Anand Krishnan, Jain Satish, Paul Eldho, Srivastava Achal, Sahariah Sirazul A, Kapoor Suresh K
Comprehensive Rural Health Services Project (AIIMS), Ballabgarh, India.
Epilepsia. 2005 May;46(5):743-50. doi: 10.1111/j.1528-1167.2005.41104.x.
To develop and test a clinical case definition for identification of generalized tonic-clonic seizures (GTCSs) by community-based health care providers.
To identify symptoms that can help identify GTCSs, patients with history of a jerky movements or rigidity in any part of the body ever in life were recruited from three sites: the community, secondary care hospital, and tertiary care hospital. These patients were administered a 14-item structured interview schedule focusing on the circumstances surrounding the seizure. Subsequently, a neurologist examined each patient and, based on available investigations, classified them as GTCS or non-GTCS cases. A logistic regression analysis was performed to select symptoms that were to be used for case definition of GTCSs. Validity parameters for the case definition at different cutoff points were calculated in another set of subjects.
In total, 339 patients were enrolled in the first phase of the study. The tertiary care hospital contributed the maximal number of GTCS cases, whereas cases of non-GTCS were mainly from the community. At the end of phase I, the questionnaire was shortened from 14 to eight questions based on statistical association and clinical judgment. After phase II, which was conducted among 170 subjects, three variables were found to be significantly related to the presence of GTCSs by logistic regression: absence of stress (13.1; 4.1-41.3), presence of frothing (13.7; 4.0-47.3), and occurrence in sleep (8.3; 2.0-34.9). As a case definition using only three variables did not provide sufficient specificity, three more variables were added based on univariate analysis of the data (incontinence during the episode and unconsciousness) and review of literature (injury during episode). A case definition consisting of giving one point to an affirmative answer for each of the six questions was tested. At a cutoff point of four, sensitivity was 56.9 (47.4-66.0) and specificity, 96.3 (86.2-99.4). Among the 197 GTCS and 26 new non-GTCS patients recruited from hospitals from select SEAR Member Countries, in phase III, the sensitivity of this clinical case definition was 72% and specificity, 100%. A stratified analysis by gender in all the three phases did not show any differences between the sexes.
Based on these criteria, we recommend that all patients with a history of two or more episodes of jerking or rigidity of limbs, having a score of > or =4 in the case definition, be identified as having GTCSs and started on antiepileptic medications. This clinical case definition can be very useful for community-based health care providers to identify and manage cases of GTCSs in the community. This should play a major role in the reduction of treatment gap for epilepsy in developing countries.
制定并测试一种临床病例定义，以便社区医疗服务提供者识别全面性强直阵挛发作（GTCS）。
为确定有助于识别GTCS的症状，从三个地点招募曾有过身体任何部位抽搐或僵硬病史的患者：社区、二级护理医院和三级护理医院。对这些患者进行了一项包含14个项目的结构化访谈，重点关注发作时的情况。随后，一名神经科医生对每位患者进行检查，并根据现有检查结果将他们分类为GTCS或非GTCS病例。进行逻辑回归分析以选择用于GTCS病例定义的症状。在另一组受试者中计算了不同截断点处病例定义的有效性参数。
在研究的第一阶段共招募了339名患者。三级护理医院贡献的GTCS病例数最多，而非GTCS病例主要来自社区。在第一阶段结束时，根据统计关联和临床判断，问卷从14个问题缩短至8个问题。在对170名受试者进行的第二阶段研究后，通过逻辑回归发现有三个变量与GTCS的存在显著相关：无压力（13.1；4.1 - 41.3）、有口吐白沫（13.7；4.0 - 47.3）以及在睡眠中发作（8.3；2.0 - 34.9）。由于仅使用三个变量的病例定义没有提供足够的特异性，基于数据的单变量分析（发作期间失禁和昏迷）以及文献回顾（发作期间受伤）又增加了三个变量。测试了一个病例定义，即对六个问题中的每一个肯定回答给予一分。在截断点为4时，敏感性为56.9（47.4 - 66.0），特异性为96.3（86.2 - 99.4）。在第三阶段，从选定的东南亚区域合作组织成员国的医院招募的197名GTCS患者和26名新的非GTCS患者中，该临床病例定义的敏感性为72%，特异性为100%。在所有三个阶段按性别进行的分层分析未显示出性别差异。
基于这些标准，我们建议所有有两次或更多次肢体抽搐或僵硬发作史、在病例定义中得分≥4分的患者被认定为患有GTCS，并开始使用抗癫痫药物治疗。这种临床病例定义对于社区医疗服务提供者在社区中识别和管理GTCS病例可能非常有用。这在缩小发展中国家癫痫治疗差距方面应发挥重要作用。
