Need for a national epilepsy control program

Efficacy and Safety of adjunctive Perampanel in a prospective, real-world, Phase IV study in Indian patients aged ≥12 years for Treatment of focal-onset Epilepsy: Study 508

OBJECTIVE

ESPRITE (Study 508; NCT03836924) evaluated the real-world safety, tolerability, and efficacy of adjunctive perampanel in patients aged ≥12 years with focal-onset seizures (FOS), with or without focal to bilateral tonic-clonic seizures (FBTCS), in India.

METHODS

ESPRITE was a prospective, multicenter, single-arm, observational, Phase IV study with a 6-month Treatment Period. Patients were aged ≥12 years and had been prescribed perampanel for adjunctive treatment of FOS, with or without FBTCS. Assessments included incidence of treatment-emergent adverse events (TEAEs; primary endpoint), median percent reduction in seizure frequency per 28 days from baseline, 50% responder rates, and seizure-freedom rates.

RESULTS

Overall, 200 patients were enrolled (199 patients in the Safety Analysis Set and 174 patients who completed all visits in the main efficacy analyses). TEAEs (all mild or moderate in severity) were reported in 18.1% (n = 36/199) of patients (the most common were dizziness [3.0%] and irritability [2.0%]). TEAEs leading to discontinuation of perampanel were reported in 2.0% of patients; no deaths or serious TEAEs occurred. At 6 months, median percent reduction in seizure frequency was 100.0%, 50% responder rate was 83.3%, and seizure-freedom rate was 49.4%.

SIGNIFICANCE

Adjunctive perampanel (at a mean daily dose of 4 mg/day) was shown to be well tolerated and effective in patients aged ≥12 years with FOS, with or without FBTCS, from India.

PLAIN LANGUAGE SUMMARY

Many patients do not receive adequate treatment for epilepsy and need effective seizure control medications. In this 6-month clinical study, 199 patients from India, aged 12 years or older, added perampanel to the anti-seizure medications they were already taking. At 6 months, 49% of patients experienced no seizures since starting perampanel and seizure frequency was reduced by half in 83% of patients. Side effects occurred in 18% of patients (most commonly dizziness and irritability) and caused 2% to stop perampanel; no deaths were reported. Perampanel was an effective and generally safe added medication for patients with epilepsy from India.

Effectiveness of Yoga Intervention in Reducing Felt Stigma in Adults With Epilepsy: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Persons with epilepsy are afflicted with comorbidities such as stigma, anxiety, and depression which have a significant impact on their quality of life. These comorbidities remain largely unaddressed in resource-limited countries. This randomized controlled trial (RCT) aimed to investigate whether yoga and psychoeducation were effective in reducing felt stigma (primary outcome), neuropsychiatric outcomes, and seizure frequency, as compared with sham yoga and psychoeducation in persons with epilepsy.

METHODS

This was an assessor-blinded, sham yoga-controlled RCT. Patients clinically diagnosed with epilepsy, aged 18-60 years, and scoring higher than the cutoff score for felt stigma as measured by the Kilifi Stigma Scale (KSS) in our population were randomly assigned to receive either yoga therapy plus psychoeducation (intervention) or sham yoga therapy plus psychoeducation (comparator) for a duration of 3 months. The primary outcome was a significant decrease in felt stigma as compared with the comparator arm as measured by the KSS. Primary and secondary outcomes (seizure frequency, quality of life, anxiety, depression, mindfulness, trait rumination, cognitive impairment, emotion regulation) were assessed at baseline, 3 months, and 6 months. Parametric/nonparametric analysis of covariance and the χ2 test were used to compare the 2 arms.

RESULTS

A total of 160 patients were enrolled in the trial. At the end of the follow-up period (6 months), the intervention arm reported significant reduction in felt stigma as compared with the control arm (Cohen's d = 0.23, 95% CI -0.08 to 0.55, p = 0.006). Significantly higher odds of >50% seizure reduction (odds ratio [OR] 4.11, 95% CI 1.34-14.69, p = 0.01) and complete seizure remission (OR 7.4, 95% CI 1.75-55.89, p = 0.005) were also observed in the intervention group. The intervention group showed significant improvement in symptoms of anxiety, cognitive impairment, mindfulness, and quality of life relative to the control group at the end of follow-up period (p < 0.05).

DISCUSSION

Yoga can alleviate the burden of epilepsy and improve the overall quality of life in epilepsy by reducing perceived stigma.

TRIAL REGISTRATION INFORMATION

Clinical Trials Registry of India (CTRI/2017/04/008385).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that yoga reduces felt stigma in adult patients with epilepsy.

Understanding the Role of Stigma and Misconceptions in the Experience of Epilepsy in India: Findings From a Mixed-Methods Study

It is surprising that although 12 million people in India suffer from epilepsy this remains a thoroughly under-researched area in the sociology of health and practice. We address this intellectual and policy neglect by reviewing the social, psychological and legal challenges governing the lives of people living with epilepsy (PWE) by paying particular attention to negotiations in arranged marriages and employment. Drawing on the analytical frameworks of the sociological study of stigma, critical race theory and paying attention to the cultural models of health and suffering, this study utilized a combination of (online) survey data (N = 100) and in-depth qualitative interviews (N = 10) with PWE and their families. The online survey was administered to map the level of awareness about epilepsy and its clinical management among the general population, whereas the in-depth interviews were conducted to understand the experience, self-perception and everyday struggles of those diagnosed with the condition. Findings from the survey on non-PWE suggest a general lack of awareness and fearful misconceptions around epilepsy related seizures. In-depth interviews with PWEs revealed concealment (of the illness) as a dominant coping strategy to attenuate the social alienation and rejection associated with epilepsy. Further, PWE participants reported persistent discrimination, harassment and prejudiced understanding of diminished cognitive capacities at workplaces as a result of cultural myths and popular representations of epilepsy-related seizures. The study also demonstrated the significance of institutional support groups in assisting PWE to cope with symbolic violence and forge solidarities. We conclude with reflections on the ethical dilemmas faced by medical practitioners while dealing with social-medical interventions of epilepsy treatment. Overall, results from this study undergird the significance to revisit the social-moral as well as legal frameworks that persistently restrict opportunities for PWE in India. In an attempt to reimagine inclusive futures regardless of disease, disability and affliction, we attempt to move beyond the biomedical gaze and instead privilege stories of individual personhood, struggles and aspirations.

Role of Neuromodulation for Treatment of Drug-Resistant Epilepsy

The choice of neuromodulation techniques has greatly increased over the past two decades. While vagal nerve stimulation (VNS) has become established, newer variations of VNS have been introduced. Following the SANTE's trial, deep brain stimulation (DBS) is now approved for clinical use. In addition, responsive neurostimulation (RNS) has provided exciting new opportunities for treatment of drug-resistant epilepsy. While neuromodulation mostly offers only a 'palliative' measure, it still provides a significant reduction of frequency and intensity of epilepsy. We provide an overview of all the techniques of neuromodulation which are available, along with long-term outcomes. Further research is required to delineate the exact mechanism of action, the indications and the stimulation parameters to extract the maximum clinical benefit from these techniques.

Epilepsy treatment gap and stigma reduction in Pakistan: A tested public awareness model

High epilepsy treatment gap (ETG) and stigma remain a major issue globally. Addressing the basic problems is necessary, for advances in management to be effective. According to the 1987 population-based study, prevalence of active epilepsy in Pakistan is 0.98% with 98.1% ETG in rural and 72.5% in urban population and the presence of stigma. These dismal figures were a stimulus for our reported activities. Recognizing the problems faced by 2.2 million people with epilepsy (PWE) in the country, a group of volunteers mostly from the medical community has attempted to address these issues with an ongoing sustained awareness program over the last 18 years, working within the constraints of prevailing healthcare system, with gratifying results. In 2001, under a nongovernmental organization (NGO), the Comprehensive Epilepsy Control Programme of Pakistan (CECP) was launched to address the various paucities in knowledge, attitude, and practice about epilepsy; especially ETG and stigma. The CECP has two primary components: Epilepsy Support Pakistan (CECP-ESP) for awareness and mass education and National Epilepsy Centre (CECP-NEC) for holistic management of PWE, professional education, and research. Both work in tandem, and there is an overlap of their activities. This article only evaluates the outcome of sustained awareness activities of the CECP-ESP, through direct and indirect measures after 5 years of its initiation. A significant reduction in ETG and stigma exclusively through public awareness has been possible. This model can be easily replicated by any country, with involvement of the local population.

Functional MRI in epilepsy - Comparison of Lateralization index and language scoring

Aims:

To evaluate the role of functional magnetic resonance imaging (fMRI) in epilepsy management and to ascertain whether laterality index (LI) derived from fMRI data, using routinely utilized paradigms, can serve as an adjunct to/or replace preoperative neuropsychological testing for evaluation of language lateralization and impairment.

Materials and Methods:

This was a prospective study which included 20 consecutive patients with a clinical diagnosis of temporal lobe epilepsy over a period of 1 year. Neuropsychological assessment included oral word association test and animal names test. The scores of both tests were compared with normographic data provided in the NIMHANS neuropsychology battery. Three fMRI paradigms were used, namely, picture naming, word generation, and sentence completion. Processing and statistical analysis were performed subsequently.

Results and Conclusion:

Right temporal lobe epilepsy (RTLE) was seen in 12 patients and left temporal lobe epilepsy (LTLE) in 8 patients. All patients were right handed. The activation pattern was predominantly left lateralized. Language lateralization varied with the type of paradigm. The overall percentage of patients showing left lateralization ranged from 44.00% for the picture naming task to 75% for the sentence completion. Reduced left lateralization was noted in both LTLE and RTLE patients. A negative correlation was observed in LTLE patients between performance in the verbal fluency and the lateralization index in the temporal and parietal regions of interest (ROI) in the word generation paradigm, suggesting that increased left lateralization was associated with a poorer score on neuropsychological tests. In RTLE patients, however, there was no significant correlation between performance in neuropsychological tests and LI. In conclusion, language lateralization using LI can serve as an adjunct during preoperative evaluation. However, it cannot replace neuropsychological testing.

Automatic Seizure Detection Based on Morphological Features Using One-Dimensional Local Binary Pattern on Long-Term EEG

Epileptic neurological disorder of the brain is widely diagnosed using the electroencephalography (EEG) technique. EEG signals are nonstationary in nature and show abnormal neural activity during the ictal period. Seizures can be identified by analyzing and obtaining features of EEG signal that can detect these abnormal activities. The present work proposes a novel morphological feature extraction technique based on the local binary pattern (LBP) operator. LBP provides a unique decimal value to a sample point by weighing the binary outcomes after thresholding the neighboring samples with the present sample point. These LBP values assist in capturing the rising and falling edges of the EEG signal, thus providing a morphologically featured discriminating pattern for epilepsy detection. In the present work, the variability in the LBP values is measured by calculating the sum of absolute difference of the consecutive LBP values. Interquartile range is calculated over the preprocessed EEG signal to provide dispersion measure in the signal. For classification purpose, K-nearest neighbor classifier is used, and the performance is evaluated on 896.9 hours of data from CHB-MIT continuous EEG database. Mean accuracy of 99.7% and mean specificity of 99.8% is obtained with average false detection rate of 0.47/h and sensitivity of 99.2% for 136 seizures.

The individual with epilepsy: perceptions about the disease and implications on quality of life

Purpose

The present study aims to analyze the perceptions of individuals with epilepsy about the disease and its impact in their quality of life (QoL).

Methods

This is a cross-sectional, qualitative and quantitative study conducted in a tertiary referral hospital associated with the Brazilian National Health System (SUS). Data were collected from 30 individuals with diagnosis of refractory temporal lobe epilepsy (RTLE). The study participants responded to a questionnaire to collect sociodemographic and clinical data, as well as their perceptions about the disease. QoL was assessed by the Subjective Handicap of Epilepsy (SHE) and the Stigma Scale of Epilepsy (SSE).

Results

Significant correlation was found between stigma and quality of life and the work and activity and social and personal life domains, as well as between stigma and perceptions about epilepsy. The responses provided by the participants were organized into four categories: definitions and causes, seizures and treatment, family and social impacts, and impact on individuals' lives.

Conclusion

The results show that participants have limited knowledge about epilepsy and that there is a negative impact caused by the stigma related to this disease on their QoL. It was possible to verify that QoL and stigma are directly related to the understanding of participants about epilepsy. Therefore, it is important to implement programs and actions that aim to provide patients and their families with more comprehensive knowledge about epilepsy; promote communication between health professionals and patients; and encourage the participation of patients and their families during treatment.

A screening tool to identify surgical candidates with drug refractory epilepsy in a resource limited settings

OBJECTIVES

Access to epilepsy surgery remains a considerable challenge in contemporary healthcare systems. Given the limitations in resources and demand for Epilepsy Monitoring Unit (EMU) assessments, information that can be used to expedite the process is of great value. The purpose of this study was to identify variables prior to EMU admission that may be associated with candidacy for prospective epilepsy surgery.

METHODS

This was a prospective study conducted at the Department of Neurology, All India Institute of Medical Sciences, New Delhi, India. We identified two subgroups of patients from 501 drug refractory epilepsy (DRE) patients admitted in EMU of Neurology Department, AIIMS from 2006 onwards following validation of proposed tool in 40 patients. They on subsequent investigations were either cleared or not cleared for epilepsy surgery. A tool consisting of variables likely to predict surgical candidacy in persons with DRE in Indian settings was developed for identification of patients who might benefit from an early epilepsy surgery evaluation.

RESULTS

Statistical analysis revealed significant differences between the two groups for several variables. Non-surgical candidates had non-disabling seizures, seizures improved with a combination of drugs, had little/no AEDs side effects and had near normal or normal scalp EEG and MRI brain.

SIGNIFICANCE

Using the best available evidence, we developed a decision making tool which can provide a comprehensive quick guide for determining candidacy for epilepsy surgery evaluations in resource limited settings. Given the demand for EMU assessments, information that can be used to expedite the process is of value.

Health and economic benefits of public financing of epilepsy treatment in India: An agent-based simulation model

OBJECTIVE

An estimated 6-10 million people in India live with active epilepsy, and less than half are treated. We analyze the health and economic benefits of three scenarios of publicly financed national epilepsy programs that provide: (1) first-line antiepilepsy drugs (AEDs), (2) first- and second-line AEDs, and (3) first- and second-line AEDs and surgery.

METHODS

We model the prevalence and distribution of epilepsy in India using IndiaSim, an agent-based, simulation model of the Indian population. Agents in the model are disease-free or in one of three disease states: untreated with seizures, treated with seizures, and treated without seizures. Outcome measures include the proportion of the population that has epilepsy and is untreated, disability-adjusted life years (DALYs) averted, and cost per DALY averted. Economic benefit measures estimated include out-of-pocket (OOP) expenditure averted and money-metric value of insurance.

RESULTS

All three scenarios represent a cost-effective use of resources and would avert 800,000-1 million DALYs per year in India relative to the current scenario. However, especially in poor regions and populations, scenario 1 (which publicly finances only first-line therapy) does not decrease the OOP expenditure or provide financial risk protection if we include care-seeking costs. The OOP expenditure averted increases from scenarios 1 through 3, and the money-metric value of insurance follows a similar trend between scenarios and typically decreases with wealth. In the first 10 years of scenarios 2 and 3, households avert on average over US$80 million per year in medical expenditure.

SIGNIFICANCE

Expanding and publicly financing epilepsy treatment in India averts substantial disease burden. A universal public finance policy that covers only first-line AEDs may not provide significant financial risk protection. Covering costs for both first- and second-line therapy and other medical costs alleviates the financial burden from epilepsy and is cost-effective across wealth quintiles and in all Indian states.

Epilepsy in India II: Impact, burden, and need for a multisectoral public health response

Epilepsy is a common neurological disorder whose consequences are influenced socially and culturally, especially in India. This review (second of the two part series) was carried out to understand the social impact and economic burden to develop comprehensive program for control and prevention of epilepsy. Epilepsy is known to have adverse effect on education, employment, marriage, and other essential social opportunities. Economic burden associated with epilepsy is very high with treatment and travel costs emerging as an important contributing factor. A vicious cycle between economic burden and poor disease outcome is clear. There is no significant change in the perception, stigma, and discrimination of epilepsy across the country despite improvement in educational and social parameters over the time. The huge treatment gap and poor quality of life is further worsened by the associated comorbidities and conditions. Thus, a multidisciplinary response is needed to address the burden and impact of epilepsy which calls for an integrated and multipronged approach for epilepsy care, prevention, and rehabilitation. Service delivery, capacity building, integration into the existing program, mobilizing public support, and increasing public awareness will be the hallmarks of such an integrated approach in a public health model.

Do expressed emotions result in stigma? A potentially modifiable factor in persons with epilepsy in India

OBJECTIVE

Feeling stigmatized or having comorbid depression in a PWE may significantly influence epilepsy care and treatment. An important contributory factor to this can be the expressed emotions (EEs) from family, friends, or society. The present study aimed at understanding the influence of EEs, as exhibited by close relatives, on the perception of stigma and comorbid depression experienced by PWEs.

METHOD

Eighty PWEs aged 18 years and above, both genders, visiting neurology OPD in AIIMS Hospital, were recruited. Using the PHQ-09, we subdivided them into Group I (PWEs with comorbid depression) and Group II (PWEs without comorbid depression), followed by administration of Levels of Expressed Emotions Scale and Stigma Scale for Epilepsy, respectively.

RESULTS

The comparative analysis, using independent t-test (for categorical data), Pearson's correlation (for continuous data), and multivariate regression analysis, reflected significant influence of EEs on depression and stigma, with more than 20% of the participants reporting comorbid depression, out of which more than 50% further expressed feelings of inferiority or disgrace due to the ways in which family or society discriminated them from healthy persons, thereby highlighting a greater associations of high EEs as opposed to low EEs from key individuals on patients' perception of stigma or feeling of depression.

CONCLUSION

The result suggested that EEs from a relative might go unnoticed but may significantly overwhelm the patient, thereby making him succumb to depression or feeling stigmatized. The analysis of such a clinical profile and relationship between EEs and perceived stigma/depression may help us understand the pattern of attribution styles adopted by PWEs, thereby utilizing it further for enhancing the efficacy of cognitive-behavioral therapy for facilitating sustained recovery and improved quality of life for PWEs.

Inverse relationship between stigma and quality of life in India: is epilepsy a disabling neurological condition?

OBJECTIVE

Stigma associated with epilepsy has negative effects on psychosocial outcomes, affecting quality of life (QOL) and increasing disease burden in persons with epilepsy (PWEs). The aim of our study was to measure the impact of stigma on the QOL of PWEs and the prevalence of neurological disability due to stigmatized epilepsy.

METHOD

A prospective observational study with a sample of 208 PWEs was conducted. Neuropsychological Tests used were the Indian Disability Evaluation Assessment Scale (IDEAS) to measure disability, the Dysfunctional Analysis Questionnaire (DAQ) to measure QOL, and the Stigma Scale for Epilepsy (SSE) to assess stigma.

RESULTS

Spearman correlation was calculated, and stigma (SSE) was highly significant with QOL (DAQ) (0.019) and disability due to stigmatized epilepsy (IDEAS) (0.011).

CONCLUSION

The present study supports the global perception of stigma associated with epilepsy and its negative impact on their overall QOL and its contribution to the escalation of the disease burden.

Telemedicine for epilepsy support in resource-poor settings

The Problem: Epilepsy is a common disease worldwide causing significant physical and social disability. It is one of the most treatable neurological diseases. Yet, in rural, poorer countries like much of India and Nepal, most people with epilepsy are not undergoing any treatment often because they cannot access doctors.

Conventional Approaches: It is being appreciated that perhaps doctors are not the solution and that enabling health workers to treat epilepsy may be better. Few details, however, have been put forward about how that might be achieved.

Thinking Differently: Untreated epilepsy should be considered a public health problem like HIV/AIDS, the various steps needed for treatment identified and solutions found.

Telemedicine Approaches: Telemedicine might contribute to two steps – diagnosis and review. A tool that enables non-doctors to diagnose episodes as epileptic has been developed as a mobile phone app and has good applicability, sensitivity, and specificity for the diagnosis. There are a number of ways in which the use of phone review or short messaging service can improve management.

Conclusion: Telemedicine, as part of a public health program, can potentially help the millions of people in the resource-poor world with untreated epilepsy.

Epilepsy Research in India: A Scientometric Analysis of Publications Output during 2002-11

This study analyses the research output of India in epilepsy research during 2002-11 on several parameters including the growth, rank and global publications share, citation impact, share of international collaborative papers, contribution of major collaborative partner countries, contribution of various subject-fields, contribution and impact of most productive institutions and authors, media of communication and characteristics of high cited papers. The Scopus Citation Database has been used to retrieve the data for 10 years (2002-11) by searching the keywords “epilepsy research” in the combined Title, Abstract and Keywords fields. Among the top 20 most productive countries in epilepsy research, India ranks at 11^th position (with 1550 papers) with a global publication share of 2.88% and an annual average publication growth rate of 15.31% during 2002-11. Its global publication share has increased over the years, rising from 2.06% in 2002 to 4.65% during 2011. Its citation impact per paper was 2.77 during 2002-11, which decreased from 3.48 during 2002-06 to 2.41 during 2007-11. Its international collaborative publications share was 12.32% during 2002-11, which decreased from 12.45% during 2002-06 to 12.26% during 2007-11. Concludes that India needs to increase both the quantity and quality of research and also the need to share research data and stimulate national and international collaborative research, which will increase both the quantity and quality of research in epilepsy. There is a need to develop a national program on epilepsy as a part of national health plan, besides suggesting the funding agencies to establish a more ambitious funding program into the causes, prevention, cure and care of epilepsy. There is a need to build capacity at all levels of human resources for the management of epilepsy.