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Liu HY, Zeng S, Chen YW, Yi M, Tan XY, Xie JH, Wu X, Zhu LH. A simulation training of family management for parents of children with epilepsy: a randomized clinical trial. Ital J Pediatr 2024; 50:77. [PMID: 38641843 PMCID: PMC11027396 DOI: 10.1186/s13052-024-01646-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/07/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Epilepsy is a chronic neurological disorder that is more likely to be diagnosed in children. The main treatment involves long-term use of anti-epileptic drugs and above all, home care is of great importance. As there has not been a widely accepted home care protocols, simulating a home care environment is necessary for caregivers to develop skills of proper home care. This study aims to evaluate the effectiveness of a simulation training of family management style (STOFMS) for parents of children with epilepsy in China. METHODS A randomized controlled trial was conducted on 463 children with epilepsy and their families. They were recruited from March 2020 to November 2022 and randomly assigned to the STOFMS group or the conventional group in a 1:1 ratio. Scores of family management measures, 8-item of Morisky Medication Adherence and epilepsy clinical symptom of both groups were collected at three points of time: within 24 h after admission (T0), 3 months after discharge (T1), and 6 months after discharge (T2). Changes due to intervention were compared across groups by repeated-measures ANOVA. The study report followed the CONSORT 2010 checklist. RESULTS There were statistically significant differences between the two groups at T2. A considerable increase over the baseline was observed in the total management level score and subscale scores in the STOFMS group at T1, compared with essentially no change in the control group. In terms of medication adherence, the STOFMS group performance improved greatly at T1 and T2 compared with the control group. The same result was also found in clinical efficacy at T2 (p < 0.05). CONCLUSION STOFMS is an effective intervention to improve family management level, treatment adherence and clinical efficacy for children with epilepsy. TRIAL REGISTRATION The registration number is ChiCTR2200065128. Registered at 18 October 2022, http://www.medresman.org.cn.
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Affiliation(s)
- Hua-Yan Liu
- Hunan Children's Hospital, Changsha, Hunan, China
| | - Shan Zeng
- Hunan Children's Hospital, Changsha, Hunan, China
| | - Yue-Wei Chen
- Hunan Children's Hospital, Changsha, Hunan, China
| | - Min Yi
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Xiao-Yan Tan
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Jian-Hui Xie
- Hunan Children's Hospital, Changsha, Hunan, China
| | - Xia Wu
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Li-Hui Zhu
- Hunan Children's Hospital, Changsha, Hunan, China.
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Matricardi S, Scorrano G, Prezioso G, Burchiani B, Di Cara G, Striano P, Chiarelli F, Verrotti A. The latest advances in the pharmacological management of focal epilepsies in children: a narrative review. Expert Rev Neurother 2024; 24:371-381. [PMID: 38433525 DOI: 10.1080/14737175.2024.2326606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Focal epilepsy constitutes the most common epilepsy in children, and medical treatment represents the first-line therapy in this condition. The main goal of medical treatment for children and adolescents with epilepsy is the achievement of seizure freedom or, in drug-resistant epilepsies, a significant seizure reduction, both minimizing antiseizure medications (ASM)-related adverse events, thus improving the patient's quality of life. However, up to 20-40% of pediatric epilepsies are refractory to drug treatments. New ASMs came to light in the pediatric landscape, improving the drug profile compared to that of the preexisting ones. Clinicians should consider several factors during the drug choice process, including patient and medication-specific characteristics. AREAS COVERED This narrative review aims to summarize the latest evidence on the effectiveness and tolerability of the newest ASMs administered as monotherapy or adjunctive therapy in pediatric epilepsies with focal onset seizures, providing a practical appraisal based on the existing evidence. EXPERT OPINION The latest ASMs have the potential to be effective in the pharmacological management of focal onset seizures in children, and treatment choice should consider several drug- and epilepsy-related factors. Future treatments should be increasingly personalized and targeted on patient-specific pathways. Future research should focus on discovering new chemical compounds and repurposing medications used for other indications.
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Affiliation(s)
- Sara Matricardi
- Department of Paediatrics, University of Chieti, Chieti, Italy
| | | | | | | | - Giuseppe Di Cara
- Department of Paediatrics, University of Perugia, Perugia, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | | | - Alberto Verrotti
- Department of Paediatrics, University of Perugia, Perugia, Italy
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D'Onofrio G, Roberti R, Riva A, Russo E, Verrotti A, Striano P, Belcastro V. Pharmacodynamic rationale for the choice of antiseizure medications in the paediatric population. Neurotherapeutics 2024; 21:e00344. [PMID: 38521667 PMCID: PMC11070715 DOI: 10.1016/j.neurot.2024.e00344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024] Open
Abstract
In the landscape of paediatric epilepsy treatment, over 20 anti-seizure medications (ASMs) have gained approval from Drug Regulatory Agencies, each delineating clear indications. However, the complexity of managing drug-resistant epilepsy often necessitates the concurrent use of multiple medications. This therapeutic challenge highlights a notable gap: the absence of standardized guidelines, compelling clinicians to rely on empirical clinical experience when selecting combination therapies. This comprehensive review aims to explore current evidence elucidating the preferential utilization of specific ASMs or their combinations, with a primary emphasis on pharmacodynamic considerations. The fundamental objective underlying rational polytherapy is the strategic combination of medications, harnessing diverse mechanisms of action to optimize efficacy while mitigating shared side effects. Moreover, the intricate interplay between epilepsy and comorbidities partly may influence the treatment selection process. Despite advancements, unresolved queries persist, notably concerning the mechanisms underpinning drug resistance and the paradoxical exacerbation of seizures. By synthesizing existing evidence and addressing pertinent unresolved issues, this review aims to contribute to the evolving landscape of paediatric epilepsy treatment strategies, paving the way for more informed and efficacious therapeutic interventions.
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Affiliation(s)
- Gianluca D'Onofrio
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Roberta Roberti
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Antonella Riva
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Emilio Russo
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | | | - Pasquale Striano
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy; Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
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Serrano-Castro PJ, Ramírez-García T, Cabezudo-Garcia P, Garcia-Martin G, De La Parra J. Effect of Cenobamate on Cognition in Patients with Drug-Resistant Epilepsy with Focal Onset Seizures: An Exploratory Study. CNS Drugs 2024; 38:141-151. [PMID: 38265735 PMCID: PMC10881647 DOI: 10.1007/s40263-024-01063-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Most second and third generation antiseizure medications (ASMs) are associated with cognitive adverse events, which are a major concern for patients. However, the profile of cognitive adverse events differs between ASMs. This study investigated the effects of cenobamate on cognition in patients with drug-resistant epilepsy (DRE) within the Spanish Expanded Access Program (EAP). METHODS This was a retrospective, observational study. Inclusion criteria were age ≥ 18 years, DRE with focal seizures, and availability of cognition assessments and EAP authorization. Data were sourced from the clinical records of patients who took part in the Spanish cenobamate EAP. Primary endpoints included cognition (based on 20 neuropsychological outcomes, including verbal and visuospatial episodic memory, verbal fluency, executive function, working memory, attention, and speed of processing), seizure frequency, and concomitant antiseizure medication (ASM) usage at 6 months. RESULTS The study included 20 patients; 10 patients (50%) had daily seizures, 7 (35%) had weekly seizures and 3 (15%) had monthly seizures. The median number of prior antiseizure medications (ASMs) and concomitant ASMs were 10 and 3, respectively. Mean cenobamate doses were 12.5 mg/day at baseline and 191.2 mg/day at 6 months. There was a statistically significant improvement in cognitive scores between baseline and 6 months for two measures of verbal episodic memory (p = 0.0056 and p = 0.0013) and one measure of visuospatial episodic memory (p = 0.011), and a significant worsening in cognitive score for attention (p = 0.030). At 6 months, 14 patients (70%) had a ≥ 50% reduction in seizure frequency, 3 patients (15%) had a ≥ 90% reduction, and 1 patient (5%) was seizure free. There were significant decreases in the mean number of concomitant ASMs (p = 0.0009), the sum of the ratios of prescribing daily dose/daily defined dose (total ratio of DDD) for concomitant ASMs (p < 0.0001), and concomitant ASM drug load (p = 0.038) between baseline and 6 months. Total ratio of DDD was significantly lower at 6 months for perampanel (p = 0.0016), benzodiazepines (p = 0.035), and sodium channel blockers (p = 0.0005) compared with baseline. Based on analysis of covariance, cognitive tests related to verbal or visuospatial episodic memory (e.g., RT of FCSRT, or ROCFT), executive functions (e.g., TMT-B), and processing speed (some 5-Digit Test subtests) appeared to be closely related to the reduction in pharmacological burden rather than the improvement in seizure control. CONCLUSIONS Significant improvements in cognition, seizure frequency, and concomitant ASM usage were observed after the introduction of cenobamate in patients with DRE in a real-world setting. Covariance analysis supports the reduction in concomitant ASMs as the most important factor driving cognitive improvements with cenobamate. As this was an exploratory study with an uncontrolled, retrospective design and a low number of patients, further studies are required to confirm the findings.
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Affiliation(s)
- Pedro J Serrano-Castro
- Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma Bionand), Málaga, Spain.
- Hospital Regional Universitario de Málaga, Avenida Carlos Haya, S/N, Pabellon B, 4º Planta, CP: 24010, Málaga, Spain.
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain.
- Red Andaluza de Investigación Clínica y Traslacional (Neuro-RECA), Málaga, Spain.
| | - Teresa Ramírez-García
- Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma Bionand), Málaga, Spain
- Red Andaluza de Investigación Clínica y Traslacional (Neuro-RECA), Málaga, Spain
| | - Pablo Cabezudo-Garcia
- Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma Bionand), Málaga, Spain
- Hospital Regional Universitario de Málaga, Avenida Carlos Haya, S/N, Pabellon B, 4º Planta, CP: 24010, Málaga, Spain
- Red Andaluza de Investigación Clínica y Traslacional (Neuro-RECA), Málaga, Spain
| | - Guillermina Garcia-Martin
- Instituto de Investigación Biomédica de Málaga (IBIMA-Plataforma Bionand), Málaga, Spain
- Hospital Regional Universitario de Málaga, Avenida Carlos Haya, S/N, Pabellon B, 4º Planta, CP: 24010, Málaga, Spain
- Red Andaluza de Investigación Clínica y Traslacional (Neuro-RECA), Málaga, Spain
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Pietrafusa N, Falcicchio G, Russo E, Lattanzi S, Goffredo B, Simeoli R, Cairoli S, Corsetti T, Roberti R, De Tommaso M, Vigevano F, La Neve A, Specchio N. Cenobamate as add-on therapy for drug resistant epilepsies: effectiveness, drug to drug interactions and neuropsychological impact. What have we learned from real word evidence? Front Pharmacol 2023; 14:1239152. [PMID: 38186643 PMCID: PMC10768012 DOI: 10.3389/fphar.2023.1239152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Background: Cenobamate (CNB) is an anti-seizure medication (ASM) approved in 2021 in Europe for adjunctive treatment of focal-onset seizures in adults who were not adequately controlled with at least two previous ASMs. Methods: seizure outcome, treatment-emergent adverse events, neuropsychological profile, and blood levels of CNB and concomitant ASM were analyzed in a real world setting in two different Italian epilepsy centers in the context of CNB early access program. All patients performed a general cognitive evaluation, while 32 patients underwent the administration of a battery of neuropsychological tests at baseline and 6 months after CNB treatment. We performed CNB quantification in plasma in 31 patients at different doses in the range of 100-400 mg/day (65 measures). Results: we enrolled 54 patients with a median age of 27.9 years. The mean follow-up was 10.7 months. Most (91%) completed the efficacy analysis. At last follow-up visit, a 69.5% median seizure reduction was registered. Thirty-two patients (59.2%) had a ≥50% reduction of seizures that was ≥75% in 20 (42.0%) cases, whilst 10 (20.2%) patients were seizure-free. The most common adverse events were somnolence (53.1%), dizziness (28.1%) and diplopia (12.5%). The correlation between CNB dose and plasma concentration, revealed a significant linear correlation (r = 0.86, p < 0.0001), and there was a significant difference in mean plasma concentration/dose administered ratio (C/D ratio) between patients taking or not at least one inducer (0.10 ± 0.04 [(μg/mL)/(mg/day)]; n = 47 vs. 0.13 ± 0.05 [(μg/mL)/(mg/day)]; n = 18, p = 0.04). CNB dose was inversely correlated (r = -0.31, p = 0.02) to the C/D ratio of Carbamazepine blood levels. and positively correlated (r = 0.74, p < 0.0001) with an increased plasma concentration of the active Clobazam metabolite N-desmethylclobazam. General Anxiety Disorder-7 showed a significant improvement of score from baseline evaluation of 6.82 to follow-up 6 months evaluation of 4.53 (p = 0.03). Conclusion: In this real-world study, we registered a clinically meaningful reduction in seizure frequency after CNB administration in most patients along with a good tolerability profile. CNB treatment is correlate to a reduction in symptom severity of anxiety score. Plasma levels measurements confirm that CNB acts both as "victim" and as "perpetrator" of drug-drug interactions.
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Affiliation(s)
- Nicola Pietrafusa
- Clinical and Experimental Neurology, Full Member of European Reference Network EpiCARE, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giovanni Falcicchio
- Department of Translational Biomedicine and Neurosciences, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Emilio Russo
- Science of Health Department, University Magna Grecia of Catanzaro, Catanzaro, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Bianca Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Tiziana Corsetti
- Hospital Pharmacy Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Roberta Roberti
- Science of Health Department, University Magna Grecia of Catanzaro, Catanzaro, Italy
| | - Marina De Tommaso
- Department of Translational Biomedicine and Neurosciences, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Federico Vigevano
- Head of Neurological Sciences and Rehabilitation Medicine Scientific Area, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Angela La Neve
- Department of Translational Biomedicine and Neurosciences, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Nicola Specchio
- Clinical and Experimental Neurology, Full Member of European Reference Network EpiCARE, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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Aungaroon G. Cenobamate: Real-World Experience Matches Clinical Trials. Epilepsy Curr 2023; 23:348-350. [PMID: 38269341 PMCID: PMC10805087 DOI: 10.1177/15357597231197105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Adjunctive Cenobamate in Highly Active and Ultra-Refractory Focal Epilepsy: A “Real-World” Retrospective Study Pena-Ceballos J, Moloney PB, Munteanu T, Doyle M, Colleran N, Liggan B, Breen A, Murphy S, El-Naggar H, Widdess-Walsh P, Delanty N. Epilepsia . 2023;64(5):1225-1235. doi:10.1111/epi.17549 Objective: Recent clinical trials have shown that cenobamate substantially improves seizure control in focal-onset drug-resistant epilepsy (DRE). However, little is known about cenobamate’s performance in highly active (≥20 seizures/month) and ultra-refractory focal epilepsy (≥6 failed epilepsy treatments, including antiseizure medications [ASMs], epilepsy surgery, and vagus nerve stimulation). Here, we studied cenobamate’s efficacy and tolerability in a “real-world” severe DRE cohort. Methods: We conducted a single-center retrospective analysis of consecutive adults treated with cenobamate between October 2020 and September 2022. All patients received cenobamate through an Early Access Program. Cenobamate retention, seizure outcomes, treatment-emergent adverse events, and adjustments to concomitant ASMs were analyzed. Results: Fifty-seven patients received cenobamate for at least 3 months (median duration, 11 months). The median cenobamate dose was 250 mg/day (range 75–350 mg). Baseline demographics were consistent with highly active (median seizure frequency, 60/month) and ultra-refractory epilepsy (median previously failed ASMs, nine). Most (87.8%) had prior epilepsy surgery and/or vagus nerve stimulation. Six patients stopped cenobamate due to lack of efficacy and/or adverse events. One patient died from factors unrelated to cenobamate. Among patients who continued cenobamate, three achieved seizure freedom (5.3% of cohort), 24 had a 75%–99% reduction in seizures (42.1% of cohort), and 16 had a 50%–74% reduction (28.1% of cohort). Cenobamate led to abolition of focal to bilateral tonic–clonic seizures in 55.6% (20/36) of patients. Among treatment responders, 67.4% (29/43) were treated with cenobamate doses of ≥250 mg/day. Three-fourths of patients reported at least one side-effect, most commonly fatigue and somnolence. Adverse events most commonly emerged at cenobamate doses of ≥250 mg/day. Side-effects were partially manageable by reducing the overall ASM burden, most often clobazam, eslicarbazepine, and perampanel. Significance: Patients with highly active and ultra-refractory focal epilepsy experienced meaningful seizure outcomes on cenobamate. Emergence of adverse events at doses above 250 mg/day may limit the potential for further improvements in seizure control at higher cenobamate doses.
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Affiliation(s)
- Gewalin Aungaroon
- Department of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati
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Makridis KL, Kaindl AM. Real-world experience with cenobamate: A systematic review and meta-analysis. Seizure 2023; 112:1-10. [PMID: 37713961 DOI: 10.1016/j.seizure.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/17/2023] Open
Abstract
PURPOSE Despite many new ASM, the rate of patients with drug-resistant epilepsy (DRE) has not changed. Cenobamate (CNB) is a novel ASM for the treatment of focal-onset seizures in adults with high seizure freedom rates in randomized controlled trials (RCT). Although CNB appears to be effective, it is not commonly prescribed to patients with DRE, resulting in a lack of "real-world data". METHODS To evaluate the real-world effect of CNB and to assess the generalizability of RCT data, a systematic review and meta-analysis was conducted. Pooled proportions were calculated using a random intercept logistic regression model. RESULTS The analysis included seven studies with a total of 229 patients with DRE, 77.3 % of whom were adults and 91.5 % had focal-onset seizures. Seizure reduction >50 % was achieved in 68 % of patients [54.54; 79.07], with seizure freedom in 16.2 % [8.38; 28.97]. There was no difference between pediatric and adult patients. CNB was discontinued in 10 % [6.74; 14.6] of patients, mostly due to lack of efficacy (39 %) or adverse effects (AE, 43 %). AE, observed in 57.3 % [39.7; 73.2] of patients, included fatigue and vertigo. A comparison of the rates calculated in this meta-analysis to the active arm of equivalent RCTs revealed no significant difference. CONCLUSION CNB achieves a good treatment response in patients with DRE in real-world settings, like the effect reported in RCTs. The high heterogeneity between studies calls for studies focusing on specific DRE subpopulations.
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Affiliation(s)
- Konstantin L Makridis
- Charité - Universitätsmedizin Berlin, Department of Pediatric Neurology, Berlin, Germany; Charité - Universitätsmedizin Berlin, Center for Chronically Sick Children, Berlin, Germany; Charité - Universitätsmedizin Berlin, German Epilepsy Center for Children and Adolescents, Berlin, Germany; Charité - Universitätsmedizin Berlin, Institute of Cell Biology and Neurobiology, Berlin, Germany
| | - Angela M Kaindl
- Charité - Universitätsmedizin Berlin, Department of Pediatric Neurology, Berlin, Germany; Charité - Universitätsmedizin Berlin, Center for Chronically Sick Children, Berlin, Germany; Charité - Universitätsmedizin Berlin, German Epilepsy Center for Children and Adolescents, Berlin, Germany; Charité - Universitätsmedizin Berlin, Institute of Cell Biology and Neurobiology, Berlin, Germany.
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Villanueva V, Santos‐Carrasco D, Cabezudo‐García P, Gómez‐Ibáñez A, Garcés M, Serrano‐Castro P, Castro‐Vilanova MD, Sayas D, Lopez‐Gonzalez FJ, Rodríguez‐Osorio X, Torres‐Gaona G, Saiz‐Diaz RA, Hampel KG, Martinez‐Ferri M, Aguilar‐Amat MJ, Mercedes‐Alvarez B, García‐Morales V, del Villar‐Igea A, Massot‐Tarrús A, Rodríguez‐Uranga JJ. Real-world safety and effectiveness of cenobamate in patients with focal onset seizures: Outcomes from an Expanded Access Program. Epilepsia Open 2023; 8:918-929. [PMID: 37149853 PMCID: PMC10472366 DOI: 10.1002/epi4.12757] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/03/2023] [Indexed: 05/09/2023] Open
Abstract
OBJECTIVE This study investigated early, real-world outcomes with cenobamate (CNB) in a large series of patients with highly drug-resistant epilepsy within a Spanish Expanded Access Program (EAP). METHOD This was a multicenter, retrospective, observational study in 14 hospitals. Inclusion criteria were age ≥18 years, focal seizures, and EAP authorization. Data were sourced from patient clinical records. Primary effectiveness endpoints included reductions (100%, ≥90%, ≥75%, and ≥50%) or worsening in seizure frequency at 3-, 6-, and 12-month visits and at the last visit. Safety endpoints included rates of adverse events (AEs) and AEs leading to discontinuation. RESULTS The study included 170 patients. At baseline, median epilepsy duration was 26 years and median number of seizures/month was 11.3. The median number of prior antiseizure medications (ASMs) and concomitant ASMs were 12 and 3, respectively. Mean CNB dosages/day were 176 mg, 200 mg, and 250 mg at 3, 6, and 12 months. Retention rates were 98.2%, 94.5%, and 87% at 3, 6, and 12 months. At last available visit, the rate of seizure freedom was 13.3%; ≥90%, ≥75%, and ≥50% responder rates were 27.9%, 45.5%, and 63%, respectively. There was a significant reduction in the number of seizures per month (mean: 44.6%; median: 66.7%) between baseline and the last visit (P < 0.001). Responses were maintained regardless of the number of prior or concomitant ASMs. The number of concomitant ASMs was reduced in 44.7% of patients. The cumulative percentage of patients with AEs and AEs leading to discontinuation were 68.2% and 3.5% at 3 months, 74.1% and 4.1% at 6 months, and 74.1% and 4.1% at 12 months. The most frequent AEs were somnolence and dizziness. SIGNIFICANCE In this highly refractory population, CNB showed a high response regardless of prior and concomitant ASMs. AEs were frequent but mostly mild-to-moderate, and few led to discontinuation.
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Affiliation(s)
- Vicente Villanueva
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | - Daniel Santos‐Carrasco
- Centro Neurología AvanzadaSevillaSpain
- Departamento de Psicología ExperimentalUniversidad de SevillaSevillaSpain
| | | | | | - Mercedes Garcés
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | | | | | - Débora Sayas
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | | | | | | | | | - Kevin G. Hampel
- Hospital Universitario y Politécnico La Fe, Member of EPICAREValenciaSpain
| | | | - Maria J. Aguilar‐Amat
- Instituto de Investigación Sanitaria del Hospital Universitario La Paz—IdiPAZMadridSpain
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Perucca E, Bialer M, White HS. New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: I. Role of GABA as a Modulator of Seizure Activity and Recently Approved Medications Acting on the GABA System. CNS Drugs 2023; 37:755-779. [PMID: 37603262 PMCID: PMC10501955 DOI: 10.1007/s40263-023-01027-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/22/2023]
Abstract
γ-Aminobutyric acid (GABA) is the most prevalent inhibitory neurotransmitter in the mammalian brain and has been found to play an important role in the pathogenesis or the expression of many neurological diseases, including epilepsy. Although GABA can act on different receptor subtypes, the component of the GABA system that is most critical to modulation of seizure activity is the GABAA-receptor-chloride (Cl-) channel complex, which controls the movement of Cl- ions across the neuronal membrane. In the mature brain, binding of GABA to GABAA receptors evokes a hyperpolarising (anticonvulsant) response, which is mediated by influx of Cl- into the cell driven by its concentration gradient between extracellular and intracellular fluid. However, in the immature brain and under certain pathological conditions, GABA can exert a paradoxical depolarising (proconvulsant) effect as a result of an efflux of chloride from high intracellular to lower extracellular Cl- levels. Extensive preclinical and clinical evidence indicates that alterations in GABAergic inhibition caused by drugs, toxins, gene defects or other disease states (including seizures themselves) play a causative or contributing role in facilitating or maintaning seizure activity. Conversely, enhancement of GABAergic transmission through pharmacological modulation of the GABA system is a major mechanism by which different antiseizure medications exert their therapeutic effect. In this article, we review the pharmacology and function of the GABA system and its perturbation in seizure disorders, and highlight how improved understanding of this system offers opportunities to develop more efficacious and better tolerated antiseizure medications. We also review the available data for the two most recently approved antiseizure medications that act, at least in part, through GABAergic mechanisms, namely cenobamate and ganaxolone. Differences in the mode of drug discovery, pharmacological profile, pharmacokinetic properties, drug-drug interaction potential, and clinical efficacy and tolerability of these agents are discussed.
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Affiliation(s)
- Emilio Perucca
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia.
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia.
- Melbourne Brain Centre, 245 Burgundy Street, Heidelberg, VIC, 3084, Australia.
| | - Meir Bialer
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
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10
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Makridis KL, Klotz KA, Ramantani G, Becker L, San Antonio‐Arce V, Syrbe S, Wagner K, Shah MJ, Thomale U, Tietze A, Elger CE, Borggraefe I, Kaindl AM. Epilepsy surgery in early infancy: A retrospective, multicenter study. Epilepsia Open 2023; 8:1182-1189. [PMID: 37458529 PMCID: PMC10472416 DOI: 10.1002/epi4.12791] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/01/2023] [Indexed: 07/25/2023] Open
Abstract
Although epilepsy surgery is the only curative therapeutic approach for lesional drug-resistant epilepsy (DRE), there is reluctance to operate on infants due to a fear of complications. A recent meta-analysis showed that epilepsy surgery in the first 6 months of life can achieve seizure control in about two thirds of children. However, robust data on surgical complications and postoperative cognitive development are lacking. We performed a retrospective multicenter study of infants who underwent epilepsy surgery in the first 6 months of life. 15 infants underwent epilepsy surgery at a median age of 134 days (IQR: 58) at four centers. The most common cause was malformation of cortical development, and 13 patients underwent a hemispherotomy. Two thirds required intraoperative red blood transfusions. Severe intraoperative complications occurred in two patients including death in one infant due to cardiovascular insufficiency. At a median follow-up of 1.5 years (IQR: 1.8), 57% of patients were seizure-free. Three patients where reoperated at a later age, resulting in 79% seizure freedom. Anti-seizure medication could be reduced in two thirds, and all patients improved in their development. Our findings suggest that early epilepsy surgery can result in good seizure control and developmental improvement. However, given the perioperative risks, it should be performed only in specialized centers.
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Affiliation(s)
- Konstantin L. Makridis
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Institute of Cell‐ and NeurobiologyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Kerstin Alexandra Klotz
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Georgia Ramantani
- Department of NeuropediatricsUniversity Children's Hospital ZurichZurichSwitzerland
- University of ZurichZurichSwitzerland
- Children's Research CentreUniversity Children's Hospital ZurichZurichSwitzerland
| | - Lena‐Luise Becker
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Institute of Cell‐ and NeurobiologyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Victoria San Antonio‐Arce
- Freiburg Epilepsy Center, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Steffen Syrbe
- Division of Paediatric Epileptology, Centre for Paediatrics and Adolescent MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Kathrin Wagner
- Freiburg Epilepsy Center, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Mukesch Johannes Shah
- Department of Neurosurgery, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | | | - Anna Tietze
- Institute of Neuroradiology, Charité—Universitätsmedizin BerlinBerlinGermany
| | - Christian E. Elger
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Beta Neurologie—Kompetenzzentrum für Epilepsie, Beta Klinik GmbHBonnGermany
| | - Ingo Borggraefe
- Division of Pediatric Neurology, Developmental Medicine and Social Pediatrics, Department of Pediatrics, Dr. von Hauner Children's HospitalLMU University Hospital MunichMunichGermany
- Comprehensive Epilepsy CenterLMU University Hospital MunichMunichGermany
| | - Angela M. Kaindl
- Department of Pediatric NeurologyCharité—Universitätsmedizin BerlinBerlinGermany
- Center for Chronically Sick ChildrenCharité—Universitätsmedizin BerlinBerlinGermany
- German Epilepsy Center for Children and AdolescentsCharité—Universitätsmedizin BerlinBerlinGermany
- Institute of Cell‐ and NeurobiologyCharité—Universitätsmedizin BerlinBerlinGermany
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11
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Rissardo JP, Fornari Caprara AL. Cenobamate (YKP3089) and Drug-Resistant Epilepsy: A Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1389. [PMID: 37629678 PMCID: PMC10456719 DOI: 10.3390/medicina59081389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/08/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023]
Abstract
Cenobamate (CNB), ([(R)-1-(2-chlorophenyl)-2-(2H-tetrazol-2-yl)ethyl], is a novel tetrazole alkyl carbamate derivative. In November 2019, the Food and Drug Administration approved Xcopri®, marketed by SK Life Science Inc., (Paramus, NJ, USA) for adult focal seizures. The European Medicines Agency approved Ontozry® by Arvelle Therapeutics Netherlands B.V.(Amsterdam, The Neatherlands) in March 2021. Cenobamate is a medication that could potentially change the perspectives regarding the management and prognosis of refractory epilepsy. In this way, this study aims to review the literature on CNB's pharmacological properties, pharmacokinetics, efficacy, and safety. CNB is a highly effective drug in managing focal onset seizures, with more than twenty percent of individuals with drug-resistant epilepsy achieving seizure freedom. This finding is remarkable in the antiseizure medication literature. The mechanism of action of CNB is still poorly understood, but it is associated with transient and persistent sodium currents and GABAergic neurotransmission. In animal studies, CNB showed sustained efficacy and potency in the 6 Hz test regardless of the stimulus intensity. CNB was revealed to be the most cost-effective drug among different third-generation antiseizure medications. Also, CNB could have neuroprotective effects. However, there are still concerns regarding its potential for abuse and suicidality risk, which future studies should clearly assess, after which protocols should be changed. The major drawback of CNB therapy is the slow and complex titration and maintenance phases preventing the wide use of this new agent in clinical practice.
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Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil;
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Friedo AL, Greshake B, Makridis KL, Straub HB. Cenobamate significantly improves seizure control in intellectually disabled patients with drug-resistant epilepsy and allows drug load reduction. Front Neurol 2023; 14:1209487. [PMID: 37528853 PMCID: PMC10390252 DOI: 10.3389/fneur.2023.1209487] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/22/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction Epilepsy patients with intellectual disability often suffer from drug-resistant epilepsy (DRE), which severely affects patients' quality of life. Cenobamate (CNB) is a recently approved novel and effective ASM that can achieve high rates of seizure freedom in previously drug-resistant patients. Methods We performed a retrospective data analysis of the first patients treated with CNB at a single center. Outcome and treatment response were assessed at two different time points, and ASM burden was calculated. Results A 12 patients (7 males and 5 females) began treatment at a median age of 43 years, six of whom had developmental and epileptic encephalopathies. Prior to treatment with CNB, patients had tried a median of 13 different ASM. At the start of CNB therapy, patients were taking a median of 3 ASM. Treatment outcomes were available for 11 patients. After the first follow-up period (median 9 months), 55% of patients showed a significant seizure reduction of more than 50%, with three patients showing a reduction of more than 75% (27%). One patient achieved complete seizure freedom, while one patient did not respond to treatment. These response rates were consistently maintained at second follow-up after a median of 22 months. Ten patients (83%) reported adverse events (AE), the most common of which were dizziness and fatigue. No cases of drug reactions with eosinophilia and systemic symptoms (DRESS) were observed. The majority of AEs were mild and resolved over time. In addition, most patients were able to reduce their concomitant ASM. Discussion Cenobamate has been shown to be an effective ASM in patients with DRE and in patients with intellectual disabilities. After more than 1 year of treatment with CNB, close monitoring and management of drug-drug interactions may reduce enzyme-inducing ASMs and lead to better long-term outcomes. With CNB treatment, many patients can achieve a reduced overall drug burden while maintaining a reduction in seizures.
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Affiliation(s)
| | | | - Konstantin L. Makridis
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell Biology and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Falcicchio G, Lattanzi S, Negri F, de Tommaso M, La Neve A, Specchio N. Treatment with Cenobamate in Adult Patients with Lennox-Gastaut Syndrome: A Case Series. J Clin Med 2022; 12:jcm12010129. [PMID: 36614931 PMCID: PMC9821211 DOI: 10.3390/jcm12010129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/21/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Background. Lennox-Gastaut syndrome (LGS) is a developmental and epileptic encephalopathy (DEE) in which drug resistance to antiepileptic drugs (AEDs) is common. Focal-onset seizures (FOS) are among the seizure types characterizing LGS. Cenobamate (CNB) is a new AED indicated for the treatment of FOS and it has shown promising results in terms of seizure frequency reduction in both clinical trials and real-world experience. To date, the use of CNB in patients with DEEs is limited to Dravet syndrome. Methods: This was a retrospective study aimed to determine the 12-month effectiveness and tolerability of CNB in patients with LGS following real-world practice. Results: Four patients with LGS receiving CNB treatment were identified. At 12 months from starting CNB, the reduction in baseline seizure frequency ranged from 25 to 74%, with two patients achieving ≥50% seizure reduction. CNB was generally well tolerated and adjustments in doses of concomitant AEDs were required. Conclusions: CNB may represent a promising therapeutic option in patients with drug-resistant epilepsy associated with LGS. Further research is needed to confirm this preliminary evidence.
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Affiliation(s)
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, 60020 Ancona, Italy
- Correspondence:
| | - Francesco Negri
- DiBraiN Department, University of Bari ‘Aldo Moro’, 70124 Bari, Italy
| | - Marina de Tommaso
- DiBraiN Department, University of Bari ‘Aldo Moro’, 70124 Bari, Italy
| | - Angela La Neve
- DiBraiN Department, University of Bari ‘Aldo Moro’, 70124 Bari, Italy
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Full Member of European Reference Network EpiCARE, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
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Makridis KL, Friedo AL, Kellinghaus C, Losch FP, Schmitz B, Boßelmann C, Kaindl AM. Successful treatment of adult Dravet syndrome patients with cenobamate. Epilepsia 2022; 63:e164-e171. [PMID: 36176237 DOI: 10.1111/epi.17427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 01/11/2023]
Abstract
Dravet syndrome (DS) is a rare, drug-resistant, severe developmental and epileptic encephalopathy caused by pathogenic variants in the α subunit of the voltage-gated sodium channel gene SCN1A. Hyperexcitability in DS results from loss of function in inhibitory interneurons. Thus sodium channel blockers are usually contraindicated in patients with DS as they may lead to disease aggravation. Cenobamate (CNB) is a novel antiseizure medication (ASM) with promising rates of seizure freedom in patients with focal-onset, drug-resistant epilepsy. CNB blocks persistent sodium currents by promoting the inactive states of sodium channels. In a multi-center study, we analyzed retrospectively the effect of an add-on therapy of CNB in adult patients with DS. We report four adult patients with DS in whom the use of CNB resulted in a significant seizure reduction of more than 80%, with a follow-up of up to 542 days. CNB was the first drug in these patients that resulted in a long-lasting and significant seizure reduction. No severe adverse events occurred. We highlight CNB as an ASM that may lead to a clinically meaningful reduction of seizure frequency in adult patients with DS. It is unclear, however, if all patients with DS benefit, requiring further investigation and functional experiments.
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Affiliation(s)
- Konstantin L Makridis
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Cell and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna-Lena Friedo
- Epilepsy Center Berlin-Brandenburg, Epilepsieklinik Tabor, Bernau, Germany
| | | | | | - Bettina Schmitz
- Department of Neurology, Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Christian Boßelmann
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Angela M Kaindl
- Department of Pediatric Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Chronically Sick Children, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute of Cell and Neurobiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Epilepsy Center for Children and Adolescents, Charité - Universitätsmedizin Berlin, Berlin, Germany
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