Community-Sourced Reporting of Mortalities in Angelman Syndrome (1979-2022)

Angelman syndrome (AS) is a severe genetic neurodevelopmental disorder with an estimated prevalence of 1:20,000. Life expectancy appears to be normal, however, data regarding lifespan in AS are scarce. Until 2018, there was no unique diagnosis code for AS, thus true incidence, prevalence, mortality and morbidity rates are unknown. A social media effort was launched by caregivers of people with AS to gather community-sourced data to understand AS mortality risks. Information on 220 deaths was verified with obituaries and public postings. Respiratory illness was the primary cause of death among people with AS overall, followed by accidents and seizures. Surprisingly, sudden unexpected death in sleep (SUDS) was the fourth most common cause, which has not been reported previously. Approximately 91% of people with AS have epilepsy, thus some SUDS cases may represent sudden unexpected deaths in epilepsy (SUDEP). Causes of death vary by age, and differ from the general population. Though there are obvious limitations to data collected through social media, grass roots science is a starting point to amass preliminary data and inform future epidemiological research on AS.

Epilepsy-related mortality: A cross-sectional study in a tertiary center in Riyadh, Saudi Arabia

OBJECTIVE

People with epilepsy (PWE) have higher likelihood of dying prematurely compared to the general population. However, data on epilepsy mortality in some regions of the world are deficient or completely absent. The aim of this study was to investigate epilepsy-related deaths in PWE in a tertiary care center in Riyadh, Saudi Arabia.

METHODS

PWE who expired in the period from 2016 to 2020 at King Abdulaziz Medical City in Riyadh, Saudi Arabia were included. Demographic data, epilepsy classification, and causes of death were retrieved from the patients' electronic medical records, and death certificates. Death causes were classified based on Devinsky's classification.

RESULTS

We found that 145 PWE died during the study period. The median age at death was 66 years, with an interquartile range of 49-78. Half of the patients who died were male (50.3 %). Of the 145 deaths, 93 (64.1 %) were unrelated to epilepsy, 27 (18.6 %) were due to underlying neurological disease, 15 (10.3 %) were directly due to epilepsy, 7 (4.8 %) were indirectly due to epilepsy, and 3 (2.1 %) were due to acute symptomatic seizures. Sudden unexpected death in epilepsy (SUDEP) has never been recorded as a cause of death in any of the cases.

SIGNIFICANCE

Epilepsy-related deaths are largely overlooked by physicians who document death certificates. More efforts are needed to increase awareness among physicians about SUDEP and epilepsy-related mortality.

A comprehensive evaluation of interpretable artificial intelligence for epileptic seizure diagnosis using an electroencephalogram: A systematic review

Background

Epilepsy is a sensitive social and health issue that causes sudden death in epilepsy. Awake and sleep electroencephalogram (EEG) first test confirms 80% of patients with confirmed epilepsy. Explainable artificial intelligence (XAI) for epileptic seizures (ESs) emerged to overcome drawbacks of artificial intelligence (AI) models like lack of right to explain, fairness, and trustworthiness, and an overwhelming paper was published. However, there is a lack of reporting interpretable and performance tradeoffs, stating the most interpretable AI applied, describing the most useful waveforms learned in XAI models, documenting areas of interest, and identifying the relationship between frequency bands and epilepsy. Therefore, this systematic review aims to comprehensively evaluate the performance and the interpretability of interpretable AI methods used for ES monitoring using an EEG.

Methods

This study followed PRISMA guidelines for systematic review. Advanced search queries were hardheaded into five reputable databases. Rayyan online platform for a systematic review was used. The disagreement was resolved through discussions.

Results

Twenty-three papers are included. A total of 14 datasets are used. A total of 16,200 populations are participated in all the included studies. CHB-MIT Dataset is frequently used (12 times). Minimizing the number of waveforms learned will increase the accuracy and reduce the memory used. Interpretability to accuracy trade-offs are observed in the studies included.

Discussion

The result of this systematic review implies that further studies are needed on interpretable to accuracy tradeoffs, multi-modal care recommendations, and onset early warning to minimize sudden unexpected death in epilepsy and damage. Optimizing waveforms for ESs needs more investigation. Subjective matrices must be investigated very well before being used by XAI. This study has no ethical considerations associated with it. It has been registered with PROSPERO: registration number: CRD42023479926.

Insights into the Emerging Therapeutic Targets of Triple-negative Breast Cancer

Triple-negative Breast Cancer (TNBC), the most aggressive breast cancer subtype, is characterized by the non-appearance of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Clinically, TNBC is marked by its low survival rate, poor therapeutic outcomes, high aggressiveness, and lack of targeted therapies. Over the past few decades, many clinical trials have been ongoing for targeted therapies in TNBC. Although some classes, such as Poly (ADP Ribose) Polymerase (PARP) inhibitors and immunotherapies, have shown positive therapeutic outcomes, however, clinical effects are not much satisfiable. Moreover, the development of drug resistance is the major pattern observed in many targeted monotherapies. The heterogeneity of TNBC might be the cause for limited clinical benefits. Hence,, there is a need for the potential identification of new therapeutic targets to address the above limitations. In this context, some novel targets that can address the above-mentioned concerns are emerging in the era of TNBC therapy, which include Hypoxia Inducible Factor (HIF-1α), Matrix Metalloproteinase 9 (MMP-9), Tumour Necrosis Factor-α (TNF-α), β-Adrenergic Receptor (β-AR), Voltage Gated Sodium Channels (VGSCs), and Cell Cycle Regulators. Currently, we summarize the ongoing clinical trials and discuss the novel therapeutic targets in the management of TNBC.

Sudden death in epilepsy: the overlap between cardiac and neurological factors

People with epilepsy are at risk of premature death, of which sudden unexpected death in epilepsy (SUDEP), sudden cardiac death (SCD) and sudden arrhythmic death syndrome (SADS) are the primary, partly overlapping, clinical scenarios. We discuss the epidemiologies, risk factors and pathophysiological mechanisms for these sudden death events. We reviewed the existing evidence on sudden death in epilepsy. Classification of sudden death depends on the presence of autopsy and expertise of the clinician determining aetiology. The definitions of SUDEP, SCD and SADS lead to substantial openings for overlap. Seizure-induced arrhythmias constitute a minority of SUDEP cases. Comorbid cardiovascular conditions are the primary determinants of increased SCD risk in chronic epilepsy. Genetic mutations overlap between the states, yet whether these are causative, associated or incidentally present is often unclear. Risk stratification for sudden death in people with epilepsy requires a multidisciplinary approach, including a review of clinical history, toxicological analysis and complete autopsy with histologic and, preferably, genetic examination. We recommend pursuing genetic testing of relatives of people with epilepsy who died suddenly, mainly if a post-mortem genetic test contained a Class IV/V (pathogenic/likely pathogenic) gene variant. Further research may allow more precise differentiation of SUDEP, SCD and SADS and the development of algorithms for risk stratification and preventative strategies.

The Epileptic Heart Syndrome: Epidemiology, pathophysiology and clinical detection

Population studies report elevated incidence of cardiovascular events in patients with chronic epilepsy. Multiple pathophysiologic processes have been implicated, including accelerated atherosclerosis, myocardial infarction, altered autonomic tone, heart failure, atrial and ventricular arrhythmias, and hyperlipidemia. These deleterious influences on the cardiovascular system have been attributed to seizure-induced surges in catecholamines and hypoxemic damage to the heart and coronary vasculature. Certain antiseizure medications can accelerate heart disease through enzyme-inducing increases in plasma lipids and/or increasing risk for life-threatening ventricular arrhythmias as a result of sodium channel blockade. In this review, we propose that this suite of pathophysiologic processes constitutes "The Epileptic Heart Syndrome." We further propose that this condition can be diagnosed using standard electrocardiography, echocardiography, and lipid panels. The ultimate goal of this syndromic approach is to evaluate cardiac risk in patients with chronic epilepsy and to promote improved diagnostic strategies to reduce premature cardiac death.

Linking activity dyshomeostasis and sleep disturbances in Alzheimer disease

The presymptomatic phase of Alzheimer disease (AD) starts with the deposition of amyloid-β in the cortex and begins a decade or more before the emergence of cognitive decline. The trajectory towards dementia and neurodegeneration is shaped by the pathological load and the resilience of neural circuits to the effects of this pathology. In this Perspective, I focus on recent advances that have uncovered the vulnerability of neural circuits at early stages of AD to hyperexcitability, particularly when the brain is in a low-arousal states (such as sleep and anaesthesia). Notably, this hyperexcitability manifests before overt symptoms such as sleep and memory deficits. Using the principles of control theory, I analyse the bidirectional relationship between homeostasis of neuronal activity and sleep and propose that impaired activity homeostasis during sleep leads to hyperexcitability and subsequent sleep disturbances, whereas sleep disturbances mitigate hyperexcitability via negative feedback. Understanding the interplay among activity homeostasis, neuronal excitability and sleep is crucial for elucidating the mechanisms of vulnerability to and resilience against AD pathology and for identifying new therapeutic avenues.

Cardiovascular Disease Burden, Mortality, and Sudden Death Risk in Epilepsy: A UK Biobank Study

BACKGROUND

Sudden death is the leading cause of mortality in medically refractory epilepsy. Middle-aged persons with epilepsy (PWE) are under investigated regarding their mortality risk and burden of cardiovascular disease (CVD).

METHODS

Using UK Biobank, we identified 7786 (1.6%) participants with diagnoses of epilepsy and 6,171,803 person-years of follow-up (mean 12.30 years, standard deviation 1.74); 566 patients with previous histories of stroke were excluded. The 7220 PWE comprised the study cohort with the remaining 494,676 without epilepsy as the comparator group. Prevalence of CVD was determined using validated diagnostic codes. Cox proportional hazards regression was used to assess all-cause mortality and sudden death risk.

RESULTS

Hypertension, coronary artery disease, heart failure, valvular heart disease, and congenital heart disease were more prevalent in PWE. Arrhythmias including atrial fibrillation/flutter (12.2% vs 6.9%; P < 0.01), bradyarrhythmias (7.7% vs 3.5%; P < 0.01), conduction defects (6.1% vs 2.6%; P < 0.01), and ventricular arrhythmias (2.3% vs 1.0%; P < 0.01), as well as cardiac implantable electric devices (4.6% vs 2.0%; P < 0.01) were more prevalent in PWE. PWE had higher adjusted all-cause mortality (hazard ratio [HR], 3.9; 95% confidence interval [CI], 3.01-3.39), and sudden death-specific mortality (HR, 6.65; 95% CI, 4.53-9.77); and were almost 2 years younger at death (68.1 vs 69.8; P < 0.001).

CONCLUSIONS

Middle-aged PWE have increased all-cause and sudden death-specific mortality and higher burden of CVD including arrhythmias and heart failure. Further work is required to elucidate mechanisms underlying all-cause mortality and sudden death risk in PWE of middle age, to identify prognostic biomarkers and develop preventative therapies in PWE.

Characteristics of deceased subjects transported to a postmortem imaging center due to unusual death related to epilepsy

OBJECTIVE

Patients with epilepsy have high risk of experiencing uncommon causes of death. This study aimed to evaluate patients who underwent unusual deaths related to epilepsy and identify factors that may contribute to these deaths and may also include sudden unexpected death in epilepsy (SUDEP).

METHODS

We analyzed 5291 cases in which a postmortem imaging (PMI) study was performed using plane CT, because of an unexplained death. A rapid troponin T assay was performed using peripheral blood samples. Clinical information including the cause of death suspected by the attending physician, body position, place of death, medical history, and antiseizure medications was evaluated.

RESULTS

A total of 132 (2.6%) patients had an obvious history of epilepsy, while 5159 individuals had no history of epilepsy (97.4%). Cerebrovascular disease was the cause of death in 1.6% of patients in the group with epilepsy, and this was significantly lower than that in the non-epilepsy group. However, drowning was significantly higher (9.1% vs. 4.4%). Unspecified cause of death was significantly more frequent in the epilepsy group (78.0% vs. 57.8%). Furthermore, the proportion of patients who demonstrated elevation of troponin T levels without prior cardiac disease was significantly higher in the epilepsy group (37.9% vs. 31.1%). At discovery of death, prone position was dominant (30.3%), with deaths occurring most commonly in the bedroom (49.2%). No antiseizure medication had been prescribed in 12% of cases, while 29.5% of patients were taking multiple antiseizure medications.

SIGNIFICANCE

The prevalence of epilepsy in individuals experiencing unusual death was higher than in the general population. Despite PMI studies, no definitive cause of death was identified in a significant proportion of cases. The high troponin T levels may be explained by long intervals between death and examination or by higher incidence of myocardial damage at the time of death.

PLAIN LANGUAGE SUMMARY

This study investigated unusual deaths in epilepsy patients, analyzing 5291 postmortem imaging cases. The results showed that 132 cases (2.6%) had a clear history of epilepsy. In these cases, only 22% cases were explained after postmortem examination, which is less than in non-epilepsy group (42.2%). Cerebrovascular disease was less common in the epilepsy group, while drowning was more common. Elevated troponin T levels, which suggest possibility of myocardial damage or long intervals between death and examination, were also more frequent in the epilepsy group compared to non-epilepsy group.

Seizure Remission and Its Predictors Among Epileptic Patients on Follow-Up at Public Hospitals in Eastern Ethiopia: A Retrospective Cohort Study

Background

Epilepsy is one of the common chronic neurological disorders with varying therapeutic responses. Despite the high prevalence of epilepsy and the significant treatment gaps in developing nations, such as Ethiopia, there is a dearth of data on seizure remission and its predictors in Eastern Ethiopia in particular.

Objective

This study aimed to determine seizure remission and its predictors among epileptic patients on follow-up in Hiwot Fana Specialized University Hospital (HFSUH) and Dilchora Referral Hospital (DCRH), from July 2 to 31, 2021.

Methods

A retrospective cohort study was conducted among 418 newly diagnosed epilepsy patients receiving anti-seizure drugs (ASDs) between July 1, 2014, and July 31, 2019, in two public hospitals in Eastern Ethiopia. Relevant data were collected for all patients with a minimum follow-up period of two years. Data were analyzed using SPSS Version 21. Cox proportional hazards model was performed to identify predictors of seizure remission.

Results

Overall, 252 (60.3%) of the study participants have achieved seizure remission for at least one year. The mean time to achieve seizure remission was 1.9 ± 0.87 years. Regarding the seizure remission pattern, 171 (40.9%) patients achieved early remission, 81 (19.4%) achieved late remission, and 166 (39.7%) achieved no remission. Shorter pre-treatment duration (AHR = 2.36, 95% CI: 1.28-4.37); good adherence to ASDs (AHR = 2.40, 95% CI: 1.33-4.34); and monotherapy (AHR = 0.56, 95% CI: 0.32-0.98) were predictors of seizure remission.

Conclusion

We observed that less than two-thirds of epileptic patients had achieved seizure remission. A shorter pre-treatment duration, good adherence to ASDs, and monotherapy were predictors of seizure remission. Therefore, we recommend the requirement of an integrated effort from different health disciplines that increases patients' adherence to ASDs, promotes early visits to medical facilities, and improves the health-seeking behavior of epileptic patients.

Optimizing treatment persistence in epilepsy: a comparative analysis of combined antiseizure medications with different mechanisms of action

BACKGROUND

Combination therapy with antiseizure medications (ASMs) is a rational strategy if monotherapy cannot effectively control seizures, thereby aiming to improve tolerance and treatment persistence.

OBJECTIVES

To compare the efficacy of different ASM combinations among patients.

DESIGN

Patients with epilepsy on monotherapy who had a second ASM added as concomitant two-drug therapy from January 2009 to May 2019 in the Chang Gung Research Database, Taiwan, were included in the analysis.

METHODS

ASM combinations were compared based on their primary mechanism of action (MoA) which are as follows: gamma-aminobutyric acid receptor (G), sodium channel blocker (SC), synaptic vesicle protein 2A (SV2), calcium channel blocker (C), and multiple mechanisms (M). Treatment persistence was compared, and the predictors of persistence were analyzed.

RESULTS

In total, 3033 patients were enrolled in this study. Combined ASMs with different MoAs had significantly longer treatment persistence than ASMs with similar MoAs, specifically SC and M combinations. Patients receiving combined ASMs with different MoAs were less likely to discontinue treatment [adjusted hazards ratio: 0.83 (95% CI: 0.75-0.93), p < 0.001]. Among all combinations, the SC + SV2 combination had the longest treatment persistence (mean ± SD: 912.7 ± 841.6 days). Meanwhile, patients receiving the G combination had a higher risk of treatment discontinuation than those receiving the SC + SV2 combination. Underlying malignancies were associated with an increased risk of treatment discontinuation across all MoA categories. Male patients receiving the SC, SV2, and M combinations were more likely to discontinue treatment than female patients. Moreover, patients with renal disease were more likely to discontinue treatment with the SV2 combinations.

CONCLUSION

ASM combinations with different MoAs had superior efficacy and tolerability to ASM combinations with similar MoAs, particularly SC and M combinations. In our cohort, factors associated with treatment discontinuation included underlying malignancy, male sex, and renal disease. These findings may provide valuable insights into the use of ASM combinations if monotherapy cannot adequately control seizures.

Anti-inflammatory and antioxidative effects of elderberry diet in the rat model of seizure: a behavioral and histological investigation on the hippocampus

The present study was designed to evaluate whether elderberry (EB) effectively reduces inflammation and oxidative stress in hippocampal cells to modify seizure damage. Seizure was induced in rats by the injection of pentylenetetrazol (PTZ). In the Seizure + EB group, EB powder was added to the rats' routine diet for eight consecutive weeks. The study included several behavioral tests, immunohistopathology, Voronoi tessellation (to estimate the spatial distribution of cells in the hippocampus), and Sholl analysis. The results in the Seizure + EB group showed an improvement in the behavioral aspects of the study, a reduction in astrogliosis, astrocyte process length, number of branches, and intersections distal to the soma in the hippocampus of rats compared to controls. Further analysis showed that EB diet increased nuclear factor-like 2 expression and decreased caspase-3 expression in the hippocampus in the Seizure + EB group. In addition, EB protected hippocampal pyramidal neurons from PTZ toxicity and improved the spatial distribution of hippocampal neurons in the pyramidal layer and dentate gyrus. The results of the present study suggest that EB can be considered a potent modifier of astrocyte reactivation and inflammatory responses.

KCNH2 variants in a family with epilepsy and long QT syndrome: A case report and literature review

OBJECTIVE

Genes associated with Long QT syndromes (LQTS), such as KCNQ1, KCNH2, and SCN5A, are common causes of epilepsy. The Arg 744* variant of KCNH2 has been previously reported in people with epilepsy or LQTS, but none of these patients were reported to simultaneously suffer from epilepsy and LQTS. Herein, we report the case of a family with epilepsy and cardiac disorders.

METHOD

The proband, a 25-year-old woman, with a family history of epilepsy and LQTS was followed at West China Hospital. The proband experienced her first seizure at the age of seven. Video electroencephalograms (vEEGs) showed epileptic discharges. Her 24-h dynamic electrocardiograms 2 (ECGs) showed QTc prolongation. The proband's mother, who is 50 years old, had her first generalized tonic-clonic seizure (GTCS) at the age of 18 years old. After she gave birth at the age of 25, the frequency of seizures increased, so antiepileptic therapy was initiated. When she was 28 years old, she complained of palpitations and syncope for the first time, and QTc prolongation was detected on her 24-h dynamic ECGs. The proband's grandmother also had complaints of palpitations and syncope at the age of 73. Her 24-h dynamic ECGs indicated supraventricular arrhythmia, with the lowest heart rate being 41 bpm, so she agreed to a pacemaker. Considering the young patient's family history, blood samples of the patient and her parents were collected for genetic analysis.

RESULTS

A heterozygous variant of KCNH2 [c.2230 (exon9) C>T, p. Arg744Ter, 416, NM_000238, rs189014161] was found in the proband and her mother. According to the guidelines of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology, we classified the KCNH2 variant as pathogenic.

SIGNIFICANCE

This study expands the clinical phenotype of the Arg 744* KCNH2 pathogenic variant. In the context of channelopathies, because of the genetic susceptibility of the brain and the heart, the risk of comorbidity should be considered. This also indicates the importance of precise antiepileptic drug (AED) management and regular ECG monitoring for patients with channelopathies.

Multimorbidity in People with Epilepsy

Multimorbidity is an emerging priority in healthcare due to associations with the ageing population, frailty, polypharmacy, health and social care demands. It affects 60-70% of adults and 80% of children with epilepsy. Neurodevelopmental conditions are commonly seen in children with epilepsy, while cancer, cardiovascular and neurodegenerative conditions often afflict older people with epilepsy. Mental health problems are common across the lifespan. Genetic, environmental, social and lifestyle factors contribute to multimorbidity and its consequences. Multimorbid people with epilepsy (PWE) are at higher risk of depression and suicide, premature death, suffer lower health-related quality of life, and require more hospital admissions and health care costs. The best management of multimorbid PWE requires a paradigm shift from the traditional single disease-single comorbidity approach and a refocus on a person-centred approach. Improvements in health care must be informed by assessing the burden of multimorbidity associated with epilepsy, delineating disease clusters, and measuring the effects on health outcomes.

Mortality, and life expectancy in Epilepsy and Status epilepticus-current trends and future aspects

Patients with epilepsy carry a risk of premature death which is on average two to three times higher than in the general population. The risk of death is not homogenously distributed over all ages, etiologies, and epilepsy syndromes. People with drug resistant seizures carry the highest risk of death compared to those who are seizure free, whose risk is similar as in the general population. Most of the increased risk is directly related to the cause of epilepsy itself. Sudden unexplained death in epilepsy patients (SUDEP) is the most important cause of epilepsy-related deaths especially in the young and middle-aged groups. Population based studies with long-term follow up demonstrated that the first years after diagnosis carry the highest risk of death, while in the later years the mortality decreases. Improved seizure control and being exposed to a specialized comprehensive care centre may help to reduce the risk of death in patients with epilepsy. The mortality of status epilepticus is substantially increased with case fatality rates between 4.6% and 39%, depending on its cause and duration, and the age of the population studied. The epidemiological data on overall and cause specific mortality as well as their determinants and risk factors are critically reviewed and methodological issues pertinent to the studies on mortality of epilepsy and Status epilepticus are discussed.

Sodium channel-inhibiting drugs and cancer-specific survival: a population-based study of electronic primary care data

OBJECTIVES

Antiepileptic and antiarrhythmic drugs inhibit voltage-gated sodium (Na+) channels (VGSCs), and preclinical studies show that these medications reduce tumour growth, invasion and metastasis. We investigated the association between VGSC inhibitor use and survival in patients with breast, bowel and prostate cancer.

DESIGN

Retrospective cohort study.

SETTING

Individual electronic primary healthcare records extracted from the Clinical Practice Research Datalink.

PARTICIPANTS

Records for 132 996 patients with a diagnosis of breast, bowel or prostate cancer.

OUTCOME MEASURES

Adjusted Cox proportional hazards regression was used to analyse cancer-specific survival associated with exposure to VGSC inhibitors. Exposure to non-VGSC-inhibiting antiepileptic medication and other non-VGSC blockers were also considered. Drug exposure was treated as a time-varying covariate to account for immortal time bias.

RESULTS

During 1 002 225 person-years of follow-up, there were 42 037 cancer-specific deaths. 53 724 (40.4%) patients with cancer had at least one prescription for a VGSC inhibitor of interest. Increased risk of cancer-specific mortality was associated with exposure to this group of drugs (HR 1.59, 95% CI 1.56 to 1.63, p<0.001). This applied to VGSC-inhibiting tricyclic antidepressants (HR 1.61, 95% CI 1.50 to 1.65, p<0.001), local anaesthetics (HR 1.49, 95% CI 1.43 to 1.55, p<0.001) and anticonvulsants (HR 1.40, 95% CI 1.34 to 1.48, p<0.001) and persisted in sensitivity analyses. In contrast, exposure to VGSC-inhibiting class 1c and 1d antiarrhythmics was associated with significantly improved cancer-specific survival (HR 0.75, 95% CI 0.64 to 0.88, p<0.001 and HR 0.54, 95% CI 0.33 to 0.88, p=0.01, respectively).

CONCLUSIONS

Association between VGSC inhibitor use and mortality in patients with cancer varies according to indication. Exposure to VGSC-inhibiting antiarrhythmics, but not anticonvulsants, supports findings from preclinical data, with improved survival. However, additional confounding factors may underlie these associations, highlighting the need for further study.

"Untold Distress" - How did the COVID-19 pandemic affect those who had previously experienced an epilepsy-related bereavement?

PURPOSE

This study explores the impact of the COVID-19 pandemic and lockdown on people with lived experience of sudden bereavement as a consequence of an epilepsy-related death.

METHOD

We developed an online survey with fixed choice and open-ended response formats to collect data on grief symptoms and well-being during the pandemic. A total of 275 people bereaved by epilepsy-related deaths between 1980-2020 participated in this study: with 79 participants providing free-text responses for inductive thematic analysis.

RESULTS

In total, 84% of participants reported a bereavement following a sudden death of a person aged under 40, with 22% aged 19 and under. The majority (77% of participants) reported they had been thinking more about the person who died compared to before the COVID-19 outbreak and 54% had experienced more distressing flashbacks to the time of death. Additionally, 61% reported more difficulties falling asleep and staying asleep and 88% of participants reported that the outbreak and response measures had negatively impacted upon their mental health. Medication was being taken for a diagnosed mental health condition by 33% of participants at the time of the study. We categorized these negative experiences during COVID in to four main-themes - 'Family', 'Lifestyle', 'Personal Well-being' and 'Health Services and Shielding Populations'. The 'Personal Well-being' theme was inextricably linked to grief symptoms including 'reflection on the death', 're-exposure to feeling', 'grief', 'salience of sudden deaths in the media' and 'inability to commemorate anniversaries and rituals'. These findings were consistent for bereaved people irrespective of the recency of the death.

CONCLUSION

This study highlights the impact of the disruption caused by the pandemic on the grief-management of those bereaved by epilepsy-related death. Grief is not static and its management is connected to the psychosocial and formal support structures that were disrupted during the pandemic. The removal of these supports had an adverse effect upon the mental health and well-being of many bereaved. There is an urgent need for a system-wide transformation of epilepsy and mental health services to be inclusive of the needs and experiences of people impacted by sudden deaths in epilepsy and the contribution of the specialist service developed by families and clinicians to meet this gap.

An economic evaluation of vagus nerve stimulation as an adjunctive treatment to anti-seizure medications for the treatment of drug resistant epilepsy in the United States

INTRODUCTION

People with recurrent epileptic seizures are typically treated with anti-seizure medications (ASMs). Around a third of epilepsy patients fail to achieve an adequate response to ASMs and may be eligible to receive vagus nerve stimulation (VNS) therapy for their drug-resistant epilepsy (DRE) if they are unsuited to surgery. VNS received approval from the United States (US) Food and Drug Administration agency. However, there has to date been no comprehensive cost effectiveness evaluation of VNS within the US setting. This study was designed, using a US Medicare perspective, to estimate costs and quality-adjusted life years (QALYs) associated with VNS as an adjunct to ongoing ASM therapy, compared to ASMs alone.

METHODS

We developed a cohort state transition model in Microsoft Excel, with four health states defined by different percentage reductions in seizure frequency, with a 3-month cycle and transition probabilities derived from published clinical trials and registry data. Sensitivity analyses were conducted to understand the impact of parameter uncertainty. Costs included the VNS device, placement, programming, battery changes, and removal; ASM therapy; adverse events associated with VNS (dyspnea, hoarseness, and cough); and costs associated with seizure burden (i.e. hospitalizations, emergency department visits, neurologist visits).

RESULTS

Under base case assumptions, treatment with VNS was associated with a 0.385 QALY gain and a $109,678 saving per patient, when compared with ASM therapy alone. The incremental net monetary benefit (iNMB) was $128,903 at a threshold of $50,000 per QALY, with the positive iNMB indicating that VNS is a highly cost effective treatment. This result is explained by the modeled reduction in relative seizure frequency and associated reduction in healthcare resource use that the VNS group experienced. Sensitivity analyses supported this conclusion.

CONCLUSIONS

VNS was evaluated as a cost effective addition to the current standard of care in the treatment of DRE in the US Medicare context.

Shame, stigma, and social exclusion: The lived experiences of epileptic patients in a health facility in Ilorin, Nigeria

BACKGROUND

The highest number of persons living with epilepsy (PLWE) are in Africa and the majority live in deplorable conditions, while dealing with varying layers of stigma, social exclusion, and discrimination.

OBJECTIVE

This study explored the lived experiences of PLWE in Ilorin.

METHODS

Adopting a qualitative design and a phenomenological lens, 10 PLWE between the ages of 18 and 60 were purposively selected from the University of Ilorin Teaching Hospital (UITH) for in-depth interviews.

RESULTS

Findings suggest that PLWE bear multiple and intersecting burdens, including physical injuries; institutional, cultural, and economic constraints; psychological strain; social exclusion; and stigma. These disadvantages are often sustained and reproduced by various assumptions about epilepsy; as such, PLWE conceal their condition, and this implicatively reinforce stigma. Difficulty sustaining intimate relationships, overt physical scars, and inferiority complexes are recurrent challenges for PLWE. The study showed that adherence to drugs, self-management, personal precautions towards seizure signs, and family support are important coping strategies.

CONCLUSION

The study recommends that it is imperative to enhance and sustain systems, processes, and attitudes that prioritise the physical, social, and emotional needs of PLWE, because this is significant for their enhanced quality of life (QoL).

Cognitive functioning and prevalence of seizures among older persons in Uganda: A hospital-based, cross-sectional study

There is limited data on the prevalence of seizures and dementia among older persons in Uganda. We evaluated cognitive functioning, and the prevalence and factors associated with seizures among older persons attending an outpatient medical clinic in Uganda. We randomly selected older adults (60 years and above) attending Kiruddu National Referral Hospital medical outpatient clinics between October 2020 and March 2021. We excluded individuals with a history of head injury, brain tumors, mental retardation, co-morbidity with HIV and patients who have had recent brain surgery. Cognitive functioning was assessed using the Identification for Dementia in Elderly Africans (IDEA) tool. We enrolled 407 participants, with a median (inter-quartile range) age of 67 (64-73) years. Majority were female (n = 292, 71.7%). The prevalence of seizure was 1.5% (95% confidence interval [CI]: 0.7-3.3). All 6 participants reported generalized tonic-clonic seizure type. Self-reported seizure was associated with being female (adjusted prevalence ratio [aPR]: 0.79, 95%CI: 0. 67-0.93, P = .02) and residing in Mukono district (aPR: 17.26, 95%CI: 1.64-181.55, P = .018). Overall, 114 (28.1%) participants had cognitive deficit; 9 (2.2%) dementia and 105 (25.9%) impaired cognition. Cognitive deficit was independently associated with female gender (aPR: 0.61, 95%CI: 0.44-0.85, P = .003), formal employment (aPR: 0.53, 95%CI: 0.35-0.81, P = .003), age 70-74 (aPR: 1.69, 95%CI: 1.00-2.86, P = .049), and ≥ 75 years (aPR: 2.81, 95%CI: 1.71-4.61, P = .001). Prevalence of seizures among participants with cognitive deficit was 5.3% (6/114). Among older persons attending a medical clinic in Uganda, almost one-third had cognitive deficit with seizure prevalence being higher among these individuals.

Association between status epilepticus and cardiorespiratory comorbidity in patients with epilepsy: A population-based study

PURPOSE

This study aimed to evaluate the relationship between status epilepticus (SE) and cardiorespiratory comorbidity in patients with epilepsy.

METHODS

We conducted a population-based study using cloud-based aggregated electronic medical records from >53 million patients in the US (Explorys, IBM Watson; January 1999 to November 2020). During the study period, we identified patients with epilepsy with SE. Patients with a history of cardiac arrest, anoxic encephalopathy, and/or cerebrovascular disease were excluded. We reported the prevalences and prevalence ratios of cardiorespiratory and medical comorbidities using age- and sex-adjusted standardization.

RESULTS

We identified 494,790 patients with epilepsy and 19,190 had SE. Cardiovascular and respiratory diseases were statistically significantly more prevalent in patients with epilepsy with SE than in those without SE (adjusted prevalence ratio (APR) 1.13, prevalence 68.7% [95% confidence interval (CI): 67.6-69.9] vs 60.9% [95% CI: 60.7-61.1]) and (APR 1.25, 73.1% [95% CI: 71.8-74.3] vs 58.4% [95% CI: 58.1-58.6]), respectively. Aspiration pneumonia (APR 3.12, 0.47% [95% CI: 0.37-0.57] vs 0.15% [95% CI: 0.14-0.16]) and acute respiratory distress syndrome (APR 2.40, 0.47% [95% CI: 0.37-0.57] vs 0.20% [95% CI: 0.18-0.21]) were more prevalent in patients with epilepsy with SE. Common cardiovascular risk factors such as diabetes mellitus (APR 1.13, 17.1% [95% CI: 16.5-17.6] vs 15.1% [95% CI: 1.50-15.2]) and hypertension (APR 1.28, 10.6% [95% CI: 10.2-11.0] vs 8.31% [95% CI: 8.23-8.39]) were also more common in patients with epilepsy with SE.

CONCLUSION

In this population-based study, patients with epilepsy with SE had a statistically significantly higher prevalence of cardiorespiratory comorbidities than in those without SE.

Epilepsy is overrepresented among young people who died from COVID-19: Analysis of nationwide mortality data in Hungary

BACKGROUND

Studies examining epilepsy as a COVID-related death risk have come to conflicting conclusions. Our aim was to assess the prevalence of epilepsy among COVID-related deaths in Hungary.

METHODS

Each COVID-19 infection case is required to be reported on a daily basis to the National Public Health Center of Hungary. This online report includes the beginning and end of the infection, as well as information on comorbidities. Death during infection is regarded as COVID-related. The anonymized data of each deceased patient are published on an information website (www.koronavirus.gov.hu) and provides up-to-date information on each patient with the date of death, the patient's sex, age, and chronic illness.

RESULTS

There were 11,968 patients who died of COVID-19 in Hungary between 13 March 2020 and 23 January 2021. Among 11,686 patients with no missing values for comorbidities, 255 patients had epilepsy (2.2%). Epilepsy was much more common among those who died at a young age: 9.3% of those who died under the age of 50 had epilepsy, compared with only 1.3% in those over the age of 80. The younger an age group was, the higher was the prevalence of epilepsy.

CONCLUSION

Patients who died of COVID-19 under the age of 50 were 10 to 20 times more likely to have epilepsy than what would have been expected from epidemiological data. Our results highlight the need for increased protection of young people with epilepsy from COVID-19 infection and the development of a vaccination strategy accordingly.

Epilepsy-Related Mortality in Children and Young Adults in Denmark: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

Mortality is increased in epilepsy, but the important issue is that a proportion of epilepsy-related death is potentially preventable by optimized therapy and needs therefore to be identified. A new systematic classification of epilepsy-related mortality has been suggested by Devinsky et al. in 2016 to identify these preventable deaths. We applied this classification to an analysis of premature mortality in persons with epilepsy younger than 50 years.

METHODS

The study was a population-based retrospective cohort of all Danish citizens with and without epilepsy aged 1-49 years during 2007-2009. Information on all deaths was retrieved from the Danish Cause of Death Registry, autopsy reports, death certificates, and the Danish National Patient Registry. The primary cause of death in persons with epilepsy was evaluated independently by three neurologist, one neuro-pediatrician, and two cardiologists. In case of uncertainty a pathologist was consulted. All deaths were classified as either epilepsy- or not-epilepsy-related, and the underlying causes or modes of death were compared between persons with and without epilepsy.

RESULTS

During the study period 700 deaths were identified in persons with epilepsy, and 440 (62.9%) of these were epilepsy-related, hereof, 169 (38%) directly related to seizures and 181 (41%) due to an underlying neurological disease. SUDEP accounted for 80% of deaths directly related to epilepsy. Aspiration pneumonia was the cause of death in 80% of cases indirectly related to epilepsy.Compared with the background population, persons with epilepsy had a nearly four-fold increased all-cause mortality (adjusted mortality hazard ratio of 3.95 [95% CI 3.64-4.27], p<0.0001) and a higher risk of dying from various underlying causes including alcohol-related conditions (hazard ratio of 2.91 [95% CI 2.23-3.80], p<0.0001) and suicide (hazard ratio of 2.10 [95% CI 1.18-3.73], p=0.01).

DISCUSSION

The newly proposed classification for mortality in persons with epilepsy was useful in an unselected nationwide cohort. It helped classifying unnatural causes of death as epilepsy-related or not, and it helped identifying potentially preventable deaths. The leading causes of premature mortality in persons younger than 50 years were related to epilepsy and were thus potentially preventable by good seizure control.

Changes in epilepsy causes of death: A US population study

OBJECTIVES

Since 2000, medical treatment for epilepsy and cardiovascular risk-reduction strategies have advanced significantly in the United States (US). However, seizure-free rates remain unchanged, and people with epilepsy are at higher risk than the general population for heart disease and stroke. The purpose of this study is to determine how cardiovascular, epilepsy-related, and other causes of death are changing in epilepsy in comparison with the US population.

MATERIALS & METHODS

Changes in the 15 underlying causes of death in epilepsy (ICD-10 G40-G40.9) and the US population were analyzed and compared from 2000 to 2018. The CDC multiple cause-of-death database was utilized as the primary data source. Changes in the relative proportions for each cause-of-death over were evaluated using logistic regression.

RESULTS

The proportions of deaths in epilepsy due to heart disease declined 34.4% (p < .001), a rate similar to the general population (39.9%). Epilepsy-related deaths declined 25% as a percentage of all epilepsy deaths (p < .001). The proportions of deaths due to stroke and neoplasms increased significantly in epilepsy versus the US population (p < .001 linear trend).

CONCLUSIONS

The reduction in ischemic heart disease in epilepsy is a novel and highly significant finding, which reflects widespread implementation of cardiovascular risk-factor reduction and treatment in the United States. Reductions in epilepsy-related deaths are an exciting development which requires further investigation into causality. The increase in deaths due to neoplasms and stroke relative to the US population is concerning, warranting vigilance and increased efforts at recognition, prevention, and treatment.

Epilepsy and mortality: a retrospective cohort analysis with a nested case-control study identifying causes and risk factors from primary care and linkage-derived data

OBJECTIVES

People with epilepsy (PWE) have a higher mortality rate than the general population. Epilepsy-related deaths have increased despite all-cause mortality decreasing in the general population pre-COVID-19. We hypothesised that clinical and lifestyle factors may identify people more at risk.

DESIGN

We used a retrospective cohort study to explore cause of death and a nested case-control study to identify risk factors.

SETTING

We explored factors associated with mortality using primary care population data from 1 April 2004 to 31 March 2014. Data were obtained from the Clinical Practice Research Datalink which compiles anonymised patient data from primary care in the UK. Cause of death data was supplemented from the Office of National Statistics when available.

PARTICIPANTS

The analysis included 70 431 PWE, with 11 241 registered deaths.

RESULTS

The number of deaths within the database increased by 69% between the first and last year of the study. Epilepsy was considered as a contributing cause in approximately 45% of deaths of PWE under 35. Factors associated with increased risk of death included attendance at emergency departments and/or emergency admissions (OR 3.48, 95% CI 3.19 to 3.80), antiepileptic drug (AED) polytherapy (2 AEDs: OR 1.60, 95% CI 1.51 to 1.71; 3 AEDs: OR 2.06, 95% CI 1.86 to 2.29; 4+AEDs: OR 2.62, 95% CI 2.23 to 3.08), status epilepticus (OR 2.78, 95% CI 1.64 to 4.71), depression (OR 1.67, 95% CI 1.57 to 1.76) and injuries (OR 1.54, 95% CI 1.43 to 1.67). No seizures in the prior year (OR 0.52, 95% CI 0.41 to 0.65).

CONCLUSION

Our results add to existing evidence that deaths in epilepsy are increasing. Future studies could focus on identifying PWE at high risk and addressing them with clinical interventions or better self-management. Identifying specific risk factors for younger people should be a priority as epilepsy may be a factor in close to half of deaths of PWE under 35 years of age.

Impact of Rehabilitation Intensity on 3-Year Mortality among Children with Moderate to Severe Cerebral Palsy: A Population-Based Cohort Study

Though numerous studies demonstrated the positive effect of rehabilitation on cerebral palsy (CP) children, there was no literature addressing the role of rehabilitation on mortality among children with CP. Therefore, we aimed to evaluate the impact of rehabilitation intensity on mortality among children with moderate to severe CP. This retrospective cohort study was conducted by National Health Insurance Research Database in Taiwan. Children (<12 years) with newly diagnosed moderate to severe CP between 1 January 2000 and 31 December 2013 were included. All patients were followed up for 3 years after CP diagnosis or death or until 31 December 2013. The intensity of rehabilitation therapy within 6 months after CP diagnosis was categorized into <6 times and ≥6 times. The Cox proportional hazard analysis was used to determine the association between rehabilitation intensity and all-cause mortality after adjusting age, sex, other demographic factors and comorbidities. Among 3936 severe CP children, 164 (4.2%) died during the 3-year follow-up period. The mortality rate was higher among patients receiving rehabilitation < 6 times within 6 months than those ≥6 times within 6 months after adjusting demographic profile and comorbidities (adjust HR (aHR): 1.96, 95% CI 1.33–2.89, p < 0.001). We found that patients who were younger (aHR: 0.84, 95% CI 0.76–0.92, p < 0.001), who were receiving inpatient care more than twice in 1 year before their CP diagnosis (aHR: 2.88; 95% CI: 1.96–4.23; p < 0.001), and who have pneumonia (aHR: 1.41, 95% CI 1.00–1.96, p = 0.047), epilepsy (aHR: 1.41, 95% CI: 1.02–1.95, p = 0.039) and dysphagia (aHR: 1.55, 95% CI: 1.06–2.26, p = 0.024) have higher risk of mortality. Rehabilitation ≥ 6 times within 6 months has a potentially positive impact on pediatric CP survival. Besides having a younger age, being hospitalized more than twice within a year before diagnosis and having pneumonia, epilepsy and dysphagia were modifiable risk factors in clinical practice for these children.

Atherogenic Risk Factors among Young Indian Adults with Epilepsy on Treatment with Phenytoin: Need for Novel Therapeutic Strategies

Background

Risk for the development of coronary heart disease and diabetes is found to be more among people with epilepsy especially when on treatment. Redox imbalance contributes to this risk especially in India as it is the diabetic capital of the world with higher prevalence of inflammation.

Objectives

The aim of this study was to evaluate atherogenic risk factors; dyslipidemia, oxidative stress, and systemic inflammation among young Indian adults with epilepsy on treatment with Phenytoin.

Material and Methods

Three groups of age and gender-matched young subjects were recruited. Group 1-Healthy control subjects, Group 2- Newly diagnosed epileptic young adults with recent epileptic seizures, Group 3- Epileptic adults on treatment with Phenytoin for more than 6 months were recruited.

Results

Dyslipidemia was found among the newly diagnosed epileptic subjects in comparison to healthy subjects. The LDL-cholesterol further increased, and HDL-cholesterol further decreased in the third group treated with Phenytoin. Body mass index of these treated epileptic subjects was more in comparison to healthy control. Low-grade inflammation as assessed by hsCRP and oxidative stress were significantly higher among the newly diagnosed epileptic subjects when compared to the healthy controls which further increased on treatment with phenytoin. We found dyslipidemia, oxidative stress, and low-grade inflammation among newly diagnosed epileptic subjects which further increased on treatment with Phenytoin for more than 6 months.

Conclusion

From this study, we conclude that dyslipidemia, oxidative stress and low-grade inflammation are identified among the newly diagnosed young adult Indian epileptic patients. Phenytoin treatment further augmented these complications.

Electrocardiography Parameters Changes in Epilepsy and Febrile Convulsion Children Compared with Controls

Epilepsy and febrile convulsion are the most common neurological diseases with significant effect on cardiac functions. This study aimed to evaluate electrocardiography parameters alterations in epilepsy and febrile convulsion children compared with controls. In this comparison study, 270 children analyzed who shared equally in epilepsy, febrile convulsion, and healthy that aged from 0.5 to 5 years. The participants were collected from Ali ibn Abi Talib Hospital of Zahedan, Iran. Epilepsy confirmed based on definition of having at least two unprovoked seizures in 24 hours. Febrile convulsion was confirmed based on its definition by the International League against Epilepsy. Healthy children selected from those referred to the hospital with fever and without any underline diseases. Electrocardiography was performed by a pediatric cardiologist. Data were analyzed using SPSS 19 with p < 0.05 significant level. Heart rate was higher in epilepsy (129.64 ± 27.63) compared with control (108.78 ± 26.01) and febrile convulsion (125.79 ± 25.38; X 2 = 28.701, p < 0.001). S wave in lead V1 was higher in controls (0.72 ± 0.36) compared with epilepsy (0.58 ± 0.45) and febrile convulsion (0.58 ± 0.36). QT dispersion and QTc dispersion levels were higher in epilepsy than febrile convulsion children that both were higher than controls. Concluded that R in aVL, LV mass (LVM), QT dispersion, and QTc dispersion were higher significantly in epilepsy compared with febrile convulsion children. To maintain a good strategic treatment in patients with epilepsy and febrile convulsion, there is a need to assess alternations in ECG parameters, especially QT interval changes that lead to better comprehensive autonomic changes.

Impact of a Brief Structured Psychoeducation Session on Antiepileptic Drug Adherence and Treatment Outcome in Persons with Epilepsy: A Prospective Cohort Study

Background:

Poor adherence to antiepileptic drugs is one of the most important causes of treatment failure in persons with epilepsy (PWE). This study was aimed at assessing the impact of psychoeducation on drug adherence and treatment outcome in PWE.

Methods:

It was a prospective cohort study with a pre and posttest intervention design. A cohort of 100 epilepsy patients aged 18–65 years and on antiepileptic drugs for at least 6 months attending the outpatient department was enrolled in the study. Drug adherence was measured by Medication Adherence Rating Scale. A structured eight-domain epilepsy psychoeducation session with pictorial description was given to the study subjects in two parts (group and individually) lasting for a total of 30 min on the day of baseline assessment. Adherence and treatment outcome variables were assessed by an independent observer 4 months after the psychoeducation session. Chi-square test and paired t-test were used to analyze the data using SPSS version 20 with P value less than 0.05 considered as significant.

Results:

There was a statistically significant (P < 0.001) increase in the number of patients who were adherent to medications after psychoeducation session. There was a significant reduction in mean seizure frequency (0.68 ± 0.65) and seizure severity in terms of injuries sustained during seizure episodes post intervention. Regularities in the follow-up visits were also witnessed. A significant decrease in the number of hospital admissions (0.09 ± 0.32), mean inpatient treatment days (0.44 ± 2.19), and emergency room visits (0.19 ± 0.15) was noted 4 months after the psychoeducation session indicative of better treatment outcome.

Conclusion:

The present study proves the efficacy of a structured educational program in improving drug adherence and treatment outcome in a cohort of people with epilepsy.

Sudden unexpected death in epilepsy in persons younger than 50 years: A retrospective nationwide cohort study in Denmark

OBJECTIVE

Persons with epilepsy have an increased mortality including a high risk of sudden unexplained death (SUD), also referred to as sudden unexpected death in epilepsy (SUDEP). We aimed to evaluate the risk of SUDEP in comparison to other causes of death and the risk of SUD in persons with and without epilepsy.

METHODS

We undertook a retrospective population-based cohort study of all Danish citizens with and without epilepsy aged 1-49 years during 2007-2009. All deaths in the population were evaluated, and all cases of SUD identified. Primary causes of death in persons with epilepsy were evaluated independently by three neurologists and one neuropediatrician, using the unified SUDEP criteria.

RESULTS

The three most frequent causes of death in persons with epilepsy were cancer (2.38 per 1000 person-years), SUDEP (1.65 per 1000 person-years), and pneumonia (1.09 per 1000 person-years) compared with cancer (.17 per 1000 person-years), accident-related deaths (.14 per 1000 person-years), and cardiovascular disease (.09 per 1000 person-years) in persons without epilepsy. Considering definite, definite plus, and probable cases, the SUDEP incidence was .27 per 1000 person-years (95% confidence interval [CI] = .11-.64) in children aged 1-17 years and 1.21 per 1000 person-years (95% CI = .96-1.51) in adults aged 18-49 years. Adjusted for age and sex, persons with epilepsy younger than 50 years had a 10.8-fold (95% CI = 9.97-11.64, p < .0001) increased all-cause mortality and a 34.4-fold (95% CI = 23.57-50.28, p < .0001) increased risk of SUD compared with persons without epilepsy. SUDEP accounted for 23.3% of all SUD.

SIGNIFICANCE

This nationwide study of all deaths in persons with epilepsy younger than 50 years found a lower SUDEP risk in children compared with adults, and that epilepsy was a major risk factor for SUD in the background population. This underlines the importance of addressing risk factors for SUDEP to prevent premature death.

Missed, mistaken, stalled: Identifying components of delay to diagnosis in epilepsy

A substantial proportion of individuals with newly diagnosed epilepsy report prior seizures, suggesting a missed opportunity for early epilepsy care and management. Consideration of the causes and outcomes of diagnostic delay is needed to address this issue. We aimed to review the literature pertaining to delay to diagnosis of epilepsy, describing the components, characteristics, and risk factors for delay. We undertook a systematic search of the literature for full-length original research papers with a focus on diagnostic delay or seizures before diagnosis, published 1998-2020. Findings were collated, and a narrative review was undertaken. Seventeen papers met the inclusion criteria. Studies utilized two measures of diagnostic delay: seizures before diagnosis and/or a study-defined time between first seizure and presentation/diagnosis. The proportion of patients with diagnostic delay ranged from 16% to 77%; 75% of studies reported 38% or more to be affected. Delays of 1 year or more were reported in 13%-16% of patients. Seizures prior to diagnosis were predominantly nonconvulsive, and usually more than one seizure was reported. Prior seizures were often missed or mistaken for symptoms of other conditions. Key delays in the progression to specialist review and diagnosis were (1) "decision delay" (the patient's decision to seek/not seek medical review), (2) "referral delay" (delay by primary care/emergency physician referring to specialist), and (3) "attendance delay" (delay in attending specialist review). There were few data available relevant to risk factors and virtually none relevant to outcomes of diagnostic delay. This review found that diagnostic delay consists of several components, and progression to diagnosis can stall at several points. There is limited information relating to most aspects of delay apart from prevalence and seizure types. Risk factors and outcomes may differ according to delay characteristics and for each of the key delays, and recommendations for future research include examining each before consideration of interventions is made.

Mortality in adult epilepsy patients in Malaysia: a hospital-based study

BACKGROUND

The standardized mortality ratio (SMR) of epilepsy in Asia ranges from 2.5 to 5.1. However, there are no such published data in Malaysia to date. Understanding the mortality rate and related factors will allow us to better assess and monitor the health status of PWE, thereby, preventing premature deaths among PWE. Hence, this study aimed to determine the mortality rate of adults with epilepsy (PWE) at the University Malaya Medical Centre (UMMC), a tertiary hospital in Malaysia.

METHOD

A total of 2218 PWE were recruited retrospectively into this study. Deceased cases from 2009-2018 were identified from the National Registry Department of Malaysia. Age-, gender-, and ethnic-specific SMR were calculated.

RESULT

There was a total of 163 deaths, of which 111 (68.1%) were male. The overall case-fatality rate (CFR) was 7.3%. Male PWE had higher CFR (9.2%) compared to females (5.1%, p<0.001). The annual death rate of PWE was 867 per 100, 000 persons. The overall all-cause SMR was 1.6 (CI 95% 1.3-1.8). The SMR for younger age groups (15-19 and 20-29 years) were higher (5.4-5.5) compared to other age groups (0.4-2.5). Overall SMR for male PWE (1.8, 95% CI 1.5-2.1) was higher than females (1.2, 95% CI 0.9-1.6). However, the SMR for female PWE in the younger age groups (15-19, 20-29 and 30-39 years) was higher. SMR among the Indian PWE was the highest (1.6, 95% CI 1.2-2.0) compared to the Chinese (1.5, 95% CI 1.2-1.9) and the Malays (1.4, 95% 1.0-1.9). The CFR was higher in those with focal epilepsy (8.5% vs. 2.5-3.7% in genetic and other generalized epilepsies, p=0.003), epilepsy with structural cause (9.5% vs. 5.9% in others, p=0.005) and uncontrolled seizures (7.9% vs. 5.2% in seizure-free group, p<0.001).

CONCLUSION

The mortality rate of PWE in Malaysia is higher than that of the general population but lower compared to other Asian countries. Specifically, the rates are higher in the younger age group, male gender, and Indian ethnicity. Those with focal epilepsy, structural causes and uncontrolled seizures have higher mortality rates.

Anti-seizure medication is not associated with an increased risk to develop cancer in epilepsy patients

Objective

Whether anti-seizure medication (ASM) increases the risk for cancer has been debated for decades. While for some ASM, a carcinoma-promoting effect has been suspected, carcinoma-protective effects have been shown for other ASM. However, the issue remains unresolved as data from preclinical and clinical studies have been inconsistent and contradictory.

Methods

We collected anonymous patient data from practice neurologists throughout Germany between 2009 and 2018 using the IMS Disease Analyzer database (QuintilesIMS, Frankfurt, Germany). People with epilepsy (PWE) with an initial cancer diagnosis and antiepileptic therapy prior to the index date were 1:1 matched with a control group of PWE without cancer according to age, gender, index year, Charlson Comorbidity Index, and treating physician. For both groups, the risk to develop cancer under treatment with different ASMs was analyzed using three different models (ever use vs. never use (I), effect per one (II) and per five therapy years (III).

Results

A total of 3152 PWE were included (each group, n = 1,576; age = 67.3 ± 14.0 years). The risk to develop cancer was not significantly elevated for any ASM. Carbamazepine was associated with a decreased cancer risk (OR Model I: 0.699, p < .0001, OR Model II: 0.952, p = .4878, OR Model III: 0.758, p < .0004).

Significance

Our findings suggest that ASM use does not increase the risk of cancer in epilepsy patients.

Supplementary Information

The online version of this article (10.1007/s00415-020-10379-4) contains supplementary material, which is available to authorized users.

An economic evaluation of vagus nerve stimulation as an adjunctive treatment to anti-seizure medications for the treatment of drug-resistant epilepsy in England

INTRODUCTION

Anti-seizure medications (ASMs) are commonly used to prevent recurring epileptic seizures, but around a third of people with epilepsy fail to achieve an adequate response. Vagus nerve stimulation (VNS) is clinically recommended for people with drug-resistant epilepsy (DRE) who are not suitable for surgery, but the cost-effectiveness of the intervention has not recently been evaluated. The study objective is to estimate costs and quality-adjusted life-years (QALYs) associated with using VNS as an adjunct to ongoing ASM therapy, compared to the strategy of using only ASMs in the treatment of people with DRE, from an English National Health Service perspective.

METHODS

A cohort state transition model was developed in Microsoft Excel to simulate costs and QALYs of the VNS + ASM and ASM only strategies. Patients could transition between five health states, using a 3-month cycle length. Health states were defined by an expected percentage reduction in seizure frequency, derived from randomized control trial data. Costs included the VNS device as well as its installation, setup, and removal; ASM therapy; adverse events associated with VNS (dyspnea, hoarseness, and cough); and health-state costs associated with epilepsy including hospitalizations, emergency department visits, neurologist visits, and primary care visits. A range of sensitivity analyses, including probabilistic sensitivity analysis, were run to assess the impact of parameter and structural uncertainty.

RESULTS

In the base case, VNS + ASM had an estimated incremental cost-effectiveness ratio (ICER) of £17,771 per QALY gained compared to ASMs alone. The cost-effective ICER was driven by relative reductions in expected seizure frequency and the differences in health care resource use associated therewith. Sensitivity analyses found that the amount of resource use per epilepsy-related health state was a key driver of the cost component.

CONCLUSIONS

VNS is expected to be a cost-effective intervention in the treatment of DRE in the English National Health Service.

Etiology of Non-Traumatic Seizures in Children Admitted to PICU: An Eight-Year Retrospective Study

Purpose

Seizure is a serious neurological symptom in the pediatric intensive care unit (PICU), yet data on etiologies of non-traumatic childhood seizures in China are scarce. We aimed to investigate the etiological trends of seizures in children admitted to the PICU in our tertiary center.

Patients and Methods

We performed a retrospective analysis of all patients (aged 29 days to 14 years) with non-traumatic seizures, admitted to the PICU of Xiangya Hospital from 2010 to 2017. Etiological analysis was performed to compare data between 2010–2013 and 2014–2017.

Results

The study included 318 patients (male: female = 1.27:1) with mean age of 5.4 ± 4.0 years. The most frequent causes observed were CNS infections (109/318, 34.3%), unknown reason epilepsy (96/318, 30.2%), and immune (56/318, 17.6%). Comparison of the 2010–2013 and 2014–2017 periods revealed a significant decrease in the percentage of CNS infections [48.8% (59/121) vs 25.4% (50/197), p < 0.001] and a significant increase in the incidence of unknown reason epilepsy [(24/121, 19.8%) vs (72/197, 36.5%), p < 0.001] and immune causes [(12/121, 9.9%) vs (44/197, 22.3%), p = 0.005].

Conclusion

CNS infections were the most common cause of seizures during 2010–2013, while non-infectious diseases such as epilepsy and immune disorders represented the leading causes during 2014–2017. Continuous improvement in medical technology and understanding of disease patterns would greatly improve early diagnosis and therapeutic management of such conditions.

Nonadherence to Antiepileptic Medications and Its Determinants among Epileptic Patients at the University of Gondar Referral Hospital, Gondar, Ethiopia, 2019: An Institutional-Based Cross-Sectional Study

Introduction

Nonadherence to antiepileptic medication is the extent of a patient's passive failure to follow the prescribed therapeutic regimen. The prevalence and impact of nonadherence to antiepileptic medication are high globally. The main purpose of this study was to assess nonadherence to antiepileptic medications and its associated factors among epileptic patients at the University of Gondar Referral Hospital, Gondar, Ethiopia, 2019.

Methods

An institutional-based cross-sectional study was conducted among 365 epileptic patients at the University of Gondar Referral Hospital, who were selected by a systematic random sampling technique. Data were collected by face to face interviews using a structured pretested questionnaire. Data were entered into EPI Info version 7 and then exported to SPSS version 22 for analysis. The data were described by descriptive statistics. Binary logistic regression analysis was used as a model, and variables with a p value of less than 0.05 were considered as statistically significant with nonadherence to antiepileptic medications.

Results

A total of 356 epileptic patients participated in the study yielding a response rate of 97.5%. The overall prevalence of nonadherence to antiepileptic medications among epileptic patients attending at the University of Gondar Referral Hospital was 38.5% (95% CI: 33.1–43.8). Divorced and/or widowed marital status (AOR: 3.38 (95% CI: 1.54, 7.44)), treatment duration of 3–5 years (AOR = 3.58 (95% CI: 1.38, 9.29)), treatment duration of 5 and above years (AOR: 3.49 (95% CI: 1.53, 7.95)), comorbidity (AOR: 2.42 (95% CI: 1.08, 5.43)), side effects of antiepileptic medications (AOR: 3.36 (95% CI: 1.67, 6.74)), absence of health information (AOR: 1.98 (95% CI: 1.11, 3.52)), epilepsy-related stigma (AOR: 2.81 (95% CI: 1.57, 5.02)), and negative attitude towards antiepileptic medications (AOR: 2.46 (95% CI: 1.36, 4.45)) were significantly associated with nonadherence to antiepileptic medications.

Conclusions

Prevalence of nonadherence to antiepileptic medications among epileptic patients at the University of Gondar Referral Hospital was found to be high. Hence, giving health information about epilepsy and its management will help to reduce antiepileptic medications' nonadherence.

Incidence and mortality in adults with epilepsy in northern Spain

OBJECTIVES

We aimed to determine the regional incidence and mortality of adult epilepsy, compare mortality rates with the expected in the general population, and identify predictors of shorter survival.

MATERIALS AND METHODS

We included all consecutive newly diagnosed epilepsy visited at a university hospital in Spain throughout 2012. We collected all relevant clinical data up to December 2018. We analyzed the incidence of epilepsy in our catchment area, studied mortality rates, and explored factors predictive of shorter survival.

RESULTS

The annual incidence of epilepsy among adults was 37.7 cases/100,000 inhabitants. We studied 110 patients with newly diagnosed epilepsy. Mean age was 52.6 years, and 53.6% were men. Eighty-nine patients (80.9%) had focal epilepsy, 50 (45.5%) had a structural etiology, and 45 (40.9%) had an unknown cause. Nineteen patients died over a median follow-up of 5.3 years. Mortality was almost four times higher than expected in general population and was increased in patients aged 40-59 years. Mortality rates were 5.5%, 12%, and 16.8% in the first, second, and third year, after which they remained stable to the end of follow-up. Independent predictors of mortality were age (p = 0.001), tumor-related epilepsy (p = 0.003), and generalized seizures (p = 0.020).

CONCLUSIONS

There is a high incidence of epilepsy among adults in our geographic area, with a mortality rate quadrupling that expected for the general population. Age, generalized seizures, and tumor-related epilepsy are independently associated with a higher risk of death.

Suicidal behavior among people with epilepsy in Northwest Ethiopia: A comparative cross-sectional study

INTRODUCTION

Premature mortality is common in people with epilepsy, but the causes vary where suicide is considered as one of the commonest.

OBJECTIVE

The objective of this study was to compare suicidal behavior between people with epilepsy and the general population and identify associated factors in Northwest Ethiopia.

METHODS

We have conducted a comparative cross-sectional study in Northwest Ethiopia. We have selected people with epilepsy from outpatient departments and the comparisons from the general population. Suicidal behavior was assessed by the revised version of Suicidal Behaviors Questionnaire (SBQ-R). Logistic regression was implemented to look for associations between factors and the dependent variable.

RESULTS

The prevalence of suicidal behavior in people with epilepsy was 18.2%, significantly higher than the community sample, which was 9.8% (p-value = .001). This difference persists in the multivariable logistic regression model by which the odds of suicidal behavior in people with epilepsy was two times more as compared to the community sample. Other variables positively associated with suicidal behavior for the overall sample were depressive symptoms, no formal education, divorced/widowed marital status, and higher perceived criticism. Better social support was protective factor for suicidal behavior.

CONCLUSION

The proportion of suicidal behavior is twofold higher in people with epilepsy than the general population. Routine screening for suicide risk should be an integral part of epilepsy treatment.

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.

Predicted Efficacy of Once-Daily Extended-Release Oxcarbazepine (Oxtellar XR®) Monotherapy in Adults and Children with Partial-Onset Seizures: Exposure-Response Modeling and Simulation

PURPOSE

We conducted exposure-response modeling and simulations to compare the predicted efficacy of extended-release oxcarbazepine (OXC-XR), an oral once-daily (qd) antiepileptic drug, with that of immediate-release (IR) OXC twice-daily (bid) when the agents are used as monotherapy or adjunctive therapy in patients with epilepsy characterized by partial-onset seizures (POS).

METHODS

Modeling assessed percent change from baseline 28-day seizure frequency (PCH) as a function of minimum concentration (Cmin) of monohydroxy derivative (MHD), the clinically relevant metabolite of OXC. For OXC-IR, the model used historical data; values for OXC-XR were derived from observed data. The model was simulated (N=100) to predict PCH at MHD Cmin concentrations achieved with 1200 and 2400 mg/day in adults and children receiving OXC-XR qd or OXC-IR bid. Mean PCH and 95% confidence intervals (CIs) were generated and compared.

RESULTS

Predicted efficacy was not different (ie, 95% CI of mean PCH overlapped) for OXC-XR qd vs OXC-IR bid at mean MHD Cmin concentrations achieved with 1200 and 2400 mg/day adjunctive OXC-XR (47.4 and 76.4 µmol/L) and at target MHD Cmin concentrations for OXC-IR monotherapy (59.1 and 112 µmol/L) in adults. Predicted efficacy in adults vs children was not different between formulations. Depending on MHD Cmin, the predicted mean PCH in adults ranged from -51.4% to -73.4% with OXC-XR qd and -53.2% to -78.5% with OXC-IR bid. In children, the predicted mean PCH ranged from -48.4% to -58.1% (OXC-XR qd) and -32.5% to -70.4% (OXC-IR bid).

CONCLUSION

This model-based analysis predicted comparable efficacy for OXC-XR qd vs OXC-IR bid at MHD Cmin concentrations corresponding to 1200 and 2400 mg/day as monotherapy or adjunctive therapy. Based on this analysis, the US Food & Drug Administration approved OXC-XR for use as monotherapy in adults and children ≥6 years of age with POS.

Dramatic outcomes in epilepsy: depression, suicide, injuries, and mortality

In this narrative review, we will discuss some of the significant risks and dramatic consequences that are associated with epilepsy: depression, suicide, seizure-related injuries, and mortality, both in adults and in children. Considering the high prevalence of depression among people with epilepsy (PWE), routine and periodic screening of all PWE for early detection and appropriate management of depression is recommended. PWE should be screened for suicidal ideation regularly and when needed, patients should be referred for a psychiatric evaluation and treatment. When starting an antiepileptic drug (AED) or switching from one to another AED, patients should be advised to report to their treating physician any change in their mood and existence of suicidal ideation. The risk of injuries for the general epilepsy population is increased only moderately. The risk is higher in selected populations attending epilepsy clinics and referral centers. This being said, there are PWE that may suffer frequent, severe, and sometimes even life-threatening seizure-related injuries. The most obvious way to reduce risk is to strive for improved seizure control. Finally, PWE have a 2-3 times higher mortality rate than the general population. Deaths in PWE may relate to the underlying cause of epilepsy, to seizures (including sudden unexpected death in epilepsy [SUDEP] and seizure related injuries) and to status epilepticus, as well as to other conditions that do not appear directly related to epilepsy. Improving seizure control and patient education may be the most important measures to reduce epilepsy related mortality in general and SUDEP in particular.

Why are epilepsy mortality rates rising in the United States? A population-based multiple cause-of-death study

INTRODUCTION

Epilepsy mortality rates are rising. It is unknown whether rates are rising due to an increase in epilepsy prevalence, changes in epilepsy causes of death, increase in the lethality or epilepsy or failures of treatment. To address these questions, we compare epilepsy mortality rates in the USA with all-cause and all-neurological mortality for the years 1999 to 2017.

OBJECTIVES

To determine changes in US epilepsy mortality rates versus all-cause mortality, and to evaluate changes in the leading causes of death in people with epilepsy.

DESIGN

Retrospective population-based multiple cause-of-death study.

PRIMARY OUTCOME

Change in age-adjusted epilepsy mortality rates compared with mortality rates for all-cause and all-neurological mortality.

SECONDARY OUTCOME

Changes in the leading causes of death in epilepsy.

RESULTS

From 1999 to 2017, epilepsy mortality rates in the USA increased 98.8%, from 5.83 per million in 1999 to 11.59 per million (95% CI 88.2%-110.0%), while all-cause mortality declined 16.4% from 8756.34 per million to 7319.17 per million (95% CI 16.3% to 16.6%). For the same period, all-neurological mortality increased 80.8% from 309.21 to 558.97 per million (95% CI 79.4%-82.1%). The proportion of people with epilepsy who died due to neoplasms, vascular dementia and Alzheimer's increased by 52.3%, 210.1% and 216.8%, respectively. During the same period, the proportion who died due to epilepsy declined 27.1%, while ischaemic heart disease as a cause of death fell 42.6% (p<0.001).

CONCLUSIONS

Epilepsy mortality rates in the USA increased significantly from 1999 to 2017. Likely causes include increases in all-neurological mortality, increased epilepsy prevalence and changes in the underlying causes of death in epilepsy, led by increases in vascular dementia and Alzheimer's. An important finding is that ischaemic heart disease and epilepsy itself are declining as underlying causes of death in people with epilepsy.

Economic Value of Adjunctive Brivaracetam Treatment Strategy for Focal Onset Seizures in Finland

Introduction

There is an unmet need for well-tolerated antiepileptic drugs (AEDs) that effectively control focal onset seizures. This study aimed to evaluate the economic value of new AEDs in the treatment of focal onset seizure, with or without secondary generalization, in Finnish adults and adolescents with epilepsy, comparing brivaracetam with perampanel as adjunctive AEDs.

Methods

Economic value was assessed using cost-utility analysis. Periods of AED initiation, titration, response assessment (seizure freedom, ≥ 50% reduction, no response), switching in no response or treatment-emergent adverse events (TEAEs), and death were simulated using a discrete-event simulation model. Responses and switching were simulated based on a comprehensive Bayesian network meta-analysis. The primary modeled outcome was the 3%/year discounted incremental cost-effectiveness ratio (ICER). Discounted quality-adjusted life-years (QALYs), payer costs (year 2017 Euro) per patient, and net monetary benefit (NMB) were secondary outcomes. Probabilistic and comprehensive deterministic sensitivity analyses were conducted.

Results

Brivaracetam was more efficacious and had fewer TEAEs than perampanel and other AEDs. Modeled average 5-year QALYs and costs were 3.671 and €28,297 for brivaracetam and 3.611 and €27,979 for perampanel, respectively. The resulting ICER for brivaracetam versus perampanel was only €5345/QALY gained in a deterministic base case scenario. Brivaracetam had a positive NMB and high probability of cost-effectiveness of €1190 and 71% or €1944 and 80% with the assumed willingness to pay of €25,358 or €38,036/QALY gained, respectively. The primary result was robust, with a positive NMB persistent in all sensitivity analysis scenarios. When switching from brivaracetam to perampanel was excluded from the modeling or switching from perampanel to brivaracetam was included, brivaracetam was cost-saving and more effective than perampanel (dominant).

Conclusion

These simulated comparisons demonstrated that brivaracetam was more effective and potentially also more affordable than perampanel. Thus, brivaracetam is likely a cost-effective and net beneficial alternative to perampanel for treatment of focal onset seizures.

Plain Language Summary

Plain language summary available for this article.

Electronic supplementary material

The online version of this article (10.1007/s12325-019-01155-6) contains supplementary material, which is available to authorized users.

Risk of hospitalization among patients with epilepsy using long versus short half-life adjunctive antiepileptic drugs

INTRODUCTION

While antiepileptic drugs (AEDs) remain the primary treatment for epilepsy, many patients continue to have seizures. Uncontrolled seizures may be related to AED half-life, since short half-life (SHL) AEDs require more frequent dosing compared with the simplified regimens of long half-life (LHL) AEDs. Long half-life AEDs may also improve seizure control by extending missed dose forgiveness periods. The value of LHL AEDs may be assessed as reduced healthcare utilization. The study's objective was to examine the impact of adding an LHL versus SHL adjunctive AED on the risk of hospitalizations in patients with uncontrolled epilepsy.

METHODS

This was a retrospective, longitudinal cohort study using the Symphony Health Solution Patient Integrated Dataverse. Patients ≥12 years old with uncontrolled epilepsy (≥2 medical claims ≥30 days apart) were identified during a study period (8/1/2012-7/31/2017). Patients were selected if they were subsequently initiated an adjunctive AED (excluding modified release formulations), and the prescription date served as the index. Patients were stratified into two mutually exclusive cohorts based on the index AED half-life (≤20 versus >20 h). Poisson regressions with robust error variances were performed for the relative risks (RRs) of all-cause, epilepsy-related, and injury-related hospitalizations.

RESULTS

A total of 4984 patients were identified (2705 in the LHL and 2279 in the SHL cohort). Compared with those in the SHL cohort, patients in the LHL cohort were significantly younger [mean (SD, years): 43.9 (18.5) versus 49.2 (17.2), p < 0.001] and were less comorbid [mean (SD) of Charlson comorbidity index: 1.2 (1.8) versus 1.8 (2.2), p < 0.001]. In the one-year postindex date, adjusting for group differences, the risks of both all-cause and epilepsy-related hospitalizations were significantly lower in the LHL cohort than in the SHL cohort [all-cause: 0.84 (95% CI: 0.76-0.93), p = 0.0006; epilepsy-related: 0.83 (0.73-0.94), p = 0.0046].Injury-related hospitalizations did not differ between LHL and SHL cohorts.

CONCLUSION

In patients with uncontrolled epilepsy who were initiated on an adjunctive AED, the choice of an LHL versus SHL was associated with significantly lower risks of all-cause and epilepsy-related hospitalizations.