdirected, and the final diagnosis and treatment incorrect. Syncope is much more common than epilepsy and may present with symptoms akin to the latter. This fact is not well appreciated and often leads to misdiagnosis. This article deals with the clinical features of the three main causes of blackouts, the value of investigations in arriving at a diagnosis and the problem of misdiagnosis. Pathways for managing patients presenting with blackouts are suggested.