2016 has been a remarkable year for Seizure, and 2017 will be no less significant as we plan for our 25th anniversary celebrations next year. It was a pleasure to see our impact factor soaring and an increase in the quality and breadth of articles submitted to the journal. This cornucopia is reflected in the nine Editor’s choice articles from 2016. The papers of special merit that were chosen for additional attention really showcase the scope of Seizure.
Understanding of Epilepsy
Our focus on seizure onset and localisation can blind us to the importance of connectivity. Disrupting seizure propagation can be an effective method of limiting the effects of some epilepsies. Epilepsy is seen in two thirds of patients with complete or partial CC agenesis. This review on the corpus callosum and the role of callostomy is a timely reminder of the importance of the brain as a network and epilepsy as a network disruption disorder.
Treatment of epilepsy
When a new anti-epileptic drug has mechanistic similarities to an existing drug, it is important that we have head to head studies. The FDA approved brivaracetam this year and ahead of genuine head-to-head trials this paper created a virtual trial of 1765 people on levetiracetam and 1919 on brivaracetam.
Drug trials are criticised for lumping all patients in together – so what value a report of a homogenous group all with the same cause for their epilepsy? PCDH19 mutations cause a distinct epilepsy in females associated with intellectual difficulty. In this report of 58 patients clobazam and bromide were the most efficacious.
Epilepsy Diagnosis and monitoring
Seizure detection devices are at the forefront of the study in to SUDEP prevention, although they currently lack an evidence base. They have many benefits ahead of the current paper based diary and can be used to aim self-empowerment with regards to risk reduction.
Psychogenic non-epileptic attacks
Research in to psychogenic non-epileptic attacks (PNES) is greatly lacking and is therefore a special focus of Seizure. In the first paper 21 studies were analysed to collect the accounts of 220 people with PNEs discussing their attacks and the implications of the attacks and diagnosis on their lives. The diagnostic delay can be lengthy, their relationship with their healthcare provider precarious and even the words we use to describe this can induce resistance.
In the second paper 55 children with PNES and 35 siblings, underwent a psychiatric interview and a wide-ranging assessment. Those with PNES who internalised their disorder were more likely to be female and have an older age of PNES attack onset; those who somatised were more likely to have co-morbid epilepsy; and those with anxiety sensitivity were more likely to be female and have adverse life events such as being the victim of bullying.
Fatigue is a commonly reported symptom from people with epilepsy and one that is frustrating to treat because of its likely multifactorial aetiology. It is worth the effort however, as fatigue is a big driver of reduced quality of life and this was particularly so in people with poorly controlled seizures.
The UK and Ireland Epilepsy and Pregnancy register was born in Belfast and so one would expect the region to be a standard bearer in joint neurological and obstetric care. However, over half of women with epilepsy in Northern Ireland do not access the regional joint service. The most marginalised patient groups were women with epilepsy who were younger and those who lived a great distance from secondary care services.
Epilepsy surgery clearly has an evidence based capability to significantly improve the control of an individual’s epilepsy and this is reflected in their reduced use of healthcare. However, are there greater societal benefits to epilepsy surgery? 254 people with epilepsy and 989 controls were studied – surprisingly successful surgery conferred no benefit on social status in terms of a change in occupation and educational level.
It has been said that you can tell a lot about a man from the company that he keeps. So who has been the selected companions of our Editor, Markus Reuber in 2015? The year started with a piece from husband and wife team Carol and Peter Camfield looking at seizure related injuries in epilepsy. Their epidemiological studies in geographically restricted Nova Scotia, have added so much to the world of epilepsy. 11% of children with epilepsy experienced one or more serious injury: lacerations were most common (30%), but dental fractures (14%) and concussion (10%) were also frequently seen. They conclude that the best practical solution is to improve seizure control. The next selected article comes from the epilepsy surgery department at UCL, London and asks about the cognitive outcome of people who had temporal lobe surgery. As expected left-sided operations carried the greater risk of cognitive problems and that older adults also fare less well. The third paper looking at long term outcome focussed on children who underwent epilepsy surgery. Using the Swedish National Epilepsy Register, Reinholdson and colleagues were able to report that the initial post-operative seizure freedom often persists; 44% were seizure free at 5 or 10 years.
In addition to studying comorbidities Seizure has a history of publishing papers describing epilepsy treatments. Levetiracetam, particularly in secondary care, is a commonly prescribed drug in many territories. A meta-analysis from an Italian study group found 26 studies and 2832 people with epilepsy who were taking levetiracetam. Although generally well tolerated, some adverse effects were seen. In addition to the near ubiquitous anti-epilepsy drug side effects of somnolence, dizziness, and fatigue they identified two other adverse effects: nasopharyngitis and irritability. The next paper was a large prospective, multicentre description of an algorithm to trigger a vagus nerve stimulator. What is novel was that the trigger for this algorithm was cardiac rhythm and rate. This promising study needs replication but may provide a strategy to improve the efficacy of the device.
The next paper from Western Australia is a systematic review demonstrating the poor sensitivity and specificity of the amplitude-integrated EEG for seizure monitoring. This is important because it has gained popularity in a number of neonatal units. The tests used to monitor the most vulnerable children in hospital need to be more accurate than this. The last Editor’s choice of the year returned to look at epilepsy comorbidities, this time with a common but poorly understood symptom – interictal fatigue. 270 patients from Korea were used to show that poor seizure control and depression increased fatigue levels. They used a self-reporting scale, PROMIS, to identify sleep-disturbance – which reportedly, has benefits over both the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale. So over twelve months Markus has rubbed shoulders with authors from all four corners of the globe. He has chosen to highlight both articles important for the future (such as the use of cardiac rhythm for seizure detection) and those of use for people with epilepsy and people who care for people with epilepsy. With this breadth 2016 looks to be a very promising year.