Search

Abstract: Driving for the person with epilepsy (PWE) remains an important issue. Requirements for reporting PWE to driving authorities vary across the United States. We studied the prior experiences of PWE regarding counseling for driving in a reporting state (37% in New Jersey) and a nonreporting state (52% in Arizona). A prospective voluntary anonymous survey was conducted among patients with new-onset epilepsy at two epilepsy referral centers. Subjects were queried about prior interactions with health care professionals regarding attitudes toward and knowledge of driving regulations. Practitioners caring for PWE are in the position to provide advice and counsel regarding driving regulations. Fifty percent or fewer subjects were appropriately counseled, regardless of residence requirements. PWE felt they were honest with their physician and 10% of subjects have driven against medical advice. A performance gap exists in the appropriate counseling regarding driving for PWE that has potentially significant safety and legal implications. [ABSTRACT FROM AUTHOR]

Abstract: Eyewitnesses frequently perceive seizures as life threatening. If an event occurs on the hospital premises, a “code blue” can be called which consumes considerable resources. The purpose of this study was to determine the frequency and characteristics of code blue calls for seizures and seizure mimickers. A retrospective review of a code blue log from 2001 through 2008 identified 50 seizure-like events, representing 5.3% of all codes. Twenty-eight (54%) occurred in inpatients; the other 22 (44%) events involved visitors or employees on the hospital premises. Eighty-six percent of the events were epileptic seizures. Seizure mimickers, particularly psychogenic nonepileptic seizures, were more common in the nonhospitalized group. Only five (17.9%) inpatients had a known diagnosis of epilepsy, compared with 17 (77.3%) of the nonhospitalized patients. This retrospective survey provides insights into how code blues are called on hospitalized versus nonhospitalized patients for seizure-like events. [Copyright &y& Elsevier]

Abstract: This study was designed to evaluate the utility of subtraction ictal SPECT coregistered to MRI (SISCOM) in atypical psychogenic nonepileptic seizures (PNES). Video-EEG monitoring (vEEG) is the gold standard for PNES diagnosis but, like any modality, has limitations. In difficult cases in which the diagnosis is suspected but remains in question after vEEG, a complementary study that could help differentiate epilepsy from PNES would be desirable. Thirteen SISCOM studies performed in patients with a final diagnosis of PNES were retrospectively reviewed. Common indications for SISCOM were semiology consistent with partial epilepsy (9/13), abnormal head MRI (5/13), and reported abnormal routine EEG (5/13). SISCOM was negative in 85% (11/13) of patients and was helpful in increasing the diagnostic certainty of PNES in these exceptional cases. [Copyright &y& Elsevier]

Abstract Psychological assessment measures are frequently used to evaluate patients in epilepsy monitoring units. One goal of that assessment is to contribute information that may help with differential diagnosis between epilepsy and psychogenic nonepileptic seizures (PNES). The Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) is one such measure. Del Bene et al. (2017) recently published an analysis that was the first to compare MMPI-2-RF scale elevations between diagnostic groups stratified by sex. The purpose of the present study was to replicate that analysis in a larger sample. Similar to previous work, we found that both men and women with PNES were more likely than men and women with epilepsy to report high levels of somatic complaints (2 to 5 times greater odds of somatic symptom reporting) and a variety of types of complaints. Mood disturbance scales were not significantly elevated in our PNES sample. Results contribute to the small body of research on sex differences in patients with PNES and suggest that somatization is a key characterization across sexes. [ABSTRACT FROM AUTHOR]

Background The diagnosis of epilepsy is at times elusive for both neurologists and nonneurologists, resulting in delays in diagnosis and therapy. The development of screening methods has been identified as a priority in response to this diagnostic and therapeutic gap. EpiFinder is a novel clinical decision support tool designed to enhance the process of information gathering and integration of patient/proxy respondent data. It is designed specifically to take key terms from a patient's history and incorporate them into a heuristic algorithm that dynamically produces differential diagnoses of epilepsy syndromes. Objective The objective of this study was to test the usability and diagnostic accuracy of the clinical decision support application EpiFinder in an adult population. Methods Fifty-seven patients were prospectively identified upon admission to the Epilepsy Monitoring Unit (EMU) for episode classification from January through June of 2017. Based on semiologic input, the application generates a list of epilepsy syndromes. The EpiFinder-generated diagnosis for each subject was compared to the final diagnosis obtained via continuous video electroencephalogram (cVEEG) monitoring. Results Fifty-three patients had habitual events recorded during their EMU stay. A diagnosis of epilepsy was confirmed (with cVEEG monitoring) in 26 patients while 27 patients were found to have a diagnosis other than epilepsy. The algorithm appropriately predicted differentiation between the presence of an epilepsy syndrome and an alternative diagnosis with 86.8% (46/53 participants) accuracy. EpiFinder correctly identified the presence of epilepsy with a sensitivity of 86.4% (95% confidence interval [CI]: 65.0–97.1) and specificity of 85.1% (95% CI: 70.2–96.4). Conclusion The initial testing of the EpiFinder algorithm suggests possible utility in differentiating between an epilepsy syndrome and an alternative diagnosis in adult patients. [ABSTRACT FROM AUTHOR]

Falls are one of the most common adverse events occurring in the epilepsy monitoring unit (EMU) and can result in significant injury. Protocols and procedures to reduce falls vary significantly between institutions as it is not yet known what interventions are effective in the EMU setting. This study retrospectively examined the frequency of falls and the impact of serial changes in fall prevention strategies utilized in the EMU between 2001 and 2014 at a single institution. Overall fall rate was 2.81 per 1000 patient days and varied annually from 0 to 9.02 per 1000 patient days. Both seizures and psychogenic nonepileptic events occurring in the bathroom were more likely to result in falls compared with events occurring elsewhere in the room. With initiation of increased patient education, hourly nurse rounding, nocturnal bed alarms, having two persons assisting for high fall risk patients when out of bed, and immediate postfall team review between 2001 and 2013, there was a trend of decreasing fall frequency; however, no specific intervention could be identified as having a particular high impact. In late 2013, a ceiling lift system extending into the bathroom was put in place for use in all EMU patients when out of bed. In the subsequent 15 months, there have been zero falls. The results reinforce both the need for diligent safety standards to prevent falls in the EMU as well as the challenges in identifying the most effective practices to achieve this goal. [ABSTRACT FROM AUTHOR]

Patients with recurrent, stereotyped neurological events of unclear etiology often warrant admission for continuous video-EEG monitoring in an epilepsy monitoring unit (EMU) for diagnosis. Epilepsy monitoring unit admission duration has been reported to range from days to weeks. To date, there are limited data on the average duration of admission for patients admitted to the EMU for spell classification. Many EMUs are forced to limit the overall duration of admission for numerous reasons including limited resources. It is unclear if a time-limited EMU stay reduces the event capture rate and, therefore, diagnostic yield of event classification admissions. The goal of this study was to determine how a time-limited length of stay strategy impacted event capture in patients admitted for spell classification. A retrospective chart review was performed at two comparable adult epilepsy monitoring units, Mayo Clinic Hospital (MCH) in Phoenix, Arizona, and Banner Good Samaritan Medical Center (BGSMC) in Phoenix, Arizona. Banner Good Samaritan Medical Center is only staffed Monday through Friday, thereby limiting the total possible duration of admission to five days. The goal was to determine if the rate of event capture differed between two institutions employing a time-limited EMU admission (BGSMC) when compared with the nonlimited admission (MCH). A total of 300 patient admissions at MCH and 260 patient admissions at BGSMC were reviewed over a comparable time period. The event capture rates at MCH and BGSMC were 74% and 72%, respectively. There was a greater percentage of patients with nonepileptic events (NEEs) at MCH than at BGSMC (62.7% vs. 47.3%). The mean duration until first event was 31 h at MCH and 38 h at BGSMC. The mean length of stay was greater at MCH (4.5 days) when compared with BGSMC (3.3 days). The overall diagnostic yield of a time-limited EMU admission was similar to that of a nonlimited admission for the purpose of spell classification. There was a statistically significant difference when comparing the time until first event at both institutions; however, this still fell within the 5-day duration that the time-restricted admission was limited to. These results may be important in optimizing an EMU practice in patients requiring admission for spell classification. [ABSTRACT FROM AUTHOR]

• Counseling PNES patients on driving is challenging given a lack of information. • Drivers with epileptic seizures have less car crashes but more hospitalizations. • Drivers with PNES have more frequent crashes, but fewer crash related injuries. Driving is a critical topic to counsel among patients with epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES), with significant legal and public health implications. This prospective cohort study examined the frequency of ES and PNES in a single institution's Epilepsy Monitoring Unit (EMU) and assessed driving-related issues between each group. Adult patients from the Mayo Clinic Arizona Epilepsy Monitoring Unit (EMU) were given comprehensive surveys addressing driving history. Descriptive analysis and statistics were used to summarize differences between patients with ES and PNES. Differences between patients with epilepsy and PNES were determined by Pearson chi-square. Nearly half (n = 75/163) of all patients admitted to the EMU were diagnosed with PNES. Although the PNES group had a statistically significant higher frequency of events (p = 0.01), 87.7% of these patients reported compliance with the driving law recommendations, suggesting a trend that patients who have been counseled regarding fitness-to-drive are likely to follow the recommendation. One-third of patients with PNES reported an event while operating a motor vehicle and 8% (n = 2/25) resulted in a motor vehicle collision severe enough to require hospitalization. In contrast to those with ES, 25% of patients reported a typical event while driving and 25% (n = 2/8) of those resulted in a collision requiring hospitalization. The incidence of habitual events while driving is higher in the population with PNES (n = 25) when compared to those with ES (n = 8); however, it appears that patients with PNES were less likely to become involved in an accident resulting in seriously bodily injury than in ES. Compared to patients with PNES, patients with ES have less frequent events but more severe collisions. This study reinforces the need for diligent driving counseling to help prevent driving-related injuries in patients with PNES and ES. [ABSTRACT FROM AUTHOR]

Abstract: The Somatic Complaints scale (SOM) and Conversion subscale (SOM-C) of the Personality Assessment Inventory perform best in classifying psychogenic non-epileptic seizures (PNES) from epileptic seizures (ES); however, the impact of positive impression management (PIM) and negative impression management (NIM) scales on SOM and SOM-C classification has not been examined. We studied 187 patients from an epilepsy monitoring unit with confirmed PNES or ES. On SOM, the best cut score was 72.5T when PIM was elevated and 69.5T when there was no bias. On SOM-C, when PIM was elevated, the best cut score was 67.5T and 76.5T when there was no bias. Negative impression management elevations (n=9) were too infrequent to analyze separately. Despite similarities in classification accuracy, there were differences in sensitivity and specificity with and without PIM, impacting positive and negative predictive values. The presence of PIM bias generally increases positive predictive power of SOM and SOM-C but decreases negative predictive power. [Copyright &y& Elsevier]

Abstract: The two most common personality measures used in evaluation of patients on epilepsy monitoring units (EMUs) are the Personality Assessment Inventory (PAI) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Both have been evaluated separately for their ability to distinguish patients with epilepsy from patients with psychogenic events, but they have never been compared directly. The primary aim of this study was to provide comparison data in an EMU population between the PAI, MMPI-2, and the MMPI-2-RF (MMPI-2 Restructured Form). Results show that the PAI Somatic Complaints (SOM) scale and the Conversion subscale (SOM-C), with classification rates of 79%, outperform other indicators from the PAI and indicators from the MMPI-2 and the MMPI-2-RF. Given its other strengths combined with better diagnostic validity performance, the PAI may be the better personality assessment measure for use in distinguishing patients with epilepsy from those with psychogenic seizures in the EMU. [Copyright &y& Elsevier]

Abstract: The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) is a restructuring of the MMPI-2 that has improved the psychometric characteristics of the test. The primary aim of this study was to provide diagnostic utility data on the MMPI-2-RF in an epilepsy monitoring unit population (N =429). Mean comparisons revealed group differences on Validity Scales Fs and FBS-r; Restructured Clinical Scales RC1 and RC3; and Somatic Scales MLS, GIC, HPC, and NUC. Diagnostic utility data are provided for those scales with the largest effect sizes: RC1, FBS-r, and NUC. On RC1, sensitivity was 76% and specificity was 60%, similar to values found when applying published decision rules to the MMPI-2. RC1 explains unique variance in diagnosis beyond that explained by demographic or medical history risk factors. We provide likelihood ratios for scores on RC1, FBS-r, and NUC that can be used by the clinician to calculate posttest odds and probability of nonepileptic seizures using the base rate of nonepileptic seizures in his/her population. [Copyright &y& Elsevier]

Abstract: Epilepsy monitoring unit (EMU) admissions during 2007–2009 at Mayo Clinic Hospital Arizona were reviewed. Of the 106 indeterminate admissions, 13 (12%) went on to have a second admission. During the second admission, 8 (62%) were diagnosed. Five patients went on to have a third or fourth admission, with none of them receiving a diagnosis. Nineteen (18%) patients had ambulatory EEG monitoring after an indeterminate admission, with only one (5%) receiving a diagnosis after ambulatory EEG monitoring. Even in patients who were initially indeterminate, medication management changed 37% of the time. Admission to the EMU was helpful for spell classification, with 80% of the patients receiving a diagnosis after the first admission. Based on this study, a second admission should be considered if no diagnosis is reached after the first admission. If no diagnosis is made after the second EMU admission, subsequent admissions are unlikely to produce a definitive diagnosis. [Copyright &y& Elsevier]

Abstract: In Arizona, other states, and other countries, people who experience a seizure or other transient alteration of consciousness may be legally restricted from driving. Arizona law requires that people with these conditions submit themselves for a medical review, whereas health care providers are not required to report to the authorities. Therefore, counseling people with these medical conditions about driving generally falls to health care providers, who are often not neurologists. Three hundred thirty-five consecutive charts of patients discharged from our Emergency Department were retrospectively reviewed by diagnosis codes associated with altered consciousness. A total of 267 patients met our inclusion criteria, of whom 27 (10.1%) were counseled regarding driving—by the Emergency Department physician and/or consulting neurologist. Although the counseling rate for driving was 10/29 (34.5%) when a neurologist was involved, it was found to be only 17/238 (7.1%) when neurological services were not sought. Patients presenting with seizure were more likely to be counseled than those presenting with other episodes of loss of consciousness. Accurate knowledge of driving laws by health care workers and patients has the potential to minimize liability and improve public safety and quality of care. [Copyright &y& Elsevier]