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The COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures multicentre randomised controlled trial is the largest, fully-powered study to test the clinical and cost-effectiveness of a psychotherapeutic intervention in this population. We also explored predictors or moderators of outcomes and investigated mechanisms of change in therapy. In this current review of findings, we discuss issues related to the design of the trial and consider the study’s nested qualitative studies which were undertaken not only to shed light on the original research questions but to provide insights and recommendations for other researchers in the field of functional neurological disorder. Finally, we consider issues relating to the possible clinical application of our study findings.

The COVID-19 pandemic brought telemedicine into mainstream medical practice. Although it is widely agreed that telemedicine could be beneficial for patients with seizures, there has been little prior research investigating patients’ views on this subject. In this qualitative study, we conducted semi-structured interviews with 10 patients and one companion about their experiences of telemedicine. We also received written thoughts from one additional patient. Participants’ views fell under three broad themes. The first, “Convenience and practicality”, saw participants praising the flexibility of telephone consultations while noting that such consultations could introduce new practical problems. The second, “(Lack of) shared presence”, covered participants’ generally negative feelings about not being in the same room as their neurologists. The third, “Situation dependency”, saw participants drawing fine distinctions about the circumstances in which face-to-face and telephone consultations were suitable. Overall, although patients with seizures are generally positive about the convenience of telephone consultations, they have concerns about how they may lead to misunderstandings or affect the doctor-patient relationship. These concerns could be assuaged to some extent by offering video consultations or scheduling alternating telephone and face-to-face consultations.

Introduction: Functional motor disorder (FMD) is a common cause of disabling neurological symptoms such as weakness and tremor. Physio4FMD is a pragmatic, multicentre single blind randomised controlled trial to evaluate effectiveness and cost effectiveness of specialist physiotherapy for FMD. Like many other studies this trial was affected by the COVID-19 pandemic. Methods: The planned statistical and health economics analyses for this trial are described, as well as the sensitivity analyses designed to assess the disruption caused by COVID-19. The trial treatment of at least 89 participants (33%) was disrupted due to the pandemic. To account for this, we have extended the trial to increase the sample size. We have identified four groups based on how participants’ involvement in Physio4FMD was affected; A: 25 were unaffected; B: 134 received their trial treatment before the start of the COVID-19 pandemic and were followed up during the pandemic; C: 89 were recruited in early 2020 and had not received any randomised treatment before clinical services closed because of COVID-19; D: 88 participants were recruited after the trial was restarted in July 2021. The primary analysis will involve groups A, B and D. Regression analysis will be used to assess treatment effectiveness. We will conduct descriptive analyses for each of the groups identified and sensitivity regression analyses with participants from all groups, including group C, separately. Discussion: The COVID-19 mitigation strategy and analysis plans are designed to maintain the integrity of the trial while providing meaningful results. Trial registration: ISRCTN56136713.

Introduction Ambulances services are asked to further reduce avoidable conveyances to emergency departments (EDs). Risk of Adverse Outcomes after a Suspected Seizure seeks to support this by: (1) clarifying the risks of conveyance and non-conveyance, and (2) developing a risk prediction tool for clinicians to use ‘on scene’ to estimate the benefits an individual would receive if conveyed to ED and risks if not.Methods and analysis Mixed-methods, multi-work package (WP) project. For WP1 and WP2 we shall use an existing linked data set that tracks urgent and emergency care (UEC) use of persons served by one English regional ambulance service. Risk tools are specific to clinical scenarios. We shall use suspected seizures in adults as an exemplar.WP1: Form a cohort of patients cared for a seizure by the service during 2019/2020. It, and nested Knowledge Exchange workshops with clinicians and service users, will allow us to: determine the proportions following conveyance and non-conveyance that die and/or recontact UEC system within 3 (/30) days; quantify the proportion of conveyed incidents resulting in ‘avoidable ED attendances’ (AA); optimise risk tool development; and develop statistical models that, using information available ‘on scene’, predict the risk of death/recontact with the UEC system within 3 (/30) days and the likelihood of an attendance at ED resulting in an AA.WP2: Form a cohort of patients cared for a seizure during 2021/2022 to ‘temporally’ validate the WP1 predictive models.WP3: Complete the ‘next steps’ workshops with stakeholders. Using nominal group techniques, finalise plans to develop the risk tool for clinical use and its evaluation.Ethics and dissemination WP1a and WP2 will be conducted under database ethical approval (IRAS 307353) and Confidentiality Advisory Group (22/CAG/0019) approval. WP1b and WP3 have approval from the University of Liverpool Central Research Ethics Committee (11450). We shall engage in proactive dissemination and knowledge mobilisation to share findings with stakeholders and maximise evidence usage.

Abstract Video‐encephalographic (vEEG) seizure recordings make essential contributions to the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES). The yield of vEEG examinations can be increased through suggestive seizure manipulation (SSM) (ie, activation/provocation/cessation procedures), but its use has raised ethical concerns. In preparation for guidelines on the investigation of patients with PNES, the ILAE PNES Task Force carried out an international survey to investigate practices of and opinions about SSM. An online questionnaire was developed by the ILAE PNES Task Force. Questions were asked at clinical unit or individual respondent level. All ILAE chapters were encouraged to send questionnaires to their members. The survey was open from July 1, 2019, to August 31, 2019. A total of 487 clinicians from 411 units across 94 countries responded. Some form of SSM was used in 296/411 units (72.0%). Over 90% reported the use of verbal suggestion, over 80% the use of activation procedures also capable of eliciting epileptic activity (hyperventilation or photic stimulation). Only 26.3% of units used techniques specifically intended to provoke PNES (eg, saline injection). Fewer than 10% of units had established protocols for SSM, only 20% of units required written patient consent, in 12.2% of units patients received explicitly false information to provoke seizures. Clinicians using SSM tended to perceive no ethical problems, whereas those not using SSM were likely to have ethical concerns about these methods. We conclude that the use of invasive nocebo techniques intended to provoke PNES in diagnostic settings has declined, but SSM is commonly combined with activation procedures also capable of eliciting epileptic activity. While research suggests that openness about the use of PNES‐specific nocebo techniques does not reduce diagnostic yield, very few units have suggestion protocols or seek patient consent. This could be addressed through establishing consensus guidance for the practice of SSM.

Abstract Epilepsy is a risk factor for the development of psychogenic non-epileptic seizures (PNES) and comorbid epilepsy is recognized as a comorbidity in about 10–30% of patients with PNES. The combination of epileptic and nonepileptic seizures poses a particular diagnostic challenge. In patients with epilepsy, additional PNES may be suspected on the basis of their typical semiology. The possibility of additional PNES should also be considered if seizures fail to respond to antiepileptic drug treatment, in patients with frequent emergency admissions with seizures and in those who develop new types of seizures. The description of semiological details by patients and witnesses can suggest additional PNES. Home video recordings can support an initial diagnosis, however, especially in patients with mixed seizure disorders it is advisable to seek further diagnostic confirmation by capturing all habitual seizure types with video-EEG. The clinical features of PNES associated with epilepsy are similar to those in isolated PNES disorders and include longer duration, fluctuating course, asynchronous movements, pelvic thrusting, side-to-side head or body movement, persistently closed eyes and mouth, ictal crying, recall of ictal experiences and absence of postictal confusion. PNES can also present as syncope-like episodes with unresponsiveness and reduced muscle tone. There is no unique epileptological or brain pathology profile putting patients with epilepsy at risk of additional PNES. However, patients with epilepsy and PNES typically have lower educational achievements and higher levels of psychiatric comorbidities than patients with epilepsy alone. Psychological trauma, including sexual abuse, appears to be a less relevant aetiological factor in patients with mixed seizure disorders than those with isolated PNES, and the gender imbalance (i.e. the greater prevalence in women) is less marked in patients with PNES and additional epilepsy than those with PNES alone. PNES sometimes develop after epilepsy surgery. A diagnosis of ‘known epilepsy’ should never be accepted without (at least brief) critical review. This narrative review summarises clinical, electrophysiological and historical features that can help identify patients with epilepsy and additional PNES.

Summary Objectives The Psychology Task Force of the Medical Therapies Commission of the International League Against Epilepsy (ILAE) has been charged with taking steps to improve global mental health care for people with epilepsy. This study aimed to inform the direction and priorities of the Task Force by examining epilepsy healthcare providers’ current practical experiences, barriers, and unmet needs around addressing depression and anxiety in their patients. Methods A voluntary 27‐item online survey was distributed via ILAE chapters and networks. It assessed practices in the areas of screening, referral, management, and psychological care for depression and anxiety. A total of 445 participants, from 67 countries (68% high income), commenced the survey, with 87% completing all components. Most respondents (80%) were either neurologists or epileptologists. Results Less than half of respondents felt adequately resourced to manage depression and anxiety. There was a lack of consensus about which health professionals were responsible for screening and management of these comorbidities. About a third only assessed for depression and anxiety following spontaneous report and lack of time was a common barrier (>50%). Routine referrals to psychiatrists (>55%) and psychologists (>41%) were common, but approximately one third relied on watchful waiting. A lack of both trained mental health specialists (>55%) and standardized procedures (>38%) was common barriers to referral practices. The majority (>75%) of respondents’ patients identified with depression or anxiety had previously accessed psychotropic medications or psychological treatments. However, multiple barriers to psychological treatments were endorsed, including accessibility difficulties (52%). Significance The findings suggest that while the importance of managing depression and anxiety in patients with epilepsy is being recognized, there are ongoing barriers to effective mental health care. Key future directions include the need for updated protocols in this area and the integration of mental health professionals within epilepsy settings.

Abstract Objectives This International League Against Epilepsy (ILAE) Report: (a) summarizes the literature about “driving and psychogenic nonepileptic seizures (PNES)”; (b) presents the views of international experts; and (c) proposes an approach to assessing the ability of persons with PNES (PwPNES) to drive. Methods Phase 1: Systematic literature review. Phase 2: Collection of international expert opinion using SurveyMonkey®. Experts included the members of the ILAE PNES Task Force and individuals with relevant publications since 2000. Phase 3: Joint analysis of the findings and refinement of conclusions by all participants using email. As an ILAE Report, the resulting text was reviewed by the Psychiatry Commission, the ILAE Task Force on Driving Guidelines, and Executive Committee. Results Eight studies identified by the systematic review process failed to provide a firm evidence base for PNES‐related driving regulations, but suggest that most health professionals think restrictions are appropriate. Twenty‐six experts responded to the survey. Most held the view that decisions about driving privileges should consider individual patient and PNES characteristics and take account of whether permits are sought for private or commercial driving. Most felt that those with active PNES should not be allowed to drive unless certain criteria were met and that PNES should be thought of as “active” if the last psychogenic seizure had occurred within 6 months. Significance Recommendations on whether PwPNES can drive should be made at the individual patient level. Until future research has determined the risk of accidents in PwPNES a proposed algorithm may guide decisions about driving advice.

Introduction The Vagus Nerve Stimulation Therapy System (VNS Therapy) is an adjunctive neuromodulatory therapy that can be efficacious in reducing the frequency and severity of seizures in people with drug-resistant epilepsy (DRE). CORE-VNS aims to examine the long-term safety and clinical outcomes of VNS in people with DRE.Methods and analysis The CORE-VNS study is an international, multicentre, prospective, observational, all-comers, post-market registry. People with DRE receiving VNS Therapy for the first time as well as people being reimplanted with VNS Therapy are eligible. Participants have a baseline visit (prior to device implant). They will be followed for a minimum of 36 months and a maximum of 60 months after implant. Analysis endpoints include seizure frequency (average number of events per month), seizure severity (individual-rated categorical outcome including very mild, mild, moderate, severe or very severe) as well as non-seizure outcomes such as adverse events, use of antiseizure medications, use of other non-pharmacological therapies, quality of life, validated measures of quality of sleep (Pittsburgh Sleep Quality Index or Children’s Sleep Habit Questionnaire) and healthcare resource utilisation. While the CORE-VNS registry was not expressly designed to test hypotheses, subgroup analyses and exploratory analysis that require hypothesis testing will be conducted across propensity score matched treatment groups, where possible based on sampling.Ethics and dissemination The CORE-VNS registry has already enrolled 823 participants from 61 centres across 15 countries. Once complete, CORE-VNS will represent one of the largest real-world clinical data sets to allow a more comprehensive understanding of the management of DRE with adjunctive VNS. Manuscripts derived from this database will shed important new light on the characteristics of people receiving VNS Therapy; the practical use of VNS across different countries, and factors influencing long-term response.Trail registration number NCT03529045.

Background: Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited. Objectives: To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive–behavioural therapy for adults with dissociative seizures. Design: This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial. Setting: This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive–behavioural therapy services. Participants: Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017. Interventions: Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive–behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care. Main outcome measures: The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness. Results: In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive–behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1–35 dissociative seizures); cognitive–behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0–20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive–behavioural therapy at a p-value

Abstract Background Patients with functional motor disorder (FMD) experience persistent and disabling neurological symptoms such as weakness, tremor, dystonia and disordered gait. Physiotherapy is usually considered an important part of treatment; however, sufficiently-powered controlled studies are lacking. Here we present the protocol of a randomised controlled trial (RCT) that aims to evaluate the clinical and cost effectiveness of a specialist physiotherapy programme for FMD. Methods/design The trial is a pragmatic, multicentre, single blind parallel arm randomised controlled trial (RCT). 264 Adults with a clinically definite diagnosis of FMD will be recruited from neurology clinics and randomised to receive either the trial intervention (a specialist physiotherapy protocol) or treatment as usual control (referral to a community physiotherapy service suitable for people with neurological symptoms). Participants will be followed up at 6 and 12 months. The primary outcome is the Physical Function domain of the Short Form 36 questionnaire at 12 months. Secondary domains of measurement will include participant perception of change, mobility, health-related quality of life, health service utilisation, anxiety and depression. Health economic analysis will evaluate the cost impact of trial and control interventions from a health and social care perspective as well as societal perspective. Discussion This trial will be the first adequately-powered RCT of physical-based rehabilitation for FMD. Trial registration International Standard Randomised Controlled Trials Number ISRCTN56136713. Registered 27 March 2018.

Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.

Symptoms and functioning can be measured subjectively using self-report measures or objectively, based on physiological changes. This raises the question whether subjective and objective measures are closely correlated and – if not – whether one is more accurate or meaningful than the other, especially in patients with Functional Seizures (FS) or other Functional Neurological Symptom Disorders (FND), where subjective and objective observations may be thought particularly likely to deviate. This systematic review explores these questions focussing on measures of distress, arousal and symptom burden. Eighteen studies (12 FS, 6 other FND) capturing 396 FND patients were included. Eleven reported no correlation between subjective and objective measures. Only four studies reported significant correlations (r’s = −0.74–0.59, p’s

Abstract Background Dissociative seizures (DSs), also called psychogenic non-epileptic seizures, are a distressing and disabling problem for many patients in neurological settings with high and often unnecessary economic costs. The COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES) trial is an evaluation of a specifically tailored psychological intervention with the aims of reducing seizure frequency and severity and improving psychological well-being in adults with DS. The aim of this paper is to report in detail the quantitative and economic analysis plan for the CODES trial, as agreed by the trial steering committee. Methods The CODES trial is a multicentre, pragmatic, parallel group, randomised controlled trial performed to evaluate the clinical effectiveness and cost-effectiveness of 13 sessions of cognitive behavioural therapy (CBT) plus standardised medical care (SMC) compared with SMC alone for adult outpatients with DS. Discussion The objectives and design of the trial are summarised, and the aims and procedures of the planned analyses are illustrated. The proposed analysis plan addresses statistical considerations such as maintaining blinding, monitoring adherence with the protocol, describing aspects of treatment and dealing with missing data. The formal analysis approach for the primary and secondary outcomes is described, as are the descriptive statistics that will be reported. This paper provides transparency to the planned inferential analyses for the CODES trial prior to the extraction of outcome data. It also provides an update to the previously published trial protocol and guidance to those conducting similar trials. Trial registration ISRCTN registry ISRCTN05681227 (registered on 5 March 2014); ClinicalTrials.gov NCT02325544 (registered on 15 December 2014).

Psychogenic Non-epileptic Seizures (PNES) are ‘medically unexplained’ seizure-like episodes which superficially resemble epileptic seizures but which are not caused by epileptiform discharges in the brain. While many experts see PNES disorder as a multifactorial biopsychosocial condition, little is known about the neurobiological processes which may predispose, precipitate and/or perpetuate PNES symptomology. This systematic meta-review advances our knowledge and understanding of the neurobiological correlates of PNES by providing an up-to-date assessment of neuroimaging studies performed on individuals with PNES. Although the results presented appear inconclusive, they are consistent with an association between structural and functional brain abnormalities and PNES. These findings have implications for the way in which we think about this “medically unexplained” disorder and how we communicate the diagnosis to patients. However, it is also evident that neuroimaging studies in this area suffer from a number of significant limitations and future larger studies will need to better address these if we are to improve our understanding of the neurobiological correlates of predisposition to and/or manifestation of PNES. Keywords: Psychogenic Non-epileptic Seizures (PNES), Dissociation, Diffusion tensor imaging (DTI), Magnetic resonance imaging (MRI), Positron emission tomography (PET), Single photon emission computed tomography (SPECT)

The gold-standard for the diagnosis of psychogenic non-epileptic seizures (PNES) is capturing an attack with typical semiology and lack of epileptic ictal discharges on video-EEG. Despite the importance of this diagnostic test, lack of standardisation has resulted in a wide variety of protocols and reporting practices. The goal of this review is to provide an overview of research findings on the diagnostic video-EEG procedure, in both the adult and paediatric literature. We discuss how uncertainties about the ethical use of suggestion can be resolved, and consider what constitutes best clinical practice. We stress the importance of ictal observation and assessment and consider how diagnostically useful information is best obtained. We also discuss the optimal format of video-EEG reports; and of highlighting features with high sensitivity and specificity to reduce the risk of miscommunication. We suggest that over-interpretation of the interictal EEG, and the failure to recognise differences between typical epileptic and nonepileptic seizure manifestations are the greatest pitfalls in neurophysiological assessment of patients with PNES. Meanwhile, under-recognition of semiological pointers towards frontal lobe seizures and of the absence of epileptiform ictal EEG patterns during some epileptic seizure types (especially some seizures not associated with loss of awareness), may lead to erroneous PNES diagnoses. We propose that a standardised approach to the video-EEG examination and the subsequent written report will facilitate a clear communication of its import, improving diagnostic certainty and thereby promoting appropriate patient management. Keywords: Psychogenic nonepileptic seizures, Nonepileptic attack disorder, Suggestion, EEG

Neurodegenerative diseases causing dementia are known to affect a person's speech and language. Part of the expert assessment in memory clinics therefore routinely focuses on detecting such features. The current outpatient procedures examining patients' verbal and interactional abilities mainly focus on verbal recall, word fluency, and comprehension. By capturing neurodegeneration-associated characteristics in a person's voice, the incorporation of novel methods based on the automatic analysis of speech signals may give us more information about a person's ability to interact which could contribute to the diagnostic process. In this proof-of-principle study, we demonstrate that purely acoustic features, extracted from recordings of patients' answers to a neurologist's questions in a specialist memory clinic can support the initial distinction between patients presenting with cognitive concerns attributable to progressive neurodegenerative disorders (ND) or Functional Memory Disorder (FMD, i.e., subjective memory concerns unassociated with objective cognitive deficits or a risk of progression). The study involved 15 FMD and 15 ND patients where a total of 51 acoustic features were extracted from the recordings. Feature selection was used to identify the most discriminating features which were then used to train five different machine learning classifiers to differentiate between the FMD/ND classes, achieving a mean classification accuracy of 96.2%. The discriminative power of purely acoustic approaches could be integrated into diagnostic pathways for patients presenting with memory concerns and are computationally less demanding than methods focusing on linguistic elements of speech and language that require automatic speech recognition and understanding.

Background: We report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another. Objectives: To (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making. Design: A mixed-methods secondary analysis of recorded neurology consultations and associated questionnaire responses. We coded every recommendation, PVE and option-list together with a range of variables internal (e.g. patients’ responses) and external to the consultation (e.g. self-reported patient satisfaction). The resulting matrix captured the qualitative and quantitative data for every decision. Setting and participants: The primary study was conducted in two neurology outpatient centres. A total of 14 neurologists, 223 patients and 114 accompanying others participated. Results: Distribution of practices – recommending was the most common approach to decision-making. Patient demographics did not appear to play a key role in patterning decisional practices. Several clinical factors did show associations with practice, including (1) that neurologists were more likely to use option-lists or PVEs when making treatment rather than investigation decisions, (2) they were more certain about a diagnosis and (3) symptoms were medically explained. Consequences of practices – option-lists and PVEs (compared with recommendations) – were strongly associated with choice by neurologists and patients. However, there was no significant difference in overall patient satisfaction relating to practices employed. Recommendations were strongly associated with a course of action being agreed. Decisions containing PVEs were more likely to end in rejection. Option-lists often ended in the decision being deferred. There was no relationship between length of consultation and the practice employed. Limitations: A main limitation is that we judged only outcomes based on the recorded consultations and the self-report data collected immediately thereafter. We do not know what happened beyond the consultation. Conclusions: Patient choice is harder to enact than policy directives acknowledge. Although there is good evidence that neurologists are seeking to enact patient choice, they are still more likely to make recommendations. This appears to be partly due to concerns that ‘choice’ might conflict with doctors’ duty of care. Future guidance needs to draw on evidence regarding choice in practice to support doctors and patients to achieve the wider goal of shared decision-making. Future research: To advance understanding of how interactional practices might have effects beyond the clinic, a priority is to investigate associations between decision-making practices and external outcomes (such as adherence). Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Epilepsy is a neurological disorder that causes changes in the autonomic nervous system. Heart rate variability (HRV) reflects the regulation of cardiac activity and autonomic nervous system tone. The early detection of epileptic seizures could foster the use of new treatment approaches. This study presents a new methodology for the prediction of epileptic seizures using HRV signals. Eigendecomposition of HRV parameter covariance matrices was used to create an input for a support vector machine (SVM)-based classifier. We analyzed clinical data from 12 patients (9 female; 3 male; age 34.5 ± 7.5 years), involving 34 seizures and a total of 55.2 h of interictal electrocardiogram (ECG) recordings. Data from 123.6 h of ECG recordings from healthy subjects were used to test false positive rate per hour (FP/h) in a completely independent data set. Our methodological approach allowed the detection of impending seizures from 5 min to just before the onset of a clinical/electrical seizure with a sensitivity of 94.1%. The FP rate was 0.49 h−1 in the recordings from patients with epilepsy and 0.19 h−1 in the recordings from healthy subjects. Our results suggest that it is feasible to use the dynamics of HRV parameters for the early detection and, potentially, the prediction of epileptic seizures.

Background: The NHS is committed to offering patients more choice. Yet even within the NHS, the meaning of patient choice ranges from legal ‘rights to choose’ to the ambition of establishing clinical practice as a ‘partnership’ between doctor and patient. In the absence of detailed guidance, we focused on precisely how to engage patients in decision-making. Objectives: To contribute to the evidence-base about whether or not, and how, patient choice is implemented to identify the most effective communication practices for facilitating patient choice. Design: We used conversation analysis to examine practices whereby neurologists offer choice. The main data set consists of audio- and video-recorded consultations. Patients completed pre- and post-consultation questionnaires and neurologists completed the latter. Setting and participants: The study was conducted in neurology outpatient clinics in Glasgow and Sheffield. Fourteen neurologists, 223 patients and 120 accompanying others took part. Results: Patients and clinicians agreed that choice had featured in 53.6% of consultations and that choice was absent in 14.3%. After 32.1% of consultations, either patient or neurologist thought choice was offered. The presence or absence of choice was not satisfactorily explained by quantitatively explored clinical or demographic variables. For our qualitative analysis, the corpus was divided into four subsets: (1) patient and clinician agree that choice was present; (2) patient and clinician agree that choice was absent; (3) patient ‘yes’, clinician ‘no’; and (4) patient ‘no’, clinician ‘yes’. Comparison of all subsets showed that ‘option-listing’ was the only practice for offering choice that was present only (with one exception, which, as we show, proves the rule) in those consultations for which participants agreed there was a choice. We show how option-listing can be used to engage patients in decision-making, but also how very small changes in the machinery of option-listing [for instance the replacement or displacement of the final component of this practice, the patient view elicitor (PVE)] can significantly alter the slot for patient participation. In fact, a slightly modified form of option-listing can be used to curtail choice. Finally, we describe two forms of PVE that can be used to hand a single-option decision to the patient, but which, we show, can raise difficulties for patient choice. Conclusions: Choice features in the majority of recorded consultations. If doctors want to ensure a patient knows she or he has a choice, option-listing is likely to be best understood by patients as an invitation to choose. However, an important lesson from this study is that simply asking doctors to adopt a practice (like option-listing) will not automatically lead to a patient-centred approach. Our study shows that precisely how a practice is implemented is crucial. Future research: Future research should investigate (1) links between the practices identified here and relevant outcome measures (like adherence); (2) whether being given a choice is better or worse for patients than receiving a doctor’s recommendation, taking account of clinical and demographic factors; and (3) how our approach could be fruitfully applied in other settings. Funding: The National Institute for Health Research Health Services and Delivery Research programme.