Letter to the Editor: ‘Causes of Hospitalisation and Mortality in Persons With Epilepsy: The EpiLink Bologna Cohort, Italy’

Abstract

It is with great interest that we have read the article by Muccioli et al. [1] which addresses the causes of hospitalisation and mortality in persons with epilepsy (PWEs). While the study provides valuable insights, we would like to address some additional perspectives, especially regarding the limitations of the ILAE (International League Against Epilepsy) classification, the time since diagnosis of epilepsy in each patient and the patients' socioeconomic status, quality of life in the post-ictal phase, which were not fully explored in this study. Addressing these aspects could significantly enhance the care given to PWEs pre- and post-admissions.

While the study's categorisation of the sample was robust, a subgroup analysis could have been performed on the basis of age, gender and duration of symptoms, which, if considered, can enhance the validity of the results. Furthermore, the age at diagnosis and the duration of disease were not parameters taken into consideration for categorisation or subgroup analysis. PWEs diagnosed in childhood would have much higher rates of mortality and various other comorbidities, which may not be present in adults diagnosed with epilepsy. Patients suffering from epilepsy for longer periods of time are naturally predisposed to more electrolyte imbalances, trauma, cerebrovascular diseases, infections or other conditions requiring hospitalisation.

This study employs the ILAE 2017 classification, which has limitations of its own. Consciousness in defining seizures has been voluntarily removed from this classification in an attempt to use simpler terminologies. Instead, the term awareness is used. However, the term is still valid and clinically significant as many seizures present with an impaired consciousness level, which could indicate the severity of the patients' condition, something which the term ‘awareness’ cannot provide. Further stressing the importance of consciousness is the result of a survey conducted by Mathern et al., in which about 77% of the respondents believe that the term ‘consciousness’ was significant, and therefore, should be maintained in the seizure and epilepsy classification. Additionally, patients with sensory-motor deficits may have behavioural unresponsiveness, which can lead to impaired awareness, but unimpaired consciousness [2].

Although the authors mention the interventions (polytherapy and monotherapy) that patients received, they omit describing the role of lifestyle in triggering seizures and how comorbidities can be managed by simple lifestyle changes. Ensuring adequate REM sleep and having a stress-free lifestyle is crucial to avoid seizure episodes [3]. Alcohol, a well-known trigger for epilepsy, when consumed in excess or for long periods, can cause increased rates of hospitalisation, episodes of status epilepticus and sudden unexpected death in epilepsy (SUDEP) [4]. Considering these parameters in future studies will help in understanding their potential impact on patient outcomes and hospitalisation rates.

Lastly, the study, while effectively considering several parameters, does not take into account the socioeconomic status of the patients in the various subgroups, as well as in the control cohort. Socioeconomic status is a vital aspect in the management of many comorbidities. Higher socioeconomic status has been linked with decreased mortality and higher life expectancy, due to better access to healthcare. Assessing the quality of life (QOL) parameter in PWEs pre- and post-admission might have greatly enhanced the findings of the study. This would evaluate the impact of epilepsy and its associated comorbidities on the daily lives of patients. As the study is retrospective, the authors could have focused on developing a method of prognostication for the patients of various types of epilepsy, which would further aid in predicting patients' quality of life.

In conclusion, while the study by Lorenzo Muccioli et al. offers valuable insights, we believe that a more comprehensive, integrated subgroup analysis, including parameters such as socioeconomic status, time of diagnosis, gender, age, etiology and duration of symptoms, can enhance the validity of the results. We further believe that there is great value in exploring the role of lifestyle modifications in PWEs. Future studies can also aim at evaluating the quality of life of patients pre- and post-admission, as medical treatments are intrinsically aimed at not only preserving life, but also enhancing its quality.

Maanini Singhvi: conceptualization, supervision, writing – review and editing, writing – original draft, data curation, formal analysis, visualization, project administration, methodology, investigation, funding acquisition, resources, validation, software. Leroy D'Souza: conceptualization, data curation, formal analysis, writing – review and editing, visualization, writing – original draft, methodology, validation. Vivekhan Raja: conceptualization, writing – original draft, writing – review and editing, investigation, methodology, validation, resources. Rohan Nikhil Dubeer: writing – original draft, writing – review and editing, resources.

The authors declare no conflicts of interest.