The Changing Face of Epileptology? Results of the Initial Q-PULSE Survey

Epilepsy Currents, Vol. 13, No. 6 (November/December) 2013 pp. 305–307 © American Epilepsy Society Despite the increasing options for pharmacologic management of epilepsy, epilepsy surgery remains the best option for many patients with treatment resistant focal epilepsy. Anterior temporal lobectomy (ATL) has been demonstrated to be an effective treatment (1) and is the recommended treatment approach in patients with temporal lobe epilepsy (2). There has been an increasing perception, at least among some epileptologists, that there has been a decline in ATLs for patients with medial temporal lobe epilepsy (MTLE) over the past two decades. A recent study of the use of ATL in a communitybased population (3) and a retrospective review of epilepsy surgery cases from nine centers on three continents (4) have demonstrated declines in the use of ATL. For the first question addressed by the Quantitative Practical Use-Driven Learning Survey in Epilepsy (Q-PULSE), panel members were surveyed on their perception of the case types and complexity through a series of six questions. A total of 97 responses were received from the 143 members of the Q-PULSE panel who responded to the initial request to join. Many respondents (40%) have been practicing within their current metropolitan area for more than 15 years (Figure 1). The majority of respondents felt that only 10 to 50 percent of the treatment resistant patients seen in their clinic fit a classic definition of mesial temporal lobe epilepsy (5) (Table 1). The majority of respondents (64%) reported seeing fewer patients with MTLE now than 10 years ago (Figure 2). A majority of respondents (67%) felt that the overall complexity of cases was greater now than 10 years ago (Table 2). Five potential factors were identified—along with the option of writing in other factors—to explain the observed change, and the panel was asked to rank the factors from 1 to 6 in order of importance (Figure 3). Forty-one percent of respondents identified more patients being managed outside major epilepsy centers as the number one reason for the perceived change, and 24% reported that the primary factor was that the majority of potential “good” surgical candidates have already been offered surgery. Of the 97 respondents, 88 also responded to the demographic survey to allow a more detailed analysis to be undertaken. Of these, 75 characterized themselves as in an academic center versus 13 in private practice, and 64 characterized themselves as practicing in a major metropolitan area (population >1 million) versus a smaller city. There was no difference between either practice area or practice type and whether they reported seeing fewer or more patients with MTLE (Fisher exact for practice type p = 0.6; for practice area p = 0.16). These survey results demonstrate that there is a broad, but not universal, impression that there are fewer MTLE cases and an overall increase in case complexity seen in epilepsy centers. The data that have been reviewed and presented recently (3, 4) support this opinion. Equally importantly, this was attributed primarily to management outside of the larger epilepsy centers, and only a small number (13.5%) of respondents identified the reason for this perceived change The Changing Face of Epileptology? Results of the Initial Q-PULSE Survey