Costs and cost-driving factors for acute treatment of adults with status epilepticus: A multicenter cohort study from Germany

Status epilepticus in patients with brain tumors and metastases: A multicenter cohort study of 208 patients and literature review

OBJECTIVE

Brain tumors and metastases account for approximately 10% of all status epilepticus (SE) cases. This study described the clinical characteristics, treatment, and short- and long-term outcomes of this population.

METHODS

This retrospective, multi-center cohort study analyzed all brain tumor patients treated for SE at the university hospitals of Frankfurt and Marburg between 2011 and 2017.

RESULTS

The 208 patients (mean 61.5 ± 14.7 years of age; 51% male) presented with adult-type diffuse gliomas (55.8%), metastatic entities (25.5%), intracranial extradural tumors (14.4%), or other tumors (4.3%). The radiological criteria for tumor progression were evidenced in 128 (61.5%) patients, while 57 (27.4%) were newly diagnosed with tumor at admission and 113 (54.3%) had refractory SE. The mean hospital length of stay (LOS) was 14.8 days (median 12.0, range 1-57), 171 (82.2%) patients required intensive care (mean LOS 8.9 days, median 5, range 1-46), and 44 (21.2%) were administered mechanical ventilation. All patients exhibited significant functional status decline (modified Rankin Scale) post-SE at discharge (p < 0.001). Mortality at discharge was 17.3% (n = 36), with the greatest occurring in patients with metastatic disease (26.4%, p = 0.031) and those that met the radiological criteria for tumor progression (25%, p < 0.001). Long-term mortality at one year (65.9%) was highest in those diagnosed with adult-type diffuse gliomas (68.1%) and metastatic disease (79.2%). Refractory status epilepticus cases showed lower survival rates than non-refractory SE patients (log-rank p = 0.02) and those with signs of tumor progression (log-rank p = 0.001).

CONCLUSIONS

SE occurrence contributed to a decline in functional status in all cases, regardless of tumor type, tumor progression status, and SE refractoriness, while long-term mortality was increased in those with malignant tumor entities, tumor progressions, and refractory SE. SE prevention may preserve functional status and improve survival in individuals with brain tumors.

How much refractory is 'refractory status epilepticus'? A retrospective study of treatment strategies and clinical outcomes

BACKGROUND AND PURPOSE

This study aimed to evaluate whether differences in clinical outcomes exist according to treatments received and seizure activity resolution in patients with refractory status epilepticus (RSE).

METHODS

Consecutive episodes of non-hypoxic status epilepticus (SE) in patients ≥ 14 years old were included. Episodes of RSE were stratified in: (i) SE persistent despite treatment with first-line therapy with benzodiazepines and one second-line treatment with antiseizure medications (ASMs), but responsive to successive treatments with ASMs (RSE-rASMs); (ii) SE persistent despite treatment with first-line therapy with benzodiazepines and successive treatment with one or more second-line ASMs, but responsive to anesthetic drugs [RSE-rGA (general anesthesia)]. Study endpoints were mortality during hospitalization and worsening of modified Rankin Scale (mRS) at discharge.

RESULTS

Status epilepticus was responsive in 298 (54.1%), RSE-rASMs in 152 (27.6%), RSE-rGA in 46 (8.3%), and super-refractory (SRSE) in 55 (10.0%) out of 551 included cases. Death during hospitalization occurred in 98 (17.8%) and worsening of mRS at discharge in 287 (52.1%) cases. Multivariable analyses revealed increased odds of in-hospital mortality with RSE-rGA (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.27-7.35) and SRSE (OR 3.83, 95%. CI 1.73-8.47), and increased odds of worsening of mRS with RSE-rASMs (OR 2.06, 95% CI 1.28-3.31), RSE-rGA (OR 4.44, 95% CI 1.97-10.00), and SRSE (OR 13.81, 95% CI 5.34-35.67).

CONCLUSIONS

In RSE, varying degrees of refractoriness may be defined and suit better the continuum spectrum of disease severity and the heterogeneity of SE burden and prognosis.

Trends and Differences in Status Epilepticus Treatment of Children and Adults Over 10 Years: A Comparative Study of Medical Records (2012-2021) from a University Hospital in Germany

BACKGROUND AND OBJECTIVES

Over the last decade, significant advancements have been made in status epilepticus (SE) management, influenced by landmark trials such as ESETT and RAMPART. The objectives of this study were to explore the evolution of drug treatments for patients with SE, to investigate its association with outcomes and mortality, and to evaluate differences in treatment patterns between adults and children for a potential shift in medication trends due to the above mentioned trials.

METHODS

The medical records of patients with SE treated at University Hospital Frankfurt between 2012 and 2021 were evaluated for medication trends and outcomes. Children and adults were analyzed separately and jointly.

RESULTS

This study included 1151 SE episodes in 1021 patients (mean age = 53.3 ± 28.3 years; 52.5 % female [n = 533]). The overall percentage of patients with SE treated prehospital was stable over the last decade. More than half (53.6 %) of children were treated prehospital, compared with less than one-third (26.7 %) of adults. Prehospital midazolam use increased over time, while diazepam use decreased. Lorazepam was the most commonly used benzodiazepine in hospitals in 2012-2013, used in 40.8 % of all episodes. However, its use declined to 27.2 % in 2020-2021, while midazolam use increased to 44.0 %. While the use of older antiseizure medications (ASMs) such as phenobarbital (p = 0.02), phenytoin (p < 0.001), and valproate (p < 0.001) decreased, the use of newer ASMs such as levetiracetam and lacosamide significantly increased (p < 0.001). Propofol and continuous midazolam infusion remained the most used third-line therapy drugs. Overall mortality was 16.5 % at discharge and 18.9 % at 30 days. Mortality rates did not change between 2012 and 2021.

CONCLUSION

Midazolam has become the preferred benzodiazepine in pre- and in-hospital settings, both in children and adults. The same applies to the increased use of levetiracetam and lacosamide over time in children and adults, while phenobarbital, phenytoin, and valproate use decreased. Continuous midazolam infusion and propofol remain the most frequently used anesthetic drugs. Mortality and outcome remain stable despite changes in medication patterns.

Clinical characteristics and outcomes of patients with recurrent status epilepticus episodes

BACKGROUND

Multiple studies have focused on medical and pharmacological treatments and outcome predictors of patients with status epilepticus (SE). However, a sufficient understanding of recurrent episodes of SE is lacking. Therefore, we reviewed recurrent SE episodes to investigate their clinical characteristics and outcomes in patients with relapses.

METHODS

In this retrospective, multicenter study, we reviewed recurrent SE patient data covering 2011 to 2017 from the university hospitals of Frankfurt and Marburg, Germany. Clinical characteristics and outcome variables were compared among the first and subsequent SE episodes using a standardized form for data collection.

RESULTS

We identified 120 recurrent SE episodes in 80 patients (10.2% of all 1177 episodes). The mean age at the first SE episode was 62.2 years (median 66.5; SD 19.3; range 21-91), and 42 of these patients were male (52.5%). A mean of 262.4 days passed between the first and the second episode. Tonic-clonic seizure semiology and a cerebrovascular disease etiology were predominant in initial and recurrent episodes. After subsequent episodes, patients showed increased disability as indicated by the modified Rankin Scale (mRS), and 9 out of 80 patients died during the second episode (11.3%). Increases in refractory and super-refractory SE (RSE and SRSE, respectively) were noted during the second episode, and the occurrence of a non-refractory SE (NRSE) during the first SE episode did not necessarily provide a protective marker for subsequent non-refractory episodes. An increase in the use of intravenous-available anti-seizure medication (ASM) was observed in the treatment of SE patients. Patients were discharged from hospital with a mean of 2.8 ± 1.0 ASMs after the second SE episode and 2.1 ± 1.2 ASMs after the first episode. Levetiracetam was the most common ASM used before admission and on discharge for SE patients.

CONCLUSIONS

This retrospective, multicenter study used the mRS to demonstrate worsened outcomes of patients at consecutive SE episodes. ASM accumulations after subsequent SE episodes were registered over the study period. The study results underline the necessity for improved clinical follow-ups and outpatient care to reduce the health care burden from recurrent SE episodes.

The potential of intravenous topiramate for the treatment of status epilepticus

There is considerable clinical evidence that topiramate (TPM) has a high potential in the treatment of refractory and super-refractory status epilepticus (RSE, SRSE). Because TPM is only approved for oral administration, it is applied as suspension via a nasogastric tube for SE treatment. However, this route of administration is impractical in an emergency setting and leads to variable absorption with unpredictable plasma levels and time to peak concentration. Thus, the development of an intravenous (i.v.) solution for TPM is highly desirable. Here we present data on two parenteral formulations of TPM that are currently being developed. One of these solutions is using sulfobutylether-β-cyclodextrin (SBE-β-CD; Captisol®) as an excipient. A 1% solution of TPM in 10% Captisol® has been reported to be well tolerated in safety studies in healthy volunteers and patients with epilepsy or migraine, but efficacy data are not available. The other solution uses the FDA- and EMA-approved excipient amino sugar meglumine. Meglumine is much more effective to dissolve TPM in water than Captisol®. A 1% solution of TPM can be achieved with 0.5-1% of meglumine. While the use of Captisol®-containing solutions is restricted in children and patients with renal impairment, such restrictions do not apply to meglumine. Recently, first-in-human data were reported for a meglumine-based solution of TPM, indicating safety and efficacy when used as a replacement for oral administration in a woman with epilepsy. Based on the multiple mechanisms of action of TPM that directly target the molecular neuronal alterations that are thought to underlie the loss of efficacy of benzodiazepines and other anti-seizure medications during prolonged SE and its rapid brain penetration after i.v. administration, we suggest that parenteral (i.v.) TPM is ideally suited for the treatment of RSE and SRSE. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.

Epidemiology, real-world treatment and mortality of patients with status epilepticus in Germany: insights from a large healthcare database

Status epilepticus is a life-threatening emergency, and to date, few studies have reported on its long-term treatment and outcomes. This study aimed to estimate the incidence, the treatment and outcomes, the healthcare resource utilization and the costs of status epilepticus in Germany. Data from 2015 to 2019 were obtained from German claims (AOK PLUS). Patients with ≥1 status epilepticus event and no event in the preceding 12 months (baseline) were included. A subgroup of patients with an epilepsy diagnosis during baseline was also analysed. Of the 2782 status epilepticus patients (mean age = 64.3 years; 52.3% female), 1585 (57.0%) were previously diagnosed with epilepsy. The age- and sex-standardized incidence was 25.5 cases/100 000 persons in 2019. The mortality rate after 12 months was 39.8% overall (19.4% and 28.2% after 30 and 90 days, respectively) and 30.4% in the epilepsy patient subgroup. Factors associated with higher mortality were age, comorbidity status, presence of brain tumours and an acute stroke. An epilepsy-related hospitalization at onset of or 7 days prior to the status epilepticus event as well as prescription of antiseizure medication during baseline was associated with a better survival rate. Overall, 71.6% of patients (85.6% in the epilepsy subgroup) were prescribed with out-patient antiseizure medication and/or rescue medication within 12 months. All patients sustained on average 1.3 status epilepticus-related hospitalizations (20.5% had more than one) during a mean follow-up period of 545.2 days (median 514 days); total direct costs including in-patient and out-patient status epilepticus treatments were 10 826€ and 7701€ per patient-year overall and for the epilepsy patient subgroup, respectively. The majority of status epilepticus patients received an out-patient treatment in line with epilepsy guidelines, and patients previously diagnosed with epilepsy have a higher likelihood to receive it. The mortality in the affected patient population is high; risk factors were older age, higher comorbidity burden, the presence of brain tumours or an acute stroke.

Does diabetes mellitus affect the safety profile of valproic acid for the treatment of status epilepticus? A retrospective cohort study

Background

In the treatment of status epilepticus less is known about the influence of comorbidities on the safety profile of anticonvulsive drugs. Especially patients with diabetes mellitus may be predisposed to certain adverse events that have been related to therapy with valproic acid. In this single-center retrospective cohort study we examined if the complications of the intravenous treatment with valproic acid is different in patients with or without diabetes.

Methods

Patients who were treated for status epilepticus with intravenous valproic acid between 2008 and 2020 were identified. Primary endpoint was the discontinuation of therapy with valproic acid due to adverse events. Relevant secondary endpoints were the functional status at the time of discharge from hospital in comparison to the premorbid state and the in-hospital mortality. Both groups (patients with or without diabetes) were compared by Mann–Whitney U-Test or Pearson´s Chi² test. To identify therapy with valproic acid as a risk factor of in-hospital mortality, a binary regression model was used.

Results

During the study period 408 patients and 482 episodes of status epilepticus were treated with intravenous valproic acid. Group comparisons did not reveal a significant difference in the rates of discontinuation of therapy. A difference was found in the rate of thrombocytopenia (p = 0.015), which occurred more often in patients with diabetes. In total, 36 hypoglycemic episodes could be identified, two occurred spontaneously under intravenous valproic acid. After correction for potential confounders, continuous therapy with valproic acid could not be confirmed as an independent risk factor for in-hospital mortality (p = 0.079). In patients with diabetes, the proportion of patients with a good functional state, indicated by the modified Rankin Scale, was significantly lower in both times (premorbid: 55% vs. 69%, p = 0.008; at discharge: 22% vs. 36%, p = 0.004).

Conclusions

Tolerability of the treatment with valproic acid was similar in patients with or without diabetes. Diabetes as a relevant comorbidity can signal a potentially increased risk of a poor outcome after status epilepticus.

Trial registration: The study was registered at the German Clinical Trials Register on 8 April 2022 (DRKS 00,027,836).

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-022-00212-w.

Repetitive Electroencephalography as Biomarker for the Prediction of Survival in Patients with Post-Hypoxic Encephalopathy

Predicting survival in patients with post-hypoxic encephalopathy (HE) after cardiopulmonary resuscitation is a challenging aspect of modern neurocritical care. Here, continuous electroencephalography (cEEG) has been established as the gold standard for neurophysiological outcome prediction. Unfortunately, cEEG is not comprehensively available, especially in rural regions and developing countries. The objective of this monocentric study was to investigate the predictive properties of repetitive EEGs (rEEGs) with respect to 12-month survival based on data for 199 adult patients with HE, using log-rank and multivariate Cox regression analysis (MCRA). A total number of 59 patients (29.6%) received more than one EEG during the first 14 days of acute neurocritical care. These patients were analyzed for the presence of and changes in specific EEG patterns that have been shown to be associated with favorable or poor outcomes in HE. Based on MCRA, an initially normal amplitude with secondary low-voltage EEG remained as the only significant predictor for an unfavorable outcome, whereas all other relevant parameters identified by univariate analysis remained non-significant in the model. In conclusion, rEEG during early neurocritical care may help to assess the prognosis of HE patients if cEEG is not available.

Impact of COVID-19 pandemic on physical and mental health status and care of adults with epilepsy in Germany

Background

To mitigate the potential consequences of the coronavirus disease 2019 (COVID-19) pandemic on public life, the German Federal Government and Ministry of Health enacted a strict lockdown protocol on March 16, 2020. This study aimed to evaluate the impact of the COVID-19 pandemic on physical and mental health status and the supply of medical care and medications for people with epilepsy (PWE) in Germany.

Methods

The Epi2020 study was a large, multicenter study focused on different healthcare aspects of adults with epilepsy. In addition to clinical and demographic characteristics, patients were asked to answer a questionnaire on the impact of the first wave of the COVID-19 pandemic between March and May 2020. Furthermore, the population-based number of epilepsy-related admissions in Hessen was evaluated for the January-June periods of 2017–2020 to detect pandemic-related changes.

Results

During the first wave of the pandemic, 41.6% of PWE reported a negative impact on their mental health, while only a minority reported worsening of their seizure situation. Mental and physical health were significantly more negatively affected in women than men with epilepsy and in PWE without regular employment. Moreover, difficulties in ensuring the supply of sanitary products (25.8%) and antiseizure medications (ASMs; 19.9%) affected PWE during the first lockdown; no significant difference regarding these impacts between men and women or between people with and without employment was observed. The number of epilepsy-related admissions decreased significantly during the first wave.

Conclusions

This analysis provides an overview of the general and medical care of epilepsy patients during the COVID-19 pandemic. PWE in our cohort frequently reported psychosocial distress during the first wave of the pandemic, with significant adverse effects on mental and physical health. Women and people without permanent jobs especially reported distress due to the pandemic. The COVID‐19 pandemic has added to the mental health burden and barriers to accessing medication and medical services, as self-reported by patients and verified in population-based data on hospital admissions.

Trial registration

German Clinical Trials Register (DRKS), DRKS00022024. Registered October 2, 2020, http://www.drks.de/DRKS00022024

Intravenous ganaxolone for the treatment of refractory status epilepticus: Results from an open-label, dose-finding, phase 2 trial

OBJECTIVE

Patients with refractory status epilepticus (RSE) have failed treatment with benzodiazepines and ≥1 second-line intravenous (IV) antiseizure medication (ASM). Guidelines recommend IV anesthesia when second-line ASMs have failed, but potential harms can outweigh the benefits. Novel treatments are needed to stop and durably control RSE without escalation to IV anesthetics. Ganaxolone is an investigational neuroactive steroid in development for RSE treatment. This study's objective was to determine the appropriate dosing for IV ganaxolone in RSE and obtain a preliminary assessment of efficacy and safety.

METHODS

This was an open-label, phase 2 trial conducted from February 19, 2018 to September 18, 2019, at three sites in the United States. Patients were aged ≥12 years, had convulsive or nonconvulsive SE, and failed to respond to ≥1 second-line IV ASM. Twenty-one patients were screened; 17 were enrolled. Patients received IV ganaxolone added to standard-of-care ASMs. Ganaxolone infusion was initiated as an IV bolus (over 3 min) with continuous infusion of decreasing infusion rates for 48-96 h followed by an 18-h taper. There were three ganaxolone dosing cohorts: low, 500 mg/day; medium, 650 mg/day; and high, 713 mg/day. The primary end point was the number of patients not requiring escalation to IV anesthetic treatment within 24 h of ganaxolone initiation.

RESULTS

Most of the 17 enrolled patients (65%) had nonconvulsive SE, and had failed a median of three prior ASMs, including first-line benzodiazepine and second-line IV ASM therapy. Median time to SE cessation following ganaxolone initiation was 5 min. No patient required escalation to third-line IV anesthetics during the 24-h period following ganaxolone initiation. Two treatment-related serious adverse events (sedation) were reported. Of the three deaths, none was considered related to ganaxolone; all occurred 9-22 days after completing ganaxolone.

SIGNIFICANCE

IV ganaxolone achieved rapid and durable seizure control in patients with RSE, and showed acceptable safety and tolerability.

Trends in antiseizure medication prescription patterns among all adults, women, and older adults with epilepsy: A German longitudinal analysis from 2008 to 2020

INTRODUCTION

The prescription patterns of antiseizure medication (ASM) are subject to new scientific evidence and sociodemographic and practical aspects. This study analyzed trends in ASM prescription patterns among all adults with epilepsy, with special consideration for women of childbearing potential (WOCBP) and older adult (≥65 years old) patients.

METHODS

Data from four questionnaire-based cohort studies, conducted in 2008, 2013, 2016, and 2020, were analyzed for ASM prescription frequencies and common mono- and dual therapy regimens. Statistical comparisons were performed with the Chi-square test and one-way analysis of variance.

RESULTS

Overall, the individual prescription patterns among 1,642 adult patients with epilepsy were analyzed. A significant increase in the prescription frequency of third-generation ASMs, from 59.3% to 84.2% (p = 0.004), was accompanied by a decrease in the frequency of first- and second-generation ASMs (5.4% to 2.1% and 34.9% to 12.6%, respectively). This trend was accompanied by a significant decrease in the use of enzyme-inducing ASMs, from 23.9% to 4.6% (p = 0.004). Among frequently prescribed ASMs, prescriptions of carbamazepine (18.6% to 3.1%, p = 0.004) and valproate (15.4% to 8.7%, p = 0.004) decreased, whereas prescriptions of levetiracetam (18.0% up to 32.4%, p = 0.004) increased significantly. The prescription frequency of lamotrigine remained largely constant at approximately 20% (p = 0.859). Among WOCBP, the prescription frequencies of carbamazepine (11.4% to 2.0%, p = 0.004) and valproate (16.1% to 6.1%, p = 0.004) decreased significantly. Levetiracetam monotherapy prescriptions increased significantly (6.6% to 30.4%, p = 0.004) for WOCBP, whereas lamotrigine prescriptions remained consistent (37.7% to 44.9%, p = 0.911). Among older adult patients, a significant decrease in carbamazepine prescriptions (30.1% to 7.8%, p = 0.025) was the only relevant change in ASM regimens between 2008 and 2020. In patients with genetic generalized epilepsies, levetiracetam was frequently used as an off-label monotherapy (25.0% to 35.3%).

CONCLUSION

These results show a clear trend toward the use of newer and less interacting third-generation ASMs, with lamotrigine, levetiracetam, and lacosamide representing the current ASMs of choice, displacing valproate and carbamazepine over the last decade. In WOCBP, prescription patterns shifted to minimize teratogenic effects, whereas, among older adults, the decrease in carbamazepine use may reflect the avoidance of hyponatremia risks and attempts to reduce the interaction potential with other drugs and ASMs. Levetiracetam is frequently used off-label as a monotherapy in patients with genetic generalized epilepsy.

Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis

BACKGROUND

Convulsive status epilepticus is defined as ≥ 5 minutes of either continuous seizure activity or repetitive seizures without regaining consciousness. It is regarded as an emergency condition that requires prompt treatment to avoid hospitalisation and to reduce morbidity and mortality. Rapid pre-hospital first-line treatment of convulsive status epilepticus is currently benzodiazepines, administered either by trained caregivers in the community (e.g. buccal midazolam, rectal diazepam) or by trained health professionals via intramuscular or intravenous routes (e.g. midazolam, lorazepam). There is a lack of clarity about the optimal treatment for convulsive status epilepticus in the pre-hospital setting.

OBJECTIVES

To assess the current evidence on the clinical effectiveness and cost-effectiveness of treatments for adults with convulsive status epilepticus in the pre-hospital setting.

DATA SOURCES

We searched major electronic databases, including MEDLINE, EMBASE, PsycInfo®, CINAHL, CENTRAL, NHS Economic Evaluation Database, Health Technology Assessment Database, Research Papers in Economics, and the ISPOR Scientific Presentations Database, with no restrictions on publication date or language of publication. Final searches were carried out on 21 July 2020.

REVIEW METHODS

Systematic review of randomised controlled trials assessing adults with convulsive status epilepticus who received treatment before or on arrival at the emergency department. Eligible treatments were any antiepileptic drugs offered as first-line treatments, regardless of their route of administration. Primary outcomes were seizure cessation, seizure recurrence and adverse events. Two reviewers independently screened all citations identified by the search strategy, retrieved full-text articles, extracted data and assessed the risk of bias of the included trials. Results were described narratively.

RESULTS

Four trials (1345 randomised participants, of whom 1234 were adults) assessed the intravenous or intramuscular use of benzodiazepines or other antiepileptic drugs for the pre-hospital treatment of convulsive status epilepticus in adults. Three trials at a low risk of bias showed that benzodiazepines were effective in stopping seizures. In particular, intramuscular midazolam was non-inferior to intravenous lorazepam. The addition of levetiracetam to clonazepam did not show clear advantages over clonazepam alone. One trial at a high risk of bias showed that phenobarbital plus optional phenytoin was more effective in terminating seizures than diazepam plus phenytoin. The median time to seizure cessation from drug administration varied from 1.6 minutes to 15 minutes. The proportion of people with recurrence of seizures ranged from 10.4% to 19.1% in two trials reporting this outcome. Across trials, the rates of respiratory depression among participants receiving active treatments were generally low (from 6.4% to 10.6%). The mortality rate ranged from 2% to 7.6% in active treatment groups and from 6.2% to 15.5% in control groups. Only one study based on retrospective observational data met the criteria for economic evaluation; therefore, it was not possible to draw any robust conclusions on cost-effectiveness.

LIMITATIONS

The limited number of identified trials and their differences in terms of treatment comparisons and outcomes hindered any meaningful pooling of data. None of the included trials was conducted in the UK and none assessed the use of buccal midazolam or rectal diazepam. The review of economic evaluations was hampered by lack of suitable data.

CONCLUSIONS

Both intravenous lorazepam and intravenous diazepam administered by paramedics are more effective than a placebo in the treatments of adults with convulsive status epilepticus, and intramuscular midazolam is non-inferior to intravenous lorazepam. Large well-designed clinical trials are needed to establish which benzodiazepines are more effective and preferable in the pre-hospital setting.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020201953.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 20. See the NIHR Journals Library website for further project information.

Multicenter, cross-sectional study of the costs of illness and cost-driving factors in adult patients with epilepsy

OBJECTIVE

This study was undertaken to quantify epilepsy-related costs of illness (COI) in Germany and identify cost-driving factors.

METHODS

COI were calculated among adults with epilepsy of different etiologies and severities. Multiple regression analysis was applied to determine any epilepsy-related and sociodemographic factors that serve as cost-driving factors.

RESULTS

In total, 486 patients were included, with a mean age of 40.5 ± 15.5 years (range = 18-83 years, 58.2% women). Mean 3-month COI were estimated at €4911, €2782, and €2598 for focal, genetic generalized, and unclassified epilepsy, respectively. The mean COI for patients with drug-refractory epilepsy (DRE; €7850) were higher than those for patients with non-DRE (€4720), patients with occasional seizures (€3596), or patients with seizures in remission for >1 year (€2409). Identified cost-driving factors for total COI included relevant disability (unstandardized regression coefficient b = €2218), poorer education (b = €2114), living alone (b = €2612), DRE (b = €1831), and frequent seizures (b = €2385). Younger age groups of 18-24 years (b = -€2945) and 25-34 years (b = -€1418) were found to have lower overall expenditures. A relevant disability (b = €441), DRE (b = €1253), frequent seizures (b = €735), and the need for specialized daycare (b = €749) were associated with higher direct COI, and poorer education (b = €1969), living alone (b = €2612), the presence of a relevant disability (b = €1809), DRE (b = €1831), and frequent seizures (b = €2385) were associated with higher indirect COI.

SIGNIFICANCE

This analysis provides up-to-date COI data for use in further health economics analyses, highlighting the high economic impacts associated with disease severity, disability, and disease-related loss of productivity among adult patients with epilepsy. The identified cost drivers could be used as therapeutic and socioeconomic targets for future cost-containment strategies.

EEG patterns and their correlations with short- and long-term mortality in patients with hypoxic encephalopathy

OBJECTIVE

To analyze the association between electroencephalographic (EEG) patterns and overall, short- and long-term mortality in patients with hypoxic encephalopathy (HE).

METHODS

Retrospective, mono-center analysis of 199 patients using univariate log-rank tests (LR) and multivariate cox regression (MCR).

RESULTS

Short-term mortality, defined as death within 30-days post-discharge was 54.8%. Long-term mortality rates were 69.8%, 71.9%, and 72.9%, at 12-, 24-, and 36-months post-HE, respectively. LR revealed a significant association between EEG suppression (SUP) and short-term mortality, and identified low voltage EEG (LV), burst suppression (BSP), periodic discharges (PD) and post-hypoxic status epilepticus (PSE) as well as missing (aBA) or non-reactive background activity (nrBA) as predictors for overall, short- and long-term mortality. MCR indicated SUP, LV, BSP, PD, aBA and nrBA as significantly associated with overall and short-term mortality to varying extents. LV and BSP were significant predictors for long-term mortality in short-term survivors. Rhythmic delta activity, stimulus induced rhythmic, periodic or ictal discharges and sharp waves were not significantly associated with a higher mortality.

CONCLUSION

The presence of several specific EEG patterns can help to predict overall, short- and long-term mortality in HE patients.

SIGNIFICANCE

The present findings may help to improve the challenging prognosis estimation in HE patients.

Inpatient medical cost of status epilepticus in children: A national-wide, multicenter study from China

OBJECTIVES

To describe the inpatient medical cost during hospitalization in children with status epilepticus (SE) and identify factors associated with the cost by a nationwide, multicenter study in China.

MATERIALS & METHODS

We retrospectively identified pediatric inpatients with SE form Hospital Information System (HIS) of 44 hospitals in 27 provinces in China between 2013 and 2015. Inpatient medical cost and factors associated with the cost were analyzed.

RESULTS

A total of 4041 children diagnosed with SE with inpatient medical cost were enrolled in the present study. The median age at admission was 2.9 (range 0.1-18) years, and 2271 patients were male (56.2%). The median inpatient medical cost of children with SE was $1175.5 (665.1-2320.6). The median inpatient medical cost was $3865.6 (1837.4-8210.4) in children with SRSE and $1048.6 (619.8-1865.4) in those with N-SRSE (p < 0.0001). Children with length of hospital stay (LOS) > 7 showed a much higher inpatient medical cost than those with LOS ≤ 7 day ($2300.7 vs. $767.2, p < 0.0001). Regarding different etiologies, children with acute symptomatic etiology showed the highest median inpatient medical cost of $1681.1 (901.0-3699.6), in which children with central nervous system (CNS) infection reported $2606.0 (1380.0-5016.1) and prolonged febrile seizures (PFS) reported $909.8 (649.3-1322.0). Additionally, children with idiopathic/cryptogenic etiology reported a medical cost of $923.2 (548.9-1534.5). Multiple linear regression analysis of cost-driving factors revealed LOS > 7, examinations, treatment equipment and procedures, and treatment medicines were independently associated with a higher inpatient medical cost (R² = 60.91). In addition, PFS and idiopathic/cryptogenic epilepsy etiology were independently associated with a lower cost.

CONCLUSIONS

SE in children was a cost intensive disease in China with a median inpatient medical cost of $1175.5. LOS, etiology and examinations, treatment equipment and procedures, and treatment medicines were significantly associated with inpatient medical cost.

Status epilepticus after intracranial neurosurgery: incidence and risk stratification by perioperative clinical features

OBJECTIVE

Status epilepticus (SE) is associated with significant mortality, cost, and risk of future seizures. In one of the first studies of SE after neurosurgery, the authors assess the incidence, risk factors, and outcome of postneurosurgical SE (PNSE).

METHODS

Neurosurgical admissions from the MarketScan Claims and Encounters database (2007 through 2015) were assessed in a longitudinal cross-sectional sample of privately insured patients who underwent qualifying cranial procedures in the US and were older than 18 years of age. The incidence of early (in-hospital) and late (postdischarge readmission) SE and associated mortality was assessed. Procedural, pathological, demographic, and anatomical covariates parameterized multivariable logistic regression and Cox models. Multivariable logistic regression and Cox proportional hazards models were used to study the incidence of early and late PNSE. A risk-stratification simulation was performed, combining individual predictors into singular risk estimates.

RESULTS

A total of 197,218 admissions (218,217 procedures) were identified. Early PNSE occurred during 637 (0.32%) of 197,218 admissions for cranial neurosurgical procedures. A total of 1045 (0.56%) cases of late PNSE were identified after 187,771 procedure admissions with nonhospice postdischarge follow-up. After correction for comorbidities, craniotomy for trauma, hematoma, or elevated intracranial pressure was associated with increased risk of early PNSE (adjusted OR [aOR] 1.538, 95% CI 1.183-1.999). Craniotomy for meningioma resection was associated with an increased risk of early PNSE compared with resection of metastases and parenchymal primary brain tumors (aOR 2.701, 95% CI 1.388-5.255). Craniotomies for infection or abscess (aHR 1.447, 95% CI 1.016-2.061) and CSF diversion (aHR 1.307, 95% CI 1.076-1.587) were associated with highest risk of late PNSE. Use of continuous electroencephalography in patients with early (p < 0.005) and late (p < 0.001) PNSE rose significantly over the study time period. The simulation regression model predicted that patients at high risk for early PNSE experienced a 1.10% event rate compared with those at low risk (0.07%). Similarly, patients predicted to be at highest risk for late PNSE were significantly more likely to eventually develop late PNSE than those at lowest risk (HR 54.16, 95% CI 24.99-104.80).

CONCLUSIONS

Occurrence of early and late PNSE was associated with discrete neurosurgical pathologies and increased mortality. These data provide a framework for prospective validation of clinical and perioperative risk factors and indicate patients for heightened diagnostic suspicion of PNSE.

Economic and social cost of epilepsy in Poland: 5-year analysis

INTRODUCTION

Epilepsy affects nearly 50 million people around the world. As a common and chronic disease generates a high cost burden for healthcare system and patients.

AIM

We aimed to determine the most current direct and indirect costs of epilepsy in Poland from the social perspective for the years 2014-2018, to analyze the changes of expenditures over time, indicate trends and to determine key cost-drivers.

MATERIAL AND METHODS

Direct and indirect costs using a top-down approach were estimated based on the public institutions' data for the ICD-10 codes G40 and G41. Direct costs included pharmacotherapy, hospitalizations, outpatient specialist care and rehabilitation. A human capital approach was used to estimate loss of productivity due to sick leaves and long-term inability to work.

RESULTS

Annual total direct and indirect costs related to epilepsy accounted for EUR 410 million in 2014 and decreased in subsequent years to EUR 361 million in 2018. The indirect costs were dominant (76-83% of total costs) and in the majority related to the long-term absenteeism (87-92% of total indirect costs). In 2014-2018, patients with epilepsy generated EUR 341 million to EUR 282 million of indirect costs. Annual direct costs for patients with epilepsy were EUR 69 million in 2014 and increased to EUR 80 million in 2018. The biggest expenses were the costs of drugs (> 50%) and hospitalizations (~ 40%).

CONCLUSIONS

Epilepsy is an expensive disorder in terms of consumption of resources and social costs. Decision-makers should take it under special consideration.

Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study

OBJECTIVE

Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. To identify predictors of long LOS among elderly inpatients admitted with seizures.

METHODS

We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors.

RESULTS

The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014).

CONCLUSION

Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.

Increased occurrence of status epilepticus in patients with brain metastases and checkpoint inhibition

Integration of immune checkpoint inhibitors (ICIs) has improved the efficacy of treatment regimens for various cancers. The array of potential side effects keeps evolving and includes neurological complications. An increased risk of seizures and status epilepticus (SE) has been discussed and appears likely. In this report, we present clinical data from brain metastases patients undergoing ICI treatment revealing, for what we believe is the first time, SE as a serious adverse effect of ICI treatment. In our cohort of 3202 patients with brain metastases, we observed an increasing incidence of SE since the approval of ICIs in 2014 (16 patients in 2008–2013 vs. 36 patients in 2014–2019). Almost half of the patients treated in 2014–2019 received ICIs during the course of their disease, and in more than 80% of cases last dose of ICIs was given less than 30 days before SE. These findings suggest that ICIs may lead to an increased rate of SE in patients with brain metastases. Additional mechanistic research and prospective trials are necessary to elucidate the pathomechanism causing SE in patients treated with ICIs.

Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review

BACKGROUND

Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently.

OBJECTIVES

This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS.

METHODS

A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available.

RESULTS

There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it.

CONCLUSIONS

RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.

Treatment of status epilepticus with zonisamide: A multicenter cohort study of 34 patients and review of literature

INTRODUCTION

We present a summary of clinical cases of oral zonisamide (ZNS) used to treat refractory and super-refractory episodes of status epilepticus (SE).

METHODS

Zonisamide administration in SE was identified in the clinical records of patients treated in Frankfurt and Marburg between 2011 and 2017.

RESULTS

Zonisamide was administered during a total of 37 SE episodes in 34 patients with a mean age of 58.7 ± 17.8 years, 21 of them were female (61.7%). The median latency from the onset of SE to administration of ZNS was 6.3 days. Patients had already undergone unsuccessful treatment with a median of three other antiseizure drugs (ASDs). The median initial dose of ZNS was 100 mg/d, titrated to a median maintenance dose of 400 mg/d. Patients underwent ZNS treatment for a median period of 7 days. Zonisamide was the final drug administered in 9 of 37 (24.3%) episodes, with a clinical effect attributed to ZNS observed in 6 of 37 (16.2%) episodes. An effect attributed to ZNS was observed in 5 out of 30 episodes of refractory SE (RSE) and in one out of 7 episodes of super-refractory SE (SRSE). Possible negative side effects of ZNS were observed in two patients (one patient each with ataxia and skin rash). The mortality rate in hospitalized patients was 10.4% (n = 4).

CONCLUSION

The rate of SE resolution attributed to ZNS treatment (16.2%) can be considered relevant, particularly since ZNS treatment tends to be administered only after several other options have been tried, and has a treatment latency of over six days. Zonisamide may therefore be considered as an alternative oral treatment option in RSE and SRSE.

Efficacy, Safety, and Economics of Intravenous Levetiracetam for Status Epilepticus: A Systematic Review and Meta-Analysis

Objective

To evaluate efficacy, safety, and economics profiles of intravenous levetiracetam (LEV) for status epilepticus (SE).

Methods

We searched PubMed, Embase, the Cochrane Library, Clinicaltrials.gov, and OpenGrey.eu for eligible studies published from inception to June 12^th 2019. Meta-analyses were conducted using random-effect model to calculate odds ratio (OR) of included randomized controlled trials (RCTs) with RevMan 5.3 software.

Results

A total of 478 studies were obtained. Five systematic reviews (SRs)/meta-analyses, 9 RCTs, 1 non-randomized trial, and 27 case series/reports and 1 economic study met the inclusion criteria. Five SRs indicated no statistically significant difference in rates of seizure cessation when LEV was compared with lorazepam (LOR), phenytoin (PHT), or valproate (VPA). Pooled results of included RCTs indicated no statistically significant difference in seizure cessation when LEV was compared with LOR [OR = 1.04, 95% confidence interval (CI) 0.37 to 2.92], PHT (OR = 0.90, 95% CI 0.64 to 1.27), and VPA (OR = 1.47, 95% CI 0.81 to 2.67); and no statistically significant difference in seizure freedom within 24 h compared with LOR [OR = 1.83, 95% CI 0.57 to 5.90] and PHT (OR = 1.08, 95% CI 0.63 to 1.87). Meanwhile, LEV did not increase the risk of mortality during hospitalization compared with LOR (OR = 1.03, 95% CI 0.31 to 3.39), PHT (OR = 0.89, 95% CI 0.37 to 2.10), VPA (OR = 1.28, 95% CI 0.32 to 5.07), and placebo (plus clonazepam, OR = 0.73, 95% CI 0.16 to 3.38). LEV had lower need for artificial ventilation (OR = 0.23, 95% CI 0.06 to 0.92) and a lower risk of hypotension (OR = 0.15, 95% CI 0.03 to 0.84) compared to LOR. A trend of lower risk of hypotension and higher risk of agitation was found when LEV was compared with PHT. Case series and case report studies indicated psychiatric and behavioral adverse events of LEV. Cost-effectiveness evaluations indicated LEV as the most cost-effective non-benzodiazepines anti-epileptic drug (AED).

Conclusions

LEV has a similar efficacy as LOR, PHT, and VPA for SE, but a lower need for ventilator assistance and risk of hypotension, thus can be used as a second-line treatment for SE. However, more well-conducted studies to confirm the role of intravenous LEV for SE are still needed.

Intranasal midazolam as first-line inhospital treatment for status epilepticus: a pharmaco-EEG cohort study

Objective

We sought to evaluate the efficacy and tolerability of intranasal midazolam (in‐MDZ) as first‐line inhospital therapy in patients with status epilepticus (SE) during continuous EEG recording.

Methods

Data on medical history, etiology and semiology of SE, anticonvulsive medication usage, efficacy and safety of in‐MDZ were retrospectively reviewed between 2015 and 2018. Time to end of SE regarding the administration of in‐MDZ and ß‐band effects were analyzed on EEG and with frequency analysis.

Results

In total, 42 patients (mean age: 52.7 ± 22.7 years; 23 females) were treated with a median dose of 5 mg of in‐MDZ (range: 2.5–15 mg, mean: 6.4 mg, SD: 2.6) for SE. The majority of the patients suffered from nonconvulsive SE (n = 24; 55.8%). In total, 24 (57.1%) patients were responders, as SE stopped following the administration of in‐MDZ without any other drugs being given. On average, SE ceased on EEG at 05:05 (minutes:seconds) after the application of in‐MDZ (median: 04:56; range: 00:29–14:53; SD:03:13). Frequency analysis showed an increased ß‐band on EEG after the application of in‐MDZ at 04:07 on average (median: 03:50; range: 02:20–05:40; SD: 01:09). Adverse events were recorded in six patients (14.3%), with nasal irritations present in five (11.9%) and prolonged sedation occurring in one (2.6%) patient.

Conclusions

This pharmaco‐EEG–based study showed that in‐MDZ is effective and well‐tolerated for the acute treatment of SE. EEG and clinical effects of in‐MDZ administration occurred within 04:07 and 5:05 on average. Intranasal midazolam appears to be an easily applicable and rapidly effective alternative to buccal or intramuscular application as first‐line treatment if an intravenous route is not available.

General Trends in Prices and Prescription Patterns of Anticonvulsants in Germany between 2000 and 2017: Analysis of National and Cohort-Based Data

OBJECTIVE

Our aim was to explore trends in price evolution and prescription volumes of anticonvulsants (AEDs, antiepileptic drugs) in Germany between 2000 and 2017.

METHOD

This study used data from annual reports on mean prescription frequency and prices of defined daily doses (DDD) of AEDs in Germany to analyze nationwide trends. Interrupted time series (ITS) analysis was employed to test for significant effects of several statutory healthcare reforms in Germany on AED price evolution. These data were compared to cohort-based prescription patterns of four German cohort studies from 2003, 2008, 2013, and 2016 that included a total of 1368 patients with focal and generalized epilepsies.

RESULTS

Analysis of national prescription data between 2000 and 2017 showed that mean prices per DDD of third-generation AEDs decreased by 65% and mean prices of second-generation AEDs decreased by 36%, whereas mean prices of first-generation AEDs increased by 133%. Simultaneously, mean prescription frequency of third- generation AEDs increased by 2494%, while there was a substantial decrease in the use of first- (- 55%) and second- (- 16%) generation AEDs. ITS analysis revealed that in particular the introduction of mandatory rebates on drugs in 2003 affected prices of frequently used newer AEDs. These findings are consistent with data from cohort studies of epilepsy patients showing a general decrease of prices for frequently used AEDs in monotherapy by 62% and in combination therapies by 68%. The analysis suggests that overall expenses for AEDs remained stable despite an increase in the prescription of "newer" and "non-enzyme-inducing" AEDs for epilepsy patients.

CONCLUSION

Between 2000 and 2017, a distinct decline in AED prices can be observed that seems predominately caused by a governmentally obtained price decline of third- and second-generation drugs. These observations seem to be the result of a German statutory cost containment policy applied across all health-care sectors. The increasing use of third-generation AEDs to the disadvantage of "old" and "enzyme-inducing" AEDs reflects the preferences of physicians and patients with epilepsy and follows national treatment guidelines.

Seizure and status epilepticus in chronic subdural hematoma

BACKGROUND

Acute symptomatic seizure (ASz) and status epilepticus (SE) are serious conditions associated with poor quality of life, with unfavorable psychosocial and functional outcome. Chronic subdural hematoma (cSDH) is a common neurosurgical disease related to those complications; therefore, we aimed to evaluate incidence, predictors of ASz/SE, and outcome in this cohort.

METHODS

We retrospectively analyzed patient diagnosed cSDH between 2010 and 2017. Beside their incidence of ASz/SE, patient characteristics, symptoms at admission, comorbidities, and all previously published relevant parameters were assessed. Recurrence rate and functional outcome were analyzed at hospital discharge and 90-day follow-up.

RESULTS

A total of 375 patients were included; incidence of ASz was 15.2% and of SE, 1.9%. In the univariate analysis, drainage insertion (P =  0.004; OR = 0.3) was a significant negative predictor for ASz/SE and multivariate analysis, including all significant parameters, designated GCS ≤13 at admission (P = 0.09; OR = 1.9), remote stroke (P = 0.009; OR = 2.9), and recurrence rate within 14 days (P = 0.001; OR = 3.3; with an incidence of 13%) as independent predictors for ASz/SE. Overall, patients with ASz/SE had significantly unfavorable outcome at discharge (54.7%; P < 0.001) and follow-up (39.5%; P < 0.001) with only slight improvement. Late seizures occurred in 3.8% within follow-up period. Any patient with SE had an unfavorable outcome at discharge without any improvement at follow-up having a mortality rate of 14.2%.

CONCLUSION

Independent predictors for ASz/SE are GCS ≤13 at admission, remote stroke, and recurrent hematoma in patients with cSDH, which is associated with worse functional outcome, particularly those with SE. Due to the higher rate of seizures than recurrence rate, a routine pre- and postoperative EEG besides CT is recommended.

Seizure comorbidity boosts odds of 30-day readmission after an index hospitalization for sepsis

OBJECTIVE

The objective of this study was to evaluate the association between comorbid seizures and hospital readmissions within 30 days following an index hospitalization for sepsis.

METHODS

We analyzed data from 445,489 adult discharges derived from the 2014 National Readmission Database, to evaluate the association of an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis of seizure during an index hospitalization for sepsis and 30-day readmission rates. We excluded patients who died during hospitalization and those who had missing information on the length of stay or were discharged in December 2014. Prespecified groups were compared by their 30-day readmission and seizure status. We applied a multivariable logistic regression analysis to assess the independent association between seizure and readmission.

RESULTS

Nearly one out of 15 patients discharged with a primary diagnosis of sepsis had comorbid seizures, of which 97% were status epilepticus. Patients with sepsis and comorbid seizures were 30% more likely to be readmitted within 30-days postdischarge, compared to those with sepsis and no comorbid seizures. Additional factors associated with a significantly higher risk for hospital readmission included male sex, age 45-84 years, increased length of stay and cost of primary admission, greater medical comorbidities, and discharge destination. Patients with seizures during their index hospitalization were significantly more likely to have also had a concurrent stroke or the central nervous system (CNS) infection compared with patients without seizures.

CONCLUSIONS

Seizures are not uncommon, and patients with sepsis and comorbid seizures are 30% more likely to be readmitted within 30-days postdischarge, compared to those with sepsis and no comorbid seizures.

Vagus nerve stimulation in refractory and super-refractory status epilepticus - A systematic review

RATIONALE

Refractory status epilepticus (RSE) is the persistence of status epilepticus despite second-line treatment. Super-refractory SE (SRSE) is characterized by ongoing status despite 48 h of anaesthetic treatment. Due to the high case fatality in RSE of 16-39%, off label treatments without strong evidence of efficacy in RSE are often administered. In single case-reports and small case series totalling 28 patients, acute implantation of VNS in RSE was associated with 76% and 26% success rate in generalized and focal RSE respectively. We performed an updated systematic review of the literature on efficacy of VNS in RSE/SRSE by including all reported patients.

METHODS

We systematically searched EMBASE, CENTRAL, Opengre.eu, and ClinicalTrials.gov, and PubMed databases to identify studies reporting the use of VNS for RSE and/or SRSE. We also searched conference abstracts from AES and ILAE meetings.

RESULTS

45 patients were identified in total of which 38 were acute implantations of VNS in RSE/SRSE. Five cases had VNS implantation for epilepsia partialis continua, one for refractory electrical status epilepticus in sleep and one for acute encephalitis with refractory repetitive focal seizures. Acute VNS implantation was associated with cessation of RSE/SRSE in 74% (28/38) of acute cases. Cessation did not occur in 18% (7/38) of cases and four deaths were reported (11%); all of them due to the underlying disease and unlikely related to VNS implantation. Median duration of the RSE/SRSE episode pre and post VNS implantation was 18 days (range: 3-1680 days) and 8 days (range: 3-84 days) respectively. Positive outcomes occurred in 82% (31/38) of cases.

CONCLUSION

VNS can interrupt RSE and SRSE in 74% of patients; data originate from reported studies classified as level IV and the risk for reporting bias is high. Further prospective studies are warranted to investigate acute VNS in RSE and SRSE.

Duration of therapeutic coma and outcome of refractory status epilepticus

OBJECTIVE

Examine the association of duration of therapeutic coma (TC) with seizure recurrence, morbidity, and mortality in refractory status epilepticus (RSE). Define an optimal window for TC that provides sustained seizure control and minimizes complications.

METHODS

Retrospective, observational cohort study involving patients who presented with RSE to the University of Alabama at Birmingham or the University of California at San Francisco from 2010 to 2016. Relationship of duration of TC with primary and secondary outcomes was evaluated using two-sample t tests, simple linear regression, and chi-square tests. Multivariable linear and logistic regression models were used to identify independent predictors. Predictive ability of TC for seizure recurrence was quantified using a receiver-operating characteristic curve. Youden index was used to determine an optimal cutoff value.

RESULTS

Multivariable analysis of clinical and treatment characteristics of 182 patients who were treated predominantly with propofol as anesthetic agent showed that longer duration of the first trial of TC (27.2 vs 15.6 hours) was independently associated with a higher chance of seizure recurrence following the first weaning attempt (P = 0.038) but not with poor functional neurologic outcome upon discharge, in-hospital complications, or mortality. Furthermore, higher doses of anesthetic utilized during the first trial of TC were independently associated with fewer in-hospital complications (P = 0.003) and associated with a shorter duration of mechanical ventilation and total length of stay. Duration of TC was identified as an independent predictor of seizure recurrence with an optimal cutoff point at 35 hours.

SIGNIFICANCE

This study suggests that a shorter duration yet deeper TC as treatment for RSE may be more effective and safer than the currently recommended TC duration of 24-48 hours. Prospective and randomized trials should be conducted to validate these assertions.

Systematic review and meta-analysis of propofol versus barbiturates for controlling refractory status epilepticus

Background

Several studies have compared the efficacy and safety of propofol and barbiturates in the treatment of refractory status epilepticus (RSE). This study aims to quantitatively assess the advantages and disadvantages of propofol and barbiturates in controlling RSE.

Methods

We searched for studies with relevant data from the PubMed, Embase, Ovid, Cochrane Library, Springer Link, Web of Science, and China National Knowledge Infrastructure databases. By calculating odds ratios and standardized mean differences with 95% confidence intervals, we assessed the disease control rate (DCR), case fatality rate (CFR), average control time (ACT), average tracheal intubation placement time (ATIPT), and incidence of hypotension between propofol and barbiturates in treating RSE.

Results

Seven studies with 261 patients were included in this analysis. Meta-analysis revealed that the DCR of propofol was higher than that of barbiturates (p < 0.001) and that the CFR (p = 0.382) between the two treatment did not significantly differ in controlling RSE. Propofol shortened the ACT (p < 0.001) of RSE and reduced the ATIPT (p < 0.001) of patients with RSE more extensively than did barbiturates and did not increase the incidence of hypotension (p = 0.737).

Conclusions

In comparison with barbiturates, propofol can control RSE and shorten ATIPT in a more efficient and timely manner. Moreover, the drug does not increase the incidence of hypotension and CFR.

Factors predicting cessation of status epilepticus in clinical practice: Data from a prospective observational registry (SENSE)

OBJECTIVE

To investigate the initial termination rate of status epilepticus (SE) in a large observational study and explore associated variables.

METHODS

Data of adults treated for SE were collected prospectively in centers in Germany, Austria, and Switzerland, during 4.5 years. Incident episodes of 1,049 patients were analyzed using uni- and multivariate statistics to determine factors predicting cessation of SE within 1 hour (for generalized convulsive SE [GCSE]) and 12 hours (for non-GCSE) of initiating treatment.

RESULTS

Median age at SE onset was 70 years; most frequent etiologies were remote (32%) and acute (31%). GCSE was documented in 43%. Median latency between SE onset and first treatment was 30 minutes in GCSE and 150 minutes in non-GCSE. The first intravenous compound was a benzodiazepine in 86% in GCSE and 73% in non-GCSE. Bolus doses of the first treatment step were lower than recommended by current guidelines in 76% of GCSE patients and 78% of non-GCSE patients. In 319 GCSE patients (70%), SE was ongoing 1 hour after initiating treatment and in 342 non-GCSE patients (58%) 12 hours after initiating treatment. Multivariate Cox regression demonstrated that use of benzodiazepines as first treatment step and a higher cumulative dose of anticonvulsants within the first period of treatment were associated with shorter time to cessation of SE for both groups.

INTERPRETATION

In clinical practice, treatment guidelines were not followed in a substantial proportion of patients. This underdosing correlated with lack of cessation of SE. Our data suggest that sufficiently dosed benzodiazepines should be used as a first treatment step. ANN NEUROL 2019;85:421-432.

Autoimmune encephalitis: A costly condition

OBJECTIVE

To assess the inpatient hospitalization burden and costs of patients with autoimmune encephalitis (AE) at a tertiary care institution.

METHODS

Adult inpatients with AE were identified retrospectively from July 1, 2005, to June 30, 2015. Demographic and clinical data were collected and analyzed. Billing data were compared to those of patients with herpes simplex encephalitis (HSE). Charges were adjusted for inflation.

RESULTS

Of 244 admissions for encephalitis reviewed, 63 patients met criteria for probable or definite AE. Thirty-one (49%) patients were antibody positive, and 27 (43%) were admitted to the intensive care unit (ICU). Median hospital charges per patient with AE were more than $70,000; median length of stay (LOS) was 15 days; and in-hospital mortality was 6%. Patients admitted to the ICU had substantially higher median hospital charges (ICU $173,000 per admission vs non-ICU $50,000 per admission, p < 0.001). LOS was strongly associated with charges and was driven by delay in diagnosis of AE, prolonged treatment courses, and lack of response to therapy. Compared with HSE, median hospital charges per patient with AE were nearly 4 times higher, median AE LOS was 3 times higher, and total charges over the study period were nearly twice as high.

CONCLUSIONS

Patients with AE used more inpatient health care resources per patient during a 10-year period than patients with HSE at our institution. ICU-admitted patients with AE were responsible for a substantially higher financial burden than non-ICU-admitted patients with AE. Our data underscore the need for the development of novel diagnostic and therapeutic modalities to improve patient outcomes and to decrease hospital burden in AE.

Institutional Factors Contribute to Variation in Intubation Rates in Status Epilepticus

Background

To explore intubation rates among patients with status epilepticus (SE) and the degree of institutional variation.

Methods

Serial cross-sectional study of SE-related hospitalizations from 2004 to 2013 using data from the National Inpatient Sample. The primary outcome was intubation of patients with SE. Multivariable models identified predictors of intubation, institutional variation in intubation rates, and the proportion of variance attributable to individual hospitals. This analysis was repeated using data from 5 states in the State Inpatient Databases (SID).

Results

There were 119 337 SE hospitalizations. The overall intubation rate was 32.7% (95% confidence interval [CI]: 32.2%-33.3%). There was marked variation in estimated intubation rates, ranging from 2% to 80% in the lowest and highest quintile after adjustment. There was somewhat less variability in the SID cohort where quintiles ranged from 10% to 54%. Those undergoing intubation were more often men and presenting with stroke, intracerebral hemorrhage, central nervous system infection, hyponatremia, and alcohol withdrawal. Urban location (odds ratio [OR]: 3.8, 95% CI: 2.7-5.5) and hospitalization at a teaching institution (OR: 3.9, 95% CI: 1.2-12.6) were even stronger predictors of intubation after adjustment for clinical factors. A regression including both patient- and hospital-level variables to predict intubation also performed better than a regression including patient factors alone (C statistic 0.81 vs 0.59, respectively).

Conclusions

There is considerable institutional variation in intubation rates for SE independent of patient characteristics suggesting that decisions around intubation rest heavily on where one is hospitalized. Further work is needed to clarify how this variation influences outcomes.

Levetiracetam for epilepsy: an evidence map of efficacy, safety and economic profiles

OBJECTIVE

To evaluate the efficacy, safety and economics of levetiracetam (LEV) for epilepsy.

MATERIALS AND METHODS

PubMed, Scopus, the Cochrane Library, OpenGrey.eu and ClinicalTrials.gov were searched for systematic reviews (SRs), meta-analyses, randomized controlled trials (RCTs), observational studies, case reports and economic studies published from January 2007 to April 2018. We used a bubble plot to graphically display information of included studies and conducted meta-analyses to quantitatively synthesize the evidence.

RESULTS

A total of 14,803 records were obtained. We included 30 SRs/meta-analyses, 34 RCTs, 18 observational studies, 58 case reports and 2 economic studies after the screening process. The included SRs enrolled patients with pediatric epilepsy, epilepsy in pregnancy, focal epilepsy, generalized epilepsy and refractory focal epilepsy. Meta-analysis of the included RCTs indicated that LEV was as effective as carbamazepine (CBZ; treatment for 6 months: 58.9% vs 64.8%, OR=0.76, 95% CI: 0.50-1.16; 12 months: 54.9% vs 55.5%, OR=1.24, 95% CI: 0.79-1.93), oxcarbazepine (57.7% vs 59.8%, OR=1.34, 95% CI: 0.34-5.23), phenobarbital (50.0% vs 50.9%, OR=1.20, 95% CI: 0.51-2.82) and lamotrigine (LTG; 61.5% vs 57.7%, OR=1.22, 95% CI: 0.90-1.66). SRs and observational studies indicated a low malformation rate and intrauterine death rate for pregnant women, as well as low risk of cognitive side effects. But psychiatric and behavioral side effects could not be ruled out. LEV decreased discontinuation due to adverse events compared with CBZ (OR=0.52, 95% CI: 0.41-0.65), while no difference was found when LEV was compared with placebo and LTG. Two cost-effectiveness evaluations for refractory epilepsy with decision-tree model showed US$ 76.18 per seizure-free day gained in Canada and US$ 44 per seizure-free day gained in Korea.

CONCLUSION

LEV is as effective as CBZ, oxcarbazepine, phenobarbital and LTG and has an advantage for pregnant women and in cognitive functions. Limited evidence supports its cost-effectiveness.

REGISTERED NUMBER

PROSPERO (No CRD 42017069367).

Cost of status epilepticus (SE): Effects of delayed treatment and SE duration

BACKGROUND

The health expenditure related to status epilepticus (SE) is high because of lengthy hospitalization requirements and possible sequelae. We aimed to study the factors associated with this cost including the different timings of the treatment and SE duration.

METHODS

We evaluated retrospectively all SE recorded in 2 hospitals. The factors studied included the mean cost of hospitalization, demographics, clinical data, duration of hospitalization, in-hospital/out-of-hospital debut, time from onset to treatment, duration of SE, and destination at discharge.

RESULTS

Three hundred five patients were evaluated (December/2012-July/2017), 195 with out-of hospital and 110 with in-hospital debut. The cost of SE with out-of-hospital onset was significantly lower (6559€ vs 15,174€; p = 0.0001). In out-of-hospital cases, the factors independently related to expenditure were the level of consciousness (p < 0.001), presence of complications (p = 0.005), a potentially fatal etiology (p = 0.008), and duration of the episode (p = 0.003). Duration was significantly higher in patients discharged to a convalescence center (p = 0.006); this variable was significantly related to the time SE onset-arrival to hospital, and SE onset-administration of the treatment. In the in-hospital cases, cost was related to male sex (p = 0.002), the development of complications (p = 0.003), and the etiology (p = 0.016) but was not directly related to the SE duration or to the time onset-treatment.

CONCLUSIONS

The duration of SE and the speed with which proper management is applied have a direct impact on the healthcare expenditure resulting from out-of-hospital SE. In contrast, the etiology and development of complications are the main factors responsible for expenditure related to in-hospital SE.

The direct and indirect costs of epilepsy in Poland estimates for 2014-2016 years

BACKGROUND

According to the current data, around 1% of the Poland population have epilepsy, which comprises about 400,000 people. This group of patients requires life-long therapy including both drug therapy and hospitalization. The character of the epilepsy has a significant impact on the expenses borne by individual patients, and the prevalence of the disease has a significant impact on the health care system.

METHODS

This article aims to measure the direct and indirect costs of epilepsy in Poland estimates for the years 2014-2016 (top-down approach). We use a modified human capital approach and a unique dataset provided by the number of Polish institutions including National Health Fund, Social Insurance Institution, and Central Statistical Office.

RESULTS

Epilepsy burden in Poland is significant. In the years 2014-2016, the total direct cost of epilepsy amounted to, respectively, 355 mln PLN (84 mln EUR), 368 mln PLN (87 mln EUR), and 373 mln PLN (88 mln EUR), but the total indirect cost amounted to 1 bn PLN (239 mln EUR), 949 mln PLN (224 mln EUR), and 848 mln PLN (200 mln EUR).

CONCLUSIONS

Direct and indirect costs of epilepsy can be a useful input for health technology analyses of drugs or economic impact assessments of public health programs.

Long-term outcomes of status epilepticus: A critical assessment

We reviewed 37 studies reporting long-term outcomes after a status epilepticus (SE) episode in pediatric and adult populations. Study design, length of follow-up, outcome measures, domains investigated (mortality, SE recurrence, subsequent epilepsy, cognitive outcome, functional outcome, or quality of life), and predictors of long-term outcomes are summarized. Despite heterogeneity in the design of prior studies, overall risk of poor long-term outcome after SE is high in both children and adults. Etiology is the main determinant of outcome, and the effect of age or SE duration is often difficult to distinguish from the underlying cause. The effect of the treatment on long-term outcome after SE is still unknown.

Acute antiepileptic drug use in intensive care units

BACKGROUND

In intensive care units (ICUs), antiepileptic drugs (AEDs) are used for manifold indications. This is the first study to assess the prevalence of acute AED use in ICUs and to identify associated clinical variables.

METHODS

All patients in seven adult ICUs of a German university hospital in 2016 were retrospectively evaluated. Data were extracted from the computerized critical care information system and manually reviewed. Acute AED treatments were defined as initiated during ICU treatment or ≤ 6 h before ICU admission, excluding benzodiazepines and sedatives.

RESULTS

Among 2335 patients evaluated, 8.8% received acutely started AEDs: 5.1% due to epileptic seizures, mostly acute symptomatic, and 3.7% for other indications like pain, post-hypoxic myoclonus, and singultus. Following multivariable analyses, acute AED use was independently associated with intracranial reasons for ICU admission and long durations of ICU stay, but not with increased disease severity scores or mortality. Levetiracetam was the substance most frequently used to treat epileptic seizures (88%) as was pregabalin for other conditions (49%). Among surviving patients, acute AEDs were continued beyond ICU discharge in 86% if seizure-related and in 78% if not seizure-related, even if there was no evident need for long-term AED treatment.

CONCLUSIONS

One out of eleven ICU patients receives acute AEDs, in almost half of cases for non-seizure indications. Acute AED use is a marker for intracranial ICU indications and prolonged ICU treatments. Usually, newer-generation AEDs are employed with favourable pharmacokinetic and safety profiles. However, whenever possible, acutely started AED should be discontinued before discharge from ICU.

Use of Emergency Medication in Adult Patients with Epilepsy: A Multicentre Cohort Study from Germany

BACKGROUND

Emergency treatment with benzodiazepines is indicated in prolonged seizures, seizure clusters and status epilepticus.

OBJECTIVE

The aim of this study was to evaluate the use of emergency medication in adult patients with epilepsy.

PATIENTS AND METHODS

All adult epilepsy patients attending the epilepsy outpatient clinics of the university hospitals in Frankfurt and Marburg in 2015 were asked to participate in this questionnaire-based, retrospective survey.

RESULTS

A total of 481 patients with a mean age of 43.4 years (range 18-94 years, 54% female) participated in the study. Among them, 134 patients (27.9%) reported on the prescription of an emergency medication during the last year. Patients receiving emergency medication were younger and exhibited a lower age at epilepsy onset, a higher seizure frequency and a higher number of regularly taken antiepileptic drugs. The most frequently taken emergency drugs were oral lorazepam tablets (65.7%; n = 88 out of 134), followed by buccal midazolam (23.9%, n = 32) and rectal diazepam (17.9%, n = 24). The most common indications for administering the emergency medication were seizures continuing for several minutes (35.1%, n = 47), but almost the same number of patients (33.6%, n = 45) stated that the rescue medication was given during or after every seizure. Regarding adverse events, sedation was named as a major (18.7%, n = 25) or moderate (29.1%; n = 39) problem by a substantial number of patients. Difficulties in administration were reported by 17 (13%) patients. Two-thirds assessed the efficacy of their emergency medication as good (50.7%, n = 68) or as very good (15.7%, n = 21). For multivariate logistic regression analysis, aspects such as young age at onset, active epilepsy, structural etiology, presence of generalised tonic-clonic seizures, past medical history of status epilepticus and living with another person independently predicted prescription of emergency medication.

CONCLUSIONS

In most cases, unsuitable benzodiazepines with slow absorption due to oral administration were prescribed, or buccal midazolam solution was used off-label in adults. Furthermore, inappropriate use of emergency medication at every seizure was reported by a substantial number of participating patients.

Incidence, Risk Factors and Consequences of Epilepsy-Related Injuries and Accidents: A Retrospective, Single Center Study

Introduction: This study was designed to evaluate risk factors and incidence of epilepsy-related injuries and accidents (ERIA) at an outpatient clinic of a German epilepsy center providing healthcare to a mixed urban and rural population of over one million inhabitants. Methods: Data acquisition was performed between 10/2013 and 09/2014 using a validated patient questionnaire on socioeconomic status, course of epilepsy, quality of life (QoL), depression, injuries and accidents associated with seizures or inadequate periictal patterns of behavior concerning a period of 3 months. Univariate analysis, multiple testing and regression analysis were performed to identify possible variables associated with ERIA. Results: A total of 292 patients (mean age 40.8 years, range 18-86; 55% female) were enrolled and analyzed. Focal epilepsy was diagnosed in 75% of the patients. The majority was on an antiepileptic drug (AEDs) polytherapy (mean number of AEDs: 1.65). Overall, 41 patients (14.0%) suffered from epilepsy-related injuries and accidents in a 3-month period. Besides lacerations (n = 18, 6.2%), abrasions and bruises (n = 9, 3.1%), fractures (n = 6, 2.2%) and burns (n = 3, 1.0%), 17 mild injuries (5.8%) were reported. In 20 (6.8% of the total cohort) cases, urgent medical treatment with hospitalization was necessary. Epilepsy-related injuries and accidents were related to active epilepsy, occurrence of generalized tonic-clonic seizures (GTCS) and drug-refractory course as well as reported ictal falls, ictal loss of consciousness and abnormal peri-ictal behavior in the medical history. In addition, patients with ERIA had significantly higher depression rates and lower QoL. Conclusion: ERIA and their consequences should be given more attention and standardized assessment for ERIA should be performed in every outpatient visit.