Psychological distress, comorbidities, and health behaviors among U.S. adults with seizures: results from the 2002 National Health Interview Survey

Perampanel for Treatment of People with a Range of Epilepsy Aetiologies in Clinical Practice: Evidence from the PERMIT Extension Study

INTRODUCTION

It is important to assess the effectiveness of an antiseizure medication in treating different epilepsy aetiologies to optimise individualised therapeutic approaches. Data from the PERaMpanel pooled analysIs of effecTiveness and tolerability (PERMIT) Extension study were used to assess the effectiveness and safety/tolerability of perampanel (PER) when used to treat individuals with a range of epilepsy aetiologies in clinical practice.

METHODS

A post hoc analysis was conducted of PERMIT Extension data from individuals with a known aetiology. Retention was assessed after 3, 6 and 12 months. Effectiveness was assessed after 3, 6 and 12 months and at the last visit (last observation carried forward). Effectiveness assessments included responder rate (≥ 50% seizure frequency reduction) and seizure freedom rate (no seizures since at least the prior visit). Safety/tolerability was assessed by evaluating adverse events (AEs) and AEs leading to discontinuation.

RESULTS

PERMIT Extension included 1945 individuals with structural aetiology, 1012 with genetic aetiology, 93 with an infectious aetiology, and 26 with an immune aetiology. Retention rates at 12 months were 61.1% (structural), 65.9% (genetic), 56.8% (infectious) and 56.5% (immune). At the last visit, responder rates (total seizures) were 43.3% (structural), 68.3% (genetic), 37.0% (infectious) and 20.0% (immune), and corresponding seizure freedom rates were 15.8%, 46.5%, 11.1% and 5.0%, respectively. AE incidence rates were 58.0% (structural), 46.5% (genetic), 51.1% (infectious) and 65.0% (immune), and corresponding rates of discontinuation due to AEs over 12 months were 18.9%, 16.4%, 18.5% and 21.7%, respectively. The types of AEs reported were generally consistent across aetiology subgroups, with no idiosyncratic AEs emerging.

CONCLUSION

Although PER was effective and generally well tolerated when used to treat individuals with a range of epilepsy aetiologies in clinical practice, variability in its effectiveness and tolerability across the subgroups indicates that PER may be particularly useful for individuals with specific epilepsy aetiologies.

The epileptic heart: Cardiac comorbidities and complications of epilepsy. Atrial and ventricular structure and function by echocardiography in individuals with epilepsy - From clinical implications to individualized assessment

Epilepsy is an increasing global neurological health issue. Recently, epidemiological and mechanistic studies have raised concern about cardiac involvement in individuals with epilepsy. This has resulted in the "epileptic heart" concept. Epidemiological data linking epilepsy to cardiovascular disease indicate an increased risk for ventricular and atrial arrhythmias, myocardial infarction, heart failure, and sudden death among individuals with epilepsy. Pathways of this interaction comprise increased prevalence of traditional cardiac risk factors, genetic abnormalities, altered brain circuitry with autonomic imbalance, and antiseizure medications with enzyme-inducing and ionic channel-blocking proprieties. Pathophysiological findings in the atria and ventricles of patients with epilepsy are discussed. Echocardiographic findings and future applications of this tool are reviewed. A risk stratification model and future studies on cardiac risk assessment in individuals with epilepsy are proposed.

Dietary and Metabolic Approaches for Treating Autism Spectrum Disorders, Affective Disorders and Cognitive Impairment Comorbid with Epilepsy: A Review of Clinical and Preclinical Evidence

Epilepsy often occurs with other neurological disorders, such as autism, affective disorders, and cognitive impairment. Research indicates that many neurological disorders share a common pathophysiology of dysfunctional energy metabolism, neuroinflammation, oxidative stress, and gut dysbiosis. The past decade has witnessed a growing interest in the use of metabolic therapies for these disorders with or without the context of epilepsy. Over one hundred years ago, the high-fat, low-carbohydrate ketogenic diet (KD) was formulated as a treatment for epilepsy. For those who cannot tolerate the KD, other diets have been developed to provide similar seizure control, presumably through similar mechanisms. These include, but are not limited to, the medium-chain triglyceride diet, low glycemic index diet, and calorie restriction. In addition, dietary supplementation with ketone bodies, polyunsaturated fatty acids, or triheptanoin may also be beneficial. The proposed mechanisms through which these diets and supplements work to reduce neuronal hyperexcitability involve normalization of aberrant energy metabolism, dampening of inflammation, promotion of endogenous antioxidants, and reduction of gut dysbiosis. This raises the possibility that these dietary and metabolic therapies may not only exert anti-seizure effects, but also reduce comorbid disorders in people with epilepsy. Here, we explore this possibility and review the clinical and preclinical evidence where available.

Retention Rates and Successful Treatment with Antiseizure Medications in Newly-Diagnosed Epilepsy Patients

PURPOSE

Treatment for epilepsy primarily involves antiseizure medications (ASMs), which can be characterized using the clinical data warehouse (CDW) database. In this study, we compared retention rates and time to successful treatment for various ASMs to reflect both efficacy and adverse effects in patients with newly diagnosed epilepsy.

MATERIALS AND METHODS

We identified newly diagnosed epilepsy patients with ASM treatment for more than 12 months using CDW of a tertiary referral hospital. Clinical characteristics were compared between groups with successful and unsuccessful treatment. Cox regression analysis was performed to evaluate independent variables of age, sex, comorbidities, and attributes of ASM regimens.

RESULTS

Of 2515 eligible participants, 46.2% were successfully treated with the first ASM regimen, and 74.7% with all ASM regimens with the median time-to-treatment success of 14 months. Participants with second-generation ASM as the first ASM were more likely to be successfully treated with the first regimen compared to those with first-generation ASM (51.6% vs. 42.3%, p<0.001) and more successfully treated [hazard ratio (HR)=1.26; 95% confidence interval (CI): 1.15-1.39]. Overall, valproic acid was the most common ASM across a wide range of ages under 65 years, while levetiracetam in patients aged over 65 years or lamotrigine in female adult patients. Clinical factors associated with less favorable treatment outcomes included renal disease (HR=0.78; 95% CI: 0.66-0.92), liver disease (HR=0.65; 95% CI: 0.52-0.81), depression (HR=0.70; 95% CI: 0.57-0.84), and mechanical ventilation (HR=0.58; 95% CI: 0.50-0.67).

CONCLUSION

Second-generation ASMs have the advantage of more successful treatment with fewer ASM regimen changes compared with first-generation drugs. Various comorbid conditions as well as age and sex should be considered when selecting ASMs.

Investigating the Impact of Epilepsy on Cognitive Function: A Narrative Review

It has been noted that people who have epilepsy have an increased propensity for cognitive dysfunction. We explored 25 relevant articles on PubMed and Cochrane Library after implementing inclusion criteria. Different factors have been postulated and studied that may cause cognitive dysfunction in these patients; structural brain abnormalities, polypharmacy of antiepileptic medication, and neuropsychiatric disorders are the most common causes. Cognitive assessments such as Montreal Cognitive Assessment (MOCA) and Mini-Mental State Exam (MMSE) are the mainstay tools used to diagnose the degree of cognitive decline, and alterations in EEG (electroencephalogram) parameters have also been noted in people with cognitive decline. The mechanisms and treatments for cognitive decline are still being studied, while attention has also been directed toward preventive and predictive methods. Early detection and treatment of cognitive impairment can help minimize its impact on the patient's quality of life. Regular cognitive assessments are essential for epileptic patients, particularly those on multiple antiepileptic drugs. While proper management of epilepsy and related comorbidities would reduce cognitive decline and improve the overall quality of life for people with epilepsy.

Quality of life and functional limitations in persons with epilepsy

OBJECTIVE

Epilepsy can reduce quality of life (QOL), functionality, and social participation, but these effects have not been adequately quantified in large, population-based, controlled studies. We sought to evaluate the impact of epilepsy on patients' QOL and employment outcomes.

METHODS

In this cross-sectional study we used nationally representative, pooled data from the Medical Expenditure Panel Survey (MEPS) household component files for 2010-2018. MEPS is a population-based survey of U.S. community-dwelling persons. We included respondents with condition file records for epilepsy. We also analyzed respondents with records for seizure. The primary outcomes were short form-12 physical and mental health scores. Secondary outcomes included self-rated health status, employment status, educational attainment, school/household/work limitations, and missed workdays. We compared these outcomes between persons with epilepsy (PWE) and age- and gender-matched controls.

RESULTS

We identified 1078 people with epilepsy, 2344 seizure cases, and 3422 cases of either condition (persons with epilepsy and/or seizures). Epilepsy was associated with a decrease of - 4.0 (95% CI: -5.1 to -2.8) points in SF-12 physical health scores and - 3.1 (95% CI: -4.2 to -1.9) in SF-12 mental health scores. Epilepsy was also associated with decreases in the likelihood of reporting good/very good/excellent health status (-13.3 [95% CI: -16.1 to -10.4] percentage points). Epilepsy was also associated with adverse employment-related outcomes. Specifically, PWE were 17.9 (95% CI: 14.3-21.4) percentage points more likely to report that they had work or household limitations. The associations between outcomes and epilepsy were, in most cases, larger than those between outcomes and other common, chronic conditions.

SIGNIFICANCE

Epilepsy is associated with worse quality of life and employment-related outcomes. Interventions should aim to improve functioning and patients' ability to maintain employment.

Evaluation of eight psychoactive drugs used in Chinese cities by wastewater-based epidemiology

With rapid economic development, an increasing number of people suffer from mental health diseases, which are gradually receiving the attention of society. However, basic data from surveys of mental disorders are limited. Composite influent samples were collected from 26 wastewater treatment plants in 23 major cities in China. The concentrations of the psychoactive drugs diphenhydramine, fluoxetine, doxepin, imipramine, sulpiride, zolpidem, carbamazepine, and flunitrazepam in the wastewater were determined. The detection frequency of diphenhydramine, sulpiride, and carbamazepine was close to 100 %, whereas that of the compounds was lower than 35 %. Carbamazepine had the highest mean consumption (31.1 mg/d/1000 people), followed by diphenhydramine (10.4 mg/d/1000 people) and sulpiride (11.3 mg/d/1000 people). Wastewater-based epidemiology (WBE) estimates of the average use of the three drugs were lower than those from the drug statistics data. Consumption of diphenhydramine in northern China was higher than that in southern China. A correlation analysis of psychotropic and illicit drugs revealed a correlation between sulpiride and heroin use, which may be related to the adverse effects of sulpiride treatment after heroin withdrawal. Psychotropic drug use is associated with both economic and social factors. We found associations between the use of the three drugs and age, occupation, and obesity, which are risk factors for mental disorders. The results showed that the monitoring of psychotropic drug using WBE has a certain reference value for public health care and for improving the understanding of mental disorders.

Mendelian randomization study shows a causal effect of asthma on epilepsy risk

Objective

The relationship between asthma and epilepsy in observational studies is controversial. The purpose of this Mendelian randomization (MR) study is to investigate whether asthma causally contributes to epilepsy susceptibility.

Methods

Independent genetic variants strongly (P<5E-08) associated with asthma were from a recent meta-analysis of genome-wide association studies on 408,442 participants. Two independent summary statistics of epilepsy obtained from the International League Against Epilepsy Consortium (ILAEC, Ncases=15,212, and Ncontrols=29,677) and FinnGen Consortium (Ncases=6,260 and Ncontrols=176,107) were used in the discovery and replication stage, respectively. Several sensitivity analyses and heterogeneity analyses were further conducted to assess the stability of the estimates.

Results

Using the inverse-variance weighted approach, genetic predisposition to asthma was associated with an elevated risk of epilepsy in the discovery stage (ILAEC: odds ratio [OR]=1.112, 95% confidence intervals [CI]= 1.023-1.209, P = 0.012), but not verified in the replication stage (FinnGen: OR=1.021, 95%CI= 0.896-1.163, P =0.753). However, a further meta-analysis of both ILAEC and FinnGen showed a similar result (OR=1.085, 95% CI: 1.012-1.164, P = 0.022). There were no causal associations between the age onset of asthma and epilepsy. Sensitivity analyses yielded consistent causal estimates.

Conclusion

The present MR study suggests that asthma is associated with an increased risk of epilepsy independent of the age onset of asthma. Further studies are warranted to explain the underlying mechanisms of this association.

The impact of hydroalcoholic extract of Anacyclus pyrethrum plant on epileptic seizure induced by pentylenetetrazole in male rat

Background

The aim was to evaluate the protective effect of hydroalcoholic extract of Anacyclus pyrethrum root (APE) against pentylenetetrazole (PTZ) drug which is used for inducing epileptic seizures in animal model.

Results

50 male rats were divided: control (without any intervention), positive control 1st (received PTZ 60 mg/kg, IP), first experimental group (PTZ + Extract 500 mg/kg, gavages, 30 min before PTZ), positive control 2nd (PTZ + Phaclofen, 200 µg/µl, ICV), and second experimental group (PTZ + extract 500 mg/kg, gavage, 30 min before PTZ + Phaclofen 200 µg/µl, ICV). Several parameters were assessed during 20 min and followed up for 1.5 h. Then, the data were analyzed. APE with a dose of 500 mg/kg increased the latency time of seizures in the first experimental group, compared to the positive control 1st, also, comparison of different groups in terms of Seizure Score at the 1st time (severity of first attack) had no significant difference (P-value = 0.51, P-value = 0.34). The mean of seizure attacks (event number) was significant between the first and second positive control groups (P-value = 0.01) and also between the second positive control and the first experimental group (P-value = 0.011). Significant changes were observed in the mean score of the first and second positive control groups (P-value = 0.001) and the first experimental and second positive control groups (P-value = 0.003). In addition, the second experimental group had significant changes compared to the first positive control group (P-value = 0.014), However, no significant changes were observed between the positive control and experimental groups in terms of the severity of seizures.

Conclusion

Results have shown both blocked GABAergic receptors A and B involved in epileptic seizures. In addition, APE root increased delay time of epileptic seizures, as well as reduces epileptic seizure in dose response state.

Racial and socioeconomic disparities in the advanced treatment of medically intractable pediatric epilepsy

OBJECTIVE

Racial and ethnic disparities in healthcare have gained significant importance since the Institute of Medicine published its report on disparities in healthcare. There is a lack of evidence on how race and ethnicity affect access to advanced treatment of pediatric medically intractable epilepsy. In this context, the authors analyzed the latest Kids’ Inpatient Database (KID) for racial/ethnic disparities in access to surgical treatment of epilepsy.

METHODS

The authors queried the KID for the years 2016 and 2019 for the diagnosis of medically intractable epilepsy.

RESULTS

A total of 29,292 patients were included in the sample. Of these patients, 8.9% (n = 2610) underwent surgical treatment/invasive monitoring. The mean ages in the surgical treatment and nonsurgical treatment groups were 11.73 years (SD 5.75 years) and 9.5 years (SD 6.16 years), respectively. The most common insurance in the surgical group was private/commercial (55.9%) and Medicaid in the nonsurgical group (47.7%) (p < 0.001). White patients accounted for the most common population in both groups, followed by Hispanic patients. African American patients made up 7.9% in the surgical treatment group compared with 12.9% in the nonsurgical group. African American (41.1%) and Hispanic (29.9%) patients had higher rates of emergency department (ED) utilization compared with the White population (24.6%). After adjusting for all covariates, the odds of surgical treatment increased with increasing age (OR 1.06, 95% CI 1.053–1.067; p < 0.001). African American race (OR 0.513, 95% CI 0.443–0.605; p < 0.001), Hispanic ethnicity (OR 0.681, 95% CI 0.612–0.758; p < 0.001), and other races (OR 0.789, 95% CI 0.689–0.903; p = 0.006) had lower surgical treatment odds compared with the White population. Medicaid/Medicare was associated with lower surgical treatment odds than private/commercial insurance (OR 0.603, 0.554–0.657; p < 0.001). Interaction analysis revealed that African American (OR 0.708, 95% CI 0.569–0.880; p = 0.001) and Hispanic (OR 0.671, 95% CI 0.556–0.809; p < 0.001) populations with private insurance had lower surgical treatment odds than White populations with private insurance. Similarly, African American patients, Hispanic patients, and patients of other races with nonprivate insurance also had lower surgical treatment odds than their White counterparts after adjusting for all other covariates.

CONCLUSIONS

Based on the KID, African American and Hispanic populations had lower surgical treatment rates than their White counterparts, with higher utilization of the ED for pediatric medically intractable epilepsy.

Effects of Anti-Seizure Medication on Sleep Spindles and Slow Waves in Drug-Resistant Epilepsy

There is a close bidirectional relationship between sleep and epilepsy. Anti-seizure medications (ASM) act to reduce seizure frequency but can also impact sleep; this remains a relatively unexplored field given the importance of sleep on seizure occurrence, memory consolidation, and quality of life. We compared the effect of poly-ASM treatment on a night of sleep compared to an unmedicated night in patients with drug-resistant epilepsy, where ASMs were withdrawn and later restored as part of their pre-surgical evaluation. Within-subject analysis between medicated and unmedicated nights showed ASMs increased spindle (11-16 Hz) power and decreased slow wave (0.1-2 Hz) amplitude. Spindles became less strongly coupled to slow waves in the ASM night compared to no-ASM night, with effects to both the phase and strength of coupling and correlated with slow wave reduction. These effects were not seen in age-matched controls from the same unit where ASMs were not changed between two nights. Overall, we found that ASM polytherapy not only changed specific sleep waveforms, but also the fine interplay of spindle/slow wave coupling. Since these sleep oscillations impact both seizure occurrence and memory consolidation, our findings provide evidence towards a decoupling impact of ASMs on sleep that should be considered in future studies of sleep and memory disruption in people with epilepsy.

Incidence of mental health conditions by seizure control among adults with epilepsy in the United States

BACKGROUND

Mental health conditions (MHCs) are frequent comorbidities among people with epilepsy; however, the influence of seizure control on the incidence of MHCs is not well reported. This retrospective observational cohort study based on claims data evaluated the effects of indicators of poor seizure control on the incidence of MHCs among MHC-naïve people with epilepsy. We hypothesized that poor seizure control is associated with new-onset MHC diagnoses and/or new prescription drugs for MHCs.

METHODS

This study utilized a sample of patients from HealthVerity Marketplace, which includes more than 150 US commercial, Medicare, and Medicaid payers, to identify a cohort of adults (age ≥18 years) with prevalent epilepsy. Follow-up started on day 1 (January 1) after a 1-year eligibility assessment period occurring in calendar year 2017 or 2018. Patients were followed up until the occurrence of an incident MHC event (primary outcome), defined as a mental health diagnosis or psychotropic drug prescription. Time from follow-up to incident MHC diagnosis or to a drug prescription specific to depression or anxiety disorder was analyzed as a secondary outcome. Multivariate Cox proportional hazards regressions were estimated with time-varying covariates, measured in 6-month intervals during follow-up. Time-varying covariates were based on the occurrence of 4 variables used as indicators of poor seizure control in the prior period: epilepsy-related emergent care admissions, epilepsy-related inpatient admissions, epilepsy electroencephalography referrals, and exposure to one or more new antiseizure medications (ASMs).

RESULTS

From a random sample of 40,000 people with epilepsy, 2563 (mean age 46.1 years; 50.6% male) were included in the analysis. Incident MHC events were observed in 27.7% (incidence rate 24.4 events per 100 person-years over 2,915.7 total person-years of follow-up). Mean (standard deviation [SD]) time to event was 232.7 (186.3) days. Among the 4 variables, epilepsy-related emergent care admissions were associated with an increased risk of incident MHC events in the following 6-month period (hazard ratio [HR] = 1.676, 95% confidence interval [CI]: 1.386, 2.026, p < 0.001) as were prescriptions for new ASMs in the previous period (HR = 1.702, 95% CI: 1.359, 2.132, p < 0.001). Previous epilepsy-related emergent care admissions (HR = 1.650, 95% CI: 1.347, 2.021, p < 0.001) and new ASMs (HR = 1.632, 95% CI: 1.280, 2.081, p < 0.001) also predicted an increased risk of incident depression or anxiety in the following 6-month period.

CONCLUSIONS

Previous indicators of poor seizure control, including epilepsy-related emergent care admissions and new ASMs, predicted increased risk of new MHC events, including depression and anxiety, during the following 6-month interval in MHC-naïve patients with prevalent epilepsy. These data suggest that poor seizure control can increase the subsequent risk of new mental health diagnoses and treatment among people with epilepsy.

The interaction between circadian rhythm and epilepsy

Evidence about the interaction between circadian rhythms (CR) and epilepsy has been expanded with the application of advanced detection technology. An adequate understanding of how circadian system and epilepsy interact with each other could contribute to more accurate seizure prediction as well as rapid development of potential treatment timed to specific phases of CR. In this review, we present the reciprocal relationship between CR and epileptic activities from aspects of sleep effect, genetic modulation and brain biochemistry. It has been found that sleep-wake patterns, circadian timing systems and multidien rhythms have essential roles in seizure activities and interictal epileptiform discharge (IED). For instance, specific distribution patterns of seizures and IED have been reported, i.e., lighter non-rapid eye movement (NREM) sleep stage (stage 2) induces seizures while deeper NREM sleep stage (stage 3) activates IEDs. Furthermore, the epilepsy type, seizure type and seizure onset zone can significantly affect the rhythms of seizure occurrence. Apart from the common seizure types, several specific epilepsy syndromes also have a close correlation with sleep-wakefulness patterns. Sleep influences the epilepsy rhythm, and conversely, epilepsy alters the sleep rhythm through multiple pathways. Clock genes accompanied by two feedback loops of regulation have an important role in cortical excitability and seizure occurrence, which may be involved in the mTORopathy. The suprachiasmatic nuclei (SCN) has a rhythm of melatonin and cortisol secretion under the circadian pattern, and then these hormones can feed back into a central oscillator to affect the SCN-dependent rhythms, leading to variable but prominent influence on epilepsy. Furthermore, we discuss the precise predictive algorithms and chronotherapy strategies based on different temporal patterns of seizure occurrence for patients with epilepsy, which may offer a valuable indication for non-invasive closed-loop treatment system. Optimization of the time and dose of antiseizure medications, and resynchronization of disturbed CR (by hormone therapy, light exposure, ketogenic diet, novel small molecules) would be beneficial for epileptic patients in the future. Before formal clinical practice, future large-scale studies are urgently needed to assist prediction and treatment of circadian seizure activities and address unsolved restrictions.

Gender differences in prevalence and risk factors of sleep disturbances in patients with epilepsy

Background

Sleep disturbances are frequently observed in patients with epilepsy (PWE), with adversely effects on life quality and seizure control. The study aimed to assess the gender differences in incidence and factors of sleep disturbances in PWE.

Methods

PWE confirmed the diagnosis of epilepsy were consecutively enrolled in this cross-sectional study, with detailed information recorded. A group of healthy participants were recruited as the control. Sleep and mood disorders were evaluated with the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI).

Results

One hundred and thirty-three patients (age: 30.2 ± 10.6 years, men: 51%) and 150 healthy subjects were recruited in this study. Compared with healthy controls, PWE had higher mean scores of the ISI and BDI (p < 0.001 and p = 0.01). There were no significant gender differences in the prevalence and scores of sleep disturbances in PWE. In the overall PWE, nocturnal seizures and focal epilepsy were respectively related to insomnia and poor sleep quality (OR = 3.35, p = 0.024; OR = 3.08, p = 0.013), and mood disorders were also important factors in sleep disturbances (p < 0.05). In the analysis by gender, depression, anxiety, nocturnal seizures and focal epilepsy were associated with insomnia and poor sleep quality in men. For women, however, depression mood was the only factor of sleep disturbances.

Conclusions

Though no gender difference was observed in the incidence of sleep disturbances, factors contributing to insomnia and sleep quality were different by gender. The factors and gender differences of sleep disturbances should be taken into account in the clinical treatment.

Quality of life for patients with psychogenic nonepilepsy seizures in comparison with age- and gender-matched patients with epilepsy - Cross-sectional study

AIMS

Patients with psychogenic nonepileptic seizures (PNES), and age- and gender-matched patients with epilepsy (PWE) who utilized an out-patient service were compared regarding quality of life (QoL) and self-reported symptoms of depression. Additionally, the impact of miscellaneous clinical variables including symptoms of depression on QoL in patients with PNES and PWE in real-world settings was assessed.

SUBJECTS AND METHODS

Adult patients who had a diagnosis of definite or documented PNES based on LaFrance's criteria (PNES group, n = 62), or of epilepsy based on results of clinical and EEG procedures (Epilepsy group, n = 61) were enrolled. To assess QoL and evaluate depression, the Quality of Life in Epilepsy Inventory-10 (QOLIE-10) and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), respectively, were administered.

RESULTS

Comparisons between the groups revealed a shorter duration of illness and fewer number of attacks in patients with PNES as compared to the Epilepsy group (p < 0.0001; p = 0.0003, respectively). There was no significant difference between the groups revealed by the QOLIE-10 (p = 0.141), while the patients with PNES tended to have higher NDDI-E scores (p = 0.068). Multiple regression analysis of QOLIE-10 results in the PNES group revealed that NDDI-E score was the sole significant contributor (β = -0.425 p = 0.001). In contrast, NDDI-E score as well as attack frequency had a significant impact on QOLIE-10 results in the Epilepsy group (β = -0.283 p = 0.026; β = -0.272 p = 0.031, respectively).

CONCLUSION

In PWE and patients with PNES who utilized an out-patient service, QoL did not differ significantly between those groups. For treating PNES, psychosocial factors may be a more appropriate indicator of therapeutic goal than attack frequency.

Similar Profile and Magnitude of Cognitive Impairments in Focal and Generalized Epilepsy: A Pilot Study

Introduction: Cognitive impairments in epilepsy are not well-understood. In addition, long-term emotional, interpersonal, and social consequences of the underlying disturbances are important to evaluate.

Purpose: To compare cognitive function including language in young adults with focal or generalized epilepsy. In addition, quality of life and self-esteem were investigated.

Patients and Methods: Young adults with no primary intellectual disability, 17 with focal epilepsy and 11 with generalized epilepsy participated and were compared to 28 healthy controls. Groups were matched on age (mean = 26 years), sex, and education. Participants were administered a battery of neuropsychological tasks and carried out self-ratings of quality of life, self-esteem, and psychological problems.

Results: Similar impairments regarding cognitive function were noted in focal and generalized epilepsy. The cognitive domains tested were episodic long-term memory, executive functions, attention, working memory, visuospatial functions, and language. Both epilepsy groups had lower results compared to controls (effect sizes 0.24–1.07). The total number of convulsive seizures was predictive of episodic long-term memory function. Participants with focal epilepsy reported lower quality of life than participants with generalized epilepsy. Lowered self-esteem values were seen in both epilepsy groups and particularly in those with focal epilepsy. Along with measures of cognitive speed and depression, the total number of seizures explained more than 50% of variation in quality of life.

Conclusion: Interestingly, similarities rather than differences characterized the widespread cognitive deficits that were seen in focal and generalized epilepsy, ranging from mild to moderate. These similarities were modified by quality of life and self-esteem. This study confirms the notion that epilepsy is a network disorder.

Epilepsy-associated comorbidities among adults: A plausible therapeutic role of gut microbiota

Epilepsy is a debilitating disorder that affects about 70 million people in the world currently. Most patients with epilepsy (PWE) often reported at least one type of comorbid disorder. These may include neuropsychiatric disorders, cognitive deficits, migraine, cardiovascular dysfunction, systemic autoimmune disorders and others. Current treatment strategies against epilepsy-associated comorbidities have been based on targeting each disorder separately with either anti-seizure medications (ASMs), anti-inflammatories or anti-depressant drugs, which have often given inconsistent and ineffective results. Gut dysbiosis may be a common pathological pathway between epilepsy and its comorbid disorders, and thus may serve as a possible intervention target. Therefore, this narrative review aimed to elucidate the potential pathological and therapeutic role of the gut microbiota in adult epilepsy-associated comorbidities. This review noticed a scarcity in the current literature on studies investigating the direct role of the gut microbiota in relation to epilepsy-associated comorbidities. Nevertheless, gut dysbiosis have been implicated in both epilepsy and its associated comorbidities, with similarities seen in the imbalance of certain gut microbiota phyla (Firmicutes), but differences seen in the mechanism of action. Current gut-related interventions such as probiotics have been consistently reported across studies to provide beneficial effects in correcting gut dysbiosis and improving various disorders, independent of epilepsy. However, whether these beneficial effects may translate towards epilepsy-associated comorbidities have yet to be determined. Thus, future studies determining the therapeutic potential of gut microbiota interventions in PWE with epilepsy-associated comorbidities may effectively improve their quality of life.

The quality of life among Sudanese patients with epilepsy, Khartoum, Sudan

INTRODUCTION

This is the first study done in the National Center for Neurological Sciences, Khartoum State, to assess the quality of life among more than 100 Sudanese epileptic patients, in the period from September to December 2020.

METHODOLOGY

This is a descriptive cross-sectional study; data were collected using an interview-based semi-structured structured questionnaire and this questionnaire was modified from the SF-36 model.

RESULTS

Most of the patients were from urban areas and origin (60.2%), most of which were housewives; the majority of the patients were single and from low socioeconomic status, history of the disease was less than 3 years for most of the cases covered in this study, most of the cases were classified as generalized tonic clonic epilepsy, and normal EEG findings and normal MRI brain were found in 75.7% and 78.6%, respectively. Most patients mentioned that they experienced no attacks during the last month. Regarding mental health, 47.6% experienced symptoms of depression, and 75.7% had memory problems. In terms of physical health, 51.5% felt energetic all of the time, 9.7% experienced remarkable sleep disturbance, most of the patients are not driving nor have established hobbies during leisure time. 63.1% of the participants do not have health problems; 32% mentioned that they would feel stigmatized if an attack takes place in public. Commonest medication prescribed was carbamazepine, out of which 73.8% are fully compliant with their medication. 95.1% are not worried about long term use of medication.

CONCLUSION

Lower levels of education and manual labor are associated with poor quality of life. Epilepsy has an adverse impact on social life. There is a global decrease in cognitive function, and most of the patients are not worried about the side effects and duration of the medication usage.

Understanding successful transition to independent living: A qualitative study of young adults with disabilities

Background

Independent Living (IL) involves having choice and control over where and with whom one lives. People with disabilities are less likely to live independently than their peers without disabilities.

Objective

The purpose of this study was to understand the perceptions of young adults with mobility disabilities regarding IL, how they define IL, and what advice they would give others considering living a more independent life.

Method

Semi-structured interviews were conducted with six young adults with mobility disabilities who had successfully transitioned to living independently. A content analysis was used to identify emergent themes from the interviews.

Results

Results indicate that participants had individualized perceptions of the definition of IL. Participants identified many barriers and facilitators to IL, including the physical layout of housing, available amenities, and social support. They recommended preparing for IL in advance and taking advantage of outside resources to enable a successful transition.

Conclusion

Young adults with mobility disabilities define IL in various ways, which may have an impact on whether they consider their transition to IL successful. Findings can be used to guide recommendations for young people with disabilities to use to ensure a successful transition to IL.

Burden of Chronic and Acute Conditions and Symptoms in People With Epilepsy

BACKGROUND AND OBJECTIVES

People with epilepsy, one-third of whom in the United States are on Medicaid, experience a wide range of chronic and physical comorbidities that influence their care and outcomes. In this study, we examine the burden and racial/ethnic disparities of chronic and acute conditions, injuries, and symptoms in a large and diverse group of people with epilepsy on Medicaid.

METHODS

Using 5 years of Medicaid claims data, we identified adults with epilepsy and used all available claims and diagnoses to identify each person's Clinical Classification Codes groups diagnosed during the study period. Using association rule mining, we identified the top combinations of conditions and stratified these by race/ethnicity to identify potential prevalence disparities. We examined the top combinations of conditions in high utilizers; that is, individuals in the top quartile of hospitalizations and emergency department visits.

RESULTS

Among 81,963 patients, the most common conditions were anxiety and mood disorders (46.5%), hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache (29.5%). When examining combinations of conditions, anxiety and mood disorders continued to have an outsized prevalence, appearing in nearly every combination. There were notable disparities in disease burden, with American Indians and Alaskan Natives having a substantially higher prevalence of developmental disorders, while Black individuals had a higher prevalence of hypertension. These disparities persisted to the higher-order combinations that included these conditions. High utilizers had a much higher disease burden, with 75.8% having an anxiety or mood disorder, as well as a higher burden of injuries.

DISCUSSION

This study shows a high prevalence of psychiatric and physical conditions and identifies racial and ethnic disparities affecting people with epilepsy. Targeting interventions to consider the comorbidities, race, and ethnicity has potential to improve clinical care and reduce disparities.

Human Stem Cell-Derived GABAergic Interneurons Establish Efferent Synapses onto Host Neurons in Rat Epileptic Hippocampus and Inhibit Spontaneous Recurrent Seizures

Epilepsy is a complex disorder affecting the central nervous system and is characterised by spontaneously recurring seizures (SRSs). Epileptic patients undergo symptomatic pharmacological treatments, however, in 30% of cases, they are ineffective, mostly in patients with temporal lobe epilepsy. Therefore, there is a need for developing novel treatment strategies. Transplantation of cells releasing γ-aminobutyric acid (GABA) could be used to counteract the imbalance between excitation and inhibition within epileptic neuronal networks. We generated GABAergic interneuron precursors from human embryonic stem cells (hESCs) and grafted them in the hippocampi of rats developing chronic SRSs after kainic acid-induced status epilepticus. Using whole-cell patch-clamp recordings, we characterised the maturation of the grafted cells into functional GABAergic interneurons in the host brain, and we confirmed the presence of functional inhibitory synaptic connections from grafted cells onto the host neurons. Moreover, optogenetic stimulation of grafted hESC-derived interneurons reduced the rate of epileptiform discharges in vitro. We also observed decreased SRS frequency and total time spent in SRSs in these animals in vivo as compared to non-grafted controls. These data represent a proof-of-concept that hESC-derived GABAergic neurons can exert a therapeutic effect on epileptic animals presumably through establishing inhibitory synapses with host neurons.

Predictors of seizure recurrence in emergency department pediatric patients with first-onset afebrile seizure: A retrospective observational study

INTRODUCTION

The primary goals of emergency department (ED) clinicians when dealing with a pediatric patient experiencing a seizure are to control the seizure and prevent seizure-related complications. After stabilizing the patient, the clinician should determine whether the patient is likely to have recurrent seizures that may need treatment such as antiepileptic drugs (AEDs). The early identification of pediatric seizure patients at high risk for recurrence can be of great help in consulting with their parents. This study aimed to identify predictors of seizure recurrence in pediatric patients who visited the ED for first-onset afebrile seizure.

METHODS

This retrospective study was conducted with pediatric patients aged 1 month to 18 years who visited our ED for afebrile seizure from January 2016 to March 2020. Children with a known seizure disorder, known underlying genetic or metabolic disorder, or acute trauma history, and those lost to follow-up were excluded. Multivariable logistic regression analysis was performed to identify factors associated with seizure recurrence.

RESULTS

A total of 253 pediatric patients were included in the study. Seizure recurrence was observed in 117 patients (46.3%). From the multivariable logistic regression analysis, older age at onset (11-15 years, odds ratio [OR] 5.781, p = 0.001; 16-18 years, OR 6.223, p = 0.002), a longer seizure duration (1-5 min, OR 3.043, p = 0.002; 6-10 min, OR 5.629, p = 0.002; >10 min, OR 8.882, p = 0.002), blood pH under 7.2 (OR 8.308, p = 0.015), and a glucose level over 144 mg/dL (OR 6.408, p = 0.030) were significantly associated with seizure recurrence. The area under the receiver operating characteristic curve for the multivariable logistic regression analysis was 0.774.

CONCLUSION

Age at onset ≥11 years, a longer seizure duration, acidosis, and hyperglycemia were predictors of seizure recurrence in children who had experienced first-onset afebrile seizure.

Electrocardiographic Abnormalities and Mortality in Epilepsy Patients

Background and Objectives: People with epilepsy (PWE) have a 2–3 times higher mortality rate than the general population. Sudden unexpected death in epilepsy (SUDEP) comprises a significant proportion of premature deaths, whereas sudden cardiac death (SCD) is among the leading causes of sudden death in the general population. Cardiac pathologies are significantly more prevalent in PWE. Whether electrocardiographic (ECG) parameters are associated with remote death in PWE has yet to be elucidated. The study objective was to assess whether interictal ECG parameters are associated with mortality in the long-term. Materials and Methods: The study involved 471 epilepsy patients who were hospitalized after a bilateral tonic-clonic seizure(s). ECG parameters were obtained on the day of hospitalization (heart rate, PQ interval, QRS complex, QT interval, heart rate corrected QT interval (QTc), ST segment and T wave changes), as well as reported ECG abnormalities. Mortality data were obtained from the Latvian National Cause-of-Death database 3–11, mean 7.0 years after hospitalization. The association between the ECG parameters and the long-term clinical outcome were examined. Results: At the time of assessment, 75.4% of patients were alive and 24.6% were deceased. Short QTc interval (odds ratio (OR) 4.780; 95% confidence interval (CI) 1.668–13.698; p = 0.004) was associated with a remote death. After the exclusion of known comorbidities with high mortality rates, short QTc (OR 4.631) and ECG signs of left ventricular hypertrophy (OR 5.009) were associated with a remote death. Conclusions: The association between routine 12-lead rest ECG parameters—short QTc interval and a pattern of left ventricular hypertrophy—and remote death in epilepsy patients was found. To the best of our knowledge, this is the first study to associate rest ECG parameters with remote death in an epileptic population.

Cardiovascular disease risk, awareness, and treatment in people with epilepsy

OBJECTIVE

To evaluate whether cardiovascular risk, risk awareness, and guideline concordant treatment differ in individuals with versus without epilepsy.

METHODS

This was a retrospective cross-sectional study using the National Health and Nutrition Examination Survey. We included participants ≥18 years for 2013-2018. We classified participants as having epilepsy if reporting ≥1 medication treating seizures. We calculated 10-year atherosclerotic cardiovascular disease (ASCVD) risk using the revised pooled cohort equation. We compared unadjusted and adjusted risk for participants with versus without epilepsy. We then assessed hypertension and diabetes disease awareness and control, plus statin guideline-concordance. We assessed mediators for both ASCVD risk and cardiovascular disease awareness.

RESULTS

Of 17,961 participants, 154 (0.9%) had epilepsy. Participants with epilepsy reported poorer diet (p = 0.03), fewer minutes of moderate-vigorous activity per day (p < 0.01), and increased frequency of cardiovascular conditions (e.g. coronary heart disease, myocardial infarction, stroke). There was no difference in control of individual examination and laboratory risk factors between groups (A1c, systolic blood pressure, diastolic blood pressure, high-density lipoprotein, low-density lipoprotein, total cholesterol). However, epilepsy was associated with 52% (95% confidence interval [CI]: 0-130%) increase in ASCVD risk, which became nonsignificant after adjusting for health behaviors. No single studied variable (income, Patient Health Questionnaire-9 (PHQ-9), diet, smoking) had a significant indirect effect. Participants with epilepsy reported increased hypertension awareness which was trivially but significantly mediated by having a routine place of healthcare (indirect effect: 1% absolute increase (95% CI: 0-1%), and they reported increased rates of hypertension treatment and guideline-concordant statin therapy. Participants with versus without epilepsy reported similar rates of blood pressure control and diabetes awareness, treatment, and control.

CONCLUSIONS

Participants with epilepsy had increased ASCVD risk, despite similar or better awareness, treatment, and control of individual risk factors such as diabetes and hypertension. Our results suggest that epilepsy is associated with numerous health behaviors leading to cardiovascular disease, though the causal pathway is complex as these variables (income, depression, diet, exercise, smoking) generally served as confounders rather than mediators.

Association between allergic diseases and epilepsy: A systematic review and meta-analysis

OBJECTIVE

A number of studies have suggested a pathophysiological link between allergic diseases and epilepsy. Understanding the association between allergic diseases and epilepsy can help establish healthcare policies, implement prevention strategies, and provide a new direction for treatment. The study aimed to examine the association between allergic diseases and epilepsy.

METHODS

PubMed, EMBASE, and Web of Science were searched for relevant primary articles. Two individuals independently conducted abstract screening, full-text review, data extraction, and quality assessment. Random-effects models were used to pool the risk estimates.

RESULTS

From the 3124 citations identified, 32 were reviewed in full text. Finally, 11 studies with a total of 3,312,033 subjects were eligible for the analyses. Few studies reported the type of epilepsy, and there were inconsistent attempts to control for confounding. The pooled result showed that there was an 81% increase in the prevalence of epilepsy among individuals with asthma compared with those without asthma (odds ratio: 1.81, 95% confidence interval [CI]:1.47-2.21). The incidence of epilepsy in patients with eczema was 2.57 (95%CI: 1.54-4.27). Sensitivity analyses confirmed that no single study qualitatively influenced the pooled OR. All funnel plots were asymmetric upon visual inspection, suggesting publication bias.

CONCLUSION

Our findings suggest that patients with allergic diseases might have a high risk of epilepsy. Additional high-quality primary studies are required to confirm the association, obtain information regarding the mechanism of association, and determine prevention opportunities.

Climate change and epilepsy: Insights from clinical and basic science studies

Climate change is with us. As professionals who place value on evidence-based practice, climate change is something we cannot ignore. The current pandemic of the novel coronavirus, SARS-CoV-2, has demonstrated how global crises can arise suddenly and have a significant impact on public health. Global warming, a chronic process punctuated by acute episodes of extreme weather events, is an insidious global health crisis needing at least as much attention. Many neurological diseases are complex chronic conditions influenced at many levels by changes in the environment. This review aimed to collate and evaluate reports from clinical and basic science about the relationship between climate change and epilepsy. The keywords climate change, seasonal variation, temperature, humidity, thermoregulation, biorhythm, gene, circadian rhythm, heat, and weather were used to search the published evidence. A number of climatic variables are associated with increased seizure frequency in people with epilepsy. Climate change-induced increase in seizure precipitants such as fevers, stress, and sleep deprivation (e.g. as a result of more frequent extreme weather events) or vector-borne infections may trigger or exacerbate seizures, lead to deterioration of seizure control, and affect neurological, cerebrovascular, or cardiovascular comorbidities and risk of sudden unexpected death in epilepsy. Risks are likely to be modified by many factors, ranging from individual genetic variation and temperature-dependent channel function, to housing quality and global supply chains. According to the results of the limited number of experimental studies with animal models of seizures or epilepsy, different seizure types appear to have distinct susceptibility to seasonal influences. Increased body temperature, whether in the context of fever or not, has a critical role in seizure threshold and seizure-related brain damage. Links between climate change and epilepsy are likely to be multifactorial, complex, and often indirect, which makes predictions difficult. We need more data on possible climate-driven altered risks for seizures, epilepsy, and epileptogenesis, to identify underlying mechanisms at systems, cellular, and molecular levels for better understanding of the impact of climate change on epilepsy. Further focussed data would help us to develop evidence for mitigation methods to do more to protect people with epilepsy from the effects of climate change.

The relation of fibromyalgia and fibromyalgia symptoms to self-reported seizures

Objective

Several epidemiological and clinical reports associate fibromyalgia (FM) with seizure disorders, and clinical studies associate FM diagnosis with psychogenic non-epileptic seizures. However, these associations rely on self-reports of being diagnosed with FM or unstandardized clinical diagnosis in combination with small samples. We investigated the association of FM and self-reported seizures using a large rheumatic disease databank and the current established self-reported, symptom-based FM diagnostic criteria.

Methods

We selected a random observation from 11,378 subjects with rheumatoid arthritis (RA), 2,390 (21.0%) of whom satisfied 2016 revised criteria for FM. Patients were inquired about the presence of any kind of seizures in the previous 6 months, anti-epileptic medications, and patient-reported symptoms and outcomes.

Results

Seizures were reported by 89 RA patients who met FM criteria (FM+) and by 97 patients who did not (FM-), resulting in an age- and sex-adjusted seizure prevalence of 3.74 (95% CI 2.95 to 4.53) per 100 FM+ subjects and 1.08 (95% CI 0.87 to 1.30) in FM- subjects. The seizure odds ratio of FM+ to FM- cases was 3.54 (95% CI 2.65 to 4.74). Seizures were associated to a very similar degree with symptom reporting (somatic symptom count and comorbidity index) as to FM diagnosis variables. RA patients reporting seizures also reported worse pain, quality of life, and functional status. Seizure patients treated with anti-seizure medication had worse outcomes and more comorbidities than seizure patients with no seizure drugs.

Conclusions

We found a significant and similar association of both FM diagnostic variables and FM-related symptom variables, including the number of symptoms and comorbidities, with self-reported seizures in people with RA. The observed association was similar to those found in previous studies of symptoms variables and seizures and does not suggest a unique role for fibromyalgia diagnosis. Rather, it suggests that multi-symptom comorbidity is linked to seizures in a complex and not yet clearly understood way. As the current study relied on self-reported seizures and was not able to distinguish between epileptic and psychogenic nonepileptic seizures, future studies are needed to replicate the findings using both validated FM criteria assessments and clinically verified diagnoses of epileptic and psychogenic seizures.

Risk factors, etiologies, and comorbidities in urban pediatric epilepsy

The Seizures and Outcomes Study in Children (SOS-KIDS) identifies risk factors, etiologies, and comorbidities in a pediatric epilepsy population in a major city with diversity in socioeconomic levels. A thorough understanding of the range of issues impacting children with epilepsy is critical to establishing treatment that will produce better health outcomes. SOS-KIDS is a cross-sectional cohort study of pediatric epilepsy patients who live in Washington D.C. and are evaluated at Children's National Hospital. Families were recruited at the time of the child's routine clinic appointment or inpatient visit. Information was extracted from participants' electronic medical records (EMR) and parent reports; participants were screened for comorbidities using standardized screening measures. Data were collected from 289 participants (47% female, 53% male), and mean age was 7.9 years (2 months to 17 years). Twenty-nine percent of participants had primary generalized epilepsy, 63% focal epilepsy, 0.3% combined generalized and focal epilepsy, and 8% could not be distinguished. There were a variety of epilepsy risk factors including prematurity (10%), intraventricular hemorrhage (7%), neonatal seizures (8%), and febrile seizures (17%). The most common etiologies were cerebral malformations (13%) and genetic disorders (25%). Numerous participants had documented comorbidities including developmental delay (56%), intellectual disability (20%), headaches (16%), attention-deficit hyperactivity disorder (23%), and autism (7%). Of participants aged six years and older, depression, and anxiety were reported in 5% and 6% within the EMR, 14% and 19% in parent surveys, and 22% and 33% with standardized screening measures. We identified a wide variety of risk factors and etiologies among urban pediatric epilepsy patients, with genetic and structural being the most common. Neurologic and psychiatric comorbidities were common, but the prevalence of several psychiatric disorders reported within the EMR was substantially lower compared to that found when using parent surveys and standardized screening measures.

The relation of major depression, OCD, personality disorders and affective temperaments with Temporal lobe epilepsy

BACKGROUND

In patients with temporal lobe epilepsy (TLE), studies demonstrate frequent comorbidity with mood disorders, personality disorders (especially obsessive-compulsive disorder) and major depression, but there are conflicting findings. This study aimed to investigate psychiatric comorbidities and affective temperament among TLE patients and to explore the relationships between obsessive compulsive disorder, other personality disorders, major depression and affective temperament in order to clarify the mediator effect of TLE in these relationships.

METHODS

Thirty patients with TLE and 30 healthy volunteers were included. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Structured Clinical Interview for DSM III-R Axis II Disorders (SCID-II), Hamilton Anxiety (HAM-A) scale, Hamilton Depression (HAM-D) scale, Beck Suicidal Ideation Scale (BSSI) and Yale Brown Obsession Compulsion Scale (YBOCS) were applied and evaluated by a psychiatrist. Additionally, all individuals completed The Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A).

RESULTS

Patients with temporal lobe epilepsy had higher scores in TEMPS-A, HAM-A, HAM-D, YBOCS and BSSI. Major depression, obsessive compulsive disorder and dependent and antisocial personality disorders were prevalent in patients. With respect to affective temperaments, depressive, cyclothymic and anxious temperaments were associated with obsessive compulsive disorder comorbidity; whereas, depressive and anxious temperaments were found to be associated with major depression comorbidity in patients with TLE. Furthermore, cluster A and cluster C personality disorders were associated with affective temperaments in patients with TLE. Affective temperaments had no correlation with illness duration, seizure frequency, depression severity and suicidal thoughts, but obsessions and compulsions. Suicidal thoughts were associated with obsessions and compulsions.

CONCLUSION

Affective temperaments are core personality traits with biological background and they may provide a foundation for psychiatric disorders, especially mood disorders. Considering that TLE originates from abnormalities in brain circuitry, it may form a basis for psychiatric disorders. Therefore, psychiatric evaluation to determine comorbidities may be beneficial to increase the quality of life of patients with TLE.

Screening for suicidality and its relation to undiagnosed psychiatric comorbidities in children and youth with epilepsy

INTRODUCTION

Depression and anxiety are the most common psychiatric comorbidities in children and youth with epilepsy (CYE) and known to contribute to suicidality among them. However, not much is known about suicidality in CYE without established psychiatric comorbidities. Our research aimed to fill this knowledge gap and correlate this latent suicidality with screening tests for depression and anxiety.

METHOD

After Institutional Review Board (IRB) approval, CYE who attended the epilepsy clinic or underwent testing in the pediatric epilepsy monitoring unit at the Cleveland Clinic and lacked established psychiatric diagnosis were enrolled. They filled out self-reported, validated scales for screening of depression, anxiety, and suicidality (Center for Epidemiological Studies Depression Scale for Children [CES-DC], Screen for Child Anxiety Related Emotional Disorders [SCARED], and Ask Suicide-Screening Questions [ASQ], respectively). Univariate descriptive statistics along with χ² test of association and independent Student's t-test were performed for statistical analysis.

RESULTS

A total of 119 (54.6% females) CYE were included in the study. Close to a third (30.2%) of CYE were positive for anxiety on SCARED, and 41.2% were positive for depression based on CSE-DC scoring. A total of 13 (10.9%) CYE indicated suicidality by answering at least one positive response on ASQ. The SCARED had a low positive correlation with the ASQ (r = 0.32) but a moderate positive correlation with the CES-DC (r = 0.64).

CONCLUSION

We found that a small but significant 11% of CYE without any established psychiatric diagnosis expressed suicidality on a self-reported questionnaire. This highlights the importance of using psychiatry screening tests in all CYE. Future research using a larger, diversified cohort is needed to confirm our findings.

Hippocampal Neural Stem Cell Grafting after Status Epilepticus Alleviates Chronic Epilepsy and Abnormal Plasticity, and Maintains Better Memory and Mood Function

Hippocampal damage after status epilepticus (SE) leads to multiple epileptogenic changes, which lead to chronic temporal lobe epilepsy (TLE). Morbidities such as spontaneous recurrent seizures (SRS) and memory and mood impairments are seen in a significant fraction of SE survivors despite the administration of antiepileptic drugs after SE. We examined the efficacy of bilateral intra-hippocampal grafting of neural stem/progenitor cells (NSCs) derived from the embryonic day 19 rat hippocampi, six days after SE for restraining SE-induced SRS, memory, and mood impairments in the chronic phase. Grafting of NSCs curtailed the progression of SRS at 3-5 months post-SE and reduced the frequency and severity of SRS activity when examined at eight months post-SE. Reduced SRS activity was also associated with improved memory function. Graft-derived cells migrated into different hippocampal cell layers, differentiated into GABA-ergic interneurons, astrocytes, and oligodendrocytes. Significant percentages of graft-derived cells also expressed beneficial neurotrophic factors such as the fibroblast growth factor-2, brain-derived neurotrophic factor, insulin-like growth factor-1 and glial cell line-derived neurotrophic factor. NSC grafting protected neuropeptide Y- and parvalbumin-positive host interneurons, diminished the abnormal migration of newly born neurons, and rescued the reelin+ interneurons in the dentate gyrus. Besides, grafting led to the maintenance of a higher level of normal neurogenesis in the chronic phase after SE and diminished aberrant mossy fiber sprouting in the dentate gyrus. Thus, intrahippocampal grafting of hippocampal NSCs shortly after SE considerably curbed the progression of epileptogenic processes and SRS, which eventually resulted in less severe chronic epilepsy devoid of significant cognitive and mood impairments.

Quality of life, fatigue and seizure severity in people living with epilepsy in a selected Nigerian population

BACKGROUND

Epilepsy, a chronic seizure disorder, can cause elevated fatigue and reduced quality of life (QOL) of the sufferers. Hence, improving QOL, seizure severity (SS) and fatigue are important areas of therapeutic interventions for people living with epilepsy (PLWE). Therefore, there is need to ascertain the levels and interrelationships among these constructs in PLWE.

OBJECTIVE

This study compared fatigue and QOL of PLWE with those of apparently healthy individuals (AHIs) and also determined the interrelationships between fatigue, QOL and SS in PLWE.

METHOD

This cross-sectional survey involved 91 PLWE and 101 AHIs consecutively recruited from purposively selected hospitals and hosting communities. The Short-form Health Survey (SF-36) questionnaire, the Fatigue Severity Scale, the Modified Fatigue Impact Scale and the Seizure Severity Questionnaire were used to evaluate QOL, fatigue severity (FS), fatigue impact (FI) and SS respectively. Data was analyzed using frequency count, proportions, mean and standard deviation, range, Chi-square test, Mann-Whitney U test and Spearman-rank order correlation. Alpha level was set at 0.05.

RESULTS

PLWE had significantly lower QOL compared to AHIs (U = 3057.00;p < 0.01). The two groups however experienced similar fatigue severity, but PWE suffered greater fatigue impact (U = 2798.00;p < 0.01). Significant relationships existed among FI, FS, SS and QOL in PLWE (p < 0.01).

CONCLUSION

Compared with AHIs, PLWE had poorer QOL, similar FS, and higher FI. QOL of PLWE was negatively associated with SS, FI and FS. Clinical interventions geared towards minimizing seizure, severity and impact of fatigue may improve the QOL of PLWE.

Synthetic and medicinal chemistry of phthalazines: Recent developments, opportunities and challenges

Fused diaza-heterocycles constitute the core structure of numerous bioactive natural products and effective therapeutic drugs. Among them, phthalazines have been recognized as remarkable structural leads in medicinal chemistry due to their wide application in pharmaceutical and agrochemical industries. Accessing such challenging pharmaceutical agents/drug candidates with high chemical complexity through synthetically efficient approaches remains an attractive goal in the contemporary medicinal chemistry and drug discovery arena. In this review, we focus on the recent developments in the synthetic routes towards the generation of phthalazine-based active pharmaceutical ingredients and their biological potential against various targets. The general reaction scope of these innovative and easily accessible strategies was emphasized focusing on the functional group tolerance, substrate and coupling partner compatibility/limitation, the choice of catalyst, and product diversification. These processes were also accompanied by the mechanistic insights where deemed appropriate to demonstrate meaningful information. Moreover, the rapid examination of the structure-activity relationship analyses around the phthalazine core enabled by the pharmacophore replacement/integration revealed the generation of robust, efficient, and more selective compounds with pronounced biological effects. A large variety of in silico methods and ADME profiling tools were also employed to provide a global appraisal of the pharmacokinetics profile of diaza-heterocycles. Thus, the discovery of new structural leads offers the promise of improving treatments for various tropical diseases such as tuberculosis, leishmaniasis, malaria, Chagas disease, among many others including various cancers, atherosclerosis, HIV, inflammatory, and cardiovascular diseases. We hope this review would serve as an informative collection of structurally diverse molecules enabling the generation of mature, high-quality, and innovative routes to support the drug discovery endeavors.

Associations between seizure severity change and patient characteristics, changes in seizure frequency, and health-related quality of life in patients with focal seizures treated with adjunctive eslicarbazepine acetate: Post hoc analyses of clinical trial results

The relationships between seizure severity change and patient characteristics, changes in seizure frequency, and health-related quality of life (HRQoL) may be important for determining the overall impact of medication therapy on patients with epilepsy. The objectives of these post hoc analyses of the global Phase III 093-0304 trial (NCT00988429, Study 304) of adjunctive eslicarbazepine acetate (ESL) in patients with refractory focal (partial-onset) seizures (FS) were to evaluate associations between seizure severity change, measured by the Seizure Severity Questionnaire (SSQ), and 1) patient characteristics, 2) seizure frequency change, standardized as the seizure frequency (SSF) per 28-day period, and 3) change in HRQoL, evaluated by the Quality of Life in Epilepsy Inventory-31 (QOLIE-31) and the Montgomery-Åsberg Depression Rating Scale (MADRS). The analyses were conducted on the per-protocol population (PPP) of patients who were randomized to a placebo arm (n = 188) or an ESL-active group that included treatment with adjunctive ESL 800 mg once daily (QD; n = 184) or adjunctive ESL 1200 mg QD (n = 175). General linear models (GLM) were used to measure the association between SSQ change and patient baseline characteristics or percentage change in the SSF from baseline. Associations between changes in the SSQ and changes in the QOLIE-31 and MADRS were examined using GLM with patient baseline characteristics as covariates. Subgroup analyses were performed for patients in the ESL-active group and those treated with ESL 800 mg or ESL 1200 mg. Minimal clinically important difference (MCIDs) thresholds were used to assess improvements in SSQ scores. The analyses included 547 per-protocol patients. Patients using 1 antiepileptic drug (AED) at baseline had greater improvements in the SSQ compared with those receiving 2 AEDs (P = 0.0606). Treatment with ESL 1200 mg was significantly associated with clinically meaningful improvements in the SSQ (P = 0.0005). The SSQ improvements were significantly associated with an SSF reduction of ≥75%, compared with no reduction (P < 0.0001). In the PPP and the ESL-active group, SSQ improvements were significantly associated with improvements in QOLIE-31 Total Score (TS; P < 0.0001) and the Seizure Worry (SW; P < 0.0001) and Social Functioning (SF; P = 0.0030) subscales. In the ESL 1200 mg subgroup, SSQ improvements were significantly associated with improvements in QOLIE-31 TS (P < 0.0001) and the SW (P < 0.0001) and Energy/Fatigue (EF; P = 0.0007) subscales. In the ESL 800 mg subgroup, improvements in the SSQ were significantly associated with improvements in QOLIE-31 TS (P = 0.0362) and the SW (P = 0.0241) subscale. There was no significant association between changes in the SSQ and changes in the MADRS in patients treated with ESL. These findings demonstrated that in this clinical trial population, adding ESL to baseline AED therapy had utility for decreasing seizure severity and improving HRQoL. There were no significant associations between changes in seizure severity and changes in depressive symptoms in patients with FS.

Synthesis of 1,3,4-oxadiazole derivatives with anticonvulsant activity and their binding to the GABAA receptor

In this study, a series of 1,3,4-oxadiazole derivatives (5a-s, 10a-s, and 16a-d) were designed and synthesized using maximal electroshock (MES) and subcutaneous pentylenetetrazole (scPTZ) models, to test the anticonvulsant activity of the target compounds in vivo. The neurotoxicity (NT) of the target compounds was measured using the rotating rod (ROT) method. Seven compounds with potential activity were selected to test the 50% effective dose (ED₅₀) and 50% toxic dose (TD₅₀). Pharmacological experiments revealed that 6-((5-(pentylthio)-1,3,4-oxadiazol-2-yl)methoxy)-3,4-dihydroquinolin-2(1H)-one (5b) showed the best anticonvulsant activity (MES, ED₅₀ = 8.9 mg/kg; scPTZ, ED₅₀ = 10.2 mg/kg), which was greater than the activities of carbamazepine and ethosuximide. Compound 5b exhibited the most potent binding affinity toward the GABA_A receptor (IC₅₀ = 0.11 μM) in the in vitro binding experiments. Compound 5b displayed significant anxiolytic activity at a low dose (1 mg/kg) in the elevated plus maze (EPM) test. The GABA content in rat brains was also investigated, and the results showed that compound 5b might have affected the GABA system. In our molecular docking experiment, compound 5b showed significant interactions with residues present at the benzodiazepine binding site on the GABA_A receptor. The structure and physicochemical and pharmacokinetic properties of the target compound were predicted using Discovery Studio 2019 and ChemBioDraw Ultra 14.0. Finally we demonstrated that compound 5b mainly acted on GABA_A receptor. Thus the present study has provided potential candidates for further investigation in epilepsy.

CDC-supported epilepsy surveillance and epidemiologic studies: A review of progress since 1994

To report progress, to identify gaps, and to plan epilepsy surveillance and research activities more effectively, the Centers for Disease Control and Prevention (CDC) Epilepsy Program has summarized findings from selected CDC-supported surveillance and epidemiologic studies about epilepsy from 1994 through 2019. We identified publications supported by CDC funding and publications conducted by the CDC Epilepsy Program alone or with partners. We included only epilepsy surveillance and epidemiologic studies focusing on epilepsy burden, epilepsy-related outcomes, and healthcare utilization. We describe the findings of these studies in the following order: 1)prevalence; 2)incidence; 3)epilepsy-related outcomes by selected demographic characteristics; 4)cysticercosis or neurocysticercosis (NCC); 5)traumatic brain injury (TBI); 6)comorbidity; 7)mortality; 8)access to care; 9)quality of care; and 10) cost. We have characterized these findings in relation to the scope of the first three domains of the 2012 Institute of Medicine report on epilepsy and its relevant first four recommendations. From 1994 through 2019, 76 publications on epilepsy-related epidemiologic and surveillance studies were identified. Over the past 25 years, CDC has expanded community, state, and national surveillance on epilepsy and supported epidemiologic studies by using multiple assessment methods and validated case-ascertainment criteria to identify epilepsy burden, epilepsy-related outcomes, and healthcare utilization in the general population or in population subgroups. Among identified research opportunities, studies on epilepsy incidence and risk factors, mortality, and cost are considered as important surveillance gaps. Other remaining gaps and suggested surveillance strategies are also proposed. Findings from this review may help epilepsy researchers and other stakeholders reference and prioritize future activities for epidemiologic and surveillance studies in epilepsy.

Epilepsy self-management behaviors among African Americans with epilepsy

PURPOSE

Although self-management practices are heavily studied in the general population of adults with epilepsy, African American people with epilepsy (PWE) have been understudied. Improving understanding about epilepsy self-management among African Americans is warrantedbecause of the significantly greater mortality rates among this population compared withPWE from other racial/ethnic groups. The purpose of this study was to assess the reliability and validity of the Adult Epilepsy Self-Management Measurement Instrument (AESMMI) for Black/African American adults and describe their self-management behaviors.

METHODS

This study was a cross-sectional survey of self-identified Black/African American adults who reported that a health provider diagnosed them as having epilepsy or a seizure disorder. Participants completed a cross-sectional survey between spring 2017 and fall 2018. The survey measured self-management behaviors (65-itemAESMMI), quality of life, depression, seizure severity, epilepsy history, and demographics. We ran descriptive analyses, computed scales, and ran reliability statistics for the AESMMI. Correlations were run between total AESMMI score and depression symptoms and quality of life to assess construct validity.

RESULTS

Generally, participants (N = 114) were male (58.6%), from urban/suburban settings (90.5%), at least high school graduates (86.4%), and of lowerincome (90.3%). Their ages ranged from 19 to 64 years with a mean age of 53 years (standard deviation [SD] = 10.9). Participants had general (72.8%) and focal seizures (55.3%) primarily. Many were diagnosed at a young age (M = 10.9), were on antiepileptic medications (91.2%), and had seen a primary care doctor (68.4%) or general neurologist for treatment (54.4%). Sixty percent had visited a neurologist in the past year. African American participants had a low score on quality of life (Quality of Life in Epilepsy [QOLIE], M = 1.86) and low depression symptoms (Patient Health Questionnaire [PHQ-8], M = 3.13). Participants reported conducting self-management behaviors in the following domains more frequently: proactivity (M = 4.11), medication adherence (M = 3.92), healthcare communications (M = 3.91), and social support (M = 3.90). In contrast, they performed self-management behaviors related to treatment (M = 3.34), stress management (M = 3.56), and safety (M = 3.58) less frequently. The overall reliability of the AESMMI was 0.88. Adult Epilepsy Self-Management Measurement Instrument score was correlated with quality of life (r = 0.151).

CONCLUSION

Findings are clinically relevant as knowing patients'self-management behaviors enables healthcare clinicians to support and encourage adults to improve the management of their epilepsy. Services or interventions related to coping with stress, safety, and adherence with treatment and medication may be warranted for African Americans with epilepsy.

Identifying epilepsy psychiatric comorbidities with machine learning

OBJECTIVE

People with epilepsy are at increased risk for mental health comorbidities. Machine-learning methods based on spoken language can detect suicidality in adults. This study's purpose was to use spoken words to create machine-learning classifiers that identify current or lifetime history of comorbid psychiatric conditions in teenagers and young adults with epilepsy.

MATERIALS AND METHODS

Eligible participants were >12 years old with epilepsy. All participants were interviewed using the Mini International Neuropsychiatric Interview (MINI) or the MINI Kid Tracking and asked five open-ended conversational questions. N-grams and Linguistic Inquiry and Word Count (LIWC) word categories were used to construct machine learning classification models from language harvested from interviews. Data were analyzed for four individual MINI identified disorders and for three mutually exclusive groups: participants with no psychiatric disorders, participants with non-suicidal psychiatric disorders, and participants with any degree of suicidality. Performance was measured using areas under the receiver operating characteristic curve (AROCs).

RESULTS

Classifiers were constructed from 227 interviews with 122 participants (7.5 ± 3.1 minutes and 454 ± 299 words). AROCs for models differentiating the non-overlapping groups and individual disorders ranged 57%-78% (many with P < .02).

DISCUSSION AND CONCLUSION

Machine-learning classifiers of spoken language can reliably identify current or lifetime history of suicidality and depression in people with epilepsy. Data suggest identification of anxiety and bipolar disorders may be achieved with larger data sets. Machine-learning analysis of spoken language can be promising as a useful screening alternative when traditional approaches are unwieldy (eg, telephone calls, primary care offices, school health clinics).

Health Behaviors and Psychological Distress Among Conscripts of the Lithuanian Military Service: A Nationally Representative Cross-Sectional Study

The decline in healthy behavior in young people is a concern for public health in general and for country's defense. The aim of this study is to identify and compare health behaviors and psychological distress between male conscripts enlisted and rejected for military service. This cross-sectional study included 1243 men aged 19-26 years (mean age 22.50 ± 2.43 years). We assessed health behaviors (physical activity, adherence to healthy eating patterns, cigarette smoking, and alcohol consumption) and psychological distress. Among all conscripts, 44.7% were physically inactive, 50.2% had low adherence to healthy nutrition, 9.6% were heavy drinkers, 62.3% were current smokers, and 9.1% had high psychological distress level. Compared with physically inactive conscripts, physically active conscripts were more likely to be enlisted (adjusted odds ratio (OR) = 1.42; 95% confidence interval (CI) 1.11-2.03). Compared with current nonsmokers, current smokers were less likely to be enlisted (OR = 0.58; CI 0.39-0.86). Compared with conscripts with a high distress level, those with a low distress level were almost four times more likely to be enlisted (OR = 0.26; 95% CI 0.12-0.55). Adherence to guidelines for healthy eating and alcohol consumption was not significantly related to enlistment. These findings suggest that health behaviors in male conscripts are unsatisfactory. That is, about half are physically inactive, have a poor diet, and smoke, and nearly one in 10 is a heavy drinker and has a high psychological distress level. The enlisted conscripts were more likely to be sufficiently physically active and less likely to be a current smoker or have a high distress level. Early intervention programs to provide a heathier population of young men for conscription should focus on mental well-being and target health-related behaviors such as physical activity and not smoking. Preferably, these should be implemented as health education programs in schools to help prevent the development of adverse health behaviors among young men. Governmental policies and strategies are required to enable intersectional collaboration and shared responsibility among the education, military and health sectors.

Comparison of psychiatric comorbidities and impact on quality of life in patients with epilepsy or psychogenic nonepileptic spells

OBJECTIVES

Psychiatric comorbidity is common in people with epilepsy (PWE) and psychogenic nonepileptic spells (PNES). These comorbidities can be detrimental to quality of life (QOL) and are often underdiagnosed and undertreated. Some types of epilepsy, such as focal temporal lobe epilepsy (TLE), have been associated with higher rates of psychiatric comorbidity. This study examined the impact of psychiatric comorbidity on QOL in patients admitted to two level 4 epilepsy monitoring units (EMUs).

METHODS

In this prospective observational study, 200 patients admitted to two level 4 EMUs completed standardized surveys including the Quality of Life in Epilepsy (QOLIE-31-P), Generalized Anxiety Disorder 7-item (GAD-7), Patient Health Questionnaire (PHQ-9), and Beck Depression Inventory-II (BDI-II). Hierarchal multiple regression was performed to assess impact on QOL.

RESULTS

Of the 200 participants, 113 had a diagnosis of epilepsy, 36 had a diagnosis of PNES, and 51 were excluded for nondiagnostic evaluation or dual diagnosis. Of those with epilepsy, 65 had TLE, 28 had focal extratemporal lobe epilepsy (ETLE), and 20 had nonfocal epilepsy. Patients with PNES had higher self-reported anxiety and depression levels (GAD-7: p = 0.04, PHQ-9: p < 0.01; BDI-II: p < 0.01) but similar QOL to PWE (p = 0.78). Using hierarchal multiple regression, symptoms of anxiety and depression were significant predictors of lower QOL in PWE but not in patients with PNES. There was no difference in QOL in those with ETLE and TLE.

CONCLUSIONS

Our findings suggest that self-reported anxiety and depression symptoms are common in patients admitted to level 4 EMUs regardless of diagnosis and play an important role in predicting QOL in PWE. Our findings emphasize the importance of routinely screening all EMU patients for psychiatric comorbidity.

Optimizing therapies for neurobehavioral comorbidities of epilepsy using chronic ambulatory electrocorticography

There is an unmet need to improve therapy for neuropsychiatric comorbidities that are highly prevalent in persons with epilepsy (PWE). However, diagnosing and monitoring the neurobehavioral symptoms is challenging as their presentation can overlap with seizures. In this retrospective study, we report the advantage of chronic ambulatory electrocorticography (ECoG) from implanted Responsive Neurostimulator System (RNS®) in characterizing these psychosomatic paroxysms as a possible ictal, postictal, or interictal phenomenon and how the diagnosis guided the therapy choices. Five out of 21 patients with RNS had neuropsychiatric symptoms (panic attack, psychosis, conversion, and somatization disorders) that overlapped with their seizure semiology and were found to benefit from the use of RNS ECoG data by timely diagnosing and titrating targeted therapies. The cases illustrate the use of RNS ECoG data in diagnosing and improving the management of comorbidities in PWE. The ability to access RNS ECoG data and correlate it with patient symptoms is unique among available therapeutic options for PWE.

Common mental disorders and its determinants among epileptic patients at an outpatient epileptic clinic in Felegehiwot Referral Hospital, Bahirdar, Ethiopia: cross-sectional study

Background

Epilepsy is a chronic neurological condition that is highly predisposed to a variety of mental health problems due to its huge biological, social and psychological burdens. Despite this, there is a paucity of research in this area. Therefore, assessing common mental disorders and its determinants among epileptic patients would be of great importance.

Objective

This study was aimed to asses prevalence and associated factors of common mental disorders among people with epilepsy attending Felegehiwot Referral Hospital, Bahirdar, Ethiopia, 2019.

Methods

Institutional based analytic cross-sectional study design was utilized from January to February 2019 at Felegehiwot Referral Hospital among 422 epileptic patients who were diagnosed clinically and on follow up treatment. Systematic random sampling was applied to recruit participants. Interviewer based and pretested Self Reporting Questionnaire‐20 was used to screen common mental illness with a cut-off point 7 and above as having a common mental disorder. Bivariate and multivariable logistic regression analysis with 95% CI were computed and variables with p < 0.05 in the final model were considered as associated factors for common mental disorders.

Result

Four hundred twenty-two patients with epilepsy were included in our study with a response rate of 100% and 64.5% were males. The mean age of participants was 59 ± 13.37 years. Common mental disorder among epileptic patients was found to be 35.8%. There was a statistically significant association between marital status, comorbid medical illness, nicotine dependence, alcohol misuse, and medication non-adherence with common mental disorders at p < 0.05.

Conclusion

The prevalence of common mental distress was high (35.8%) suggesting that it is a public health issue. Marital status, comorbid medical illness, nicotine dependence, alcohol misuse, and medication non-adherence were the factors having an association with a common mental disorder. Therefore, early screening and recognition of mental distress symptoms should be a routine activity while managing epileptic patients.

Serotonin and sudden unexpected death in epilepsy

Epilepsy is a highly prevalent disease characterized by recurrent, spontaneous seizures. Approximately one-third of epilepsy patients will not achieve seizure freedom with medical management and become refractory to conventional treatments. These patients are at greatest risk for sudden unexpected death in epilepsy (SUDEP). The exact etiology of SUDEP is unknown, but a combination of respiratory, cardiac, neuronal electrographic dysfunction, and arousal impairment is thought to underlie SUDEP. Serotonin (5-HT) is involved in regulation of breathing, sleep/wake states, arousal, and seizure modulation and has been implicated in the pathophysiology of SUDEP. This review explores the current state of understanding of the relationship between 5-HT, epilepsy, and respiratory and autonomic control processes relevant to SUDEP in epilepsy patients and in animal models.

Social functions and socioeconomic vulnerability in epilepsy

Social functions are commonly impaired in people with epilepsy who are at increased risk of experiencing altered social cognition, communication problems, and interpersonal difficulties. Several factors are implicated, including developmental delay, seizure-related factors, somatic and psychiatric comorbidities, antiepileptic drugs (AEDs), and - not least - the effects of stigma. The variable interaction of all these factors can explain the differing pictures observed in the various epilepsy phenotypes but is also a source of interindividual variability depending on the strength of the effects of each factor on social cognition. This article is part of the Special Issue "Epilepsy and social cognition across the lifespan.