Mortality of epilepsy in developing countries

Mortality among persons with epilepsy in onchocerciasis-endemic and non-endemic areas of sub-Saharan Africa: A systematic review and meta-analysis

PURPOSE

To document epilepsy-related mortality in sub-Saharan Africa (SSA) and investigate possible associations with onchocerciasis endemicity.

METHODS

Systematic review with meta-analysis. Searches were performed in PubMed and Google Scholar (search terms: 'epilepsy'; 'mortality/death'; 'sub-Saharan Africa'). Included studies were classified as high-risk or low-risk for onchocerciasis based on documented endemicity data. Pooled mortality rates and annual case fatality rates (CFR) were calculated, and risk factors for mortality among persons with epilepsy (PWE) were investigated using meta-regression analysis.

RESULTS

The 28 eligible studies reported 30 epilepsy surveys, of which 9 (30.0%) were conducted in onchocerciasis high-risk sites. The pooled epilepsy mortality rate was 20.9 (95% CI: 5.9-74.4) per 100,000 person-years, and the pooled CFR was 36.2 (95% CI: 23.9-54.4) per 1,000 PWE per year, albeit with substantial between-study heterogeneity. Compared to onchocerciasis low-risk sites, high-risk sites had higher pooled mortality (342.9 versus 10.0 per 100,000 PY; p<0.001) and CFR (57.0 versus 26.6 per 1,000 PWE per year; p = 0.001). Mortality of PWE was almost five-fold that of people without epilepsy (mortality risk ratio: 4.9; 95% CI: 3.5-6.8). Studies in onchocerciasis high-risk sites and the study which recruited only PWE with nodding syndrome were associated with higher CFR (p = 0.044 and p = 0.002, respectively). The leading causes of epilepsy-related death were status epilepticus (58.5%), drowning (15.7%), and sudden unexpected death in epilepsy (10.1%).

CONCLUSION

Epilepsy mortality remains high in SSA. Most reported causes of death among PWE might be averted by improving seizure control. Better epilepsy prevention and care are urgently needed, particularly in onchocerciasis-endemic settings.

Premature Mortality and Causes of Death Among People With Epilepsy: A Nationwide Population-Based Incident Cohort Study

BACKGROUND AND OBJECTIVES

People with epilepsy (PWE) are at risk of premature death with considerable variability according to the study population. We aimed to estimate the risk and causes of death in PWE according to age, disease severity, disease course, comorbidities, and socioeconomic status in Korea.

METHODS

We conducted a nationwide population-based retrospective cohort study using the National Health Insurance database linked with the national death register. Newly treated PWE from 2008 to 2016 who were identified by antiseizure medication (ASM) prescriptions and diagnostic codes for epilepsy/seizure were included and observed until 2017. We assessed all-cause and cause-specific crude mortality rates and standardized mortality ratios (SMRs).

RESULTS

Among 138,998 PWE, 20,095 deaths were identified, and the mean follow-up period was 4.79 years. The SMR was 2.25 in the overall group of PWE, with a higher value in the younger age group at diagnosis and a shorter time interval after diagnosis. The SMR in the monotherapy group was 1.56, while that in the group with 4 or more ASMs was 4.93. PWE without any comorbidities had an SMR of 1.61. PWE who were rural residents had a higher SMR than those who were urban residents (2.47 vs 2.03, respectively). The causes of death among PWE were cerebrovascular disease (18.9%, SMR 4.50), malignant neoplasms outside the CNS (15.7%, SMR 1.37), malignant neoplasms of the CNS (6.7%, SMR 46.95), pneumonia (6.0%, SMR 2.08), and external causes (7.2%, SMR 2.17), including suicide (2.6%, SMR 2.07). Epilepsy itself and status epilepticus accounted for 1.9% of the overall death. The excess mortality associated with pneumonia and external causes was persistently high, whereas the excess mortality associated with malignancy and cerebrovascular diseases tended to decrease with increasing time since diagnosis.

DISCUSSION

This study showed excess mortality in PWE, even in those without comorbidities and those receiving monotherapy. Regional disparities and sustained risks of deaths from external causes over 10 years imply potential points of intervention. In addition to active control of seizures, education about injury prevention, monitoring for suicidal ideation, and efforts to improve accessibility to epilepsy care are all required to reduce mortality.

Status of epilepsy in the tropics: An overlooked perspective

Epilepsy is one of the most common serious chronic neurological diseases affecting people of all ages globally. It is characterized by recurrent seizures. About 50 million people worldwide have epilepsy. Indubitably, people with epilepsy (PWE) may be without access to appropriate treatment. Many studies have examined the molecular mechanisms and clinical aspects of epilepsy; nonetheless, the treatment gap exists in some special areas. In the tropics, the specific geographical and ecological conditions and a lack of medical resources result in neglect or delay of diagnosis for PWE. Herein, we summarized the epidemiology of epilepsy in the tropics and discussed the disease burden and existing problems, aiming to offer a medical environment for patients in need and highlight the importance of reducing the epileptic disease burden in tropical countries.

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.

All-cause and cause-specific mortality among people with severe mental illness in Brazil's public health system, 2000-15: a retrospective study

BACKGROUND

People with severe mental illness have a mortality rate higher than the general population, living an average of 10-20 years less. Most studies of mortality among people with severe mental illness have occurred in high-income countries (HICs). We aimed to estimate all-cause and cause-specific relative risk (RR) and excess mortality rate (EMR) in a nationwide cohort of inpatients with severe mental illness compared with inpatients without severe mental illness in a middle income country, Brazil.

METHODS

This national retrospective cohort study included all patients hospitalised through the Brazilian Public Health System (Sistema Único de Saúde [SUS]-Brazil) between Jan 1, 2000, and April 21, 2015. Probabilistic and deterministic record linkages integrated data from the Hospital Information System (Sistema de informações Hospitalares) and the National Mortality System (Sistema de Informação sobre Mortalidade). Follow-up duration was measured from the date of the patients' first hospitalisation until their death, or until April 21, 2015. Severe mental illness was defined as schizophrenia, bipolar disorder, or depressive disorder by ICD-10 codes used for the admission. RR and EMR were calculated with 95% CIs, comparing mortality among patients with severe mental illness with those with other diagnoses for patients aged 15 years and older. We redistributed deaths using the Global Burden of Diseases, Injuries, and Risk Factors Study methodology if ill-defined causes of death were stated as an underlying cause.

FINDINGS

From Jan 1, 2000, to April 21, 2015, 72 021 918 patients (31 510 035 [43·8%] recorded as male and 40 974 426 [56·9%] recorded as female; mean age 41·1 (SD 23·8) years) were admitted to hospital, with 749 720 patients (372 458 [49·7%] recorded as male and 378 670 [50·5%] as female) with severe mental illness. 5 102 055 patient deaths (2 862 383 [56·1%] recorded as male and 2 314 781 [45·4%] as female) and 67 485 deaths in patients with severe mental illness (39 099 [57·9%] recorded as male and 28 534 [42·3%] as female) were registered. The RR for all-cause mortality in patients with severe mental illness was 1·27 (95% CI 1·27-1·28) and the EMR was 2·52 (2·44-2·61) compared with non-psychiatric inpatients during the follow-up period. The all-cause RR was higher for females and for younger age groups; however, EMR was higher in those aged 30-59 years. The RR and EMR varied across the leading causes of death, sex, and age groups. We identified injuries (suicide, interpersonal violence, and road injuries) and cardiovascular disease (ischaemic heart disease) as having the highest EMR among those with severe mental illness. Data on ethnicity were not available.

INTERPRETATION

In contrast to studies from HICs, inpatients with severe mental illness in Brazil had high RR for idiopathic epilepsy, tuberculosis, HIV, and acute hepatitis, and no significant difference in mortality from cancer compared with inpatients without severe mental illness. These identified causes should be addressed as a priority to maximise mortality prevention among people with severe mental illness, especially in a middle-income country like Brazil that has low investment in mental health.

FUNDING

Bill and Melinda Gates Foundation, Fundação de Amparo a Pesquisa do Estado de Minas Gerais, FAPEMIG, and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil.

Seizure control status and associated factors among pediatric epileptic patients at a neurologic outpatient clinic in Ethiopia

BACKGROUND

Childhood epilepsy is a major public health problem worldwide. Even though anti-seizure medications (ASM) have been demonstrated to control seizures, children with epilepsy continue to have frequent seizures. There is a scarcity of data on seizure control status among pediatric epileptic patients in Ethiopia. The aim of this study was to assess seizure control status and associated factors among pediatric epileptic patients.

METHODS

A hospital based cross-sectional study was done on 261 pediatric epileptic patients being followed up at the University of Gondar Comprehensive and Specialized Hospital, Northwest Ethiopia, from May 11 to August 11, 2019. The data were collected through caregiver interviews and patients' medical records. All independent variables with p value of ≤ 0.2 in univariate analysis were taken to multivariable analysis. Adjusted odds ratio (AOR) with a 95% confidence interval was computed to see the predictors of seizure control status. Level of statistical significance was declared if p-value < 0.05.

RESULT

From a total of 261 patients, 159 (60.9%) were males and had a mean age was 10.16 ± 4.62 years. More than half (57.1%) of participants were urban dwellers. Almost all (98.5%) were diagnosed with generalized tonic-clonic seizures. Majority (75.1%) of the patients were on mono-therapy. Forty-six (17.6%) of the patients reported adverse effects related to ASMs. Two hundred-three (77.8%) of the patients were adherent to their medications. Nearly half (49.0%) of the patients had controlled seizures. Urban residency (AOR: 2.12; 95% CI: 1.15-3.89; P = 0.016), adherence to medication (AOR: 3.92; 95% CI: 1.84-8.36; P < 0.001), use of combined ASM(AOR: 0.29; 95% CI: 0.14-0.59; P = 0. 001), durations of ASM use [2-5 years (AOR: 5.81; 95% CI: 2.89-11.70; P <0.001) and >5years (AOR: 4.80; 95% CI: 1.91-12.09; P = 0.001)]were significantly associated with seizure control status.

CONCLUSION

Inadequate numbers of pediatric epileptic patients' at the Ethiopian neurologic clinic achieved seizure control. Coming from a rural area, non-adherence to ASMs, use of multiple ASMs, and the use of ASMs for <2years were found to have a significant association with poorer seizure control, needing special attention to get control of seizure. Caregivers should closely monitor and address any barriers that contribute to ASM non-adherence and adverse drug events.

Availability, affordability, and quality of essential anti-seizure medication in Cambodia

Objective

Epilepsy is a major neurological disorder that requires long‐term medical treatment. Once epilepsy is diagnosed, people with epilepsy face many difficulties in accessing treatment (treatment gap). Our objective was to assess the situation regarding the availability, price, affordability, and quality of anti‐seizure medication (ASM), which are major determinants of access to treatment.

Method

A cross‐sectional study was performed in provincial/district hospitals and private pharmacies in urban and rural areas in Cambodia. Data on ASM availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest‐paid government employee must work to purchase a monthly treatment. Samples of ASM were collected, and the quality of ASM was assessed through Medicine Quality Assessment Reporting Guidelines.

Results

Out of 138 outlets visited, only 72 outlets (52.2% [95% CI 43.5‐60.7]) had at least one ASM available. Phenobarbital 100 mg was the most available (35.5%), followed by carbamazepine 200 mg (21.7%), phenobarbital 50 mg (11.6%), sodium valproate 500 mg (9.4%), and phenytoin 100 mg (9.4%). In provincial/district hospitals, ASM was provided free of charge. In private pharmacies, affordability for phenobarbital 50 mg and 100 mg was the best, with 0.6 and 0.5 days, respectively, compared to phenytoin 100 mg (1.8 days), and other ASM. No counterfeit ASM was found in this study. Phenytoin sample presented the worst quality (33.0%) compared to carbamazepine (27.8%), and other ASM.

Significance

A lack of access to affordable and effective ASM due to low availability and poor quality of ASM was identified. Our research highlights the need for future policy efforts to ensure the quality of ASM and improve their availability. This can be achieved by involving the calculation of their annual needs for these drugs and increasing the national production of ASM.

Mortality Rates in People With Convulsive Epilepsy in Rural Northeast China

Purpose: To examine the mortality rate and causes of death of phenobarbital (PB) monotherapy and sodium valproate (VPA) monotherapy in patients with convulsive epilepsy in rural northeast China and compare the differences in the results between the two antiepileptic drugs.

Methods: Patients with convulsive epilepsy were recruited by trained public health workers in a project for epilepsy prevention and treatment. Patients were enrolled between January 2010 and December 2018 and were treated with PB or VPA. Mortality rate (MR), the proportional mortality ratio (PMR) for each cause, standardized mortality ratio, and years of potential life lost (YPLL) for sex, age, and cause were estimated based on the 2018 Chinese rural population.

Results: A total of 3,916 patients with convulsive epilepsy enrolled in the study, of whom 3,418 received PB and 498 received VPA. There were 325 reported deaths (300 from the PB group) during the follow-up period. The MRs were 9.96 and 5.73% in the PB and VPA groups, respectively. The overall SMRs were 12.92 (95% confidence intervals [CI]: 11.50–13.93) and 7.39 (95% CI: 4.78–10.91), for the PB and VPA groups, respectively. Cerebrovascular disease and heart disease were the major causes of death in both treatment groups. The average YPLL for the PB group (21.9 years) was higher than that for the VPA group (13.4 years).

Conclusion: This is the first epidemiological study to examine the MR of patients with epilepsy in rural northeast China. Our study is somewhat different from previous studies reported in China, and we provide new relevant data from northeast China.

Statistical models for longitudinal zero-inflated count data: application to seizure attacks

Background

Chronic non-communicable diseases:- such as epilepsy, are increasingly recognized as public health problems in developing and African countries. This study aimed at finding determinants of the number of epileptic seizure attacks using different count data modeling techniques.

Methods

Four common fixed-effects Poisson family models were reviewed to analyze the count data with a high proportion of zeros in longitudinal outcome, i.e., the number of seizure attacks in epilepsy patients. This is because, in addition to the problem of extra zeros, the correlation between measurements upon the same patient at different occasions needs to be taken into consideration.

Results

The investigation remarkably identified some important factors associated with epileptic seizure attacks. As people grow old, the number of seizure attacks increased and male patients had more seizures than their female counterparts. In general, a patient's age, sex, monthly income, family history of epilepsy andservice satisfaction were some of the significant factors responsible for the frequency of seizure attacks (P value<0.05).

Conclusion

This study suggests that zero-inflated negative binomial is the best model for predicting and describing the number of seizure attacks as well as identifying the potential risk factors. Addressing these risk factors will definitely contain the progression of seizure attack.

Bridging the childhood epilepsy treatment gap in northern Nigeria (BRIDGE): Rationale and design of pre-clinical trial studies

Epilepsy is the most common serious childhood neurological disorder. In the low- and middle-income countries (LMICs) of Africa, children with epilepsy suffer increased morbidity and mortality compared to their counterparts in high-income countries, and the majority do not receive treatment - the childhood epilepsy treatment gap. Reports of the childhood epilepsy treatment gap in Africa are likely underestimates; most surveys do not include several common childhood seizure types, including most types of non-convulsive epilepsy. Efforts to scale up childhood epilepsy care services in the LMICs of Africa must contend with a shortage of physicians and diagnostic technology [e.g., electroencephalograms (EEGs)]. One pragmatic solution is to integrate epilepsy care into primary care by task-shifting to community health extension workers. The aims of this project (BRIDGE) are to: 1) train, develop, and pilot task-shifted epilepsy care teams; 2) develop and pilot innovative childhood epilepsy screening and diagnostic paradigms adapted to the local Hausa language/culture in Kano, northern Nigeria; and, 3) quantify and map the childhood epilepsy treatment gap, using geographic information systems (GIS), to target limited resources to areas of greatest need. Task-shifted teams will diagnose and manage childhood epilepsy using an innovative epilepsy screening tools and diagnostic and management paradigms in environments with limited EEG access. If validated and demonstrated efficacious in clinical trials, this project can be taken to scale across broader areas of west Africa's LMICs that share language and culture. BRIDGE has the potential to enhance access to basic childhood epilepsy care and establish the foundation for childhood epilepsy clinical trials in west Africa.

Overall and cause-specific premature mortality in epilepsy: A systematic review

BACKGROUND

We conducted a systematic review to ascertain the overall mortality and causes of premature mortality in epilepsy.

METHODOLOGY

We searched PubMed and Embase to identify relevant articles reporting mortality in epilepsy. An assessment of the methodological quality and overall quality of evidence of the identified studies was done using appropriate checklists. We extracted data from these studies reporting measures of overall and cause-specific mortality in epilepsy.

RESULTS

Sixty-three articles from fifty-six cohorts met the eligibility criteria, thirty-three population- or community-based and twenty-three hospital- or institutional-based studies. The majority of studies are from high-income countries (HIC). These studies reported overall excess mortality for people with epilepsy, with wide variability reported for population- or community-based studies and from low- and middle-income countries (LMIC). Twenty-seven articles from twenty-three cohorts reported measures of mortality for cause-specific mortality in epilepsy. People with epilepsy from HIC and LMIC have a higher risk of dying from various causes compared with the general population. Those in LMIC, however, have a particularly high chance of dying from external causes such as drowning and suicide. We observed a decrement over time in measures of overall and cause-specific mortality in cohorts.

CONCLUSIONS

Despite the heterogeneity in reports, our findings support the suggestions that people with epilepsy have an increased risk of premature mortality from various causes. Further work is needed to elucidate the mechanisms, to determine biomarkers for predicting those at risk, and to understand the implications of counseling and preventive strategies.

Sudden unexpected death in epilepsy

People with epilepsy have increased risk of premature death, and their life expectancy may reduce by 2-10 yr. Population- and hospital-based studies have shown that the excess mortality in epilepsy is not entirely explained by deaths directly attributable to epilepsy such as accidents and drowning during a seizure. It is also significantly contributed by deaths from other causes such as cardiac deaths, deaths due to malignancies and other causes. It had recently been recognized that sudden unexpected deaths in epilepsy (SUDEP) contributed to a small yet important proportion of mortality in epilepsy. SUDEPs are deaths (witnessed or unwitnessed) unrelated to trauma, drowning or status epilepticus and not attributable to any specific medical conditions. Several factors related to epilepsy and drug therapy have been found to be associated with higher risk of SUDEP.

Premature mortality of epilepsy in low- and middle-income countries: A systematic review from the Mortality Task Force of the International League Against Epilepsy

To determine the magnitude of risk factors and causes of premature mortality associated with epilepsy in low- and middle-income countries (LMICs). We conducted a systematic search of the literature reporting mortality and epilepsy in the World Bank-defined LMICs. We assessed the quality of the studies based on representativeness; ascertainment of cases, diagnosis, and mortality; and extracted data on standardized mortality ratios (SMRs) and mortality rates in people with epilepsy. We examined risk factors and causes of death. The annual mortality rate was estimated at 19.8 (range 9.7-45.1) deaths per 1,000 people with epilepsy with a weighted median SMR of 2.6 (range 1.3-7.2) among higher-quality population-based studies. Clinical cohort studies yielded 7.1 (range 1.6-25.1) deaths per 1,000 people. The weighted median SMRs were 5.0 in male and 4.5 in female patients; relatively higher SMRs within studies were measured in children and adolescents, those with symptomatic epilepsies, and those reporting less adherence to treatment. The main causes of death in people with epilepsy living in LMICs include those directly attributable to epilepsy, which yield a mean proportional mortality ratio (PMR) of 27.3% (range 5-75.5%) derived from population-based studies. These direct causes comprise status epilepticus, with reported PMRs ranging from 5 to 56.6%, and sudden unexpected death in epilepsy (SUDEP), with reported PMRs ranging from 1 to 18.9%. Important causes of mortality indirectly related to epilepsy include drowning, head injury, and burns. Epilepsy in LMICs has a significantly greater premature mortality, as in high-income countries, but in LMICs the excess mortality is more likely to be associated with causes attributable to lack of access to medical facilities such as status epilepticus, and preventable causes such as drowning, head injuries, and burns. This excess premature mortality could be substantially reduced with education about the risk of death and improved access to treatments, including AEDs.

Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional Survey

Background

Epilepsy is a common neurological disorder, with over 80 % of cases found in low- and middle-income countries (LMICs). Studies from high-income countries find a significant economic burden associated with epilepsy, yet few studies from LMICs, where out-of-pocket costs for general healthcare can be substantial, have assessed out-of-pocket costs and health care utilization for outpatient epilepsy care.

Methods

Within an established health and socio-demographic surveillance system in rural South Africa, a questionnaire to assess self-reported health care utilization and time spent traveling to and waiting to be seen at health facilities was administered to 250 individuals, previously diagnosed with active convulsive epilepsy. Epilepsy patients’ out-of-pocket, medical and non-medical costs and frequency of outpatient care visits during the previous 12-months were determined.

Results

Within the last year, 132 (53 %) individuals reported consulting at a clinic, 162 (65 %) at a hospital and 34 (14 %) with traditional healers for epilepsy care. Sixty-seven percent of individuals reported previously consulting with both biomedical caregivers and traditional healers. Direct outpatient, median costs per visit varied significantly (p < 0.001) between hospital (2010 International dollar ($) 9.08; IQR: $6.41-$12.83) and clinic consultations ($1.74; IQR: $0-$5.58). Traditional healer fees per visit were found to cost $52.36 (IQR: $34.90-$87.26) per visit. Average annual outpatient, clinic and hospital out-of-pocket costs totaled $58.41. Traveling to and from and waiting to be seen by the caregiver at the hospital took significantly longer than at the clinic.

Conclusions

Rural South Africans with epilepsy consult with both biomedical caregivers and traditional healers for both epilepsy and non-epilepsy care. Traditional healers were the most expensive mode of care, though utilized less often. While higher out-of-pocket costs were incurred at hospital visits, more people with ACE visited hospitals than clinics for epilepsy care. Promoting increased use and effective care at clinics and reducing travel and waiting times could substantially reduce the out-of-pocket costs of outpatient epilepsy care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1460-0) contains supplementary material, which is available to authorized users.

Multiple anti-epileptic drug use in children with epilepsy in Mulago hospital, Uganda: a cross sectional study

BACKGROUND

Seizures in up to one third of children with epilepsy may not be controlled by the first anti-epileptic drug (AED). In this study, we describe multiple AED usage in children attending a referral clinic in Uganda, the factors associated with multiple AED use and seizure control in affected patients.

METHODS

One hundred thirty nine patients attending Mulago hospital paediatric neurology clinic with epilepsy and who had been on AEDs for ≥6 months were consecutively enrolled from July to December 2013 to reach the calculated sample size. With consent, the history and physical examination were repeated and the neurophysiologic and imaging features obtained from records. Venous blood was also drawn to determine AED drug levels. We determined the proportion of children on multiple AEDs and performed regression analyses to determine factors independently associated with multiple AED use.

RESULTS

Forty five out of 139 (32.4 %) children; 46.7 % female, median age 6 (IQR = 3-9) years were on multiple AEDs. The most common combination was sodium valproate and carbamazepine. We found that 59.7 % of children had sub-therapeutic drug levels including 42.2 % of those on multi-therapy. Sub-optimal seizure control (adjusted odds ratio [OR(a)] 3.93, 95 % CI 1.66-9.31, p = 0.002) and presence of focal neurological deficits (OR(a) 3.86, 95 % CI 1.31-11.48, p = 0.014) were independently associated with multiple AED use but not age of seizure onset, duration of epilepsy symptoms, seizure type or history of status epilepticus.

CONCLUSION

One third of children with epilepsy in Mulago receive multiple AEDs. Multiple AED use is most frequent in symptomatic focal epilepsies but doses are frequently sub-optimal. There is urgent need to improve clinical monitoring in our patients.

Psychiatric presentation of childhood epilepsy: Case series and review

Childhood-onset epilepsy has a varied presentation and may have different etiological factors. A multiaxial diagnostic approach should be used before making treatment and management decisions for any individual patient. It is widely accepted that distinction among primary psychiatric disorders, epilepsy, and nonepileptic seizures is a challenge for physicians. This case series demonstrated the identification of three atypical presentations of seizures in children on the basis of detailed history taking and electroencephalogram findings, despite having normal findings in neurological examination and magnetic resonance imaging. We report three rare cases of atypical presentation in epilepsy in patients with symptoms of episodic hallucinations, rage attacks, and secondary enuresis. Clinically, the diagnosis of epilepsy can be strengthened by paying sufficient attention to detailed history and symptom spectrum of partial epilepsy.

Epilepsy in India I: Epidemiology and public health

Of the 70 million persons with epilepsy (PWE) worldwide, nearly 12 million PWE are expected to reside in India; which contributes to nearly one-sixth of the global burden. This paper (first of the two part series) provides an in-depth understanding of the epidemiological aspects of epilepsy in India for developing effective public health prevention and control programs. The overall prevalence (3.0-11.9 per 1,000 population) and incidence (0.2-0.6 per 1,000 population per year) data from recent studies in India on general population are comparable to the rates of high-income countries (HICs) despite marked variations in population characteristics and study methodologies. There is a differential distribution of epilepsy among various sociodemographic and economic groups with higher rates reported for the male gender, rural population, and low socioeconomic status. A changing pattern in the age-specific occurrence of epilepsy with preponderance towards the older age group is noticed due to sociodemographic and epidemiological transition. Neuroinfections, neurocysticercosis (NCC), and neurotrauma along with birth injuries have emerged as major risk factors for secondary epilepsy. Despite its varied etiology (unknown and known), majority of the epilepsy are manageable in nature. This paper emphasizes the need for focused and targeted programs based on a life-course perspective and calls for a stronger public health approach based on equity for prevention, control, and management of epilepsy in India.

Burden of epilepsy in Colombia

BACKGROUND

Epilepsy lays an important burden on healthcare systems and society in general. Disability adjusted life years (DALYs) have been developed to compare the burden of this disease both between conditions and between geographical boundaries. With improving data on disease incidence and prevalence in Colombia, we can refine our DALYs-based estimates.

METHODS

Using different strategies, including the official healthcare provision database and death certificates, as well as extrapolation from published neuroepidemiologic studies, we estimated the incidence and prevalence by age groups, disease duration and attributable mortality. With this information we calculated DALYs for the year 2012.

RESULTS

Overall, it was found that epilepsy was responsible for 0.88% of all deaths in Colombia. A total of 5.25 DALYs per 1,000 person-years are lost due to epilepsy in Colombia, 75% of which (3.91 DALYs) are due to premature mortality, with a higher burden in men (6.12 DALYs) than in women (4.41 DALYs).

CONCLUSIONS

We reported new estimations on epilepsy incidence and prevalence by age groups in Colombia and conclude that DALYs lost due to epilepsy in Colombia are almost double the previous figure, mostly because of the underestimation of attributable mortality. With this figure, epilepsy ranks 12th instead of 19th in the list of the most important causes of DALYs lost.

Excess mortality from mental, neurological and substance use disorders in the Global Burden of Disease Study 2010

AIMS

Mortality-associated burden of disease estimates from the Global Burden of Disease 2010 (GBD 2010) may erroneously lead to the interpretation that premature death in people with mental, neurological and substance use disorders (MNSDs) is inconsequential when evidence shows that people with MNSDs experience a significant reduction in life expectancy. We explore differences between cause-specific and excess mortality of MNSDs estimated by GBD 2010.

METHODS

GBD 2010 cause-specific death estimates were produced using the International Classification of Diseases death-coding system. Excess mortality (all-cause) was estimated using natural history models. Additional mortality attributed to MNSDs as underlying causes but not captured through GBD 2010 methodology is quantified in the comparative risk assessments.

RESULTS

In GBD 2010, MNSDs were estimated to be directly responsible for 840 000 deaths compared with more than 13 million excess deaths using natural history models.

CONCLUSIONS

Numbers of excess deaths and attributable deaths clearly demonstrate the high degree of mortality associated with these disorders. There is substantial evidence pointing to potential causal pathways for this premature mortality with evidence-based interventions available to address this mortality. The life expectancy gap between persons with MNSDs and the general population is high and should be a focus for health systems reform.

Epilepsy and mortality in Latin America

PURPOSE

To assess the mortality related to epilepsy in Latin America.

METHODS

We searched MEDLINE, EMBASE, and LILACS from inception to December 2013 for articles evaluating mortality in patients with epilepsy in Latin America. Studies were included if they evaluated any mortality outcome, included a population of subjects with recurrent seizures or epilepsy, and contained original data analysis.

RESULTS

The search strategy yielded 177 publications in MEDLINE and EMBASE, and 59 publications in LILACS; of which 18 met inclusion criteria for our overall review of epilepsy and mortality in Latin America. Most excluded studies did not report the mortality or lacked original data. We also included two references obtained from 2 non-systematic reviews fulfilling our inclusion criteria, and able to provide data for our analyses. Five studies reported Standardized Mortality Ratio (SMR), and demonstrated that people with epilepsy had a higher risk of death than the general population. The SMRs reported in two community-based studies were 1.34 and 2.45.

CONCLUSION

The information about mortality in epilepsy in Latin America is very scarce. Comparisons cannot be made among studies due to methodological differences. More studies are needed.

Premature mortality in poor health and low income adults with epilepsy

OBJECTIVE

To examine mortality and causes of death (CODs) in socioeconomically disadvantaged persons with epilepsy (PWEs) in the United States.

METHODS

We performed a retrospective open cohort analysis using Ohio Medicaid claims data between 1992 and 2008 to assess mortality and COD in 68,785 adult Medicaid beneficiaries with epilepsy. Case fatality (CF), mortality rates (MRs), standardized mortality ratios (SMRs), and years of potential life lost (YPLLs) were calculated. The SMRs were estimated to compare risk of death in PWEs with that in the general Medicaid population with and without disabilities. Proportionate mortality ratios (PMRs), YPLLs, and SMRs for specific COD were also obtained.

RESULTS

There were 12,630 deaths in PWEs. CF was 18.4%, the age-race-sex adjusted MR was 18.6/1,000 person-years (95% confidence interval [CI], 18.3-18.9). The SMR was 1.8 (95% CI, 1.8-1.9) when compared to the general Medicaid population, and was 1.4 (95% CI, 1.3-1.6) when compared to those with disabilities. The average YPLL was 16.9 years (range 1-47 years). Both epilepsy and comorbid conditions significantly contributed to premature mortality in PWEs. Cardiovascular diseases, cancer, and unintentional injuries were the most common COD and account for a large proportion of YPLLs. Deaths from epilepsy-related causes occurred in about 10% of the cases.

SIGNIFICANCE

Socioeconomically deprived PWEs, especially young adults, experience high mortality and die 17 years prematurely. The high mortality in Medicaid beneficiaries with epilepsy affirms that comorbid conditions and epilepsy play a crucial role in premature death. Management of comorbid conditions is, at a minimum, as important as epilepsy management, and therefore deserves more attention from physicians, particularly those who care for Medicaid beneficiaries with epilepsy.

Prevalence of epilepsy--an unknown quantity

The incidence, prevalence, and mortality of epilepsy vary across countries with different economies. Differences can be explained by methodological problems, premature mortality, seizure remission, socioeconomic factors, and stigma. Diagnostic misclassification-one possible explanation-may result from inclusion of patients with acute symptomatic or isolated unprovoked seizures. Other sources of bias include age and ethnic origin of the target population, definitions of epilepsy, retrospective versus prospective ascertainment, sources of cases, and experienced and perceived stigma. Premature mortality is an issue in low-income countries (LICs), where treatment gap, brain infections, and traumatic brain injuries are more common than in high-income countries (HICs). Death rates may reflect untreated continued seizures or inclusion of acute symptomatic seizures. Lack of compliance with antiepileptic drugs has been associated with increased risk for death, increased hospital admissions, motor vehicle accidents, and fractures in poor communities. Epilepsy is a self-remitting clinical condition in up to 50% of cases. Studies in untreated individuals from LICs have shown that the proportion of remissions overlaps that of countries where patients receive treatment. When the identification of patients is based on spontaneous reports (e.g., door-to-door surveys), patients in remission may be less likely to disclose the disease for fear of stigmatization with no concurrent benefits. This might lead to underascertainment of cases when assessing the lifetime prevalence of epilepsy. In LICs, the proportion of people living in poverty is greater than in HICs. Poverty is associated with risk factors for epilepsy, risk for developing epilepsy, and increased mortality. The high incidence and prevalence of epilepsy found in LICs is also observed in low income individuals from HICs. Epileptogenic conditions are associated with an increased mortality. This may partly explain the difference between incidence and lifetime prevalence of epilepsy in LICs. Poverty within LICs and HICs could be a preventable cause of mortality in epilepsy.

Epilepsy and neurocysticercosis in Latin America: a systematic review and meta-analysis

Background

The difference in epilepsy burden existing among populations in tropical regions has been attributed to many factors, including the distribution of infectious diseases with neurologic sequels. To define the burden of epilepsy in Latin American Countries (LAC) and to investigate the strength of association with neurocysticercosis (NCC), considered one of the leading causes of epilepsy, we performed a systematic review and meta-analysis of the literature.

Methodology

Studies published until 2012 were selected applying predefined inclusion criteria. Lifetime epilepsy (LTE) prevalence, active epilepsy (AE) prevalence, incidence, mortality, treatment gap (TG) and NCC proportion among people with epilepsy (PWE) were extracted. Median values were obtained for each estimate using random effects meta-analysis. The impact of NCC prevalence on epilepsy estimates was determined using meta-regression models. To assess the association between NCC and epilepsy, a further meta-analysis was performed on case-control studies.

Principal findings

The median LTE prevalence was 15.8/1,000 (95% CI 13.5–18.3), the median AE prevalence was 10.7/1,000 (95% CI 8.4–13.2), the median incidence was 138.2/100,000 (95% CI 83.6–206.4), the overall standardized mortality ratio was 1.4 (95% CI 0.01–6.1) and the overall estimated TG was 60.6% (95% CI 45.3–74.9). The median NCC proportion among PWE was 32.3% (95% CI 26.0–39.0). Higher TG and NCC estimates were associated with higher epilepsy prevalence. The association between NCC and epilepsy was significant (p<0.001) with a common odds ratio of 2.8 (95% CI 1.9–4.0).

Significance

A high burden of epilepsy and of NCC in LAC and a consistent association between these two diseases were pointed out. Furthermore, NCC prevalence and TG were identified as important factors influencing epilepsy prevalence to be considered in prevention and intervention strategies.

Epilepsy affects approximately 70 million people worldwide and at least five million people in Latin America. Many researchers have pointed out a different distribution of epilepsy in Latin American countries, with some regions presenting higher frequencies and others presenting lower frequencies. This difference in epilepsy distribution has been attributed to many factors, mainly related to the allocation of health resources and to the presence of environmental and infectious risk factors. Among the latter stands neurocysticercosis, a parasitic disease that has been recognized as the leading cause of acquired epilepsy in the developing world, with a particularly elevated distribution in rural settings. In this study, we performed a statistical analysis to investigate whether neurocysticercosis distribution affects epilepsy distribution among Latin American countries and the relationship between these two conditions. The combined results of the studies included indicated that neurocysticercosis influences epilepsy frequency in Latin America, as countries with higher epilepsy distribution presented also higher neurocysticercosis frequency. Moreover, another analysis pointed out an association between the two diseases. These results appear very important considering that parasitic infections are modifiable factors and that their reduction may contribute to decrease epilepsy burden worldwide.

Incidence of convulsive epilepsy in a rural area in Kenya

Purpose

There are only a few studies of incidence of epilepsy in low and middle income countries (LMICs). These are often small and conducted in specific age groups or areas where the prevalence of risk factors is high; therefore, these studies are not representative of the wider populations. We determined the incidence of convulsive epilepsy (CE) in a large rural population in Kenya.

Methods

We conducted two cross‐sectional surveys 5 years apart within a health and demographic surveillance system. Initially we identified residents without epilepsy who were then reexamined in the follow‐up survey to determine incidence. We estimated the overall incidence of CE and incidence by age‐group, sex, and by administrative location. Estimates were adjusted for attrition during case identification and for the sensitivity of the screening method.

Key Findings

In a cohort of 151,408 people, 194 developed CE over the 5 years. The minimum crude incidence rate was 37.6/100,000 persons per year (95% confidence interval (CI) 32.7–43.3) and adjusted for loss to follow‐up, and the sensitivity of the survey methodology was 77.0/100,000 persons per year (95% CI 67.7–87.4). Incidence was highest in children 6–12 years (96.1/100,000 persons per year; 95% CI 78.4–117.9), and was lowest in the 29–49 year age group (37.4/100,000 persons per year; 95% CI 25.7–54.7).

Significance

We estimated a high incidence of convulsive epilepsy in this population. Incidence was highest early and late in life, suggesting that preventive interventions should target exposures that occur in these age groups. Incidence of focal epilepsy was more than twice that of generalized epilepsy, suggesting that etiologies that are amenable to intervention were most important in this population. It is likely that incidence is underestimated because of the early mortality of incident cases.

Evidence-based review on the natural history of the epilepsies

PURPOSE OF REVIEW

The present review discusses clinically important evidence for unstable remission/relapse patterns and for causes of premature mortality in patients with epilepsy.

RECENT FINDINGS

Although two of three patients become seizure-free with antiepileptic drugs (AEDs), as many as 20-40% of newly diagnosed patients with epilepsy become seizure-free without or with minimal AED treatment. Sadly, the proportion of those not becoming seizure-free despite treatment does not seem to have improved substantially over the past 50 years. There is emerging evidence that natural history of epilepsies is more complex than previously thought. Although two-thirds of patients follow stable patterns, that is, become seizure-free early and remain seizure-free (48%), or have refractory epilepsy all their life (19%), one in every three patients has an unstable course of epilepsy. Patients with an unstable course will either enter remission only after many years of having seizures (19%) or will relapse despite continued treatment (14%). Remote symptomatic epilepsy carries the highest risk of premature mortality. It remains unclear, however, why sudden unexplained death occurs more often in adults than in children and controversy exists whether entering remission prevents premature mortality.

SUMMARY

Studies of the natural history of newly diagnosed epilepsy show unexplained fluctuations of remission and relapse in as many as one in three patients and, sadly, no substantial improvement of epilepsy treatment in the past 50 years. The premature mortality of epilepsy is high and more work is needed to prevent it.

Epilepsy treatment in sub-Saharan Africa: closing the gap

According to World Health Organization (WHO), the prevalence of epilepsy is highest in low- and lower middle-income countries, which include over eighty percent of the countries of sub-Saharan Africa, where the majority of people with epilepsy are not receiving appropriate care. In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. The number of people with epilepsy, particularly children, will continue to rise as a result of projected epidemiologic and demographic changes. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy.

Mortality in children with severe epilepsy: 10 years of follow-up

Epilepsy is the main neurological condition in children and adolescents. Unfortunately patients with medical refractory epilepsy are more susceptible for clinical complications and death. We report a prospectively evaluated cohort of children followed for approximately 10 years. Fifty-three of 1012 patients died. Forty-two patients died due to epilepsy or its clinical complications and the main causes of death were pneumonia (in 16 cases), sepsis (in 9 patients), status epilepticus (in 8 patients). In 11 patients cause of death was sudden unexpected death in epilepsy (SUDEP). Mental retardation was significantly more frequent in patients who did not die from SUDEP. SUDEP may be a significant condition associated with mortality in children and adolescents with epilepsy.

Incidence of epilepsy: a systematic review and meta-analysis

OBJECTIVE

To estimate the pooled incidence of epilepsy from published studies and investigate sources of heterogeneity in the estimates.

METHODS

We searched online databases for incidence studies and used meta-analytic methods to analyze the data.

RESULTS

Thirty-three articles met the entry criteria. The median incidence of epilepsy was 50.4/100,000/year (interquartile range [IQR] 33.6-75.6), while it was 45.0 (IQR 30.3-66.7) for high-income countries and 81.7 (IQR 28.0-239.5) for low- and middle-income countries. Population-based studies had higher incidence estimates than hospital-based studies (p = 0.02) while retrospective study design was associated with lower estimates than prospective studies (p = 0.04).

CONCLUSION

We provide data that could potentially be used to assess the burden and analyze the trends in incidence of epilepsy. Our results support the need for large population-based incidence studies of epilepsy.

The natural history of epilepsy: spontaneous remission and mortality

Natural History and Mortality of Chronic Epilepsy in an Untreated Population of Rural Bolivia: A Follow-Up after 10 years. Nicoletti A, Sofia V, Vitale G, Bonelli SI, Bejarano V, Bartalesi F, Tran DS, Preux PM, Zappia M, Bartoloni A. Epilepsia 2009;50(10):2199–2206. PURPOSE: To evaluate the natural history and mortality of chronic epilepsy in an untreated prevalence cohort of people with epilepsy (PWE) in a rural area of Bolivia. METHODS: During 1994–1996 we carried out an epidemiologic survey in a sample of 9,995 subjects in the Cordillera province. At the end of the survey we identified 130 PWE, of whom 118 were classified as having “active epilepsy.” We revisited this cohort 10 years after the prevalence survey. RESULTS: We were able to trace 103 (87.3%) of the 118 PWE previously identified. Ten of the 103 subjects died during the follow-up period. Of the 93 PWE still alive, adequate information on the occurrence of seizures was available for 71 subjects, of whom 31 (43.7%) were seizure-free for more than 5 years; only 3 of these 31 subjects have taken an antiepileptic drug (AED) for more than 1 year. Generalized seizures were associated with a better prognosis. Mortality rate in our prevalent cohort was 10.0/1,000 person-year at risk [95% confidence interval (CI) 5.5–18.3], without a significant increased risk respect to the general population [standardized mortality rate (SMR) 1.34; 95% CI 0.68–2.39]; a significant increased risk of death was found for patients with remote symptomatic epilepsy (SMR 3.0; 95% CI 1.2–6.3) but not with idiopathic epilepsy. Three of the 10 subjects died of causes possibly related to epilepsy. DISCUSSION: Our data suggest that spontaneous remission of epilepsy occurs in a substantial proportion of untreated patients affected by chronic epilepsy; concerning mortality, we found a three-fold increased mortality in patients with remote symptomatic epilepsy.

Estimation of the burden of active and life-time epilepsy: a meta-analytic approach

PURPOSE

To estimate the burden of lifetime epilepsy (LTE) and active epilepsy (AE) and examine the influence of study characteristics on prevalence estimates.

METHODS

We searched online databases and identified articles using prespecified criteria. Random-effects meta-analyses were used to estimate the median prevalence in developed countries and in urban and rural settings in developing countries. The impact of study characteristics on prevalence estimates was determined using meta-regression models.

RESULTS

The median LTE prevalence for developed countries was 5.8 per 1,000 (5th-95th percentile range 2.7-12.4) compared to 15.4 per 1,000 (4.8-49.6) for rural and 10.3 (2.8-37.7) for urban studies in developing countries. The median prevalence of AE was 4.9 per 1,000 (2.3-10.3) for developed countries and 12.7 per 1,000 (3.5-45.5) and 5.9 (3.4-10.2) in rural and urban studies in developing countries. The estimates of burden for LTE and AE in developed countries were 6.8 million (5th-95th percentile range 3.2-14.7) and 5.7 million (2.7-12.2), respectively. In developing countries these were 45 (14-145) million LTE and 17 (10-133) million AE in rural areas and 17 (5-61) million LTE and 10 (5-17) million AE in urban areas. Studies involving all ages or only adults showed higher estimates than pediatric studies. Higher prevalence estimates were also associated with rural location and small study size.

CONCLUSIONS

This study estimates the global burden of epilepsy and the proportions with AE, which may benefit from treatment. There are systematic differences in reported prevalence estimates, which are only partially explained by study characteristics.

Pharmacological screening of Malian medicinal plants used against epilepsy and convulsions

ETHNOPHARMACOLOGICAL RELEVANCE

Several medicinal plants are used in Mali to treat epilepsy and convulsions. So far, no studies have investigated the pharmacological effect of these plants.

AIMS

The aim of this study was to investigate the in vitro and in vivo antiepileptic potential of the ethanolic extracts of 11 Malian medicinal plants.

MATERIALS AND METHODS

The extracts were screened for antiepileptic properties in the mouse cortical wedge preparation and in the [3H]-flumazenil binding assay. Two of the plant extracts were investigated for anticonvulsive properties in the pentylenetetrazol (PTZ) kindling model in mice. Possible side effects on motor impairment were evaluated using the rota-rod test.

RESULTS

Extracts of 10 of the 11 medicinal plants showed affinity to the benzodiazepine binding site on the GABAA receptor. Seven of the 11 extracts inhibited the spontaneous discharges (SEDs) in the mouse cortical wedge preparation, with the extracts of Flueggea virosa and Psorospermum senegalense being the most potent. However, when tested for in vivo anticonvulsive properties these two extracts failed to show any effect on PTZ-induced seizures in mice.

CONCLUSIONS

The pharmacological screening of the ethanolic extracts of 11 Malian medicinal plants in vitro lead to the identification of several extracts with potential anticonvulsant properties.

Assessing the link between omega-3 fatty acids, cardiac arrest, and sudden unexpected death in epilepsy

People with epilepsy may have abnormal cardiac function. This has been linked to a greater incidence of sudden unexpected death in epilepsy (SUDEP). In the present review, we assess the evidence linking cardiac failure to SUDEP, and propose the use of the maximal pentylenetetrazol seizure test to model SUDEP in animals to identify causal links between cardiac failure and SUDEP. We also discuss recent claims on the use of omega-3 polyunsaturated fatty acids to reduce the incidence of SUDEP because of their cardioprotective and anticonvulsant effects.

Seizure-related injury and death

Epilepsy is associated with significantly increased morbidity and mortality from a variety of causes. Patients with epilepsy have approximately two to three times the risk of death from any cause compared with persons without epilepsy. Seizures may cause significant trauma, drowning, and accidental injury. Many of the deaths in persons with epilepsy are directly related to seizures, accidents and injuries arising from seizures, and the underlying condition resulting in seizures. This review focuses on recent data regarding seizure-related injury and mortality.

Premature mortality in people with epilepsy in rural China: a prospective study

BACKGROUND

In China, few studies have described annual mortality associated with epilepsy in a general population and these have provided a range of 3.0-7.9 deaths per 100,000 people. We calculated the case fatality rate (CFR), proportional mortality rate (PMR), and standardised mortality ratio (SMR) to assess mortality in people with epilepsy in rural China.

METHODS

The target population was people with epilepsy who participated in an assessment of epilepsy management at primary health level in rural China. Neurologists confirmed the diagnosis using strict criteria in all participants who were then treated with phenobarbital. Demographic data and putative cause of death were recorded for each person whose death was reported. PMRs for each cause of death and SMRs were estimated on the basis of the 2004 Chinese population.

FINDINGS

Case fatality rate was 1.4% (35 deaths) among 2455 people with epilepsy. The age-adjusted PMRs for injury, stroke, neoplasm, myocardial infarction, and pneumonia were 30%, 30%, 15%, 6%, and 5%, respectively. The SMR was 3.9 (95% CI 3.8-3.9). Patients aged 15-29 years had higher mortality ratios than did those in other age-groups, with SMRs exceeding 23.

INTERPRETATION

Risk for premature death is three to four times higher in people with epilepsy than in the general Chinese population. Furthermore, the risk in young people with epilepsy in China is much higher than previously reported. Injury, stroke, myocardial infarction, and pneumonia are among the leading putative causes of death in patients with epilepsy in rural China.