Hye-Jin Moon

Validation of the generalized anxiety disorder-7 in people with epilepsy: a MEPSY study.

The Generalized Anxiety Disorder-7 (GAD-7) is a valuable instrument to screen for anxiety in primary care patients. However, it has not been validated in people with epilepsy (PWE). Therefore, we validated the GAD-7 and examined its differential effect from adverse effects of antiepileptic drugs (AEDs) on the detection of anxiety in Korean PWE. Eligible patients who visited outpatient clinics in 4 tertiary care hospitals and 1 secondary care hospital underwent several instruments including the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI-Plus 5.0.0), the Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E), the Korean version of the Liverpool Adverse Event Profile (K-LAEP), and the Quality of Life in Epilepsy-10 (QOLIE-10). Two hundred forty-three patients were enrolled in the study, and 51 (21.0%) patients had GAD by the MINI-Plus 5.0.0. Cronbachs α coefficient for the GAD-7 was 0.924. At a cutoff score of 6, the GAD-7 had a sensitivity of 92.2%, a specificity of 89.1%, a positive predictive value of 69.1%, and a negative predictive value of 97.7%. The GAD-7 score was well correlated with the K-NDDI-E score, the K-LAEP score, and the QOLIE-10 overall and subscale scores. The impact of adverse effects of AEDs on the GAD-7 was less than that on the K-NDDI-E. In conclusion, the GAD-7 is a reliable and valid screening tool for detecting GAD in PWE.

Suicidality and Its Risk Factors in Korean People with Epilepsy: A MEPSY Study

Background and Purpose People with epilepsy (PWE) are more likely to experience suicidality, with suicidal ideation and attempts, than people without epilepsy (PWoE). The aims of the present study were to determine 1) the characteristics of suicidality in Korean PWE, 2) whether PWE with suicidality receive psychiatric intervention, and 3) the risk factors for suicidality. Methods Patients who consecutively visited epilepsy clinics at secondary- and tertiary-care hospitals were recruited (n=684), along with age- and sex-matched PWoE (n=229). The presence of current major depressive disorder (MDD), generalized anxiety disorder (GAD), and/or suicidality was established using the Mini International Neuropsychiatric Interview-Plus Version 5.0.0. The Korean version of the Liverpool Adverse Events Profile (K-LAEP) was applied to detect adverse effects of antiepileptic drugs (AEDs). Results Suicidality was present in 208 (30.4%) of the 684 PWE. The rate of suicidality was 4.6 times higher among PWE than PWoE, and 108 (15.7%) PWE had suicidal ideation and had attempted suicide. Among those who had attempted suicide, 40.7% had made at least two attempts. The most common method of suicide attempt was drug overdose (34.9%). Unfortunately, of the 208 PWE with suicidality, 136 (65.4%) did not receive psychiatric intervention. The risk factors for suicidality were MDD [odds ratio (OR)=6.448, 95% confidence interval (CI)=3.739-11.120, p<0.001], GAD (OR=3.561, 95% CI=1.966-6.452, p<0.001), item scores of 3 or 4 on the K-LAEP (OR=2.688, 95% CI=1.647-4.387, p<0.001), and a history of febrile convulsion (OR= 2.188, 95% CI=1.318-3.632, p=0.002). Conclusions Suicidality is more prevalent in PWE than in PWoE. Clinicians should monitor psychiatric disorders and the adverse effects of AEDs in PWE in an attempt to reduce the incidence of suicidal ideation or suicide attempts in this patient population.

Perceived stress and its predictors in people with epilepsy

OBJECTIVE Perceived stress in people with epilepsy (PWE) is one of the major precipitants for seizures. We investigated the degree of perceived stress in PWE and its predictors. We also aimed to reveal the interrelationships among the predictors. METHODS This was a case-control study. Consecutive patients visiting a tertiary care epilepsy clinic completed self-reported questionnaires including the Perceived Stress Scale (PSS), Revised Stigma Scale (RSS), Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E), Generalized Anxiety Disorder - 7 (GAD-7), and short forms of the Patient-Reported Outcomes Measurement Information System - Sleep Disturbance (PROMIS-SD) and Patient-Reported Outcomes Measurement Information System - Sleep-Related Impairment (PROMIS-SRI) scales. RESULTS The mean score of the PSS was significantly lower in patients with well-controlled epilepsy (WCE) and higher in those with uncontrolled epilepsy compared with controls. Although several factors including demographic, socioeconomic, psychosomatic, and epilepsy-related factors were associated with the PSS score, the strongest predictor for the PSS score was the K-NDDI-E score, followed by the PROMIS-SRI score, the GAD-7 score, and seizure control. Psychosomatic factors exerted both a direct effect on the PSS score and an indirect effect on the PSS score through seizure control. CONCLUSION Rapid detection and appropriate management of psychiatric and sleep-related problems in PWE may lessen stress and aid in preventing further seizures.

Predictors of quality of life and their interrelations in Korean people with epilepsy: A MEPSY study

PURPOSE People with epilepsy (PWE) are more likely to have impaired quality of life (QOL) than the general population. We studied predictors of QOL and their interrelations in Korean PWE. METHODS Subjects who consecutively visited outpatient clinics in four tertiary hospitals and one secondary care hospital were enrolled. These subjects completed the Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E), the Generalized Anxiety Disorder-7 (GAD-7), the Quality of Life in Epilepsy-10 (QOLIE-10), and the Korean version of Liverpool Adverse Event Profile (K-LAEP). We evaluated the predictors of QOL by multiple regression analyses and verified the interrelations between the variables using a structural equation model. RESULTS A total of 702 PWE were eligible for the study. The strongest predictor of the overall QOLIE-10 score was the K-LAEP score (β=-0.375, p<0.001), followed by the K-NDDI-E score (β=-0.316, p<0.001), seizure control (β=-0.152, p<0.001), household income (β=-0.375, p<0.001), and GAD-7 score (β=-0.119, p=0.005). These variables explained 68.7% of the variance in the overall QOLIE-31 score. Depression and seizure control had a bidirectional relationship and exerted direct effects on QOL. These factors also exerted indirect effects on QOL by provoking adverse effects of AEDs. Anxiety did not have a direct effect on QOL; it had only indirect effect through the adverse effects of AEDs. CONCLUSION Depression, anxiety, seizure control, and adverse effects of AEDs have complex interrelations that determine the QOL of PWE.

Klüver-bucy syndrome with isolated bilateral hippocampal atrophy following status epilepticus.

Klüver-Bucy syndrome may result from affection of various location of brain. We report a case of Klüver-Bucy syndrome associated with isolated bilateral hippocampal atrophy without any abnormal lesion in other areas following status epilepticus. A 31-year-old man who had no significant medical history presented with status epilepticus after encephalitis of unknown etiology. He had been recovered from status epilepticus three weeks later, but afterwards he developed Klüver-Bucy syndrome: hyperphagia, hypersexuality, hypermetamorphosis, anterograde amnesia and dysosmia. Initial brain MRI showed T2 hyperintensity and swelling of isolated bilateral hippocampus, especially CA1 region without any abnormal lesion in other areas. One month later, follow-up brain MRI showed isolated bilateral hippocampal atrophy. This is a meaningful case report because this case differs from other reports of Klüver-Bucy syndrome in humans in that the anatomic abnormalities revealed by MRI were very selective. We report this case because this case is very educative for above reason. Moreover, this report would give us additional information of the relationship between human behavior and limbic system.

Comorbid Insomnia With Obstructive Sleep Apnea: Clinical Characteristics and Risk Factors

STUDY OBJECTIVES Obstructive sleep apnea (OSA) and chronic insomnia are two common sleep disorders and both are considered independent risk factors for heart disease. The aim of this study was to investigate the prevalence of comorbid insomnia with OSA and to compare its clinical characteristics with those of OSA without insomnia. METHODS Patients who visited two tertiary university hospital sleep centers were screened. Those with a diagnosis of OSA using polysomnography were divided into two groups based on their scores on the Korean version of the Insomnia Severity Index (ISI-K): OSA with insomnia (OSA+I) (ISI-K score ≥ 15) and OSA without insomnia (OSA-I) (ISI-K score < 15). Subjective symptoms were evaluated using sleep questionnaires including ISI-K. Demographic and clinical characteristics of OSA+I and OSA-I were compared. RESULTS Out of 476 patients with OSA, 139 (29.2%) had significant insomnia. Patients in the OSA+I group had a higher percentage of females (35.3% versus 19.6%, P < .001) and have higher rates of heart disease (19.4% versus 8.6%, P < .001). OSA+I group showed lower quality of life, lower quality of sleep, higher sleep propensity, and higher depression as measured by the Korean versions of the Short-Form 36-Item Health Survey, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Beck Depression Inventory, respectively. There were no significant differences in adherence to continuous positive airway pressure between the groups. CONCLUSIONS There is a high prevalence of comorbid insomnia with OSA (29.2%), consistent with previous findings in Western studies. Comorbid insomnia with OSA may constitute a cumulative risk factor for cardiovascular disease. These findings warrant further investigation into the mechanisms involved in its pathogenesis and devising more efficient treatments.

Surgical Treatment of Nonlesional Neocortical Epilepsy: Long-term Longitudinal Study

Importance The proportion of surgery for nonlesional neocortical epilepsy has recently increased, with a decrease in surgery for mesial temporal lobe epilepsy. However, there are only a few studies regarding the long-term surgical outcome and the potential prognostic factors for patients with nonlesional neocortical epilepsy. Objective To evaluate the long-term surgical outcome and to identify possible prognostic factors in patients with nonlesional neocortical epilepsy. Design, Setting, and Participants In a surgical cohort from September 1995 to December 2005 at the Seoul National University Hospital, we included 109 consecutive patients without lesions identifiable by magnetic resonance imaging who underwent focal surgical resection for drug-resistant neocortical epilepsy. Follow-up information for at least 10 years was available for all but 1 patient. Main Outcomes and Measures Univariate and standard multiple logistic regression analyses were performed to identify the predictors of surgical outcomes, and a generalized estimation equation model was used for the longitudinal multiple logistic regression analysis of up to 21 years of follow-up. Results The patients consisted of 64 men and 45 women with ages at surgery ranging from 7 to 56 years (mean [SD], 27.1 [7.8] years). At 1 year after surgery, 59 of 109 patients (54.1%) achieved seizure freedom, and 64 of 108 patients (59.3%) achieved seizure freedom at the last follow-up. Only 11 of 108 patients (10.2%) experienced definite changes in postoperative seizure status. Localizing patterns in functional neuroimaging (strongest odds ratio [OR], 0.30 [95% CI, 0.14-0.66] for fluorodeoxyglucose–positron emission tomography; 0.37 [95% CI, 0.15-0.87] for ictal single-photon emission computed tomography), concordant results in presurgical diagnostic evaluations (OR, 3.15 [95% CI, 1.42-7.02]), the presence of aura (OR, 3.49 [95% CI, 1.54-7.92]), and complete resection of areas of ictal onset with frequent interictal spikes during the intracranial electroencephalographic study (OR, 0.37 [95% CI, 0.16-0.85]) were favorable surgical outcome predictors. Conclusions and Relevance Our study showed that nearly 60% of patients with nonlesional neocortical epilepsy achieved freedom from long-term seizure, and that changes in postoperative seizure status were rarely observed. Several predictors of favorable surgical outcomes were identified, which can help select optimal candidates for surgical treatment among patients with nonlesional neocortical epilepsy.

The REM Sleep Behavior Disorder Screening Questionnaire: Validation Study of the Korean Version (RBDQ-KR)

STUDY OBJECTIVES REM sleep behavior disorder (RBD) is a parasomnia that is commonly associated with neurodegenerative disorders. We aimed to validate the Hong Kong version of the self-reported RBD questionnaire (RBDQ-HK) with the Korean version (RBDQ-KR) and to investigate its clinical usefulness. METHODS One-hundred five patients with RBD and 105 age- and sex-matched controls were enrolled. Thirty were randomly selected for a retest with the questionnaire after 2 to 4 weeks without any treatment. Receiver operating characteristic curve and exploratory factor analysis were used to evaluate the scale, which had a score ranging from 0 to 100. RESULTS There was no difference in mean age and sex in patients with RBD and control subjects. Patients with RBD had a significantly higher total RBDQ-KR score than the control group (P < .001). The RBDQ-KR demonstrated high sensitivity (93.3%), specificity (89.5%), positive predictive value (89.9%), and negative predictive value (93.1%). Cronbach α coefficient for internal consistency of the total score of the RBDQ-KR was 0.9, which shows high reliability. Exploratory factor analysis showed two components, dream-related and behavioral factors, consistent with the main clinical features of RBD. Based on the results, the best cutoff for the total score ranging from 0 to 100 was at 18/19 and for factor 2 ranging from 0 to 75 was at 11. CONCLUSIONS This study showed RBDQ-KR is a valid and reliable questionnaire for RBD symptoms and severity in Korea. It serves as an effective tool to identify patients with RBD and to facilitate future clinical and research studies.

Can Therapeutic-Range Chronic Phenytoin Administration Cause Cerebellar Ataxia?

Phenytoin (PHT) is a first line antiepileptic drug (AED) used to treat many epilepsy syndromes. As with other AEDs, there are various adverse effects associated with PHT. For this brief review, we searched for evidence of cerebellar ataxia as a chronic adverse effect of therapeutic-range PHT treatment. Many previous studies appeared related to this issue, but many of those studies were designed to resolve questions related to the persistent residual effects of toxic-range PHT therapy, or they were inconclusive due to an absence of critical information such as PHT serum concentration, cerebellar symptoms/signs, and other factors contributing to cerebellar degeneration. Nevertheless, there were a few reports suggesting that cerebellar ataxia may be a chronic adverse effect of therapeutic-range PHT therapy and that a possible pathomechanism for that effect is folate deficiency. Moreover, there is the possibility that there may be patient-specific susceptibility factors affecting ataxia. Further studies are needed to elucidate the incidence, risk factors, and pathomechanism of cerebellar ataxia as a chronic adverse effect of therapeutic-range PHT treatment.

Change of Patient Selection Strategy and Improved Surgical Outcome in MRI-negative Neocortical Epilepsy

Background and Purpose It is crucial to make selection strategy to identify surgical candidates among medically refractory MRI-negative neocortical epilepsy patients. In our previous study, we suggested two or more concordance between noninvasive studies (EEG, ictal scalp EEG, interictal FDG-PET, and SPECT) as a new patient selection strategy for MRI-negative neocortical epilepsy surgery. The objective of this study was to evaluate the surgical outcomes of MRI-negative neocortical epilepsy patients before and after the implementation of a new selection strategy. Methods From 1995 to 2011, we included 153 consecutive MRI-negative neocortical epilepsy patients who received focal resection and had a follow-up period of at least 2 years. These patients were divided into two groups according to their date of surgery (before and after July 2002). The old group consisted of 89 patients and the new one consisted of 53 patients. Clinical characteristics, presurgical evaluations, and pathology were reviewed. Results The new patient selection strategy led to a significant increase in the concordance between two or more modalities. The improvement in surgical outcome after 2002 was significant (seizure-free outcome, 47.2% vs. 75.5%; p = 0.001). Concordance between two or more presurgical evaluations and localizing PET were related to a seizure-free outcome in a multivariate analysis. Conclusions After a change in surgical strategy to select patients with two or more concordance between noninvasive studies, the seizure-free outcome improved up to 75.5%. MRI-negative neocortical epilepsy patients with two or more concordance between noninvasive studies seem to be good candidates for epilepsy surgery.