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To identify the views of people with epilepsy (PWE), and their significant others, on the repurposing and trialing of statins as a potential antiepileptogenic or disease-modifying treatment for those who have had the first seizure.Online questionnaire. Participants needed to be aged ≥ 16 years, UK residents, and able to independently complete a questionnaire in English. User groups distributed study adverts. Embedded infographics explained repurposing, why anti-seizure treatment is not typically started after a first seizure and the nature of randomized placebo-controlled trials (RCTs). The questionnaire asked participants to reflect and rate their expected willingness to have started an unspecified treatment after their first seizure/s (or that of the person with epilepsy they knew). They also rated willingness if the treatment were a statin, views of statins, the importance of an RCT of statins to their community, the outcomes it should assess, and their willingness to have taken part in it. The estimated number needed for the survey was 324.Responses from 213 persons were analyzed; 111 (52.1%) were PWE and 102 (47.9%) significant others. The median years diagnosed was 10 and PWE suffered from relatively severe epilepsy. One hundred and seventeen (54.9%) said they would have started an unspecified treatment after their first seizure/s (or supported the person with epilepsy they knew to have). A similar proportion (55.4%) said they would have started the treatment if it were a statin. Participants' main concern about statins, expressed by 79%, was their possible side effects. Repurposing was a concern for only 25%. Most (85.8%) rated an RCT of statins as of extreme or high importance; 54.4% said they would have participated.The PWE and significant others (SOs) responding to our survey expressed views towards repurposing statins that were generally positive and indicate a trial in those who have had a first seizure might be feasible. Concerns regarding side effects are common. Our findings could help optimize a future trial's design and the case for funding. Limitations include that we did not survey persons who had experienced a first seizure and did not go on to develop epilepsy. Also, persons with uncontrolled epilepsy were overrepresented.

BACKGROUND Meningioma is the commonest primary brain tumour. 70% of patients are seizure-free at presentation, but approximately 12% will have seizures within 12 months of surgery. Seizures impact quality of life. Neurosurgeons administer prophylactic anti-epileptic drugs (AED) to prevent seizures despite a lack of evidence to support this. A meta-analysis of RCTs in brain tumours suggests that older AED may prevent seizures in the first week after surgery but not thereafter. There are no studies assessing newer AEDs in the prophylactic setting. RESEARCH QUESTION In patients with meningioma who have never had a seizure and are undergoing surgical resection, does prophylactic levetiracetam reduce the risk of developing seizures? DESIGN multi-centre, double-blind RCT in 20 UK centres. 1:1 randomisation of 14 days levetiracetam 500mg bd started one day before surgery compared to placebo. PRIMARY OBJECTIVE Determine whether 2 weeks prophylactic levetiracetam reduces the risk of developing seizures within 12 months of surgery compared to placebo. ECONOMIC OBJECTIVE Estimate cost-effectiveness of prophylactic levetiracetam. SECONDARY OBJECTIVES Determine effect of prophylaxis on time to first seizure and first convulsive seizure, whether prophylaxis affects quality of life and influences return to driving, safety of prophylaxis. POPULATION seizure-naïve meningioma undergoing surgery. SAMPLE SIZE seizure rate at 12 months is 12.3%. A 50% reduction is clinically beneficial. A two-group chi-squared test with 5% two-sided significance level will have 90% power to detect the difference between a Group 1 proportion of 0.12 and a Group 2 proportion of 0.06 when the sample size in each group is 477. Allowing for 5% dropout, 1004 patients will be recruited. FUNDING NIHR (£1.64M) award June 2020. Study opens March 2021. TRANSLATIONAL RESEARCH MRI, blood and tissue will be collected to explore risk factors for seizures. CONCLUSIONS study will provide class I evidence of the role of prophylactic levetiracetam in meningioma surgery.

The COVID-19 pandemic will impact on how care for chronic conditions is delivered. We use epilepsy to exemplify how care for patients will be affected, and suggest ways in which healthcare systems can respond to deliver the most effective care. Where face-to-face outpatient appointments have been cancelled, telemedicine can facilitate remote clinical consultations for new and follow-up epilepsy clinic patients while reducing the risk of infection to both patients and healthcare staff. First-seizure patients will need investigation pathways rationalised, while those with chronic epilepsy will need to have reliable alternative avenues to access clinical advice. At the same time, neurologists should support emergency departments and acute medical units, advising on appropriate management of seizures and other acute neurological presentations. Ultimately, the revolution in our clinical practice is unlikely to cease after this pandemic, with reconfiguration of services likely to bring improvements in efficiency and convenience, and a reduced environmental impact.

IntroductionSeizures are a common presentation in the Emergency Department (ED). Previous rounds of NASH (2011 and 2013) identified major deficiencies in the provision of care and a disconnection between acute medicine and neurology services. Has there been any improvement?MethodsSetting137 Hospital sites across the UK. Participants: 4132 attendances between 01/06/2018– 30/06/2019 were assessed, 61% had a prior diagnosis of epilepsy and 23% presented with suspected first seizure. Outcome Measures: Data were recorded to assess prior care, the acute presentation and subsequent care including referral for specialist review.ResultsFor patients presenting with first seizure an attempt was made to contact an eyewitness in 70.4%. CT Brain was requested in the ED in 66%, which has increased from 45% in NASH 1. Onward referral for specialist review was requested in 64%.For patients with epilepsy 55% had not seen an epilepsy specialist in the previous 12 months. CT Brain was requested in 30%, increasing from 17% in NASH 1. Specialist review was requested for 35% who had not seen a specialist in the previous 12 months and for 44% who had.ConclusionsThere has been little improvement in the past decade. Improvements are urgently needed to improve the wellbeing of patients presenting with seizures, patients with epilepsy and the efficiency of the healthcare system.gpowell@liv.ac.uk34

Routinely collected administrative datasets can be used to identify healthcare resource use and inform strategic planning and policy development. We evaluate a new comprehensive epilepsy admission algorithm using ICD-10 coding data from these administrative datasets against a gold standard and existing admission identification algorithms.All consecutive admissions to a large UK general hospital meeting predefined criteria were identified over a one-month period. Case note review was performed by independent clinicians and admission classi- fied as epilepsy or not epilepsy related. The Liverpool algorithm and a widely used comparator algorithm were applied to the ICD-10 administrative data and compared to clinician classification.In total 205 admissions were identified. Case-note review (gold standard) identified that 35 cases were epilepsy related admissions, and 156 were not epilepsy related. It was not possible to classify 14 admis- sions due to missing or insufficient data. The Liverpool algorithm incorrectly classified only 17 out of 191 admissions compared to 30 incorrectly classified admissions from a comparator algorithm. The Liverpool algorithm demonstrates sensitivity of 85.7% and specificity of 92.3%.Whilst no perfect algorithm is likely to exist, the Liverpool algorithm identifies hospital admissions due to epileptic seizures using administrative data with improved sensitivity and specificity compared to previous methods.james.mitchell@liverpool.ac.uk

Aims To date, meningioma clinical trial activity has been limited, but a number of high-quality studies are underway, with more in development. There is heterogeneity in the outcomes reported in meningioma clinical trials. The COSMIC Project will develop two ‘Core Outcome Sets’ (COS) through comprehensive, transparent, consensus methodology; to ensure outcomes relevant to key stakeholders are reported within and across future meningioma clinical studies. The first will be for use in clinical effectiveness trials (COSMIC: Intervention), the second will be for use in clinical studies of incidental meningioma (COSMIC: Observation). Method Three systematic literature reviews will be performed to generate a long-list of outcomes potentially relevant to meningioma patients, healthcare professionals, researchers, and other stakeholder groups. The first systematic review will present the outcomes reported in published and ongoing meningioma clinical effectiveness trials. The second systematic review will present patient-reported outcomes (PRO) from the measurement tools utilised in meningioma PRO studies. The third systematic review will present the outcomes reported in published and ongoing clinical studies of untreated meningioma. Outcomes will be deduplicated, unique outcomes categorised according to the taxonomy presented by COMET, and the lists combined. The long-list of outcomes will be prioritised through two, 2-round, modified eDelphi surveys including meningioma patients, healthcare professionals, researchers, and other stakeholder groups. Undecided outcomes from both eDelphi surveys will be ratified at two, one-day consensus meeting, with representation from all key stakeholder groups. Results We have formed a study advisory group with international representation from key organisations. The project already has confirmed support from the International Consortium on Meningioma (ICOM), the European Association of Neuro-Oncology (EANO), the Response Assessment in Neuro-Oncology Patient-Reported Outcome group (RANO-PRO), the Society for Neuro-Oncology (SNO), British Neuro-Oncology Society (BNOS), Society of British Neurological Surgeons (SBNS), The Brain Tumour Charity (TBTC), and Brainstrust. Conclusion Standardising minimum outcome reporting in meningioma clinical effectiveness trials and meningioma clinical studies, through the development of these two COS will ensure outcomes reported are relevant to key stakeholder groups, including patients, whilst reducing research waste for a disease with increasing clinical trial activity. We seek to raise awareness of this project and invite participation from a wide range of stakeholders to ensure that the final COS reflects the opinion of the neuro-oncology community. Registration will take place via the study website www.thecosmicproject.org between June-August 2021.

Background Cauda Equina Syndrome (CES) is an emergency condition that requires acute intervention and can lead to permanent neurological deficit in working age adults. A Core Outcome Set (COS) is the minimum set of outcomes that should be reported by a research study within a specific disease area. There is significant heterogeneity in outcome reporting for CES, which does not allow data synthesis between studies. The hypothesis is that a COS for CES can be developed for future research studies using patients and healthcare professionals (HCPs) as key stakeholders. Methods and findings Qualitative semi-structured interviews with CES patients were audio-recorded, transcribed and analysed using NVivo to identify the outcomes of importance. These were combined with the outcomes obtained from a published systematic literature review of CES patients. The outcomes were grouped into a list of 37, for rating through two rounds of an international Delphi survey according to pre-set criteria. The Delphi survey had an overall response rate of 63% and included 172 participants (104 patients, 68 HCPs) from 14 countries who completed both rounds. Thirteen outcomes reached consensus at the end of the Delphi survey and there was no attrition bias detected. The results were discussed at an international consensus meeting attended by 34 key stakeholders (16 patients and 18 HCPs) from 8 countries. A further three outcomes were agreed to be included. There was no selection bias detected at the consensus meeting. There are 16 outcomes in total in the CESCOS. Discussion This is the first study in the literature that has determined the core outcomes in CES using a transparent international consensus process involving healthcare professionals and CES patients as key stakeholders. This COS is recommended as the most important outcomes to be reported in any research study investigating CES outcomes and will allow evidence synthesis in CES.

ObjectivesTo establish the appropriateness of a previously developed seizure care pathway by exploring to what extent patients valued the intervention and perceived it as being helpful or not.DesignQualitative descriptive study, using semistructured, in-depth interviews and thematic template analysis, theoretically informed by critical realism.SettingIn North West England, a seizure care pathway has been developed in collaboration with a specialist neurology hospital to support clinical management of seizure patients on initial presentation to the emergency department (ED), as well as access to follow-up services on discharge, with the aim of improving patient experience. Three National Health Service (NHS) EDs and a specialist neurology hospital provided the setting for participant recruitment to this study.Participants181 patients fulfilled the inclusion criterion with 27 participants taking part following their experience of an ED attendance and outpatient follow-up appointment after a seizure.ResultsFive main themes emerged from the data: decision to seek care, responsiveness of services, waiting and efficiency, information and support, and care continuity. Two integrative themes spanned the whole study: lived experience and communication. This paper reports on two of the main themes: care continuity, and waiting and efficiency. The average time between ED presentation and interview completion was 100 days.ConclusionsImplementation of a care pathway is a complex intervention, requiring long-term follow-up to assess its integration into practice and effectiveness in service improvement. The seizure care pathway has the potential to enhance the care of seizure patients in the ED and at follow-up by improving continuity and management of care. The study demonstrates good aspects of the seizure care pathway as observed by patients and also recognises shortcomings within current service provision and questions what the NHS should and should not be delivering. Our study suggests various ways to enhance the pathway at service level to potentially drive improved patient experience.

Aims: Utility values that can be used in the economic evaluation of treatments for epilepsy can be elicited from the general population and the patient population, but it is unclear how the health state values differ. The aim of this study is to compare the preferences of the general population and a sample of people with epilepsy for health states described by the NEWQOL-6D QALY measure. Methods: The Time Trade Off preference elicitation technique was used to value eight NEWQOL-6D health states. The general population sample was recruited and interviewed in their homes, and the sample with epilepsy was recruited and interviewed in an epilepsy service in North West England. Descriptive analysis and regression modeling were used to compare health state values across the populations. Results: A sample of 70 people with epilepsy and a sample of 60 members of the general population were included. The populations differed across a range of background characteristics, but there were limited differences between the health state values. Patients provided significantly higher (better) values for the most severe health state described by the NEWQOL-6D (p < 0.01) and nonsignificant higher values for states with intermediate severity. The general population health state value was only higher for the best health state described by the NEWQOL-6D. Conclusions: The similarities in the patient and general population values for NEWQOL-6D health states suggest that the use of the general population utility weights for the estimation of QALYs in the economic evaluation of epilepsy interventions is appropriate and largely representative of patient preferences. © 2014 Elsevier Inc.

Cost-utility analysis is used to inform the allocation of healthcare resources, using the quality-adjusted life year (QALY) as the outcome measure. We report the development of an epilepsy-specific QALY measure (NEWQOL-6D) derived from the NEWQOL measure of health-related quality of life. Firstly, psychometric and Rasch analyses established the dimension structure of NEWQOL and generated a reduced health state classification system including one item per dimension. Secondly, health states generated by the classification system were valued using Time Trade Off, and the results were modeled to generate a utility score for every health state. A classification system with 6 dimensions (worry about attacks; depression; memory; concentration; stigma; control) was produced, and generalized least squares regression was used to generate utility scores for every health state. This study is the first attempt to derive an epilepsy-specific QALY measure, and the utility values can be used in the economic evaluation of emerging technologies for epilepsy. © 2012 Elsevier Inc.

There are a number of administrative datasets that routinely record information on individuals in the UK. Such routine or ‘Big Data’ sources record specified data variables that are largely limited to those that enable the intended objectives of the data holder. Routine sources include clinical datasets such as Hospital Episode Statistics (HES) and the Clinical Practice Research Datalink (CPRD). In addition, non-health data is recorded by the Department of Work and Pensions (DWP), HM Revenue and Customs (HMRC) and The Driving and Vehicle Licensing Authority (DVLA) in order to meet the specified objectives of each authority. Routine data applied to clinical research is potentially cost and resource-use effective. Clinical sources of data such as HES and CPRD are commonly accessed to provide data for retrospective observational and record-linkage studies and there are many published examples. However, there is limited evidence on the use of routine data in prospective studies, particularly randomised controlled trials (RCTs). This on-going project aims to assess the feasibility, accuracy, reliability and additional benefits of using data from routine sources for patients participating in the Standard and New Antiepileptic Drugs II RCT. Clinical and health economic outcomes will be examined from sources including HES, CPRD, DWP, HMRC and DVLA and assessed in comparison to data obtained from traditional RCT methods. This presentation will narratively summarise the methods of access, application procedures and limitations encountered thus far with accessing individual-level, linked data from the listed routine data sources.

There are a number of clinical and non-clinical administrative datasets that routinely record information on individuals in the UK. Access for secondary uses such as clinical research is permitted when health and social care benefit can be demonstrated. Clinical sources of data are commonly accessed to provide data for retrospective observational and record-linkage studies and provide a valid dataset for this purpose. Routinely recorded data may also present advantages to prospective clinical research such as randomised controlled trials (RCTs). The majority of RCTs incur health service costs as clinicians assess participants, record outcomes and complete Case Report Forms – hence using routinely recorded data may provide an efficient alternative method for data collection in addition to reducing the burden on participants. Furthermore, data from non-clinical routine sources may inform outcomes beyond the standard RCT assessments of clinical efficacy and effectiveness. However, limitations with accuracy of coding, confidentiality, ownership and access have previously been identified as significant barriers. This study has assessed the feasibility of accessing clinical and non-clinical routinely recorded data during a RCT assessing treatments for newly diagnosed epilepsy and will assess the agreement and additional benefits of routinely recorded data compared to data collected using standard prospective methods.

INTRODUCTION Epilepsy is common, with a lifetime prevalence of 2–5% of the general population (Goodridge & Shorvon 1983a; Goodridge & Shorvon 1983b, Shorvon 1990) and a point prevalence of between 4 and 8 per 1000 (Hauser et al. 1993). Epilepsy represents a significant fraction of the workload for most neurologists, and indeed, never has specialist input been more necessary as the choice of antiepileptic drugs (AEDs) continues to grow: eight new AEDs have been licensed for use in the UK since the late 1980s, with the promise of more to come (Bialer et al. 2001). Despite these recent additions to the ranks of available anticonvulsants, epilepsy remains both stigmatizing and debilitating for many of those with the disorder (Reynolds 1990). This article deals with a number of issues surrounding the newer drugs. We will look at the certainties surrounding the older drugs, the possibilities surrounding the newer ones, and

Advice from the Medicines and Healthcare Products Regulatory Agency (MRHA) on switching between different manufacturers’ products for a particular antiepileptic drug may have unintended consequences.1 2 In a move to allay concerns about the potential loss of seizure control when switching products, the MHRA’s classification of these drugs according to their pharmacokinetic and pharmacodynamics properties may encourage switching—for cost …

Objectives Before a predictive or prognostic model, often developed using data from clinical trials, can be introduced into general practice, it needs to be externally validated to ensure that it performs satisfactorily in data sets that are fully independent of the development data. Various methods exist to handle covariates with missing data and many of these are regularly employed in the analysis of data from a single trial. We propose that several of these strategies may be adapted to handle covariates with every entry missing in the context of external validation.

Background:\ud \ud Carbamazepine causes various forms of hypersensitivity reactions, ranging from maculopapular exanthema to severe blistering reactions. The HLA-B*1502 allele has been shown to be strongly correlated with carbamazepine-induced Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS–TEN) in the Han Chinese and other Asian populations but not in European populations.\ud Methods:\ud \ud We performed a genomewide association study of samples obtained from 22 subjects with carbamazepine-induced hypersensitivity syndrome, 43 subjects with carbamazepine-induced maculopapular exanthema, and 3987 control subjects, all of European descent. We tested for an association between disease and HLA alleles through proxy single-nucleotide polymorphisms and imputation, confirming associations by high-resolution sequence-based HLA typing. We replicated the associations in samples from 145 subjects with carbamazepine-induced hypersensitivity reactions.\ud Results:\ud \ud The HLA-A*3101 allele, which has a prevalence of 2 to 5% in Northern European populations, was significantly associated with the hypersensitivity syndrome (P=3.5×10−8). An independent genomewide association study of samples from subjects with maculopapular exanthema also showed an association with the HLA-A*3101 allele (P=1.1×10−6). Follow-up genotyping confirmed the variant as a risk factor for the hypersensitivity syndrome (odds ratio, 12.41; 95% confidence interval [CI], 1.27 to 121.03), maculopapular exanthema (odds ratio, 8.33; 95% CI, 3.59 to 19.36), and SJS–TEN (odds ratio, 25.93; 95% CI, 4.93 to 116.18).\ud Conclusions:\ud \ud The presence of the HLA-A*3101 allele was associated with carbamazepine-induced hypersensitivity reactions among subjects of Northern European ancestry. The presence of the allele increased the risk from 5.0% to 26.0%, whereas its absence reduced the risk from 5.0% to 3.8%. (Funded by the U.K. Department of Health and others.)

Objective We sought to understand how antiepileptic drug (AED) decisions, similar to those that occur in observational studies on AEDs, were made between doctors and patients in the hospital clinic. We could find no previous research that focused specifically on understanding AED decision making in epilepsy. Methods In-depth interviews were conducted with patients who carried a secure diagnosis of epilepsy and who had recently attended a follow-up appointment with a consultant with a special interest in epilepsy. Interviews were digitally recorded and professionally transcribed. A “grounded theory” approach was used for analysis; the Nvivo (QRS release 2.0) computer package was used to manage the data effectively and transparently. No new important themes emerged by the final 10 transcripts, suggesting theoretical data saturation had been reached. Results Five major themes emerged: preappointment treatment considerations; preconsultation feelings and hopes; acceptance of prognosis and disillusionment; hypothetical change; and decisional ownership. Our interviewees appeared highly susceptible to the doctor’s suggestions. All those with active epilepsy and seizures that impacted their life appeared happy to follow the doctor’s advice—whatever that may be. This highlights both the desperation many patients have to be free of epilepsy and also the doctor’s authority; the perceived authority of the doctor seemed to explain why even patients who were seizure free said they would follow the advice to change treatment, were it suggested. Conclusion Our findings describe decision making from the patients’ perspective and support a dominant role for the doctor in the decision making process. There may be factors specific to intractable epilepsy that may be disempowering to involvement in decision making. However, whether patients wish for greater involvement in decision making remains unanswered as stated by one patient “But you’re there to take their [the doctor’s] advice, that’s what you go for don’t you?”.

The ILAE treatment guidelines for initial monotherapy emphasise the poor quality of information available to inform everyday clinical practice. Industry sponsored studies comparing antiepileptic drugs answer restricted licensing questions, rather than those relevant to the clinical community (patients, health professionals and founders of health care). The SANAD study, a pragmatic randomized clinical trial, offers a methodology to address some of these questions. It identifies lamotrigine as a cost-effective alternative to carbamazepine for the treatment of focal epilepsies, but confirms valproate as the most effective drug for the treatment of generalized or unclassified epilepsy.

There have been very few national audits of the care provided to patients with epilepsy. The confidential enquiry into maternal deaths in epilepsy and the Clinical Standards Advisory Group report identified deficiencies in the care of people with epilepsy in the UK. However, the Department of Health's response was lukewarm and additional investment earmarked for services was not forthcoming. Neither epilepsy nor neurological conditions moved up the list of priorities for commissioning. Similarly, the National Services Framework for longer term conditions did not come with ring-fenced resources. So, will the National Audit of Seizure Management in Hospitals (NASH)1 receive a similar response? This is possible, but we should take encouragement from the success of other national audits, such as those for stroke or chronic obstructive pulmonary disease, since they played a major role in driving up standards and moving these conditions up the commissioning agenda. Seizures account for 2–3% of emergency …

Purpose A third of people with epilepsy are pharmacoresistant. As pharmacoresistance is a complex trait, a genome-wide pathway-level approach is likely to prove especially fruitful in its study. Methods We performed a genome-wide association study (GWAS) of pharmacoresistant partial epilepsy, with discovery and replication cohorts including, in total, 421 cases and 2624 normal population controls, and 5,519,310 genotyped and imputed SNPs. Results At the single variant level, there was no overlap in the top results of the two cohorts. However, at the gene-set and pathway level, there was clear replication of results between the two cohorts. For the combined ‘mega-analysis’, there were 71 distinct enriched pathways. We showed using network analysis that these enriched pathways form a highly interconnected network in which each pathway is directly connected, on average, to 8.4 other pathways. The enriched pathways, therefore, form a coherent whole, and changes in one pathway in this network will have a cascading effect on the rest of the network. Finally, we identified, using betweenness centrality network analysis, the most important central pathway in this network: signalling by NGF. Conclusion We have performed the first ever GWAS of pharmacoresistant partial epilepsy and identified the most central pathway underlying this phenotype.

Background NASH1 (National Audit of Seizure management in UK Hospitals) collected data in 2011 and fed back in 2012. It identified significant shortfalls and variability in the way that care was provided. Here we report the second round–NASH2. Methods NASH2 assessed the prior, immediate, and onward care of patients attending Emergency Departments with seizures. Sites provided anonymous data on 30 consecutive cases via a web-based database between June and September 2013. Results Data were collected from over 4,500 patients across 154 sites in the UK (mean age=47.1, 57% male). Results show considerable inter-site variability, with a few sites performing well to show good care is possible. Assessment on arrival was again inadequate, a proper neurological examination with plantar responses recorded in 34% (IQR 20.0–43.3), an attempt to gain an eyewitness description in 69% (IQR 60.0–83.3), and an ECG performed in 75% (IQR 65.9–86.7). Only 55% of first seizure patients were referred for any form of neurology specialist assessment, and less than half for known epilepsy. 45% had a previous attendance in the last 12 months. Conclusions Findings confirm unacceptable variability in the provision of care. Commissioners, primary, secondary and tertiary care, and the public must work together to commission and deliver better services.

Gabapentin, lamotrigine, tiagabine, topiramate, vigabatrin, and zonisamide are all administered as add-on therapy for treatment of patients with refractory epilepsy. To date, no comparative randomized trials have been performed that could potentially allow an evidence-based choice to be made between these antiepileptic drugs (AEDs). We report a series of meta-analyses of placebo-controlled, randomized add-on trials in patients with partial epilepsy. Results of these meta-analyses are compared, thus giving broad estimates of the comparative efficacy and tolerability of these AEDs. The efficacy outcome is the odds ratio for the number of patients with aor = 50% reduction in seizure frequency. Reported side effects are also used as tolerability outcomes, and study withdrawal is used as a global outcome measure. Results are summarized as odds ratios with 95% confidence intervals (CIs). When each outcome is compared among drugs, the 95% CIs overlap. Therefore, no conclusive evidence of a difference in efficacy or tolerability between these AEDs was derived, even though the apparently most effective agent (topiramate) may be twice as effective as the apparently least effective agent (lamotrigine). Comparative randomized studies are needed to further evaluate these drugs.

Background Little is known about the organisation and delivery of epilepsy care in the UK. The National Audit of Seizure management in Hospitals (NASH) is the first comprehensive UK-wide epilepsy audit. Methods NASH assessed the immediate care, onward care pathways and prior care of patients attending Emergency Departments with seizures. Sites provided anonymous data on 30 consecutive cases via a bespoke web-based database. Results Data were collected from over 3750 patients across 127 sites in the UK (mean age=45.8 (SD 19.9), 57% male). Results show considerable variability, with a few sites performing well demonstrating that good care is possible. But overall, assessment on arrival was inadequate, routine measurements were not done (temperature in only 83% of patients), a proper neurological examination with plantar responses recorded in 37% (IQR 20.0–49.1), an attempt to gain an eyewitness description in 58% (IQR 43.3–73.3), and an ECG performed in 59% (IQR 43.3–75.8). Only 51% of first seizure patients were referred for any form of neurology specialist assessment. Conclusions Basic care currently provided shows wide variability and in many centres is inadequate to achieve good patient outcomes. Neurologists have to engage with acute services to improve this.