Long-term seizure and psychosocial outcomes of vagus nerve stimulation for intractable epilepsy

Vagus nerve stimulation (VNS) is a widely used adjunctive treatment option for intractable epilepsy. Most studies have demonstrated short-term seizure outcomes, usually for up to 5 years, and thus far, none have reported psychosocial outcomes in adults. We aimed to assess long-term seizure and psychosocial outcomes in patients with intractable epilepsy on VNS therapy for more than 15 years. We identified patients who had VNS implantation for treatment of intractable epilepsy from 1997 to 2013 at our Comprehensive Epilepsy Program and gathered demographics including age at epilepsy onset and VNS implantation, epilepsy type, number of antiepilepsy drugs (AEDs) and seizure frequency before VNS implantation and at the last clinic visit, and the most recent stimulation parameters from electronic medical records (EMR). Phone surveys were conducted by research assistants from May to November 2014 to determine patients\u27 current seizure frequency and psychosocial metrics, including driving, employment status, and use of antidepressants. Seizure outcomes were based on modified Engel classification (I: seizure-free/rare simple partial seizures; II: \u3e90% seizure reduction (SR), III: 50-90% SR, IV:50% SR)=favorable outcome). A total of 207 patients underwent VNS implantation, 15 of whom were deceased at the time of the phone survey, and 40 had incomplete data for medical abstraction. Of the remaining 152, 90 (59%) were contacted and completed the survey. Of these, 51% were male, with the mean age at epilepsy onset of 9.4 years (range: birth to 60 years). There were 35 (39%) patients with extratemporal epilepsy, 19 (21%) with temporal, 18 (20%) with symptomatic generalized, 5 (6%) with idiopathic generalized, and 13 (14%) with multiple types. Final VNS settings showed 16 (18%) patients with an output current \u3e2 mA and 14 (16%) with rapid cycling. Of the 80 patients with seizure frequency information, 16 (20%) had a modified Engel class I outcome, 14 (18%) had class II, 24 (30%) had class III, and 26 (33%) had class IV. Eighty percent said having VNS was worthwhile. Among the 90 patients, 43 patients were ≥ 18 years old without developmental delay in whom psychosocial outcomes were further analyzed. There was a decrease in the number of patients driving (31% vs 14%, p=0.052) and working (44% vs 35%, p=0.285) and an increase in the number of patients using antidepressant medication (14% vs 28%, p=0.057) at the time of survey compared to before VNS. In this subset, patients with \u3e50% SR (60%) were taking significantly fewer AEDs at the time of survey compared to patients with unfavorable outcomes (median: 3 vs 4, p=0.045). The associations of \u3e50% SR with the psychosocial outcomes of driving, employment, and antidepressant use were not significant, although 77% of this subset said VNS was worthwhile. This is the first study that assesses both seizure and psychosocial outcomes, and demonstrates favorable seizure outcomes of \u3e50% SR in 68% of patients and seizure freedom in 20% of patients. A large majority of patients (80%) considered VNS therapy worthwhile regardless of epilepsy type and psychosocial outcomes

Effect of seizure timing on long-term survival in patients with brain tumor

OBJECTIVE: Seizures often occur in patients with primary brain tumor (BT). The aim of this study was to determine if there is an association between the time of occurrence of seizures during the course of BT and survival of these patients. METHODS: This retrospective cohort study at Henry Ford Hospital, an urban tertiary referral center, included all patients who were diagnosed with primary BTs at Henry Ford Health System between January 2006 and December 2014. Timing of seizure occurrence, if occurred at presentation or after the tumor diagnosis during follow-up period, in different grades of BTs, and survival of these patients were analyzed. RESULTS: Of the 901 identified patients, 662 (53% male; mean age: 56 years) were included in final analysis, and seizures occurred in 283 patients (43%). Patients with World Health Organization (WHO) grade III BT with seizures as a presenting symptom only had better survival (adjusted hazard ratio (HR): 0.27; 95% confidence interval (CI), 0.11-0.67; P = 0.004). Seizures that occurred after tumor diagnosis only (adjusted HR: 2.11; 95% CI, 1.59-2.81; P \u3c 0.001) in patients with WHO grade II tumors (adjusted HR: 3.41; 95% CI, 1.05-11.1; P = 0.041) and WHO grade IV tumors (adjusted HR: 2.14; 95% CI, 1.58-2.90; P \u3c 0.001) had higher mortality. Seizures that occurred at presentation and after diagnosis also had higher mortality (adjusted HR: 1.34; 95% CI, 1.00-1.80; P = 0.049), in patients with meningioma (adjusted HR: 6.19; 95% CI, 1.30-29.4; P = 0.021) and grade III tumors (adjusted HR: 6.19; 95% CI, 2.56-15.0; P \u3c 0.001). CONCLUSION: Seizures occurred in almost half of the patients with BTs. The association between seizures in patients with BT and their survival depends on the time of occurrence of seizures, if occurring at presentation or after tumor diagnosis, and the type of tumor. Better survival was noted in patients with WHO grade III BTs who had seizures at presentation at the time of diagnosis, while higher mortality was noted in WHO grade II tumors who had seizure at presentation and after tumor diagnosis, and in grade IV tumors after tumor diagnosis

ギリシア人が見た日本カザンツァキスとカズダグリス <論文>

ギリシアと日本との接触は、最近まで限られたものであり、今世紀に日本を訪れたギリシア人はごく僅かであった。その中に、日本の印象を旅行記と小説の二つの形式で描いた作家、カザンツァキスとカズダグリスがいる。本稿では、両作家が、どのように日本を観察したか、その問題点や特徴、或いは、ギリシャ性と日本文化に映し出された他性(otherness)をどのように認識したかを分析することにする。 日中戦争が勃発する前夜、1935年の2月から5月に来日したカザンツァキスの旅行記『旅の途次に、日本・中国』と小説『石の庭』は、1930年代の歴史的な事件に根ざしている。『旅の途次に、日本・中国』では、カザンツァキスは、黄色人種に対する白色人種としての自己認識を通して、対照的に他性を描いている。『石の庭』の登場人物の中で、中国人の恋人に復讐するため、中国に潜伏、スパイ活動をする日本人ヨシロは、西洋化された新しい女性で、アジアの覇権を狙い中国勢力を拡大していく日本の姿でもある。また、『石の庭』には、知性や合理的な分析ではなく、直観により経験を理解するというベルグソンの思想が見られる。更に、カザンツァキスは、当時の政治的状況と哲学とを結びつけ、太平洋における第四番目の列強となるべく、より高い次元で西洋文明化と伝統維持とを行う日本を、サムライ精神を信奉するアジアのドンキホーテとして描いている。 一方、冷戦、ギリシアの軍事政権、ヨーロッパの軍備縮小と反核運動の時代のカズダグリスは、1980年に来日し、旅行記『陸と海の旅路』、小説『マリアは水の首都を訪れる』を書く。文学的に行動を記録する日記形式の『陸と海の旅路』には、日本の精神的要素が強調され、言葉が通じない外国人が、異国の体験に関して、自国と比較して得た見解が述べられている。文化の真髄と現代生活に焦点が当てられると同時に、観光のための文化の修正に対する批判的風刺的な観察も見られるギリシア人のために書かれた日本に関する小品である。小説『マリアは水の首都を訪れる』には、広島を訪ねたマリアが政治的抵抗意識に目覚め、積極的な運動に参加する過程を通して、多義的なマリアの世界が、能に見られる三部構成で展開される。そして、そこには、人間の無力さと広島の被爆という歴史の実体験への恐怖が、明らかにされる。 異なる時代の二人のギリシア人作家は、日本に対する各時代の姿勢を示唆するとともに、戦争というものの中核にある精神的感情的パラドクスを探求した。カザンツァキスは、日本を、全著作の枠組を補足するものと見なし、日本が、世界再生の種を与え得るとの希望を抱く。これに対して、カズダグリスは、日本文化を、読者の文学的興味の境界から同時代的ギリシア文学の最前線へと移行することに成功し、同時に、民族中心主義を否定する立場を暗示している