Esther Bui

Purpose of ReviewMenopause is a neurobiological transition with important implications for neurologic care. This review summarizes the physiology and hormonal changes of spontaneous menopause and i...

Purpose of the ReviewPerimenopause and menopause are reproductive stages marked by fluctuating and subsequent permanent loss of ovarian estrogen and progesterone production. There are important con...

BACKGROUND Anxiety is the most common psychiatric comorbidity among people with epilepsy, yet epilepsy-specific (ES) interictal anxiety remains underrecognized and undertreated, highlighting the need for accessible non-pharmacological approaches. Virtual reality exposure therapy (VR-ET) can deliver controlled exposure to seizure-related fears that are difficult to reproduce in vivo, but its effects and delivery requirements need evaluation in the context of seizure unpredictability and heterogeneous seizure experiences. The epilepsy monitoring unit (EMU) allows repeated engagement under medi OBJECTIVE This mixed-methods randomized controlled trial evaluated the preliminary effectiveness of VR-ET for ES-anxiety compared with neutral VR, together with feasibility, acceptability, usability, safety, tolerability, and scenario fidelity among people with epilepsy admitted to an EMU. METHODS Fourteen people with self-reported epilepsy- or seizure-related anxiety were randomized to VR-ET (n=7) or neutral VR (n=7). Participants completed self-administered 5-minute 360-degree video sessions twice daily for up to 10 days or until discharge. VR-ET participants progressed through personalized hierarchies of graded seizure-related exposure scenes selected at baseline using a diagnostic interview; control participants viewed nature-based scenes in a standardized order. Quantitative outcomes included anxiety, fear and situational avoidance, quality of life, simulator sickness, usability, and presence, and were summarized descriptively. Post-intervention and 1-month interviews were analyzed using framework analysis with inductive coding within predefined domains. Findings were integrated through joint interpretation and cross-case comparison. RESULTS Quantitative outcomes were heterogeneous and showed no clear between-group pattern. Adherence was high, with all VR-ET participants and 5 of 7 (71.4%) neutral VR participants meeting the predefined threshold. Five of 7 (71.4%) VR-ET participants described the intervention as helpful, and 4 of 7 (57.1%) reported experiences consistent with exposure-related learning, including increased insight, self-efficacy, preparedness, cognitive reappraisal, and habituation. Fear and anxiety changes were variable, and incomplete 1-month follow-up limited interpretation of longer-term outcomes. Scenarios were generally realistic and representative of epilepsy-related fears, but emotional engagement depended on personal relevance. Seizure simulations were identified as most impactful, and participants recommended greater intensity, variety, interactivity, and treatment duration. VR-ET participants more often expressed interest in continued use outside the EMU, whereas neutral VR participants primarily described short-term calming and distraction during admission with some reporting proactive use during periods of heightened anxiety. Across groups, usability was favorable, simulator sickness was minimal, and no serious adverse events were attributable to VR. Engagement was affected by EMU-related fatigue, seizure activity, environmental interruptions, and technical problems. CONCLUSIONS The VR interventions were feasible, acceptable, and safe in this sample. VR-ET showed no clear quantitative advantage over neutral VR, but qualitative findings were consistent with exposure-related learning. Neutral VR may provide low-intensity anxiety support during EMU admission. Future research should evaluate more personalized, varied, and interactive VR-ET and examine integration with therapist-supported care. CLINICALTRIAL ClinicalTrials.gov NCT06028945

Epilepsy fellowship training in Canada is heterogeneous in program length, extent of electroencephalography (EEG) training, and exposure to transitional and surgical care. This study aimed to develop a national framework for epilepsy fellowship curricula by analyzing expert consensus within the Canadian League Against Epilepsy (CLAE) through thematic discourse analysis. We conducted a qualitative thematic discourse analysis of recorded CLAE expert panel meetings with 22 participants, including fellowship program directors and faculty educators. Discussions addressed core competencies, assessment practices, program duration, transition training, and advanced care. Transcripts were analyzed to identify recurrent discursive patterns and areas of alignment and tension. Six interrelated themes were identified, emphasizing early mastery of foundational competencies, a staged introduction of advanced skills, hybrid time-and-competency structures, the formative use of EEG examinations, flexible transition and surgical exposure pathways, and guidance rather than governance. Participants negotiated national coherence while preserving institutional flexibility. The findings support early acquisition of core competencies, context-sensitive advanced training, and formative assessment guided by competency-based medical education and sociocultural learning principles. This framework balances standardization with institutional flexibility to improve patient safety, trainee preparedness, and equitable access across Canadian programs.

Epileptologists are neurologists with advanced training in the diagnosis and management of complex epilepsy. In Canada, epilepsy fellowship programs vary considerably in duration and content because of the lack of formal accreditation or standardized curricula. Contributing factors include regional differences in resources, infrastructure, and program-specific goals. To address this variability, the Canadian League Against Epilepsy established a working group to develop a national consensus framework for postgraduate epilepsy education. The process started with a comprehensive literature review of North American and international curricula and standards to ensure alignment. The nominal group technique involved 4 rounds with Canadian epilepsy educators, focusing on idea generation, sharing, discussion, and questionnaire completion on key topics. A 70% agreement threshold was set to establish consensus. Items not reaching this threshold were revisited in a final discussion round. Recorded discussions were analyzed, with the eventual goal of incorporating these findings into a national consensus guideline for epilepsy fellowship training in Canada. Agreement was reached on core topics such as eligibility, fellowship duration, learning objectives, timing of skill acquisition, epilepsy surgery exposure, research involvement, evaluation methods, and accreditation. Areas lacking consensus underwent further exploration in a final survey round. The process also highlighted priorities for future work, including program accreditation and the development of national clinical examinations. This study represents a foundational step in establishing unified standards for epilepsy fellowship training in Canada and reinforces the importance of national collaboration to promote excellence in epilepsy and EEG education.

Subspecialty neurology fellowship training is becoming increasingly more common and a requirement to practice at academic institutions. This is especially true for electroencephalography (EEG) and epilepsy, as neurology residency does not usually provide adequate exposure to this complex field. Little is known about the availability and content of epilepsy fellowships in Canada. This study aims to identify this information and characterize available programs. Eight pediatric and eight adult epilepsy fellowship programs were identified. There was a wide range in the availability of resources in many centers, but all centers provided exposure to core EEG and epilepsy skills.

Understanding the evolution of clinical tools and models of care is fundamental to advancing the field of epilepsy. The 2025 American Epilepsy Society Annual Course examined the expanding spectrum of epilepsy care through the integration of multispecialty collaboration, innovative diagnostic modalities, and surgical and nonsurgical therapeutic interventions. The course underscored significant global advancements in epilepsy research and practice. This comprehensive review synthesizes key educational insights from the program, offering a critical perspective on the ongoing transformation of epilepsy care.

Maternal use of first-generation antiseizure medications (ASMs), such as valproate and phenobarbital, increases the risk of congenital malformations in offspring. Second-generation ASMs, such as lamotrigine and levetiracetam, pose less risk to fetal development, although topiramate seems to increase the risk of oral clefts. Less is known about the safety of newer second-generation ASMs during pregnancy including oxcarbazepine, zonisamide, and lacosamide. The aim of this study was to quantify the relative risk of major malformations in offspring after maternal use of specific ASMs early in pregnancy, with special interest in second-generation ASMs. The study population included pregnant women who enrolled in the North American Antiepileptic Drug Pregnancy Registry between 1997 and 2023. Data on ASM use and maternal characteristics were collected through phone interviews at enrollment, at 7 months of gestation, and within 3 months after delivery. Malformations were confirmed by medical records and adjudicated by a dysmorphologist. The risk of major malformations was estimated among infants exposed to specific ASMs in monotherapy during the first trimester of pregnancy. Risk ratios (RRs) and 95% CIs were estimated with logistic regression models. A total of 7,311 participants taking an ASM as monotherapy during the first trimester were eligible for analysis. The mean age was 30 years. The risk of major malformations was 2.1% (52/2,461) for lamotrigine, 2.0% (26/1,283) for levetiracetam, 2.8% (32/1,132) for carbamazepine, 5.1% (26/510) for topiramate, 2.8% (12/423) for phenytoin, 9.2% (31/337) for valproate, 1.5% (5/327) for oxcarbazepine, 1.5% (4/270) for gabapentin, 1.3% (3/228) for zonisamide, 6.0% (12/200) for phenobarbital, 3.2% (2/62) for pregabalin, and 0% (0/88) for lacosamide. Compared with lamotrigine, the RR was 5.1 (95% CI 3.0-8.5) for valproate, 2.9 (1.4-5.8) for phenobarbital, and 2.2 (1.2-4.0) for topiramate. Topiramate was specifically associated with a higher risk of cleft lip. Results confirm the association between maternal use of valproate, phenobarbital, and topiramate early in pregnancy and a higher risk of major malformations in the infant compared with lamotrigine. However, they do not support meaningful risk elevation for levetiracetam, oxcarbazepine, gabapentin, or zonisamide. Relative risk estimates for lacosamide and pregabalin are still imprecise.

Growing evidence suggests that biological sex influences disease risk, clinical presentation, treatment response, and prognosis across neurological conditions. Despite this increasing awareness of important sex differences, neurological research and clinical care remain insufficiently tailored to females. In this review, the authors highlight the importance of integrating sex-specific considerations into precision medicine for neurological disorders. Focusing on five high-prevalence and high-burden neurological conditions (epilepsy, migraine, stroke, multiple sclerosis, and neurodegenerative diseases), this review identifies critical knowledge gaps and actionable opportunities for advancing care for females. Such gaps and opportunities include: 1) improved pregnancy and lactation data in epilepsy; 2) hormonal influences across the menstrual cycle, pregnancy, and menopause in migraine; 3) sex-based disparities in symptom recognition, treatment access, and rehabilitation for stroke patients; 4) the influence of sex hormones on disease onset, progression, and prognosis in multiple sclerosis; and 5) sex differences in pathophysiology and clinical trajectories in neurodegenerative diseases. This review proposes a roadmap for integrating sex-based considerations into three key domains: clinical care, research, and neurology training. Prioritising and advancing these initiatives is essential for improving neurological care and represents a critical step towards equitable precision medicine.

While hormonal changes have been recognised to influence seizure control and have been studied in association with menstrual cycles and pregnancy, there is a paucity of data on the menopause transition in epilepsy. Given the known effects of sex steroid hormones on neuronal excitability, their endogenous fluctuations during perimenopause, as well as menopause hormone treatments, may alter seizure control. Epilepsy may also be associated with premature ovarian insufficiency and early menopause. This is especially important for epilepsy-related comorbidities, for which menopause can constitute a second hit, such as osteoporosis. Additional considerations for females with epilepsy across the menopause continuum include changes in antiseizure medication clearance and potential interactions with menopausal hormone therapy or other concomitant medications. This comprehensive review summarises the currently available literature on epilepsy and menopause, highlights gaps in knowledge, and underscores the need for research efforts, particularly longitudinal studies investigating the menopause transition.