Which outcomes should we measure in adult epilepsy trials? The views of people with epilepsy and informal carers

Seizure Cycles under Pharmacotherapy

OBJECTIVE

This study was undertaken to determine the effects of antiseizure medications (ASMs) on multidien (multiday) cycles of interictal epileptiform activity (IEA) and seizures and evaluate their potential clinical significance.

METHODS

We retrospectively analyzed up to 10 years of data from 88 of the 256 total adults with pharmacoresistant focal epilepsy who participated in the clinical trials of the RNS System, an intracranial device that keeps records of IEA counts. Following adjunctive ASM trials, we evaluated changes over months in (1) rates of self-reported disabling seizures and (2) multidien IEA cycle strength (spectral power for periodicity between 4 and 40 days). We used a survival analysis and the receiver operating characteristics to assess changes in IEA as a predictor of seizure control.

RESULTS

Among 56 (33.3%) of the 168 adjunctive ASM trials suitable for analysis, ASM introduction was followed by an average 50 to 70% decrease in multidien IEA cycle strength and a concomitant 50 to 70% decrease in relative seizure rate for up to 12 months. Individuals with a ≥50% decrease in IEA cycle strength in the first 3 months of an ASM trial had a higher probability of remaining seizure responders (≥50% seizure rate reduction, p < 10-7) or super-responders (≥90%, p < 10-8) over the next 12 months.

INTERPRETATION

In this large cohort, a decrease in multidien IEA cycle strength following initiation of an adjunctive ASM correlated with seizure control for up to 12 months, suggesting that fluctuations in IEA mirror "disease activity" in pharmacoresistant focal epilepsy and may have clinical utility as a biomarker to predict treatment response. ANN NEUROL 2024;95:743-753.

Acetylcholine receptor based chemogenetics engineered for neuronal inhibition and seizure control assessed in mice

Epilepsy is a prevalent disorder involving neuronal network hyperexcitability, yet existing therapeutic strategies often fail to provide optimal patient outcomes. Chemogenetic approaches, where exogenous receptors are expressed in defined brain areas and specifically activated by selective agonists, are appealing methods to constrain overactive neuronal activity. We developed BARNI (Bradanicline- and Acetylcholine-activated Receptor for Neuronal Inhibition), an engineered channel comprised of the α7 nicotinic acetylcholine receptor ligand-binding domain coupled to an α1 glycine receptor anion pore domain. Here we demonstrate that BARNI activation by the clinical stage α7 nicotinic acetylcholine receptor-selective agonist bradanicline effectively suppressed targeted neuronal activity, and controlled both acute and chronic seizures in male mice. Our results provide evidence for the use of an inhibitory acetylcholine-based engineered channel activatable by both exogenous and endogenous agonists as a potential therapeutic approach to treating epilepsy.

The adaptation of the desirability of outcome ranking for interventional clinical trials in epilepsy: A novel consumer-led outcome measure

Interventional clinical trials in epilepsy are typically designed and powered to detect a change in seizure frequency as the primary endpoint, with little consideration given to other benefits or harms of the therapy, or impacts on common epilepsy comorbidities. Desirability of outcome ranking (DOOR) is a novel methodology for evaluating benefits and harms associated with introduction of a new treatment. Multiple outcomes are combined and the resulting combinations are ranked according to their desirability. Herein we describe the adaptation of DOOR for use in therapy trials in epilepsy. Consumers with epilepsy were presented with a selection of measures typically included in epilepsy trials and asked to rank their importance in terms of a desirable outcome and to identify interactions between different seizure control levels and other measures. Seizure control, adverse events, and psychiatric comorbidities were identified as most important, and combinations of these outcomes were ranked to form epilepsy-DOOR. A separate consumer discussion group verified the appropriateness and accuracy of the ranking. The resultant epilepsy-DOOR includes 60 possible outcomes, representing high granularity for the assessment of future interventions. It demonstrates the importance of consumer involvement in trial design and presents an alternative to seizure frequency for evaluating new treatments for epilepsy.

Poor Seizure Control Among Children Attending a Tertiary Hospital in South Western Uganda - A Retrospective Study

Background

Seizure control among children with epilepsy (CWE) receiving anti-seizure medications (ASMs) remains a challenge in low-resource settings. Uncontrolled seizures are significantly associated with increased morbidity and mortality among CWE. This negatively impacts their quality of life and increases stigma.

Aim

This study determined seizure control status and described the factors associated among CWE receiving ASMs at Mbarara Regional Referral Hospital (MRRH).

Methods

In a retrospective chart review study, socio-demographic and clinical data were obtained from 112 medical records. CWE receiving ASMs for at least six months and regularly attending the clinic were included in the study. Physical or telephone interviews were conducted with the immediate caregivers of the CWE to establish the current seizure control status of the participants.

Results

A total of 112 participants were enrolled. Of these, three-quarters had generalized onset seizures, 23% had focal onset seizures, while 2% had unknown onset motor seizures. About 60.4% of the study participants had poor seizure control. Having a comorbidity (p-value 0.048, AOR 3.2 (95% CI 1.0-9.9)), history suggestive of birth asphyxia (p-value 0.014, AOR 17.8 (95% CI 1.8-176.8)), and being an adolescent (p-value 0.006, AOR 6.8 (95% CI 1.8-26.6)) were significantly associated with poor seizure control.

Conclusion

Seizure control among CWE receiving ASMs at MRRH remains poor. Efforts geared to addressing seizure control and optimizing drugs are needed, especially among children with comorbidities, those with history of birth asphyxia, and adolescents.

Statins as an antiepileptogenic or disease-modifying treatment? A survey of what UK patients and significant others think about repurposing and trialing them for epilepsy

OBJECTIVE

To identify the views of people with epilepsy (PWE), and their significant others, on the repurposing and trialing of statins as a potential antiepileptogenic or disease-modifying treatment for those who have had the first seizure.

METHODS

Online questionnaire. Participants needed to be aged ≥ 16 years, UK residents, and able to independently complete a questionnaire in English. User groups distributed study adverts. Embedded infographics explained repurposing, why anti-seizure treatment is not typically started after a first seizure and the nature of randomized placebo-controlled trials (RCTs). The questionnaire asked participants to reflect and rate their expected willingness to have started an unspecified treatment after their first seizure/s (or that of the person with epilepsy they knew). They also rated willingness if the treatment were a statin, views of statins, the importance of an RCT of statins to their community, the outcomes it should assess, and their willingness to have taken part in it. The estimated number needed for the survey was 324.

RESULTS

Responses from 213 persons were analyzed; 111 (52.1%) were PWE and 102 (47.9%) significant others. The median years diagnosed was 10 and PWE suffered from relatively severe epilepsy. One hundred and seventeen (54.9%) said they would have started an unspecified treatment after their first seizure/s (or supported the person with epilepsy they knew to have). A similar proportion (55.4%) said they would have started the treatment if it were a statin. Participants' main concern about statins, expressed by 79%, was their possible side effects. Repurposing was a concern for only 25%. Most (85.8%) rated an RCT of statins as of extreme or high importance; 54.4% said they would have participated.

CONCLUSION

The PWE and significant others (SOs) responding to our survey expressed views towards repurposing statins that were generally positive and indicate a trial in those who have had a first seizure might be feasible. Concerns regarding side effects are common. Our findings could help optimize a future trial's design and the case for funding. Limitations include that we did not survey persons who had experienced a first seizure and did not go on to develop epilepsy. Also, persons with uncontrolled epilepsy were overrepresented.

Neurologists' knowledge of and attitudes toward physical exercise for people with epilepsy in Latin America

INTRODUCTION

Despite the favorable effects of exercise in people with epilepsy (PWE), the lower participation in physical/sports activities may be partly due to inadequate knowledge and attitudes of health professional about their benefits. In this regard, in 2016, the International League Against Epilepsy (ILAE) through its Task Force on Sports and Epilepsy published a consensus paper that provided general guidance concerning participation in exercise/sport activities for PWE. We investigated views and attitudes toward physical exercise practice among neurologists in Latin America.

METHODS

A 22-item cross-sectional online questionnaire-based study among neurologists included the following: (1) profile of participating neurologists, (2) doctors' attitudes and perceptions about physical/sport activities for PWE, and (3) neurologist experience concerning patient's report about their involvement in physical/sport activities.

RESULTS

In total, 215 of 519 neurologists from 16 different countries returned the questionnaire. Although about one-third of neurologists had no information about the effect of exercise on epilepsy, and 60% of them did not know the published recommendations of the ILAE Task Force on Sports and Epilepsy, the majority (92.5%) advised the practice of exercise, were aware of sport activities for their patients and agreed that exercise can reduce comorbidities associated with epilepsy (X² = 249.34; p < 0.001). Most of the neurologists did not believe that exercise is a seizure-inducing factor, but more than half would restrict their patients with uncontrolled seizures for exercise practice (X² = 250.77; p < 0.001). Most barriers considered by PWE in the past, currently are not viewed by neurologists and their patients (X² = 249.34; p < 0.001).

CONCLUSION

While this study reveals that neurologists have some knowledge gaps in attitudes toward physical exercise for PWE, encouraging attitudes were observed by neurologists. Considering that physicians can impact on patient confidence and decision, a better communication between neurologists and their patients concerning the benefits of exercise can increase PWE participation in physical/sports activities. To improve this scenario, more efforts should be made to increase the neurologists' knowledge and perceptions on this issue.

Williamson P, Dodd S. A pilot study assessing the similarity between core outcome sets and outcomes included in health technology assessments

Objective: Core outcome sets (COS) are an agreed standardised collection of outcomes created with representation from all key stakeholders (such as patients, clinicians, researchers), which should be reported as a minimum for all trials in that corresponding clinical area. There has been little research investigating the use of core outcomes in Health technology assessments (HTAs) and none in non-oncology HTAs. This study aimed to assess the similarity between COS and HTA outcomes. Methods: Ten COS published between 2015 and 2019 were selected, with patient participation taken as a proxy measure for a high quality COS. The INAHTA database was used as a source to identify relevant HTAs, which were accessed through the hyperlinks provided. Outcomes selected for these assessments were categorised as either a specific, partial or no match compared to the COS. An additional cohort of non-oncology HTAs published between 2019 and 2021 were identified from the NICE website and compared against a relevant COS. Results: Six hundred and fifty-one HTAs were matched to the ten COS areas, of which 119 were reviewed. Of a possible 1318 core outcome matches, there were 562 (43%) matches, 413 (31%) specific and 149 (11%) partial. NICE HTA matches against corresponding COS ranged from 44% to 100%, with a total of 78% (73/94) matches, 57 (61%) specific and 16 (17%) partial. Conclusion: Further work is required to promote the awareness and implementation of COS within HTAs. The degree of matching between COS and NICE HTA outcomes is encouraging, demonstrating acceptance of COS by HTA producers.

Developing a Conceptual Disease Model of Patient Experiences and Identifying Patient-Reported Clinical Outcome Assessments for Use in Trials of Treatments for Focal Onset Seizures

PURPOSE

To identify concepts important to understanding the experiences of adults with focal onset seizures (FOS) and evaluate clinical outcome assessments (COAs) for measuring these concepts in clinical trials of treatments for FOS.

METHODS

A search of published qualitative research, clinical trials, and approved product labels for FOS treatments was performed to develop a conceptual disease model (CDM) of patients' experience of living with FOS. Concepts of interest (COI) were selected, and a second literature search was conducted to identify COAs measuring these concepts. Ten COAs were selected and reviewed to document their development process, evidence of measurement properties, and methods for interpreting change scores using criteria proposed in regulatory guidelines for patient-reported outcomes to support label claims.

RESULTS

Concepts identified from the published literature (13 articles, 1 conference abstract), 24 clinical trials, and 8 product labels were included in a novel CDM. Impacts on physical, cognitive, and social and emotional function were chosen as COI for evaluating treatment outcomes for FOS; the additional concept of social support and coping strategies was chosen to understand patients' lived experiences. From 51 unique COAs identified, 10 were selected based on their potential coverage of the COI; some symptom severity and health-related quality of life (HRQoL) COAs covered multiple COI. Of these 10, 8 COAs evaluated impacts/limitations on physical function, 8 measured social and emotional impacts, and 5 assessed social support and coping strategies. While most assessments had gaps in evidence validating their measurement properties, 2 COAs measuring symptom severity and 1 COA measuring HRQoL had evidence confirming their potential utility in clinical trials to support label claims.

CONCLUSION

This research provides insights into the experience of patients with FOS and identifies COAs that measure concepts considered to support endpoints in clinical trials for FOS.

Williamson P, Dodd S. A pilot study assessing the similarity between core outcome sets and outcomes included in health technology assessments

Objective: Core outcome sets (COS) are an agreed standardised collection of outcomes created with representation from all key stakeholders (such as patients, clinicians, researchers), which should be reported as a minimum for all trials in that corresponding clinical area. There has been little research investigating the use of core outcomes in Health technology assessments (HTAs) and none in non-oncology HTAs. This study aimed to assess the similarity between COS and HTA outcomes. Methods: Ten COS published between 2015 and 2019 were selected, with patient participation taken as a proxy measure for a high quality COS. The INAHTA database was used as a source to identify relevant HTAs, which were accessed through the hyperlinks provided. Outcomes selected for these assessments were categorised as either a specific, partial or no match compared to the COS. An additional cohort of non-oncology HTAs published between 2019 and 2021 were identified from the NICE website and compared against a relevant COS. Results: Six hundred and fifty-one HTAs were matched to the ten COS areas, of which 119 were reviewed. Of a possible 1318 core outcome matches, there were 562 (43%) matches, 413 (31%) specific and 149 (11%) partial. NICE HTA matches against corresponding COS ranged from 44% to 100%, with a total of 78% (73/94) matches, 57 (61%) specific and 16 (17%) partial. Conclusion: Further work is required to promote the awareness and implementation of COS within HTAs. The degree of matching between COS and NICE HTA outcomes is encouraging, demonstrating acceptance of COS by HTA producers.

The future of precision medicine in opioid use disorder: inclusion of patient-important outcomes in clinical trials

Opioid use has reached an epidemic proportion in Canada and the United States that is mostly attributed to excess availability of prescribed opioids for pain. This excess in opioid use led to an increase in the prevalence of opioid use disorder (OUD) requiring treatment. The most common treatment recommendations include medication-assisted treatment (MAT) combined with psychosocial interventions. Clinical trials investigating the effectiveness of MAT, however, have a limited focus on effectiveness measures that overlook patient-important outcomes. Despite MAT, patients with OUD continue to suffer negative consequences of opioid use. Patient goals and personalized medicine are overlooked in clinical trials and guidelines, thus missing an opportunity to improve prognosis of OUD by considering precision medicine in addiction trials. In this mixed-methods study, patients with OUD receiving MAT (n=2,031, mean age 39.1 years [SD 10.7], 44% female) were interviewed to identify patient goals for MAT. The most frequently reported patient-important outcomes were to stop treatment (39%) and to avoid all drugs (25%). These results are inconsistent with treatment recommendations and trial outcome measures. We discuss theses inconsistencies and make recommendations to incorporate these outcomes to achieve patient-centered and personalized treatment strategies.

Measuring Health Outcomes in HIV: Time to Bring in the Patient Experience

Introduction

Over the past decade, the global response to HIV has led to a reduction in the number of new infections, and a decrease in associated mortality. Yet, the number of people living with HIV (PLHIV) is high, with an estimated 38 million infected worldwide. As HIV shifts from being an acute terminal illness to a chronic condition, evaluating programmatic responses to HIV with sole reliance on biological markers (such as viral load or CD4 cell count) as proxies for patient health may no longer be suitable. HIV affects the lives of those infected in myriad ways which should be reflected in programme evaluations by measuring health-related quality of life, in addition to biomarkers.

Discussion

In this commentary we argue that there is a pressing need to review how a "good" health outcome is defined and measured in light of care systems moving towards value-based frameworks that measure value in terms of the actual health outcomes achieved (rather than processes of care), global response shifting to providing long-term care for PLHIV in the community, and integrating HIV as part of universal health coverage plans. Efforts should be directed towards validating generic and disease specific patient-reported measures of PLHIV, to identify the most suitable tools. Such efforts will ensure that patient experience is appropriately captured, especially to be used in programme or economic evaluations.

Conclusions

It is only by recognising and measuring the full range of health, mental and social outcomes related to the disease that the health status of PLHIV can be fully understood.

Outcome Measures for Functional Neurological Disorder: A Review of the Theoretical Complexities

The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.

Seizure first aid training for people with epilepsy attending emergency departments and their significant others: the SAFE intervention and feasibility RCT

Background

No seizure first aid training intervention exists for people with epilepsy who regularly attend emergency departments and their significant others, despite such an intervention’s potential to reduce clinically unnecessary and costly visits.

Objectives

The objectives were to (1) develop Seizure first Aid training For Epilepsy (SAFE) by adapting a broader intervention and (2) determine the feasibility and optimal design of a definitive randomised controlled trial to test SAFE’s efficacy.

Design

The study involved (1) the development of an intervention informed by a co-design approach with qualitative feedback and (2) a pilot randomised controlled trial with follow-ups at 3, 6 and 12 months and assessments of treatment fidelity and the cost of SAFE’s delivery.

Setting

The setting was (1) third-sector patient support groups and professional health-care organisations and (2) three NHS emergency departments in England.

Participants

Participants were (1) people with epilepsy who had visited emergency departments in the prior 2 years, their significant others and emergency department, paramedic, general practice, commissioning, neurology and nursing representatives and (2) people with epilepsy aged ≥ 16 years who had been diagnosed for ≥ 1 year and who had made two or more emergency department visits in the prior 12 months, and one of their significant others. Emergency departments identified ostensibly eligible people with epilepsy from attendance records and patients confirmed their eligibility.

Interventions

Participants in the pilot randomised controlled trial were randomly allocated 1 : 1 to SAFE plus treatment as usual or to treatment as usual only.

Main outcome measures

Consent rate and availability of routine data on emergency department use at 12 months were the main outcome measures. Other measures of interest included eligibility rate, ease with which people with epilepsy could be identified and routine data secured, availability of self-reported emergency department data, self-reported emergency department data’s comparability with routine data, SAFE’s effect on emergency department use, and emergency department use in the treatment as usual arm, which could be used in sample size calculations.

Results

(1) Nine health-care professionals and 23 service users provided feedback that generated an intervention considered to be NHS feasible and well positioned to achieve its purpose. (2) The consent rate was 12.5%, with 53 people with epilepsy and 38 significant others recruited. The eligibility rate was 10.6%. Identifying people with epilepsy from attendance records was resource intensive for emergency department staff. Those recruited felt more stigmatised because of epilepsy than the wider epilepsy population. Routine data on emergency department use at 12 months were secured for 94.1% of people with epilepsy, but the application process took 8.5 months. Self-reported emergency department data were available for 66.7% of people with epilepsy, and people with epilepsy self-reported more emergency department visits than were captured in routine data. Most participants (76.9%) randomised to SAFE received the intervention. The intervention was delivered with high fidelity. No related serious adverse events occurred. Emergency department use at 12 months was lower in the SAFE plus treatment as usual arm than in the treatment as usual only arm, but not significantly so. Calculations indicated that a definitive trial would need ≈ 674 people with epilepsy and ≈ 39 emergency department sites.

Limitations

Contrary to patient statements on recruitment, routine data secured at the pilot trial’s end indicated that ≈ 40% may not have satisfied the inclusion criterion of two or more emergency department visits.

Conclusions

An intervention was successfully developed, a pilot randomised controlled trial conducted and outcome data secured for most participants. The consent rate did not satisfy a predetermined ‘stop/go’ level of ≥ 20%. The time that emergency department staff needed to identify eligible people with epilepsy is unlikely to be replicable. A definitive trial is currently not feasible.

Future work

Research to more easily identify and recruit people from the target population is required.

Trial registration

Current Controlled Trials ISRCTN13871327.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 39. See the NIHR Journals Library website for further project information.

Seizure First Aid Training For people with Epilepsy (SAFE) frequently attending emergency departments and their significant others: results of a UK multi-centre randomised controlled pilot trial

OBJECTIVE

To determine the feasibility and optimal design of a randomised controlled trial (RCT) of Seizure First Aid Training For Epilepsy (SAFE).

DESIGN

Pilot RCT with embedded microcosting.

SETTING

Three English hospital emergency departments (EDs).

PARTICIPANTS

Patients aged ≥16 with established epilepsy reporting ≥2 ED visits in the prior 12 months and their significant others (SOs).

INTERVENTIONS

Patients (and their SOs) were randomly allocated (1:1) to SAFE plus treatment-as-usual (TAU) or TAU alone. SAFE is a 4-hour group course.

MAIN OUTCOME MEASURES

Two criteria evaluated a definitive RCT's feasibility: (1) ≥20% of eligible patients needed to be consented into the pilot trial; (2) routine data on use of ED over the 12 months postrandomisation needed securing for ≥75%. Other measures included eligibility, ease of obtaining routine data, availability of self-report ED data and comparability, SAFE's effect and intervention cost.

RESULTS

Of ED attendees with a suspected seizure, 424 (10.6%) patients were eligible; 53 (12.5%) patients and 38 SOs consented. Fifty-one patients (and 37 SOs) were randomised. Routine data on ED use at 12 months were secured for 94.1% patients. Self-report ED data were available for 66.7% patients. Patients reported more visits compared with routine data. Most (76.9%) patients randomised to SAFE received it and no related serious adverse events occurred. ED use at 12 months was lower in the SAFE+TAU arm compared with TAU alone, but not significantly (rate ratio=0.62, 95% CI 0.33 to 1.17). A definitive trial would need ~674 patient participants and ~39 recruitment sites. Obtaining routine data was challenging, taking ~8.5 months.

CONCLUSIONS

In satisfying only one predetermined 'stop/go' criterion, a definitive RCT is not feasible. The low consent rate in the pilot trial raises concerns about a definitive trial's finding's external validity and means it would be expensive to conduct. Research is required into how to optimise recruitment from the target population.

TRIAL REGISTRATION NUMBER

ISRCTN13871327.

What really matters? A mixed methods study of treatment preferences and priorities among people with epilepsy in the UK

The widening range of treatment options for epilepsy, and their potential outcomes, mean decisions about treatment for people with epilepsy (PWE) are often complex. While antiepileptic drugs (AEDs) represent the mainstay of treatment, other potential nondrug interventions are gaining in importance. These treatments all have the potential for harming those using them, as well as bringing benefits. This study examined the views and experiences of PWE about a range of treatment options. We used both qualitative and quantitative approaches - a series of depth-narrative interviews, followed by a large-scale survey. Treatment options and healthcare priorities deemed important by at least 10% of interview participants were then addressed as a series of statements in the follow-on survey questionnaire. Quantitative responses supported healthcare priorities identified through the qualitative interviews. The key goal of treatment among study participants was to be able to live 'a normal life'. Important physical, psychological, and life benefits of treatment were identified - most being the direct consequence of improved seizure control. One psychological benefit, reduced worry, was also identified as an important treatment goal. All participants viewed AEDs as appropriate first-line treatment; and since adverse effects of AEDs had implications for individual levels of daily function and wellbeing, their appropriate management was considered important. In contrast, surgery was almost always regarded as the treatment of last resort. Despite lack of research evidence supporting their use, participants were interested in complementary therapies as adjunctive treatment and a means of coping with having epilepsy, with yoga and meditation of particular interest. An important finding was the desire for targeted services to help with memory problems, as was the call to increase availability of psychological/counseling services. Our findings emphasize the importance of providing treatment responsive to the life context of individual patients. They highlight not only the level of demand for specific treatment options, but also the need for high-quality evidence to support future investment in their provision.

Self-Management education for adults with poorly controlled epILEpsy [SMILE (UK)]: a randomised controlled trial

BACKGROUND

Epilepsy is a common neurological condition resulting in recurrent seizures. Research evidence in long-term conditions suggests that patients benefit from self-management education and that this may improve quality of life (QoL). Epilepsy self-management education has yet to be tested in a UK setting.

OBJECTIVES

To determine the effectiveness and cost-effectiveness of Self-Management education for people with poorly controlled epILEpsy [SMILE (UK)].

DESIGN

A parallel pragmatic randomised controlled trial.

SETTING

Participants were recruited from eight hospitals in London and south-east England.

PARTICIPANTS

Adults aged ≥ 16 years with epilepsy and two or more epileptic seizures in the past year, who were currently being prescribed antiepileptic drugs.

INTERVENTION

A 2-day group self-management course alongside treatment as usual (TAU). The control group received TAU.

MAIN OUTCOME MEASURES

The primary outcome is QoL in people with epilepsy at 12-month follow-up using the Quality Of Life In Epilepsy 31-P (QOLIE-31-P) scale. Other outcomes were seizure control, impact of epilepsy, medication adverse effects, psychological distress, perceived stigma, self-mastery and medication adherence. Cost-effectiveness analyses and a process evaluation were undertaken.

RANDOMISATION

A 1 : 1 ratio between trial arms using fixed block sizes of two.

BLINDING

Participants were not blinded to their group allocation because of the nature of the study. Researchers involved in data collection and analysis remained blinded throughout.

RESULTS

The trial completed successfully. A total of 404 participants were enrolled in the study [SMILE (UK), n = 205; TAU, n = 199] with 331 completing the final follow-up at 12 months [SMILE (UK), n = 163; TAU, n = 168]. In the intervention group, 61.5% completed all sessions of the course. No adverse events were found to be related to the intervention. At baseline, participants had a mean age of 41.7 years [standard deviation (SD) 14.1 years], and had epilepsy for a median of 18 years. The mean QOLIE-31-P score for the whole group at baseline was 66.0 out of 100.0 (SD 14.2). Clinically relevant levels of anxiety symptoms were reported in 53.6% of the group and depression symptoms in 28.0%. The results following an intention-to-treat analysis showed no change in any measures at the 12-month follow-up [QOLIE-31-P: SMILE (UK) mean: 67.4, SD 13.5; TAU mean: 69.5, SD 14.8]. The cost-effectiveness study showed that SMILE (UK) was possibly cost-effective but was also associated with lower QoL. The process evaluation with 20 participants revealed that a group course increased confidence by sharing with others and improved self-management behaviours.

CONCLUSIONS

For people with epilepsy and persistent seizures, a 2-day self-management education course is cost-saving, but does not improve QoL after 12-months or reduce anxiety or depression symptoms. A psychological intervention may help with anxiety and depression. Interviewed participants reported attending a group course increased their confidence and helped them improve their self-management.

FUTURE WORK

More research is needed on self-management courses, with psychological components and integration with routine monitoring.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57937389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 21. See the NIHR Journals Library website for further project information.

Incorporating patients' perspectives into the initial stages of core outcome set development: a rapid review of qualitative studies of type 2 diabetes

Conducting systematic reviews of qualitative studies to incorporate patient perspectives within the early stages of core outcome set (COS) development can be resource intensive. We aimed to identify an expedited approach to be used as part of the wider COS development process. Specifically, we undertook a rapid review of qualitative studies of patients' views and experiences of type 2 diabetes. We searched MEDLINE from inception to June 2017 to identify studies reporting qualitative empirical findings of perspectives of people with type 2 diabetes. Qualitative methodological filters were used to minimize irrelevant references. Drawing on content analysis, data synthesis involved identifying text in eligible studies relevant to outcomes of type 2 diabetes and interpreting and categorizing this according to the 38 core domains of the Core Outcome Measures in Effectiveness Trials taxonomy. Of 146 studies screened, 26 were included. Four hundred and fifty-eight outcomes were derived from the included studies. In comparison to the outcomes extracted from clinical trials, more life impact outcomes were derived from the qualitative studies, but fewer physiological/clinical outcomes. Outcomes relating to 'mortality/survival' and 'role functioning' were more prevalent in studies conducted in low/middle-income countries. This rapid review and synthesis of qualitative studies identified outcomes that had not previously been identified by a systematic review of clinical trials. It also identified differences in the types of outcomes given prominence to in the clinical trials and qualitative literatures. Incorporating qualitative evidence on patient perspectives from the outset of the COS development process can help to ensure outcomes that matter to patients are not overlooked. Our method provides a pragmatic and resource-efficient way to do this. For those developing international COS, our method has potential for incorporating the perspectives of patients from diverse countries in the early stages of COS development.

Closed-Loop Brain Stimulation for Drug-Resistant Epilepsy: Towards an Evidence-Based Approach to Personalized Medicine

Closed-loop brain stimulation is one of the few treatments available for patients who are ineligible for traditional surgical resection of the epileptogenic zone, due to having generalized epilepsy, multifocal epilepsy, or focal epilepsy localized to an eloquent brain region. Due to its clinical efficacy and potential to delivery personalized therapy based on an individual's own intracerebral electrophysiology, this treatment is becoming an important part of clinical practice, despite a limited understanding of how to program detection and stimulation parameters for optimal, patient-specific benefit. To bring this challenge into focus, we review the evolution of neural stimulation for epilepsy, provide a technical overview of the RNS System (the only FDA-approved closed-loop device), and discuss the major challenges of working with a closed-loop device. We then propose an evidence-based solution for individualizing therapy that is driven by a bottom-up informatics approach.

Cognitive-behavioural therapy does not meaningfully reduce depression in most people with epilepsy: a systematic review of clinically reliable improvement

Psychological treatment is recommended for depression and anxiety in those with epilepsy. This review used standardised criteria to evaluate, for the first time, the clinical relevance of any symptom change these treatments afford patients. Databases were searched until March 2017 for relevant trials in adults. Trial quality was assessed and trial authors asked for individual participants' pre-treatment and post-treatment distress data. Jacobson's methodology determined the proportion in the different trial arms demonstrating reliable symptom change on primary and secondary outcome measures and its direction. Search yielded 580 unique articles; only eight eligible trials were identified. Individual participant data for five trials-which included 398 (85%) of the 470 participants randomised by the trials-were received. The treatments evaluated lasted ~7 hours and all incorporated cognitive-behavioural therapy (CBT). Depression was the primary outcome in all; anxiety a secondary outcome in one. On average, post-treatment assessments occurred 12 weeks following randomisation; 2 weeks after treatment had finished. There were some limitations in how trials were conducted, but overall trial quality was 'good'. Pooled risk difference indicated likelihood of reliable improvement in depression symptoms was significantly higher for those randomised to CBT. The extent of gain was though low-the depressive symptoms of most participants (66.9%) receiving CBT were 'unchanged' and 2.7% 'reliably deteriorated'. Only 30.4% made a 'reliable improvement. This compares with 10.2% of participants in the control arms who 'reliably improved' without intervention. The effect of the treatments on secondary outcome measures, including anxiety, was also low. Existing CBT treatments appear to have limited benefit for depression symptoms in epilepsy. Almost 70% of people with epilepsy do not reliably improve following CBT. Only a limited number of trials have though been conducted in this area and there remains a need for large, well-conducted trials.

The beneficial effect of probiotics as a supplementary treatment in drug-resistant epilepsy: a pilot study

Epilepsy is a neurological disease with high global prevalence. Despite the range of drug-based treatments currently available to control the condition, one in 3 patients experiences epileptic seizures. Therapeutic alternatives for these patients include the ketogenic diet, surgery or the cerebral implantation of neurostimulators; however these are benefits with limits. The target of this study is to find a new complementary treatment for these patients, studying the effectiveness of probiotics for controlling epileptic seizures in patients with drug-resistant epilepsy. A prospective study was designed in which a group of patients with drug-resistant epilepsy was administered a probiotic mixture for 4 months. Patients were assessed before and after taking the probiotics; among other variables, number of seizures and patients' quality of life (QOLIE-10) were monitored. Levels of cD-14, interleukin 6, and γ-aminobutyric acid were also analysed throughout the study. 45 patients were included in the study. In an intention-to-treat analysis, 28.9% of all patients displayed a greater than 50% reduction in the number of seizures (the parameter required in clinical trials). A significant improvement was also observed in patients' quality of life. We found that probiotics may be an option for supplementary therapy. Since the use of probiotics is safe, they may contribute to improving seizure control, and therefore quality of life, in patients with drug-resistant epilepsy. The study has been registered in https://clinicaltrials.gov with number NCT03403907.

Characteristics of large patient-reported outcomes: Where can one million seizures get us?

Objective

To analyze data from Seizure Tracker, a large electronic seizure diary, including comparison of seizure characteristics among different etiologies, temporal patterns in seizure fluctuations, and specific triggers.

Methods

Zero‐inflated negative binomial mixed‐effects models were used to evaluate temporal patterns of seizure events (during the day or week), as well as group differences in monthly seizure frequency between children and adults and between etiologies. The association of long seizures with seizure triggers was evaluated using a mixed‐effects logistic model with subject as the random effect. Incidence rate ratios (IRRs) and odds ratios were reported for analyses involving zero‐inflated negative binomial and logistic mixed‐effects models, respectively.

Results

A total of 1,037,909 seizures were logged by 10,186 subjects (56.7% children) from December 2007 to January 2016. Children had more frequent seizures than adults did (median monthly seizure frequency 3.5 vs. 2.7, IRR 1.26; p < 0.001). Seizures demonstrated a circadian pattern (higher frequency between 07:00 a.m. and 10:00 a.m. and lower overnight), and seizures were reported differentially across the week (seizure rates higher Monday through Friday than Saturday or Sunday). Longer seizures (>5 or >30 min) had a higher proportion of the following triggers when compared with shorter seizures: “Overtired or irregular sleep,” “Bright or flashing lights,” and “Emotional stress” (p < 0.004).

Significance

This study explored a large cohort of patients with self‐reported seizures; strengths and limitations of large seizure diary databases are discussed. The findings in this study are consistent with those of prior work in smaller validated cohorts, suggesting that patient‐recorded databases are a valuable resource for epilepsy research, capable of both replication of results and generation of novel hypotheses.

Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence

Review evidence for cannabinoids as adjunctive treatments for treatment-resistant epilepsy. Systematic search of Medline, Embase and PsycINFO was conducted in October 2017. Outcomes were: 50%+ seizure reduction, complete seizure freedom; improved quality of life (QoL). Tolerability/safety were assessed by study withdrawals, adverse events (AEs) and serious adverse events (SAEs). Analyses were conducted in Stata V.15.0. 36 studies were identified: 6 randomised controlled trials (RCTs), 30 observational studies. Mean age of participants was 16.1 years (range 0.5-55 years). Cannabidiol (CBD) 20 mg/kg/day was more effective than placebo at reducing seizure frequency by 50%+(relative risk (RR) 1.74, 95% CI 1.24 to 2.43, 2 RCTs, 291 patients, low Grades of Recommendation, Assessment, Development and Evaluation (GRADE) rating). The number needed to treat for one person using CBD to experience 50%+ seizure reduction was 8 (95% CI 6 to 17). CBD was more effective than placebo at achieving complete seizure freedom (RR 6.17, 95% CI 1.50 to 25.32, 3 RCTs, 306 patients, low GRADE rating), and improving QoL (RR 1.73, 95% CI 1.33 to 2.26), however increased risk of AEs (RR 1.24, 95% CI 1.13 to 1.36) and SAEs (RR 2.55, 95% CI 1.48 to 4.38). Pooled across 17 observational studies, 48.5% (95% CI 39.0% to 58.1%) of patients reported 50%+ reductions in seizures; in 14 observational studies 8.5% (95% CI 3.8% to 14.5%) were seizure-free. Twelve observational studies reported improved QoL (55.8%, 95% CI 40.5 to 70.6); 50.6% (95% CI 31.7 to 69.4) AEs and 2.2% (95% CI 0 to 7.9) SAEs. Pharmaceutical-grade CBD as adjuvant treatment in paediatric-onset drug-resistant epilepsy may reduce seizure frequency. Existing RCT evidence is mostly in paediatric samples with rare and severe epilepsy syndromes; RCTs examining other syndromes and cannabinoids are needed.

PROSPERO REGISTRATION NUMBER

CRD42017055412.

Development of outcome criteria to measure effectiveness of antiepileptic therapy in children

PURPOSE

Clinical trials of antiepileptic drugs frequently measure outcomes of seizure control, which demonstrate efficacy. Yet, functional status, quality of life, and long-term treatment effects reflecting effectiveness are scarcely assessed. We sought to use a consensus method to help identify which outcome criteria key stakeholders consider should be used to measure effectiveness in trials of antiepileptic treatments for children.

METHOD

A two-round Delphi survey was used; parents of children with epilepsy and local, international experts comprising academics and clinicians participated in the survey. In the first round, 32 experts, 50 parents, and 15 children with epilepsy aged >13years suggested outcomes that they considered important in determining effectiveness of antiepileptic therapy in children, separately for preschool and school age. In the second round, 29 experts and 42 parents scored the importance of outcomes from the list suggested by at least 10% of round 1 respondents and also proposed five most important outcomes.

RESULTS

Complete seizure freedom (67%), seizure frequency (48%), ability to perform normal day-to-day activities (45%), and quality of life (40%) were identified as the most important outcomes of antiepileptic therapy in children of both age groups. Additionally, effect on developmental milestones (47%) and child's compliance to treatment regimen (39%) were identified as most important in preschool age group and school performance (49%); adverse effects (39%) were identified as most important in school age group.

CONCLUSION

For the first time, this study has identified outcome priorities regarding antiepileptic treatment in children based on the key stakeholders' perspectives. It could be used as a provisional list of outcomes for inclusion in a core outcome set for children with epilepsy.

Who are the individuals diagnosed with epilepsy using the Public Health System in the city of Pelotas, southern Brazil?

The aim of this study was to describe sociodemographic, clinical, behavioral, nutritional, and health-related variables from people with epilepsy. A descriptive observational study was carried out in the city of Pelotas, southern Brazil. Sociodemographic, clinical, behavioral, nutritional, and health-related variables were collected. A univariate analysis was performed, calculating the measures of central tendency for continuous variables and proportions for categorical ones. The sample consisted of 101 people, age ranging from 12 to 75years, mostly male (50.5%) and white (59.4%). Only 37.2% from the sample was employed, and the average income was R$ 788.00 Brazilian Reais (US$ 245.90 at the moment of the interview). From all the subjects, 65.6% was in treatment with monotherapy, 62.9% presented more than 15 seizures during the life, 67.3% showed active epilepsy, 64.6% were physically inactive, 52.5% presented normal body mass index, and 50% showed generalized seizures. The most used antiepileptic drug was the carbamazepine. The average score of depression was 12.6±4.1 points and 34.6% showed severe depressive symptoms (equal or higher than 15 points). The mean score of trait and state anxiety was 12.2±3.6 and 15.1±3.4 points, respectively (ranging from 6 to 24 points). The mean score of quality of life and stress was 63.2±18.2 (ranging from 0 to 100 points) and 21.2±7.1 points (ranging from 0 to 40 points), respectively. Considering the medication side effects, the mean score was 42.4±8.9 points, 38.5% showing high rates (higher than 45 points), and only 16% showing good sleep quality. In conclusion, these results are important to improve understanding of these individuals' disease and to subsidize the specific public policies in countries of low and middle income.

Core Health Outcomes In Childhood Epilepsy (CHOICE): protocol for the selection of a core outcome set

BACKGROUND

There is increasing recognition that establishing a core set of outcomes to be evaluated and reported in trials of interventions for particular conditions will improve the usefulness of health research. There is no established core outcome set for childhood epilepsy. The aim of this work is to select a core outcome set to be used in evaluative research of interventions for children with rolandic epilepsy, as an exemplar of common childhood epilepsy syndromes.

METHODS

First we will identify what outcomes should be measured; then we will decide how to measure those outcomes. We will engage relevant UK charities and health professional societies as partners, and convene advisory panels for young people with epilepsy and parents of children with epilepsy. We will identify candidate outcomes from a search for trials of interventions for childhood epilepsy, statutory guidance and consultation with our advisory panels. Families, charities and health, education and neuropsychology professionals will be invited to participate in a Delphi survey following recommended practices in the development of core outcome sets. Participants will be able to recommend additional outcome domains. Over three rounds of Delphi survey participants will rate the importance of candidate outcome domains and state the rationale for their decisions. Over the three rounds we will seek consensus across and between families and health professionals on the more important outcomes. A face-to-face meeting will be convened to ratify the core outcome set. We will then review and recommend ways to measure the shortlisted outcomes using clinical assessment and/or patient-reported outcome measures.

DISCUSSION

Our methodology is a proportionate and pragmatic approach to expediently produce a core outcome set for evaluative research of interventions aiming to improve the health of children with epilepsy. A number of decisions have to be made when designing a study to develop a core outcome set including defining the scope, choosing which stakeholders to engage, most effective ways to elicit their views, especially children and a potential role for qualitative research.

Methodological issues associated with clinical trials in epilepsy

INTRODUCTION

despite methodological advances in epilepsy clinical trials, the proportion of patients reaching seizure-freedom has not substantially changed over the years. We review the main methodological limitations of current trials, the possible strategies to overcome these limits, and the issues that need to be addressed in next future. Area covered: references were identified by PubMed search until March 2017 and unpublished literature was searched on ClinicalTrials.gov. Add-on trials mainly involve refractory epilepsy subjects, reducing overall response to the investigational drug. The inclusion of subjects with earlier disease from less developed countries has partially allowed overcoming this limitation, but has introduced more random variability of results. Monotherapy trials rise methodological, economical, and ethical concerns with different regulatory requirements in European Union and in the United States of America. Newer trial designs, such as futility trials or 'time-to-event' design, have been implemented. Moreover, both add-on and monotherapy trials results might be affected by patient's ability to recognize and record seizures, and by randomness of seizures occurrence over time. Possible strategies to achieve more reliable outcomes are detailed. Expert commentary: clinical trial methodology needs to be optimized to better address regulatory agencies requirements and to encounter both patients' and clinicians' needs.

Are physical activity levels associated with better health outcomes in people with epilepsy?

The aim of the study was to investigate the association of physical activity in three categories (inactive, insufficiently active and active) with health outcomes in people with epilepsy. The dependent variables and the instruments used in the study were: a) quality of life - measured by Quality of Life in Epilepsy-31 for adults and Quality of Life in Epilepsy for Adolescents, b) side effects of medication - measured by Adverse Events Profile, c) depression - measured by Neurological Disorders Depression Inventory for Epilepsy, and d) state and trait anxiety - measured by State-Trait Anxiety Inventory. Physical activity levels were analyzed using the International Physical Activity Questionnaire (IPAQ) for adults in the commuting and leisure domains and Physical Activity Questionnaire for Adolescents (PAQ-A). Simple and multiple linear regression was used in the statistical analysis. The cross-sectional study with one hundred and one individuals was conducted in Pelotas/RS, Brazil, at the Neurology Clinic of the Faculty of Medicine of the Federal University of Pelotas. In the crude analysis, physical activity was positively associated with quality of life (p<0.001) and negatively associated with depression (p=0.046), state of anxiety (p=0.014), trait of anxiety (p=0.015) and side effect of medication (p=0.01). In addition, physical activity levels explained 10% of the quality of life (R²=0.10). In the adjusted analysis, physical activity remained associated with side effect of medication (p=0.014) and was not associated with trait anxiety (p=0.066). However, quality of life showed a positive linear trend (p=0.001) while depression (p=0.033) and anxiety state (p=0.004) showed a negative trend according to physical activity levels. Physical activity was associated with health outcomes, and can be a nonpharmacological treatment in people with epilepsy for improving health and life conditions.