Sudden unexpected death in epilepsy: addressing the challenges

Non-adherence to epileptic medications among adult patients in south west Shewa zone hospitals of central Ethiopia

Epilepsy, a global public health problem, affecting about 50 million humans. Non-adherence to antiepileptic medications leads to treatment failure, hospitalization, decreased productivity and death. Previously conducted studies in Ethiopia did not fully identify these factors, which highlights the need for further research. Hence, this study aimed to assess non-adherence to anti-epileptic medications and associated factors among adult patients with epilepsy at the specified study area. Hospital based cross-sectional study was employed to collect data from 361 patients with epilepsy from November 1, 2023 to January 9, 2024. Data was collected using a pretested structured interviewer-administered questionnaire. Systematic random sampling technique was carried out to select study participants. Data was entered into EpiData and exported to Statistical Package for Social Sciences (SPSS) version 25 for analysis. The multivariable logistic regressions were utilized and Adjusted Odds Ratio (AOR), 95% Confidence level and p-value < 0.05 was used to declare statistical significance. In this study, 43.1% (95% CI 37.8, 48.4%) of respondents were non-adherent to anti-epileptic medications. Being on treatment for 1-3 years (AOR = 4.1, 95% CI 1.768, 9.427), unable to get health information about their illness (AOR = 2.36, 95% CI 1.4, 3.9) and distance to the health facility (AOR = 2.7, 95% CI 1.56, 4.66) were factors significantly associated with non-adherence to anti-epileptic medications. The prevalence of non-adherence to anti-epileptic medications was found to be high. Duration on treatment, distance to the health facility and unable to get health information about their illness were predictors of non-adherence. Therefore, it is recommended that providing health education and counseling as well solving distance related problems to the health facility is needed to increase adherence for better treatment outcome.

Small cohort of patients with epilepsy showed increased activity on Facebook before sudden unexpected death

Sudden Unexpected Death in Epilepsy (SUDEP) remains a leading cause of death in people with epilepsy. Despite the constant risk for patients and bereavement to family members, to date the physiological mechanisms of SUDEP remain unknown. Here we explore the potential to identify putative predictive signals of SUDEP from online digital behavioral data using text and sentiment analysis tools. Specifically, we analyze Facebook timelines of six patients with epilepsy deceased due to SUDEP, donated by surviving family members. We find preliminary evidence for behavioral changes detectable by text and sentiment analysis tools. Namely, in the months preceding their SUDEP event patient social media timelines show: i) increase in verbosity; ii) increased use of functional words; and iii) sentiment shifts as measured by different sentiment analysis tools. Combined, these results suggest that social media engagement, as well as its sentiment, may serve as possible early-warning signals for SUDEP in people with epilepsy. While the small sample of patient timelines analyzed in this study prevents generalization, our preliminary investigation demonstrates the potential of social media data as complementary data in larger studies of SUDEP and epilepsy.

Cardioprotective effects of amiodarone in a rat model of epilepsy-induced cardiac dysfunction

Cardiac dysfunction is one of the leading causes of death in epilepsy. The anti-arrhythmic drug, amiodarone, is under investigation for its therapeutic effects in epilepsy. We aimed to evaluate the possible effects of amiodarone on cardiac injury during status epilepticus, as it can cause prolongation of the QT interval. Five rat groups were enrolled in the study; three control groups (1) Control, (2) Control-lithium and (3) Control-Amio, treated with 150 mg/kg/intraperitoneal amiodarone, (4) Epilepsy model, induced by sequential lithium/pilocarpine administration, and (5) the epilepsy-Amio group. The model group expressed a typical clinical picture of epileptiform activity confirmed by the augmented electroencephalogram alpha and beta spikes. The anticonvulsive effect of amiodarone was prominent, it diminished (p < 0.001) the severity of seizures and hence, deaths and reduced serum noradrenaline levels. In the model group, the electrocardiogram findings revealed tachycardia, prolongation of the corrected QT (QTc) interval, depressed ST segments and increased myocardial oxidative stress. The in-vitro myocardial performance (contraction force and - (df/dt)_max ) was also reduced. Amiodarone decreased (p < 0.001) the heart rate, improved ST segment depression, and myocardial contractility with no significant change in the duration of the QTc interval. Amiodarone preserved the cardiac histological structure and reduced the myocardial injury markers represented by serum Troponin-I, oxidative stress and IL-1. Amiodarone pretreatment prevented the anticipated cardiac injury induced during epilepsy. Amiodarone possessed an anticonvulsive potential, protected the cardiac muscle and preserved its histological architecture. Therefore, amiodarone could be recommended as a protective therapy against cardiac dysfunction during epileptic seizures with favourable effect on seizure activity.

Relationship and sexual satisfaction are associated with better disease self-management in persons with epilepsy

Prior research has demonstrated that PWEs view intimate interpersonal relationships as personally important and as a substantive challenge in their lives. This is significant as high-quality intimate relationships have been linked with greater well-being and better healthcare self-management in other disease contexts. For persons with epilepsy (PWEs), self-management is critical for seizure control, lower mortality, and better quality of life. In the current study, we conducted the first known investigation into the quality of PWEs' intimate relationships and their self-management abilities. In a sample of 88 PWEs, using the Adult Epilepsy Self-Management Instrument, results demonstrate links between greater relationship satisfaction and sexual satisfaction with better self-management on seven of the eleven subscales: health communication, coping skills, social support, seizure tracking, seizure response, stress management, and wellness; satisfaction was unrelated to the treatment, safety, medical adherence, and proactivity subscales. Importantly, these results held while controlling for age, gender, social support, and presence of comorbidities. These findings provide some evidence of the importance of intimate relationships in understanding PWEs' healthcare management abilities. Given that intimate relationship dynamics have been shown to be highly amenable to intervention, this is an area of potential interest for improving self-management in PWEs.

Parp1 hyperactivity couples DNA breaks to aberrant neuronal calcium signalling and lethal seizures

Defects in DNA single-strand break repair (SSBR) are linked with neurological dysfunction but the underlying mechanisms remain poorly understood. Here, we show that hyperactivity of the DNA strand break sensor protein Parp1 in mice in which the central SSBR protein Xrcc1 is conditionally deleted (Xrcc1Nes-Cre ) results in lethal seizures and shortened lifespan. Using electrophysiological recording and synaptic imaging approaches, we demonstrate that aberrant Parp1 activation triggers seizure-like activity in Xrcc1-defective hippocampus ex vivo and deregulated presynaptic calcium signalling in isolated hippocampal neurons in vitro. Moreover, we show that these defects are prevented by Parp1 inhibition or deletion and, in the case of Parp1 deletion, that the lifespan of Xrcc1Nes-Cre mice is greatly extended. This is the first demonstration that lethal seizures can be triggered by aberrant Parp1 activity at unrepaired SSBs, highlighting PARP inhibition as a possible therapeutic approach in hereditary neurological disease.

Influence of titration of antiseizure medications on treatment selection: Results of an online survey with clinicians in the United States

INTRODUCTION

Most antiseizure medications (ASM) need to be titrated before the optimal dose is achieved. Titration can last several weeks to months. We assessed the impact titration schedules have on ASM treatment-related decisions in the United States (US).

METHODS

An online survey was conducted with different healthcare providers (HCPs) in the US involved in the treatment and management of patients with epilepsy. The survey contained three sections: the first section with screening questions; the second on key factors that influence a HCP's decision-making when selecting treatments for different types of seizures and different treatment lines; and the third on the HCP's knowledge and perceptions regarding ASM titration for the treatment of patients with epilepsy.

RESULTS

One-hundred and fifty HCPs (63% neurologists) completed the survey. Most HCPs considered titration schedule to be important, with only 1-3% of HCPs, depending on type of seizure, considering the titration schedule to be "not important at all" when prescribing therapy. Healthcare providers' acceptance of titration increased with shorter durations (≥50% accepted titration periods of ≤2 weeks), and lower number of tablets/capsules per dose (≥50% accepted ≤3 tablets/capsules per dose), doses (≥50% accepted ≤2 doses/day), and steps (≥50% accepted ≤3 steps/dose change). Most HCPs (68-91% depending on type of seizure) considered a titration duration of 6 or more weeks only somewhat acceptable or somewhat or highly unacceptable. Almost all HCPs selected "somewhat familiar", "familiar", or "very familiar" as the attribute that best defines their knowledge level of titration, with only 4% selecting "a little familiar". While 87% of HCPs agreed or strongly agreed that they could easily understand titration schedules, only 27% of them agreed or strongly agreed that patients could easily understand titration schedules and 58% of HCPs considered that adhering to the titration schedule was difficult for patients. Most HCPs agreed or strongly agreed that a complex or long titration schedule renders it difficult to achieve their treatment objectives.

CONCLUSIONS

Healthcare providers take into account the duration and complexity of the titration period in their ASM prescribing decision-making and prefer shorter and simpler titration schedules, particularly for patients who are experiencing convulsive seizures and starting monotherapy. There was a clear difference between the HCP's belief in their own ability to understand a titration schedule, and their belief that the patient would be able to follow the titration schedule appropriately.

Continuing Burden of Refractory Epilepsy

Epilepsy is one of the most common neurological diseases, and uncontrolled seizures remain a significant problem for one-third of patients with epilepsy on drug therapy. Ongoing seizures affect the morbidity and mortality of patients with epilepsy. Premature death is up to 3 times higher in those with epilepsy than in the general population. Quality of life is affected by refractory epilepsy with physical, social, and psychological consequences. Patients may be stigmatized by society, institutions, and their own shame surrounding seizures. Questions remain on how to treat refractory epilepsy, also called drug-resistant, pharmacoresistant, or intractable epilepsy. Cenobamate, a novel antiseizure medication, may provide additional benefit for refractory epilepsy treatment.

SUDEP and Grief: Overview and Current Issues

The medical community and the general public are aware of sudden deaths in apparently healthy infants (SIDS) and in cases of cardiac arrest (SCD). However, there is a third, less-well known, form of sudden death that occurs in persons with epilepsy (SUDEP). This paper provides a detailed overview what is known about SUDEP, including the current important, unresolved issues being considered in the field (research, education, informed consent). This paper also includes an overview of the grieving process common to all three conditions. Again, the current issues being considered in the field of grieving are presented (major depression, posttraumatic stress disorder). It is written for physicians, including psychiatrists, and for the health community beyond neurologists and serves as a provider resource for persons with epilepsy, their families, and for the general public. This information about SUDEP and grief becomes also additionally important as national health care moves toward an interdisciplinary primary care model of service delivery.

Benefits of the epilepsy specialist nurses (ESN) role, standardized practices and education around the world

Epilepsy, often considered as a stigmatizing disease, affects 65 million people worldwide and is frequently associated with comorbidities that increase both direct and indirect costs. The degree of impact on quality of life and the cost of care differs depending on the social and health care organizations in place, political, medico-economic and/or socio-cultural contexts. Across the globe, healthcare is provided by nurses in primary care, urgent or emergency care, and within specialized domains of practice. In Epilepsy the global care could be enhanced by developing standardized nursing education in close collaboration with other caregivers. The impact of epilepsy nursing care has been documented in some developed countries, but the diversity of nursing practices and professional education of nurses raise difficulties in generalizing these findings. Specialized education in epilepsy will improve access, treatment and ultimately the quality of life of patients.

Cardiac arrhythmia in a mouse model of sodium channel SCN8A epileptic encephalopathy

Patients with early infantile epileptic encephalopathy (EIEE) are at increased risk for sudden unexpected death in epilepsy (SUDEP). De novo mutations of the sodium channel gene SCN8A, encoding the sodium channel Na_v1.6, result in EIEE13 (OMIM 614558), which has a 10% risk of SUDEP. Here, we investigated the cardiac phenotype of a mouse model expressing the gain of function EIEE13 patient mutation p.Asn1768Asp in Scn8a (Na_v1.6-N1768D). We tested Scn8a^N1768D/+ mice for alterations in cardiac excitability. We observed prolongation of the early stages of action potential (AP) repolarization in mutant myocytes vs. controls. Scn8a^N1768D/+ myocytes were hyperexcitable, with a lowered threshold for AP firing, increased incidence of delayed afterdepolarizations, increased calcium transient duration, increased incidence of diastolic calcium release, and ectopic contractility. Calcium transient duration and diastolic calcium release in the mutant myocytes were tetrodotoxin-sensitive. A selective inhibitor of reverse mode Na/Ca exchange blocked the increased incidence of diastolic calcium release in mutant cells. Scn8a^N1768D/+ mice exhibited bradycardia compared with controls. This difference in heart rate dissipated after administration of norepinephrine, and there were no differences in heart rate in denervated ex vivo hearts, implicating parasympathetic hyperexcitability in the Scn8a^N1768D/+ animals. When challenged with norepinephrine and caffeine to simulate a catecholaminergic surge, Scn8a^N1768D/+ mice showed ventricular arrhythmias. Two of three mutant mice under continuous ECG telemetry recording experienced death, with severe bradycardia preceding asystole. Thus, in addition to central neuron hyperexcitability, Scn8a^N1768D/+ mice have cardiac myoycte and parasympathetic neuron hyperexcitability. Simultaneous dysfunction in these systems may contribute to SUDEP associated with mutations of Scn8a.

Seizure control as a new metric in assessing efficacy of tumor treatment in low-grade glioma trials

Patients with low-grade glioma frequently have brain tumor-related epilepsy, which is more common than in patients with high-grade glioma. Treatment for tumor-associated epilepsy usually comprises a combination of surgery, anti-epileptic drugs (AEDs), chemotherapy, and radiotherapy. Response to tumor-directed treatment is measured primarily by overall survival and progression-free survival. However, seizure frequency has been observed to respond to tumor-directed treatment with chemotherapy or radiotherapy. A review of the current literature regarding seizure assessment for low-grade glioma patients reveals a heterogeneous manner in which seizure response has been reported. There is a need for a systematic approach to seizure assessment and its influence on health-related quality-of-life outcomes in patients enrolled in low-grade glioma therapeutic trials. In view of the need to have an adjunctive metric of tumor response in these patients, a method of seizure assessment as a metric in brain tumor treatment trials is proposed.

Automated non-EEG based seizure detection: Do users have a say?

PURPOSE

Quality of life of patients with epilepsy depends largely upon unpredictability of seizure occurrence and would improve by predicting seizures or at least by detecting seizures (after their clinical onset) and react timely. Detection systems are available and researched, but little is known about the actual need and user preferences. The first indicates the market potential; the second allows us to incorporate user requirements into the engineering process.

METHODS

We questioned 20 pediatric and young adult patients, 114 caregivers, and 21 involved medical doctors and described, analyzed, and compared their experiences with systems for seizure detection, their opinions on usefulness and purpose of seizure detection, and their requirements for such a device.

RESULTS

Experience with detection systems is limited, but 65% of patients and caregivers and 85% of medical doctors express the usefulness, more so during night than day. The need is higher in patients with more severe intellectual disability. The higher the seizure frequency, the higher the need, opinions in the seizure-free group being more divided. Most patients and caregivers require 100% correct detection, and on average, one false alarm per seizure (one per week for those seizure-free) is accepted. Medical doctors allow 90% correct detections and between two false alarms per week and one per month depending on seizure frequency. Detection of seizures involving heavy movement and falls is judged most important by patients and caregivers and second to most by medical doctors. The latter judge heart rate monitoring most relevant, both towards seizure detection and SUDEP (sudden unexpected death in epilepsy) prevention.

CONCLUSIONS

The results, including a goal of 90% correct detections and one false alarm per seizure, should be considered in development of seizure detectors.

Audit of practice in sudden unexpected death in epilepsy (SUDEP) post mortems and neuropathological findings

AIMS

Sudden unexpected death in epilepsy (SUDEP) is one of the leading causes of death in people with epilepsy. For classification of definite SUDEP, a post mortem (PM), including anatomical and toxicological examination, is mandatory to exclude other causes of death. We audited PM practice as well as the value of brain examination in SUDEP.

METHODS

We reviewed 145 PM reports in SUDEP cases from four UK neuropathology centres. Data were extracted for clinical epilepsy details, circumstances of death and neuropathological findings.

RESULTS

Macroscopic brain abnormalities were identified in 52% of cases. Mild brain swelling was present in 28%, and microscopic pathologies relevant to cause or effect of seizures were seen in 89%. Examination based on whole fixed brains (76.6% of all PMs), and systematic regional sampling was associated with higher detection rates of underlying pathology (P < 0.01). Information was more frequently recorded regarding circumstances of death and body position/location than clinical epilepsy history and investigations.

CONCLUSION

Our findings support the contribution of examination of the whole fixed brain in SUDEP, with high rates of detection of relevant pathology. Availability of full clinical epilepsy-related information at the time of PM could potentially further improve detection through targeted tissue sampling. Apart from confirmation of SUDEP, complete neuropathological examination contributes to evaluation of risk factors as well as helping to direct future research into underlying causes.

Genome-wide Polygenic Burden of Rare Deleterious Variants in Sudden Unexpected Death in Epilepsy

Sudden unexpected death in epilepsy (SUDEP) represents the most severe degree of the spectrum of epilepsy severity and is the commonest cause of epilepsy-related premature mortality. The precise pathophysiology and the genetic architecture of SUDEP remain elusive. Aiming to elucidate the genetic basis of SUDEP, we analysed rare, protein-changing variants from whole-exome sequences of 18 people who died of SUDEP, 87 living people with epilepsy and 1479 non-epilepsy disease controls. Association analysis revealed a significantly increased genome-wide polygenic burden per individual in the SUDEP cohort when compared to epilepsy (P = 5.7 × 10(- 3)) and non-epilepsy disease controls (P = 1.2 × 10(- 3)). The polygenic burden was driven both by the number of variants per individual, and over-representation of variants likely to be deleterious in the SUDEP cohort. As determined by this study, more than a thousand genes contribute to the observed polygenic burden within the framework of this study. Subsequent gene-based association analysis revealed five possible candidate genes significantly associated with SUDEP or epilepsy, but no one single gene emerges as common to the SUDEP cases. Our findings provide further evidence for a genetic susceptibility to SUDEP, and suggest an extensive polygenic contribution to SUDEP causation. Thus, an overall increased burden of deleterious variants in a highly polygenic background might be important in rendering a given individual more susceptible to SUDEP. Our findings suggest that exome sequencing in people with epilepsy might eventually contribute to generating SUDEP risk estimates, promoting stratified medicine in epilepsy, with the eventual aim of reducing an individual patient's risk of SUDEP.