Toward an integrated public health approach for epilepsy in the 21st century

Video-EEG monitoring as a valuable tool for antiseizure medication withdrawal in patients with epilepsy: implications for clinical practice and public health policies

This letter to the editor discusses "the use of video-EEG monitoring to guide antiseizure medication (ASM) withdrawal in patients with epilepsy" [1]. The author highlights the potential benefits of this approach, including reduced risk of seizure recurrence and improved patient outcomes. The author also notes the need for further research to refine the criteria for identifying patients who are good candidates for ASM withdrawal and to evaluate the effectiveness of this approach in different patient populations and settings. Finally, the author discusses the implications of these findings for public health policies related to epilepsy management.

Health-related quality of life in children with epilepsy: a concept analysis

PURPOSE

This study aimed to conduct a concept analysis of health-related quality of life in children with epilepsy to promote conceptual clarification and facilitate mutual understanding of the concept.

METHODS

Walker and Avant's concept analysis method was adopted.

RESULTS

Health-related quality of life in children with epilepsy consists of six attributes: health status, inner strength, close relationships, resource-rich community, social acceptance, and changeability. According to the ecological system paradigm, these attributes are structured into five dimensions: organism, microsystem, macrosystem, exosystem, and chronosystem. These dimensions provide a comprehensive approach to the relationship between children with epilepsy and their environment. Epilepsy and interactions with multilevel ecological systems that are directly and indirectly related to children with epilepsy precede the concept, followed by positive and negative affective responses.

CONCLUSION

The findings of this study may support effective communication in various practice settings, thereby contributing to the health and well-being of children with epilepsy, as well as the development and expansion of interventions to improve their health-related quality of life.

Relationship between Tumor Necrosis Factor-Alpha and Neuropeptide Y Expression and Neurological Function Score in Epileptic Children

Background

To observe the relationship between Tumor Necrosis Factor-alpha (TNF-α) and Neuropeptide Y (NPY) expression and neurological function score in epileptic children.

Methods

Fifty-four epileptic children diagnosed and treated in Xuzhou Children's Hospital, China from Feb 2017 to Mar 2018 were collected and included in a research group (RG), while 30 healthy children who underwent physical examination at the same time were included in the control group (CG). ELISA was used to detect the expression of TNF-α and NPY in the serum of children in the two groups, and those before treatment were compared. The National Institute of Health stroke scale (NIHSS) and Hamilton Anxiety (HAMA) scores before and after treatment were observed, and Pearson correlation was used to analyze the relationship between the expression levels of TNF-α and NPY in the serum as well as NIHSS and HAMA scores.

Results

The expression levels of TNF-α and NPY in the serum of children in the RG were significantly higher than those in the CG (P<0.001). The expression level of TNF-α was positively correlated with the NIHSS and HAMA scores (r=0.748, P<0.001) (r=0.772, P<0.001). The expression level of NPY was positively correlated with the NIHSS and HAMA scores (r=0.768, P<0.001) (r=0.643, P<0.001).

Conclusion

TNF-α and NPY are highly expressed in epileptic children and are positively correlated with neurological function score.

Community pharmacists' role in caring for people living with epilepsy: A scoping review

OBJECTIVE

To identify and describe studies about pharmacist-provided services for people with epilepsy and their caregivers.

METHODS

PubMed/MEDLINE and EMBASE were searched for articles that were: (1) written in English, (2) published in 1985 or later, (3) a peer-reviewed empirical study or practice report, and (4) describing an intervention provided by a pharmacist for people with epilepsy and/or their caregivers in an outpatient pharmacy setting. The abstracts and full text, when necessary, were reviewed by two investigators to assess eligibility. Data were extracted from each article by two investigators using a standardized abstraction form based on the Pharmacist Patient Care Services Intervention Reporting (PaCIR) checklist. Data elements of interest included components of service, mode of service delivery, frequency, number and duration of sessions for the service, roles and responsibilities of the community pharmacist, type of community pharmacy, outcomes and measures evaluated along with data sources, and findings and results. Risk of bias was not assessed due to the descriptive nature of the review.

RESULTS

Twelve articles were included, seven of which reported services conducted in the United States. The most common service reported was medication management (n = 7) followed by education and counseling (n = 4). One article described a care coordination documentation tool that could be used by pharmacists and physicians in epilepsy care. Most interventions were evaluated using observational designs (n = 5) or did not have an evaluation component (n = 4).

SIGNIFICANCE

This review provides examples of community pharmacists providing care to people living with epilepsy that extend beyond dispensing medications. Findings demonstrate that there is little published evidence on community pharmacists' contributions to epilepsy care and suggest opportunities for further exploration and innovation. This review serves as the first step in a project that seeks to develop a stakeholder-driven community pharmacist integrated population health intervention for people living with 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.

The Expression of ZnT3 and GFAP Is Potentiated in the Hippocampus of Drug-Resistant Epileptic Rats Induced by Amygdala Kindling

OBJECTIVE

The first-line treatment for epilepsy, a chronic neurological disorder characterized by spontaneous seizures, includes the application of anticonvulsant drug therapy. Only one-third of patients are incapable of complete controlling of their seizures after the administration of ≥2 pharmaceuticals. Here, we aimed to observe the ultrastructure changes and the expression of ZnT3 and GFAP in the hippocampus of drug-resistant epileptic rats.

METHODS

A total of 50 healthy adult male SD rats were used to generate the model ofepilepsy by amygdala kindling. After the rats were successfully kindled, pharmacoresistant epileptic (PRE) rats were selected according to their response to phenobarbital and phenytoin. The ultrastructure as well as the expression of zinc transporter 3 (ZnT3, a member of a growing family of mammalian zinc transporters) and glial fibrillary acidic protein (GFAP) were compared among PRE, pharmacosensitive epileptic (PRE), and normal (NRC) rats.

RESULTS

The PRE rats displayed severe synapses, neuronal degeneration, and necrosis. Moreover, the expression of ZnT3 and GFAP was significantly increased in both PRE and PSE rats; compared with NRC rats, the promotion of this expression was more pronounced in the PRE rats.

CONCLUSIONS

Taken together, obvious synapses, neuronal degeneration, necrosis, mossy fiber sprouting, and astrogliosis were found in the drug-resistant epileptic rat model induced by amygdala kindling.

Factors associated with 30-day readmission for patients hospitalized for seizures

Background

We sought to determine the cumulative incidence of readmissions after a seizure-related hospitalization and identify risk factors and readmission diagnoses.

Methods

We performed a retrospective cohort study of adult patients hospitalized with a primary discharge diagnosis of seizure (International Classification of Diseases, Ninth Edition, Clinical Modification codes 345.xx and 780.3x) using the State Inpatient Databases across 11 states from 2009 to 2012. Hospital and community characteristics were obtained from the American Hospital Association and Robert Wood Johnson Foundation. We performed logistic regressions to explore effects of patient, hospital, and community factors on readmissions within 30 days of discharge.

Results

Of 98,712 patients, 13,929 (14%) were readmitted within 30 days. Reasons for readmission included epilepsy/convulsions (30% of readmitted patients), mood disorders (5%), schizophrenia (4%), and septicemia (4%). The strongest predictors of readmission were diagnoses of CNS tumor (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.9-2.4) or psychosis (OR 1.8, 95% CI 1.7-1.8), urgent index admission (OR 2.0, 95% CI 1.8-2.2), transfer to nonacute facilities (OR 1.7, 95% CI 1.6-1.8), long length of stay (OR 1.7, 95% CI 1.6-1.8), and for-profit hospitals (OR 1.7, 95% CI 1.6-1.8). Our main model's c-statistic was 0.66. Predictors of readmission for status epilepticus included index admission for status epilepticus (OR 3.5, 95% CI 2.6-4.7), low hospital epilepsy volume (OR 0.4, 95% CI 0.3-0.7), and rural hospitals (OR 4.8, 95% CI 2.1-10.9).

Conclusion

Readmission is common after hospitalization for seizures. Prevention strategies should focus on recurrent seizures, the most common readmission diagnosis. Many factors were associated with readmission, although readmissions remain challenging to predict.

Considering disability and health: Reflections on the Healthy People 2020 Midcourse Review

The Healthy People 2020 (HP2020) Midcourse Review (MCR) presents an opportunity for professionals in the disability and health field to contemplate preliminary progress toward achieving specific health objectives. The MCR showed notable progress in access to primary care, appropriate services for complex conditions associated with disability, expansion of health promotion programs focusing on disability, improving mental health, and reducing the unemployment rate among job seekers with disabilities. This commentary presents potential considerations, at least in part, for such progress including increased access to health care, greater awareness of appropriate services for complex conditions, and opportunities for societal participation. Additional considerations are provided to address the lack of progress in employment among this population -- a somewhat different measure than that for unemployment. Continuing to monitor these objectives will help inform programs, policies, and practices that promote the health of people with disabilities as measured by HP2020.

Glial source of nitric oxide in epileptogenesis: A target for disease modification in epilepsy

Epileptogenesis is the process of developing an epileptic condition and/or its progression once it is established. The molecules that initiate, promote, and propagate remarkable changes in the brain during epileptogenesis are emerging as targets for prevention/treatment of epilepsy. Epileptogenesis is a continuous process that follows immediately after status epilepticus (SE) in animal models of acquired temporal lobe epilepsy (TLE). Both SE and epileptogenesis are potential therapeutic targets for the discovery of anticonvulsants and antiepileptogenic or disease-modifying agents. For translational studies, SE targets are appropriate for screening anticonvulsive drugs prior to their advancement as therapeutic agents, while targets of epileptogenesis are relevant for identification and development of therapeutic agents that can either prevent or modify the disease or its onset. The acute seizure models do not reveal antiepileptogenic properties of anticonvulsive drugs. This review highlights the important components of epileptogenesis and the long-term impact of intervening one of these components, nitric oxide (NO), in rat and mouse kainate models of TLE. NO is a putative pleotropic gaseous neurotransmitter and an important contributor of nitro-oxidative stress that coexists with neuroinflammation and epileptogenesis. The long-term impact of inhibiting the glial source of NO during early epileptogenesis in the rat model of TLE is reviewed. The importance of sex as a biological variable in disease modification strategies in epilepsy is also briefly discussed.

Comorbidities and risk factors associated with newly diagnosed epilepsy in the U.S. pediatric population

Neurobehavioral comorbidities can be related to underlying etiology of epilepsy, epilepsy itself, and adverse effects of antiepileptic drugs. We examined the relationship between neurobehavioral comorbidities and putative risk factors for epilepsy in children with newly diagnosed epilepsy. We conducted a retrospective analysis of children aged ≤18years in 50 states and the District of Columbia, using the Truven Health MarketScan® commercial claims and encounters database from January 1, 2009 to December 31, 2013. The eligible study cohort was continuously enrolled throughout 2013 as well as enrolled for any days during a baseline period of at least the prior 2years. Newly diagnosed cases of epilepsy were defined by International Classification of Diseases, Ninth Revision, Clinical Modification-coded diagnoses of epilepsy or recurrent seizures and evidence of prescribed antiepileptic drugs during 2013, when neither seizure codes nor seizure medication claims were recorded during baseline periods. Twelve neurobehavioral comorbidities and eleven putative risk factors for epilepsy were measured. More than 6 million children were analyzed (male, 51%; mean age, 8.8years). A total of 7654 children were identified as having newly diagnosed epilepsy (125 per 100,000, 99% CI=122-129). Neurobehavioral comorbidities were more prevalent in children with epilepsy than children without epilepsy (60%, 99% CI=58.1-61.0 vs. 23%, CI=23.1-23.2). Children with epilepsy were far more likely to have multiple comorbidities (36%, 99% CI=34.3-37.1) than those without epilepsy (8%, 99% CI=7.45-7.51, P<0.001). Preexisting putative risk factors for epilepsy were detected in 28% (99% CI=26.9-29.6) of children with epilepsy. After controlling for demographics, neurobehavioral comorbidities, family history of epilepsy, and other risk factors than primary interest, neonatal seizures had the strongest independent association with the development of epilepsy (OR=29.8, 99% CI=23.7-37.3, P<0.001). Compared with children with risk factors but no epilepsy, those with both epilepsy and risk factors were more likely to have intellectual disabilities (OR=13.4, 99% CI=11.9-15.0, P<0.001). The epilepsy and intellectual disabilities could share the common pathophysiology in the neuronal network.

Adults with an epilepsy history fare significantly worse on positive mental and physical health than adults with other common chronic conditions-Estimates from the 2010 National Health Interview Survey and Patient Reported Outcome Measurement System (PROMIS) Global Health Scale

Healthy People 2020, a national health promotion initiative, calls for increasing the proportion of U.S. adults who self-report good or better health. The Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Scale (GHS) was identified as a reliable and valid set of items of self-reported physical and mental health to monitor these two domains across the decade. The purpose of this study was to examine the percentage of adults with an epilepsy history who met the Healthy People 2020 target for self-reported good or better health and to compare these percentages to adults with history of other common chronic conditions. Using the 2010 National Health Interview Survey, we compared and estimated the age-standardized prevalence of reporting good or better physical and mental health among adults with five selected chronic conditions including epilepsy, diabetes, heart disease, cancer, and hypertension. We examined response patterns for physical and mental health scale among adults with these five conditions. The percentages of adults with epilepsy who reported good or better physical health (52%) or mental health (54%) were significantly below the Healthy People 2020 target estimate of 80% for both outcomes. Significantly smaller percentages of adults with an epilepsy history reported good or better physical health than adults with heart disease, cancer, or hypertension. Significantly smaller percentages of adults with an epilepsy history reported good or better mental health than adults with all other four conditions. Health and social service providers can implement and enhance existing evidence-based clinical interventions and public health programs and strategies shown to improve outcomes in epilepsy. These estimates can be used to assess improvements in the Healthy People 2020 Health-Related Quality of Life and Well-Being Objective throughout the decade.

Epilepsy by the Numbers: Epilepsy deaths by age, race/ethnicity, and gender in the United States significantly increased from 2005 to 2014

To inform public health efforts to prevent epilepsy-related deaths, we used the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER; Wonder.cdc.gov) to examine any-listed epilepsy deaths for the period 2005-2014 by age groups (≤24, 25-44, 45-64, 65-84, ≥85years), sex, and race/ethnicity (non-Hispanic White, non-Hispanic African American, Hispanic, Asian/Pacific Islander, or American Indian/Alaska Native). Epilepsy deaths were defined by the International Classification of Diseases, Tenth Revision (ICD-10) codes G40.0-G40.9. The total number of deaths per year with epilepsy as any listed cause ranged from 1760 in 2005 to 2962 in 2014. Epilepsy was listed as the underlying cause of death for about 54% of all deaths with any mention of epilepsy in 2005 and for 43% of such deaths in 2014. Age-adjusted epilepsy mortality rates (as any-listed cause of death) per 100,000 significantly increased from 0.58 in 2005 to 0.85 in 2014 (47% increase). In 2014, deaths among the non-Hispanic Black population (1.42 deaths per 100,000) were higher than among non-Hispanic White (0.86 deaths per 100,000) and Hispanic populations (0.70 deaths per 100,000). Males had a higher mortality rate than females (1.01 per 100,000 versus 0.74 per 100,000 in 2014), and those aged 85years or older had the highest mortality among age groups. Results highlight the need for heightened action to prevent and monitor epilepsy-associated mortality.

The Managing Epilepsy Well Network:: Advancing Epilepsy Self-Management

Epilepsy, a complex spectrum of disorders, affects about 2.9 million people in the U.S. Similar to other chronic disorders, people with epilepsy face challenges related to management of the disorder, its treatment, co-occurring depression, disability, social disadvantages, and stigma. Two national conferences on public health and epilepsy (1997, 2003) and a 2012 IOM report on the public health dimensions of epilepsy highlighted important knowledge gaps and emphasized the need for evidence-based, scalable epilepsy self-management programs. The Centers for Disease Control and Prevention translated recommendations on self-management research and dissemination into an applied research program through the Prevention Research Centers Managing Epilepsy Well (MEW) Network. MEW Network objectives are to advance epilepsy self-management research by developing effective interventions that can be broadly disseminated for use in people's homes, healthcare providers' offices, or in community settings. The aim of this report is to provide an update on the MEW Network research pipeline, which spans efficacy, effectiveness, and dissemination. Many of the interventions use e-health strategies to eliminate barriers to care (e.g., lack of transportation, functional limitations, and stigma). Strengths of this mature research network are the culture of collaboration, community-based partnerships, e-health methods, and its portfolio of prevention activities, which range from efficacy studies engaging hard-to-reach groups, to initiatives focused on provider training and knowledge translation. The MEW Network works with organizations across the country to expand its capacity, help leverage funding and other resources, and enhance the development, dissemination, and sustainability of MEW Network programs and tools. Guided by national initiatives targeting chronic disease or epilepsy burden since 2007, the MEW Network has been responsible for more than 43 scientific journal articles, two study reports, seven book chapters, and 62 presentations and posters. To date, two programs have been adopted and disseminated by the national Epilepsy Foundation, state Epilepsy Foundation affiliates, and other stakeholders. Recent expansion of the MEW Network membership will help to extend future reach and public health impact.

Validity and Reliability of the Quality of Life in Epilepsy Inventory (QOLIE-10) For Turkey

INTRODUCTION

The purpose of this study was to test as a shortened form of the health-related quality of life for patients with epilepsy inventory (QOLIE).

METHODS

A study of 148 adult epileptic patients admitted to the Neurology Outpatient Clinic at Cumhuriyet University Hospital in Sivas was used to derive a brief screening tool from a longer instrument (QOLIE-31).

RESULTS

The 10-item questionnaire (QOLIE-10) contains general and epilepsy-specific dimensions grouped into three domains: Epilepsy Effects (memory, physical effects, and mental effects of medication), Mental Health (energy, depression, overall quality of life), and Role Functioning (seizure worry, work, driving, social limits). Cronbach's alpha (measure of internal consistency) was high, as were the associations between QOLIE-10 and the Nottingham Health Profile (NHP). High correlations between QOLIE-10 and NHP domains (emotional reactions, energy, physical mobility, and social isolation) were found.

CONCLUSION

The QOLIE-10 questionnaire is considered to be a valid and reliable tool for use in Turkey. Health professionals are encouraged to use this questionnaire to routinely examine the influences of the disease process in epilepsy patients.

Navigating Government Service as a Physician

Working in government can be a remarkable life experience for anyone but particularly for those who have trained in the worlds of medicine and public health. This article describes some lessons learned from a physician initially based in academic medicine and public health who has since spent more than a decade serving in leadership positions at the state and federal levels. Many of the described themes about policy making can guide health professionals who wish to understand and ultimately contribute to the public sector. Certainly, the challenges and risks are noteworthy. However, for those willing and able to take the leap, government service can offer extraordinary opportunities not only for tremendous personal growth but also for making broader contributions to public health.

Descriptive epidemiology of epilepsy in the U.S. population: A different approach

OBJECTIVE

Determine prevalence and incidence of epilepsy within two health insurance claims databases representing large sectors of the U.S.

METHODS

A retrospective observational analysis using Commercial Claims and Medicare (CC&M) Supplemental and Medicaid insurance claims data between January 1, 2007 and December 31, 2011. Over 20 million continuously enrolled lives of all ages were included. Our definition of a prevalent case of epilepsy was based on International Classification of Diseases, Ninth Revision, Clinical Modification-coded diagnoses of epilepsy or seizures and evidence of prescribed antiepileptic drugs. Incident cases were identified among prevalent cases continuously enrolled for ≥ 2 years before the year of incidence determination with no epilepsy, seizure diagnoses, or antiepileptic drug prescriptions recorded.

RESULTS

During 2010 and 2011, overall age-adjusted prevalence estimate, combining weighted estimates from all datasets, was 8.5 cases of epilepsy/1,000 population. With evaluation of CC&M and Medicaid data separately, age-adjusted prevalence estimates were 5.0 and 34.3/1,000 population, respectively, for the same period. The overall age-adjusted incidence estimate for 2011, combining weighted estimates from all datasets, was 79.1/100,000 population. Age-adjusted incidence estimates from CC&M and Medicaid data were 64.5 and 182.7/100,000 enrollees, respectively. Incidence data should be interpreted with caution due to possible misclassification of some prevalent cases.

SIGNIFICANCE

The large number of patients identified as having epilepsy is statistically robust and provides a credible estimate of the prevalence of epilepsy. Our study draws from multiple U.S. population sectors, making it reasonably representative of the U.S.-insured population.