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Telemedicine is frequently used to provide remote neurological expertise for acute stroke workup and was associated with better functional outcomes when combined with a stroke unit system-of-care. We investigated whether such system-of-care yields additional benefits when implemented on top of neurological competence already available onsite.Quality improvement measures were implemented within a 'hub-and-spoke' teleneurology network in 11 hospitals already provided with onsite or telestroke expertise. Measures included dedicated units for neurological emergencies, standardization of procedures, multiprofessional training, and quality-of-care monitoring. Intervention effects were investigated in a controlled study enrolling patients insured at 3 participating statutory health insurances diagnosed with acute stroke or other neurological emergencies. Outcomes during the intervention period between November 2017 and February 2020 were compared with those pre-intervention between October 2014 and March 2017. To control for temporal trends, we compared outcomes of patients with respective diagnoses in 11 hospitals of the same region. Primary outcome was the composite of up-to-90-day death, new disability with the need of ambulatory or nursing home care, expressed by adjusted hazard ratio (aHR).We included 1,418 patients post-implementation (55% female, mean age 76.7 ± 12.8 year) and 2,306 patients pre-implementation (56%, 75.8 ± 13.0 year, respectively). The primary outcome occurred in 479/1,418 (33.8%) patients post-implementation and in 829/2,306 (35.9%) pre-implementation. The aHR for the primary outcome was 0.89 (95% confidence interval [CI]: 0.79-0.99, p = 0.04) with no improvement seen in non-participating hospitals between post- versus pre-implementation periods (aHR 1.04; 95% CI: 0.95-1.15).Implementation of a multicomponent system-of-care was associated with a lower risk of poor outcomes. ANN NEUROL 2022.

Zusammenfassung Theoretischer Hintergrund Das Vorhandensein einer organischen Grunderkrankung erschwerte lange die Diagnostik von krankheitsbezogenen Ängsten. Untersuchungen zeigen, dass ein erheblicher Anteil somatisch Erkrankter unter beeinträchtigenden Krankheitsängsten leidet. Fragestellung Es wurden Epilepsiepatient*innen untersucht, für die bisher keine Daten zu Krankheitsängsten vorlagen. Methode 76 Epilepsiepatient*innen wurden hinsichtlich ihrer Belastung (Mini-SCL), den Ängsten vor einem Voranschreiten der Erkrankung (PA-F) sowie hypochondrischen Merkmalen (MIHT) untersucht. Ergebnis Epilepsiepatient*innen waren nicht belasteter und ängstlicher als Normstichproben, zugleich lagen bei 28% (Gesamtbelastung) bis 45% (Ängstlichkeit) der Befragten klinisch auffällige Werte vor. Im Vergleich zu anderen somatischen Diagnosegruppen waren Progredienzängste gering ausgeprägt. Hypochondrietypische Merkmale fanden sich bei 7% (perzeptuell) bis 13% (affektiv/behavioral) der Befragten. Schlussfolgerung Ein erhöhtes Bewusstsein für Krankheitsängste kann helfen, die Versorgung und Lebensqualität von Epilepsiepatient*innen zu verbessern.

Objective: In Germany, six previous representative surveys on attitudes toward epilepsy (AE) have been conducted between 1967 and 2008 using the four original Caveness questions (CQs) from 1949 to 1980. The aims of this study were (1) to investigate changes in AE over the time span of 50 years, including the current survey in 2018 (2) to investigate the first-time emotional reactions measured with the Scales of Attitudes toward People with Epilepsy (SAPE) (3) to identify predictors of AE.Methods: A representative face-to-face survey with CQ, in addition with the SAPE scales of Social Distance, Stereotypes, Personal Concerns, and Emotional Reactions was carried out in Germany in 2018. One thousand and twenty-six persons who ever had heard of epilepsy participated. Respondents who answered "don't know" in the CQs were subsequently asked to answer only yes/no. The analysis of trends from 1967 to 2018 was based on the pooled data of the surveys. The four CQs in the 2018 survey were included in the SAPE item pool and an exploratory principal axis factor analysis was performed. General linear mod-els were performed to identify predictors.Results: For all four CQs, the trend of improved AE was significant over the past 50 years. In the 2018 sur-vey, excluding the "don't know" answer option increased the proportion of negative responses for contact of one's own children with a person with epilepsy (PWE) from 6.9% to 11.4% and for the marriage of one's own children with a PWE from 13.9% to 23.8%. When encountering a PWE, 30.1% would feel insecure or uncomfortable and nearly 60% were concerned that the PWE might be injured in case of a seizure. Knowing what to do in case of a seizure, knowing that seizures can be treated successfully, personal con-tact with a PWE along with younger age, and higher education were found to be the strongest predictors for positive AE identified by multivariate analyses. Exploratory principal axis factor analysis revealed that three of the four CQs items loaded > 0.30 at the factors of Social Distance and Stereotypes of SAPE but none on the factors measuring emotional reactions.Significance: AE measured by CQs have markedly improved in Germany over the last 50 years. Germany is to our knowledge the only country with such a long-term trend investigation in AE. Negative AE may be underestimated by survey questions with "don't know" answer option. Emotional aspects of attitudes are underexposed resp. neglected in the CQs, which are used worldwide for measuring AE. Additional tools like SAPE can close this gap. The identified predictors may help to derive interventions against negative AE.(c) 2022 Elsevier Inc. All rights reserved.

OBJECTIVE: The aims of this study were (1) to investigate psychometric properties of a new questionnaire (SAPE, Scales of the Attitudes toward People with Epilepsy) that assesses attitudes toward people with epilepsy (PWE) (2) to compare the effects of mode of survey administration (web-based vs. face-to-face) on attitudes, and (3) to identify predictors of attitudes.; METHODS: A face-to-face and a web-based survey were performed in Germany. Weighting factors were used to achieve representative samples of the German population. Reliability and validity of the 6 scales of the SAPE (social distance, stereotypes, personal concerns, and emotional reactions differentiated by fear, anger, and pity) were evaluated and compared for both surveys. Epilepsy knowledge was also assessed. General linear models were performed to investigate predictors of attitudes toward PWE including the type of survey.; RESULTS: In total, 1001 participants of the web-based survey and 1026 participants of face-to-face survey were included. Psychometric analyses indicated satisfactory reliability and validity of the scales and differed only slightly between modes of survey. In both surveys, fears and concerns were more pronounced than stereotypes and social distance. However, mean values of two scales were slightly or moderately higher in the face-to-face survey indicating more negative attitudes toward PWE (p

ZusammenfassungEpilepsien zählen zu den häufigsten neurologischen Erkrankungen mit etwa 600 000 Betroffenen in Deutschland. Symptome epileptischer Anfälle, die Vielzahl möglicher Epilepsieursachen und die unterschiedlichen Krankheitsverläufe erschweren sowohl die korrekte Diagnosestellung als auch die Auswahl einer geeigneten Therapie (Antikonvulsiva, epilepsiechirurgische Eingriffe, Neurostimulationsverfahren, ketogene Ernährungstherapien, Verhaltensstrategien u. a.). Zudem haben krankheitsspezifische Risiken sowie häufig auftretende Komorbiditäten nicht selten gravierende psychosoziale Konsequenzen. Daher wird bei der Versorgung von Menschen mit Epilepsie neben der vollständigen Anfallskontrolle ohne Nebenwirkungen und der Lebensqualität auch die Kontrolle bzw. Linderung typischer Begleiterkrankungen und Risiken angestrebt. Um diese Behandlungsziele zu erreichen, sind spezifische Fachkenntnisse und Untersuchungsmöglichkeiten erforderlich, die von spezialisierten Zentren vorgehalten werden. Epilepsiezentren sind als überregionale Kompetenzzentren definiert, die über spezielle Expertise und eine besondere Ausstattung zur ambulanten und stationären Versorgung von Patienten mit Epilepsien und verwandten Erkrankungen verfügen. Zu ihren Aufgaben zählen u. a. die umfassende Diagnostik, Differenzialdiagnostik und Therapie von Epilepsiepatienten sowie die multiprofessionelle und interdisziplinäre Beratung von Angehörigen und Eltern. Dieser Artikel fasst die diagnostischen und therapeutischen Herausforderungen bei der Versorgung von Menschen mit Epilepsien zusammen, beschreibt die personellen, apparativen und institutionellen Voraussetzungen von Epilepsiezentren und gibt eine Übersicht über die Vergütung epileptologischer Spezialleistungen nach G-DRG. Darüber hinaus werden Merkmale einzelner Epilepsiezentren in Deutschland skizziert sowie Perspektiven und Möglichkeiten zur Verbesserung der Versorgung von Epilepsiepatienten diskutiert.

Vagus nerve stimulation (VNS) is well established in the treatment of epilepsy and disorders of depression. The prevalence of depression is high in patients with epilepsy, but still it remains unclear how patients with a comorbidity of epilepsy and symptoms of depression respond to VNS.We investigated 59 patients with different subtypes of disorders of depression as a comorbidity of epilepsy, who underwent VNS-surgery. Before and one year after VNS surgery, the severity of symptoms of depression was evaluated by a psychiatrist using Montgomery-Åsberg Depression Rating Scale (MADRS) and Beck-Depressions-Inventory (BDI). Response towards epilepsy was measured by a seizure reduction of at least 50%.Symptoms of depression ameliorated in response to VNS in the overall of all patients MADRS 29 to 18 (p 0,001) and BDI 24 to 14 (p 0,001) and all subtypes of disorders of depression. Seizure reduction of at least 50% was achieved in two out of three of all patients two years after VNS.We were able to show the beneficial effect of VNS in the treatment of patients with pharmacoresistant epilepsy and a comorbidity of symptoms of depression.

Objective The objective of the present study was to collect systematic data on the care of adult patients with tuberous sclerosis complex (TSC) in German epilepsy centers, to describe the characteristics of patients in this age group, and to clarify whether and how the recommended interdisciplinary care is implemented. Methods This retrospective survey involved 12 major epilepsy centers in Germany. Aggregated data were collected based on an electronic questionnaire that addressed the sociodemographic data, characteristics of the epilepsy syndromes, and general healthcare setting of adult patients with TSC. Results The survey included 262 patients (mean age: 36.2 ± 9.0 years) with TSC, most of whom were reported to live in either a home for persons with a disability (37.0%), a residential care home (6.9%), or with their parents (31.1%). A further 13.0% were self-sustaining, and 8.8% were living with a partner. Most patients presented with focal (49.6%) or multifocal (33.2%) epilepsy, with complex partial, dialeptic, and automotor seizures in 66% of patients and generalized tonic–clonic seizures in 63%. Drug-refractory epilepsy was seen in 78.2% of patients, and 17.6% were seizure-free at the time of the survey. Of the 262 patients, presurgical diagnostics were performed in 27% and epilepsy surgery in 9%, which rendered 50% of these patients seizure-free. Renal screening had been performed in 56.1% within the last three years and was scheduled to be performed in 58.0%. Cases of renal angiomyolipoma were present in 46.9% of the patients. Dermatologic and pulmonary screenings were known to be planned for only few patients. Conclusion Despite TSC being a multisystem disorder causing considerable impairment, every fifth adult patient is self-sustaining or living with a partner. In clinical practice, uncontrolled epilepsy and renal angiomyolipoma are of major importance in adult patients with TSC. Most patients suffer from focal or multifocal epilepsy, but epilepsy surgery is performed in less than 10% of these patients. Interdisciplinary TSC centers may help to optimize the management of patients with TSC regardless of age and ensure early and adequate treatment that also considers the advances in new therapeutic options.

Die Studie Stimulation of the Anterior Nucleus of Thalamus for Epilepsy (SANTE) ist bislang die einzige klinische Arbeit, die die Effizienz der tiefen Hirnstimulation (THS) bei Epilepsien mit Evidenzklasse 1 untersucht hat. Weiterhin fehlen Stratifizierungen moglicher Responder bzw. potenzieller Kontraindikationen. Rationale sowie Design eines doppeltverblindeten und eines offenen interventionellen Untersuchungsprotokolls fur den Nucleus accumbens (NAC) als Zielpunkt einer THS-Therapie fur fokale Epilepsien werden vorgestellt. In beiden Untersuchungsprotokollen werden potenzielle psychiatrische Veranderungen anhand des Beck-Depression-Inventory (BDI) und des Mini-International-Neuropsychiatric-Interview (M.I.N.I.) sowie kognitive Veranderungen mithilfe einer ausfuhrlichen epilepsiespezifischen neurokognitiven Untersuchung erfasst. Zusatzlich wird zur Objektivierung moglicher Veranderungen der Anfallsschwere die Liverpool Seizure Severity Scale (LSSS) angewendet. Die Bestimmung der Lebensqualitat erfolgt mithilfe des „Quality of Life Inventory for Epilepsy P-31“. In den von den Patienten ausgefullten Anfallskalendern werden einfach-fokale, komplex-fokale und generalisierte tonisch-klonische Anfalle unterschieden und dokumentiert. Bei allen THS-behandelten Patienten wird die antiiktale Medikation wahrend des Untersuchungszeitraums unverandert belassen. Zur Aufnahme in das 6-monatige interventionelle Untersuchungsprotokoll ist eine Anfallsfrequenz von mindestens einem behindernden Anfall/Monat gefordert. Das randomisierte kontrollierte Untersuchungsprotokoll hat einen kurzeren Beobachtungszeitraum von lediglich 3 Monaten und verlangt mindestens 3 behindernde Anfalle/Monat. Bei den 4 bislang in das offene interventionelle Untersuchungsprotokoll einbezogenen Patienten war nach 6-monatiger NAC-THS eine tendenzielle Reduktion der Schwere der Anfalle (p = 0,068), allerdings ohne Veranderung der absoluten Anfallsfrequenz, festzustellen. Psychiatrische bzw. neurokognitive Auswirkungen fanden sich nicht. Diese vorlaufigen Ergebnisse weisen darauf hin, dass der NAC potenziell ein zusatzlicher Zielpunkt der THS bei einer syndromorientierten Indikationsstellung fur fokale Epilepsien sein kann. Aufgrund der geringen Fallzahl und des unverblindeten Untersuchungsdesigns stehen jedoch ein Wirksamkeitsnachweis sowie die weitergehende Charakterisierung von Wirkung und Nebenwirkungen noch aus.

The most widely used neuro-stimulation treatment for drug-resistant epilepsy is Vagus Nerve Stimulation (VNS) Therapy®. Ictal tachycardia can be an indicator of a seizure and, if monitored, can be used to trigger an additional on-demand stimulation, which may positively influence seizure severity or duration. A new VNS Therapy generator model, AspireSR®, was introduced and approved for CE Mark in February 2014. In enhancement of former models, the AspireSR has incorporated a cardiac-based seizure-detection (CBSD) algorithm that can detect ictal tachycardia and automatically trigger a defined auto-stimulation. To evaluate differences in preoperative, intraoperative and postoperative handling, we compared the AspireSR to a conventional generator model (Demipulse®).Between February and September 2014, seven patients with drug-resistant epilepsy and ictal tachycardia were implanted with an AspireSR. Between November 2013 and September 2014, seven patients were implanted with a Demipulse and served as control group. Operation time, skin incision length and position, and complications were recorded. Handling of the new device was critically evaluated.The intraoperative handling was comparable and did not lead to a significant increase in operation time. In our 14 operations, we had no significant short-term complications. Due to its larger size, patients with the AspireSR had significantly larger skin incisions. For optimal heart rate detection, the AspireSR had to be placed significantly more medial in the décolleté area than the Demipulse. The preoperative testing is a unique addition to the implantation procedure of the AspireSR, which may provide minor difficulties, and for which we provide several recommendations and tips. The price of the device is higher than for all other models.The new AspireSR generator offers a unique technical improvement over the previous Demipulse. Whether the highly interesting CBSD feature will provide an additional benefit for the patients, and will rectify the additional costs, respectively, cannot be answered in the short-term. The preoperative handling is straightforward, provided that certain recommendations are taken into consideration. The intraoperative handling is equivalent to former models-except for the placement of the generator, which might cause cosmetic issues and has to be discussed with the patient carefully. We recommend the consideration of the AspireSR in patients with documented ictal tachycardia to provide a substantial number of patients for later seizure outcome analysis.