The impact of antidepressants on seizure frequency and depressive and anxiety disorders of patients with epilepsy: Is it worth investigating?

Depression and anxiety disorders in patients with epilepsy (PWE) remain under-recognized and under-treated, despite being the most common psychiatric co-morbidities. Selective serotonin re-uptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are considered first-line treatment for primary depression and anxiety disorders. We performed this study to investigate if SSRIs and SNRIs could affect the seizure frequency of PWE and to assess whether such effect is independent of the response of the mood and anxiety disorders to these drugs. This was a retrospective study of 100 consecutive PWE who were started on an SSRI or SNRI for the treatment of a depressive and/or anxiety disorder. Every patient underwent a psychiatric evaluation by one of the investigators using a semi-structured interview who also managed the pharmacologic treatment in all the patients. Patients were excluded if they had a diagnosis of psychogenic non-epileptic seizures or if they had undergone epilepsy surgery or the implant of the vagal nerve stimulator six months before and after the start of the antidepressant therapy. The final analysis was conducted in 84 patients. For each type of seizure, an average and maximal monthly seizure frequency during the six months preceding and following the start of psychotropic drugs was extracted from the medical records. We identified the number of patients whose seizure frequency during treatment with antidepressants: (i) shifted from a <1/month to a ≥1 seizure/month and vice-versa, (ii) increased beyond maximal/monthly baseline frequency, and (iii) patients who developed de-novo generalized tonic-clonic (GTC) seizures. None of the patients with a baseline seizure frequency 50% reduction in seizure frequency after the start of treatment with SSRIs or SNRIs. A therapeutic response to SSRIs and SNRIs was found in 73% of patients. The change in seizure frequency was independent of the improvement in psychiatric symptomatology. In this retrospective observational study, SSRIs or SNRIs did not appear to worsen seizure frequency. Also, in patients with frequent seizures, SSRIs and SNRIs may be associated with a possible decrease in seizure frequency. Furthermore, these drugs appear to yield good therapeutic response of psychiatric symptoms independently of seizure frequency. It is pivotal to replicate these data in prospective, double-blind, placebo-controlled trials. •Depression and anxiety are common co-morbidities in patients with epilepsy, which remain under-recognized and under-treated.•This study investigated the impact of SSRIs and SNRIs in the seizure frequency of patients with epilepsy.•SSRIs or SNRIs did not appear to worsen seizure frequency.•In patients with frequent seizures, SSRIs and SNRIs may be associated with a decrease in seizure frequency.•The change in seizure frequency was independent of the improvement in psychiatric symptomatology

Current methods for recurrent events data with dependent termination:a Bayesian perspective

There has been a recent surge of interest in modeling and methods for analyzing recurrent events data with risk of termination dependent on the history of the recurrent events. To aid the future users in understanding the implications of modeling assumptions and modeling properties, we review the state of the art statistical methods and present novel theoretical properties, identifiability results and practical consequences of key modeling assumptions of several fully specified stochastic models. After introducing stochastic models with noninformative termination process, we focus on a class of models which allows both negative and positive association between the risk of termination and the rate of recurrent events via a frailty variable. We also discuss the relationship as well as the major differences between these models in terms of their motivations and physical interpretations. We discuss associated Bayesian methods based on Markov chain Monte Carlo tools, and novel model diagnostic tools to perform inference based on fully specified models. We demonstrate the usefulness of current methodology through an analysis of a data set from a clinical trial. In conclusion, we explore possible future extensions and limitations of the methodology

Long-Term Satisfaction and Patient-Centered Outcomes of Deep Brain Stimulation in Parkinson’s Disease

Bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) is an effective and proven treatment option for patients with advanced Parkinson’s disease (PD). Long-term outcomes (&gt;5 years) have demonstrated sustained improvement in objective motor symptoms; however, few studies have evaluated patient-centered outcomes other than quality of life (QOL). A locally developed DBS-patient-centered outcomes questionnaire was administered to PD patients &gt;5 years post-DBS. All questions were scored on a ten-point scale, whereby 0 represented the most ‘positive’ answer and 10 the most ‘negative’ answer. Pre-operative scales were repeated at the time of survey. Fifty-two patients (mean 8.2 ± 2.6 years post-DBS) were included. Satisfaction was high with median score (range) of 1/10 (0–8) at the time of survey. Patients endorsed having made the correct decision by undergoing DBS, with a score of 0 (0–10), would choose to have DBS again, with a score of 0 (0–10), and would recommend DBS to others, with a score of 0 (0–10). Pre-operative expectation target was set at a high level with a score of 2 (0–10). Parkinson’s Disease QOL (PDQ-39) Questionnaire Summary Index (SI) scores were, mean (SD), 2.1 (18.2) above baseline (p = 0.44). Those with worsening in PDQ-39-SI scores had less satisfaction with DBS (rs = 0.57, p ≤ 0.0001). This is the first study to assess long-term patient satisfaction with STN DBS. We are currently collecting data prospectively to confirm the results of these preliminary findings

Interaction of incidental microbleeds and prior use of antithrombotics with early hemorrhagic transformation: Causative or protective?

Background: Gradient echo (GRE) sequence of magnetic resonance imaging (MRI) is a sensitive tool to detect hemorrhagic transformation (HT) and old cerebral microbleeds (CMBs). Presence of CMBs and prior use of antithrombotics pose a risk of HT in ischemic stroke. We evaluated the association of CMBs and antithrombotic use with resultant HT in acute ischemic stroke (AIS). Methods: This retrospective study included AIS patients admitted to our center between January 2009 and August 2010 who underwent GRE-weighted MRI within 48 h of admission. Demographic and clinical data including diabetes mellitus, hypertension, hyperlipidemia, prior intake of antiplatelets/anticoagulants/statins, and presence of CMBs at admission were collected and compared between patients who developed HT and those who did not. We did a multivariate analysis using logistic regression to assess the effect of CMBs and prior use of antithrombotic agents on the risk of development for early HT in ischemic stroke. Results: Of 529 AIS patients, 81 (15%) were found to have HT during the initial hospital course. CMBs were found in only 9 of 81 patients (11%) with HT and in 40 out of remaining 448 patients (9%) who did not develop HT. The presence of CMBs was not associated with increased risk of HT (P = 0.53). However, prior use of antiplatelets (33% vs. 47% in the patients without HT, P = 0.02) was associated with decreased risk of HT in ischemic stroke. Conclusion: Presence of incidental CMBs was not associated with increased risk for early HT of an ischemic stroke. Interestingly, the prior intake of antiplatelets was found to be protective against HT of ischemic stroke

Remote telemedicine evaluation of deep brain stimulation candidacy: Retrospective cohort analysis.

ObjectiveTo determine whether initial presurgical evaluation of deep brain stimulation (DBS) candidacy with video telemedicine (VTEL) can reliably predict surgical candidacy (patients who will eventually undergo DBS surgery) and decrease resource utilization when compared to an in-person evaluation.MethodsIn this retrospective, cohort analysis, all out-of-state referrals to the San Francisco Veterans Affairs from 2008 to 2013 for DBS therapy were reviewed and their surgical outcomes were assessed until 2017. Patients were designated as good, borderline, or poor surgical candidates after initial evaluation, and their rates of undergoing DBS were recorded. An assessment of patient travel costs was performed.ResultsThere were 60 out-of-state DBS referrals identified out of the 148 initial presurgical DBS evaluations completed for surgical treatment of dystonia, essential tremor, or Parkinson disease; 24 patients underwent in-person consultation and 36 patients underwent evaluation via VTEL. There was no difference between the rates of undergoing surgical treatment with DBS based on surgical candidacy for patients in the in-person and VTEL cohorts. Patients who underwent initial presurgical screening via VTEL saved time and money.ConclusionsVTEL can be used to facilitate presurgical screening for DBS and saves costs

Accuracy of microelectrode trajectory adjustments during dbs assessed by intraoperative CT

Background/Aims: Microelectrode recording (MER)-guided deep brain stimulation (DBS) aims to place the DBS lead in the optimal electrophysiological target. When single-track MER or test stimulation yields suboptimal results, trajectory adjustments are made. The accuracy of these trajectory adjustments is unknown. Intraoperative computed tomography can visualize the microelectrode (ME) and verify ME adjustments. We aimed to determine the accuracy of ME movements in patients undergoing MER-guided DBS. Methods: Coordinates following three methods of adjustment were compared: (1) those within the default "+" configuration of the ME holder; (2) those involving rotation of the default "+" to the "x" configuration; and (3) those involving head stage adjustments. Radial error and absolute differences between coordinates were determined. Results: 87 ME movements in 59 patients were analyzed. Median (IQR) radial error was 0.59 (0.64) mm. Median (IQR) absolute x and y coordinate errors were 0.29 (0.52) and 0.38 (0.44) mm, respectively. Errors were largest after rotating the multielectrode holder to its "x"-shaped setup. Conclusion: ME trajectory adjustments can be made accurately. In a considerable number of cases, errors exceeding 1 mm were found. Adjustments from the "+" setup to the "x" setup are most prone to inaccuracies