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Uhl S, Konnyu K, Wilson R, Adam G, Robinson KA, Viswanathan M. Parent perceptions and decision making about treatments for epilepsy: a qualitative evidence synthesis. BMJ Open 2023; 13:e066872. [PMID: 36720580 PMCID: PMC9890834 DOI: 10.1136/bmjopen-2022-066872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Epilepsy treatment decision making is complex and understanding what informs caregiver decision making about treatment for childhood epilepsy is crucial to better support caregivers and their children. We synthesised evidence on caregivers' perspectives and experiences of treatments for childhood epilepsy. DESIGN Systematic review of qualitative studies using a best-fit framework and Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. DATA SOURCES Searched Embase, PubMed, CINAHL, PsycINFO, SocINDEX and Web of Science from 1 January 1999 to 19 August 2021. ELIGIBILITY CRITERIA We included qualitative studies examining caregiver's perspectives on antiseizure medication, diet or surgical treatments for childhood epilepsy. We excluded studies not reported in English. DATA EXTRACTION AND SYNTHESIS We extracted qualitative evidence into 1 of 14 domains defined by the Theoretical Domains Framework (TDF). One reviewer extracted study data and methodological characteristics, and two reviewers extracted qualitative findings. The team verified all extractions. We identified themes within TDF domains and synthesised summary statements of these themes. We assessed our confidence in our summary statements using GRADE-CERQual. RESULTS We identified five studies (in six reports) of good methodological quality focused on parent perceptions of neurosurgery; we found limited indirect evidence on parents' perceptions of medications or diet. We identified themes within 6 of the 14 TDF domains relevant to treatment decisions: knowledge, emotion; social/professional role and identity; social influence; beliefs about consequences; and environmental context and resources. CONCLUSIONS Parents of children with epilepsy navigate a complex process to decide whether to have their child undergo surgery. Educational resources, peer support and patient navigators may help support parents through this process. More qualitative studies are needed on non-surgical treatments for epilepsy and among caregivers from different cultural and socioeconomic backgrounds to fully understand the diversity of perspectives that informs treatment decision making.
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Affiliation(s)
- Stacey Uhl
- Center for Clinical Evidence, ECRI, Plymouth Meeting, Pennsylvania, USA
| | - Kristin Konnyu
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Renee Wilson
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gaelen Adam
- Center for Evidence Synthesis in Health, Brown University, Providence, Rhode Island, USA
| | - Karen A Robinson
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Meera Viswanathan
- Evidence-based Practice Center, RTI International, Research Triangle Park, North Carolina, USA
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Carroll JH, Cross JH, Hickson M, Williams E, Aldridge V, Collinson A. A core outcome set for childhood epilepsy treated with ketogenic diet therapy (CORE-KDT study): International parent and health professional consensus. Epilepsia 2023; 64:919-936. [PMID: 36654244 DOI: 10.1111/epi.17513] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Ketogenic diet therapy (KDT) can result in benefits (seizure-related and non-seizure-related) for children with drug-resistant epilepsy. However, clinical trials report a wide range of outcomes, making synthesis of evidence difficult, and do not adequately reflect parent views on important outcomes for their child. To address this, we established the first international parent, health professional, and researcher consensus to develop a core outcome set, guided by the Core Outcome Measures in Effectiveness Trials (COMET) Initiative (COMET registration #1116). METHODS Ethical approval was granted (London-Surrey REC19/LO/1680). A scoping review and interviews with parents identified a comprehensive list of potentially important outcomes, followed by a two-round online Delphi survey of parents and health professionals to prioritize outcomes of importance for inclusion in a core outcome set. This informed a stakeholder consensus meeting and consultation process to finalize the core outcome set. RESULTS In total, 97 outcomes were identified; 90 from the scoping review and seven from parent interviews. These were rationalized to 77 by the study advisory group, then rated in the first Delphi round by 49 parents and 96 health professionals, who suggested 12 new outcomes for rating in Round 2. Sixty-six percent of participants (30 parents and 66 professionals) completed Round 2, where 22 outcomes met criteria for inclusion. In the consensus meeting (nine parents and 13 professionals), 27 undecided outcomes were discussed and scored; one further outcome reached consensus for inclusion. After consultation and ratification, 14 outcomes across five domains were included in the core outcome set. SIGNIFICANCE A core outcome set for childhood epilepsy treated with KDT has been developed, incorporating the views of international parents and professionals. Implementation in research and clinical settings will standardize outcome selection and reporting, facilitate data synthesis, and ultimately enhance the relevance of outcomes to parents, researchers, and health professionals.
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Affiliation(s)
| | - J Helen Cross
- Developmental Neurosciences, University College London-National Institute for Health Research Biomedical Research Centre Great Ormond Street Institute of Child Health, London, UK
| | - Mary Hickson
- Faculty of Health, University of Plymouth, Devon, UK
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Scheffer IE, Bennett CA, Gill D, de Silva MG, Boggs K, Marum J, Baker N, Palmer EE, Howell KB. Exome sequencing for patients with developmental and epileptic encephalopathies in clinical practice. Dev Med Child Neurol 2023; 65:50-57. [PMID: 35701389 PMCID: PMC10952465 DOI: 10.1111/dmcn.15308] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/07/2022] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
AIM To assess the clinical utility of exome sequencing for patients with developmental and epileptic encephalopathies (DEEs). METHOD Over 2 years, patients with DEEs were recruited for singleton exome sequencing. Parental segregation was performed where indicated. RESULTS Of the 103 patients recruited (54 males, 49 females; aged 2 weeks-17 years), the genetic aetiology was identified in 36 out of 103 (35%) with management implications in 13 out of 36. Exome sequencing revealed pathogenic or likely pathogenic variants in 30 out of 103 (29%) patients, variants of unknown significance in 39 out of 103 (38%), and 34 out of 103 (33%) were negative on exome analysis. After the description of new genetic diseases, a molecular diagnosis was subsequently made for six patients or through newly available high-density chromosomal microarray testing. INTERPRETATION We demonstrate the utility of exome sequencing in routine clinical care of children with DEEs. We highlight that molecular diagnosis often leads to changes in management and informs accurate prognostic and reproductive counselling. Our findings reinforce the need for ongoing analysis of genomic data to identify the aetiology in patients in whom the cause is unknown. The implementation of genomic testing in the care of children with DEEs should become routine in clinical practice. WHAT THIS PAPER ADDS The cause was identified in 35% of patients with developmental and epileptic encephalopathies. KCNQ2, CDKL5, SCN1A, and STXBP1 were the most frequently identified genes. Reanalysis of genomic data found the cause in an additional six patients. Genetic aetiology was identified in 41% of children with seizure onset under 2 years, compared to 18% with older onset. Finding the molecular cause led to management changes in 36% of patients with DEEs.
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Affiliation(s)
- Ingrid E. Scheffer
- Epilepsy Research Centre, Department of Medicine, Austin HealthThe University of MelbourneHeidelbergVictoria
- Department of PaediatricsThe University of MelbourneVictoria
- Florey Institute of Neuroscience and Mental HealthHeidelbergVictoria
- Murdoch Children's Research InstituteParkvilleVictoria
| | - Caitlin A. Bennett
- Epilepsy Research Centre, Department of Medicine, Austin HealthThe University of MelbourneHeidelbergVictoria
| | - Deepak Gill
- TY Nelson Department of Neurology and NeurosurgeryThe Children's Hospital at WestmeadNew South Wales
| | - Michelle G. de Silva
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteRoyal Children's HospitalParkvilleVictoria
- Australian Genomics Health AllianceMelbourne
| | - Kirsten Boggs
- Australian Genomics Health AllianceMelbourne
- Sydney Children's Hospitals NetworkSydney
| | - Justine Marum
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteRoyal Children's HospitalParkvilleVictoria
| | - Naomi Baker
- Department of PaediatricsThe University of MelbourneVictoria
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteRoyal Children's HospitalParkvilleVictoria
| | | | - Katherine B. Howell
- Department of PaediatricsThe University of MelbourneVictoria
- Murdoch Children's Research InstituteParkvilleVictoria
- Department of NeurologyThe Royal Children's HospitalParkvilleVictoriaAustralia
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Data-driven historical characterization of epilepsy-associated genes. Eur J Paediatr Neurol 2023; 42:82-87. [PMID: 36586220 DOI: 10.1016/j.ejpn.2022.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/11/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Many epilepsy-associated genes have been identified over the last three decades, revealing a remarkable molecular heterogeneity with the shared outcome of recurrent seizures. Information about the genetic landscape of epilepsies is scattered throughout the literature and answering the simple question of how many genes are associated with epilepsy is not straightforward. Here, we present a computationally driven analytical review of epilepsy-associated genes using the complete scientific literature in PubMed. Based on our search criteria, we identified a total of 738 epilepsy-associated genes. We further classified these genes into two Tiers. A broad gene list of 738 epilepsy-associated genes (Tier 2) and a narrow gene list composed of 143 epilepsy-associated genes (Tier 1). Our search criteria do not reflect the degree of association. The average yearly number of identified epilepsy-associated genes between 1992 and 2021 was 4.8. However, most of these genes were only identified in the last decade (2010-2019). Ion channels represent the largest class of epilepsy-associated genes. For many of these, both gain- and loss-of-function effects have been associated with epilepsy in recent years. We identify 28 genes frequently reported with heterogenous variant effects which should be considered for variant interpretation. Overall, our study provides an updated and manually curated list of epilepsy-related genes together with additional annotations and classifications reflecting the current genetic landscape of epilepsy.
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Gakharia T, Bakhtadze S, Lim M, Khachapuridze N, Kapanadze N. Alterations of Plasma Pro-Inflammatory Cytokine Levels in Children with Refractory Epilepsies. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101506. [PMID: 36291442 PMCID: PMC9600205 DOI: 10.3390/children9101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/22/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022]
Abstract
Paediatric epilepsy is a multifaceted neurological disorder with various aetiologies. Up to 30% of patients are considered drug-resistant. The background impact of interfering inflammatory and neuronal pathways has been closely linked to paediatric epilepsy. The characteristics of the inflamed state have been described not only in epilepsies, which are considered prototypes of an inflammatory pathophysiology, but also in patients with drug-resistant epilepsy, especially in epileptic encephalopathies. The imbalance of different cytokine levels was confirmed in several epileptic models. Chemokines are new targets for exploring neuroimmune communication in epileptogenesis, which control leukocyte migration and have a possible role in neuromodulation. Additionally, prostaglandin E2 (PGE2) is an important effector molecule for central neural inflammatory responses and may influence drug responsiveness. We measured the serum interictal quantitative levels of chemokines (CCL2, CCL4, CCL11) and PGE2 in correlation with the seizure frequency and severity in controlled and intractable childhood epilepsies. Our refractory seizure group demonstrated significantly increased concentrations of eotaxin (CCL11) compared to the controlled epilepsy group. The higher level of CCL11 was correlated with an increased seizure frequency, while the PGE2 levels were associated with the severity of seizure and epilepsy, supporting the findings that proinflammatory cytokines may contribute to epileptogenesis and possibly have a role in developing seizure resistance.
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Affiliation(s)
- Tatia Gakharia
- Department of Childs Neurology, Tbilisi State Medical University, 0186 Tbilisi, Georgia
- Correspondence: ; Tel.: +995-592933291
| | - Sophia Bakhtadze
- Department of Childs Neurology, Tbilisi State Medical University, 0186 Tbilisi, Georgia
| | - Ming Lim
- Evelina London Children’s Hospital @ Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
- Women’s and Children’s Department, Faculty of Life Sciences and Medicine, Kings College London, London SE1 7EH, UK
| | - Nana Khachapuridze
- Department of Childs Neurology, Tbilisi State Medical University, 0186 Tbilisi, Georgia
| | - Nana Kapanadze
- Department of Childs Neurology, Tbilisi State Medical University, 0186 Tbilisi, Georgia
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56
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Phenotypic and Genotypic Spectrum of Early-Onset Developmental and Epileptic Encephalopathies-Data from a Romanian Cohort. Genes (Basel) 2022; 13:genes13071253. [PMID: 35886038 PMCID: PMC9322987 DOI: 10.3390/genes13071253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 02/01/2023] Open
Abstract
Early-onset developmental epileptic encephalopathy (DEE) refers to an age-specific, diverse group of epilepsy syndromes with electroclinical anomalies that are associated with severe cognitive, behavioral, and developmental impairments. Genetic DEEs have heterogeneous etiologies. This study includes 36 Romanian patients referred to the Regional Centre for Medical Genetics Dolj for genetic testing between 2017 and 2020. The patients had been admitted to and clinically evaluated at Doctor Victor Gomoiu Children’s Hospital and Prof. Dr. Alexandru Obregia Psychiatry Hospital in Bucharest. Panel testing was performed using the Illumina® TruSight™ One “clinical exome” (4811 genes), and the analysis focused on the known genes reported in DEEs and clinical concordance. The overall diagnostic rate was 25% (9/36 cases). Seven cases were diagnosed with Dravet syndrome (likely pathogenic/pathogenic variants in SCN1A) and two with Genetic Epilepsy with Febrile Seizures Plus (SCN1B). For the diagnosed patients, seizure onset was <1 year, and the seizure type was generalized tonic-clonic. Four additional plausible variants of unknown significance in SCN2A, SCN9A, and SLC2A1 correlated with the reported phenotype. Overall, we are reporting seven novel variants. Comprehensive clinical phenotyping is crucial for variant interpretation. Genetic assessment of patients with severe early-onset DEE can be a powerful diagnostic tool for clinicians, with implications for the management and counseling of the patients and their families.
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Bartolini E, Ferrari AR, Lattanzi S, Pradella S, Zaccara G. Drug-resistant epilepsy at the age extremes: Disentangling the underlying etiology. Epilepsy Behav 2022; 132:108739. [PMID: 35636351 DOI: 10.1016/j.yebeh.2022.108739] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
The incidence of epilepsy is highest at the extreme age ranges: childhood and elderly age. The most common syndromes in these demographics - self-limited epilepsies of childhood and idiopathic generalized epilepsies in pediatric age, focal epilepsy with structural etiology in older people - are expected to be drug responsive. In this work, we focus on such epilepsy types, overviewing the complex clinical background of unexpected drug-resistance. For self-limited epilepsies of childhood and idiopathic generalized epilepsies, we illustrate drug-resistance resulting from syndrome misinterpretation, reason on possible unexpected courses of epilepsy, and explicate the influence of inappropriate treatments. For elderly-onset epilepsy, we show the challenges in differential diagnosis possibly leading to pseudoresistance and analyze how drug-resistant epilepsy can arise in stroke, neurocognitive disorders, brain tumors, and autoimmune encephalitis. In children and senior people, drug-resistance can be regarded as a hint to review the diagnosis or explore alternative therapeutic strategies. Refractory seizures are not only a therapeutic challenge, but also a cardinal sign not to be overlooked in syndromes commonly deemed to be drug-responsive.
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Affiliation(s)
- Emanuele Bartolini
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy.
| | - Anna Rita Ferrari
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy.
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Silvia Pradella
- USL Centro Toscana, Neurology Unit, Nuovo Ospedale Santo Stefano, Prato, Italy.
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58
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Zuberi SM. Precision in child neurology: Networks, systems, and technology. Dev Med Child Neurol 2022; 64:673. [PMID: 35532050 DOI: 10.1111/dmcn.15222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
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Zuberi SM, Wirrell E, Yozawitz E, Wilmshurst JM, Specchio N, Riney K, Pressler R, Auvin S, Samia P, Hirsch E, Galicchio S, Triki C, Snead OC, Wiebe S, Cross JH, Tinuper P, Scheffer IE, Perucca E, Moshé SL, Nabbout R. ILAE classification and definition of epilepsy syndromes with onset in neonates and infants: Position statement by the ILAE Task Force on Nosology and Definitions. Epilepsia 2022; 63:1349-1397. [PMID: 35503712 DOI: 10.1111/epi.17239] [Citation(s) in RCA: 226] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 12/20/2022]
Abstract
The International League Against Epilepsy (ILAE) Task Force on Nosology and Definitions proposes a classification and definition of epilepsy syndromes in the neonate and infant with seizure onset up to 2 years of age. The incidence of epilepsy is high in this age group and epilepsy is frequently associated with significant comorbidities and mortality. The licensing of syndrome specific antiseizure medications following randomized controlled trials and the development of precision, gene-related therapies are two of the drivers defining the electroclinical phenotypes of syndromes with onset in infancy. The principal aim of this proposal, consistent with the 2017 ILAE Classification of the Epilepsies, is to support epilepsy diagnosis and emphasize the importance of classifying epilepsy in an individual both by syndrome and etiology. For each syndrome, we report epidemiology, clinical course, seizure types, electroencephalography (EEG), neuroimaging, genetics, and differential diagnosis. Syndromes are separated into self-limited syndromes, where there is likely to be spontaneous remission and developmental and epileptic encephalopathies, diseases where there is developmental impairment related to both the underlying etiology independent of epileptiform activity and the epileptic encephalopathy. The emerging class of etiology-specific epilepsy syndromes, where there is a specific etiology for the epilepsy that is associated with a clearly defined, relatively uniform, and distinct clinical phenotype in most affected individuals as well as consistent EEG, neuroimaging, and/or genetic correlates, is presented. The number of etiology-defined syndromes will continue to increase, and these newly described syndromes will in time be incorporated into this classification. The tables summarize mandatory features, cautionary alerts, and exclusionary features for the common syndromes. Guidance is given on the criteria for syndrome diagnosis in resource-limited regions where laboratory confirmation, including EEG, MRI, and genetic testing, might not be available.
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Affiliation(s)
- Sameer M Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Institute of Health & Wellbeing, Collaborating Centre of European Reference Network EpiCARE, University of Glasgow, Glasgow, UK
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesu' Children's Hospital, IRCCS, Member of European Reference Network EpiCARE, Rome, Italy
| | - Kate Riney
- Neurosciences Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Ronit Pressler
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Member of European Reference Network EpiCARE, London, UK
| | - Stephane Auvin
- AP-HP, Hôpital Robert-Debré, INSERM NeuroDiderot, DMU Innov-RDB, Neurologie Pédiatrique, Member of European Reference Network EpiCARE, Université de Paris, Paris, France
| | - Pauline Samia
- Department of Paediatrics and Child Health, Aga Khan University, Nairobi, Kenya
| | - Edouard Hirsch
- Neurology Epilepsy Unit "Francis Rohmer", INSERM 1258, FMTS, Strasbourg University, Strasbourg, France
| | - Santiago Galicchio
- Child Neurology Department, Victor J Vilela Child Hospital of Rosario, Santa Fe, Argentina
| | - Chahnez Triki
- Child Neurology Department, LR19ES15 Neuropédiatrie, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - O Carter Snead
- Pediatric Neurology, Hospital for Sick Children, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samuel Wiebe
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - J Helen Cross
- Programme of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, Member of European Reference Network EpiCARE, London, UK.,Young Epilepsy, Lingfield, UK
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Ingrid E Scheffer
- Austin Health and Royal Children's Hospital, Florey Institute, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Emilio Perucca
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Bronx, New York, USA.,Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA.,Montefiore Medical Center, Bronx, New York, USA
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker-Enfants Malades University Hospital, APHP, Member of European Reference Network EpiCARE, Institut Imagine, INSERM, UMR 1163, Université Paris cité, Paris, France
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Wirrell EC, Hood V, Knupp KG, Meskis MA, Nabbout R, Scheffer I, Wilmshurst J, Sullivan J. The International Consensus on Diagnosis and Management of Dravet Syndrome. Epilepsia 2022; 63:1761-1777. [PMID: 35490361 PMCID: PMC9543220 DOI: 10.1111/epi.17274] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 11/29/2022]
Abstract
Objective This study was undertaken to gain consensus from experienced physicians and caregivers regarding optimal diagnosis and management of Dravet syndrome (DS), in the context of recently approved, DS‐specific therapies and emerging disease‐modifying treatments. Methods A core working group was convened consisting of six physicians with recognized expertise in DS and two representatives of the Dravet Syndrome Foundation. This core group summarized the current literature (focused on clinical presentation, comorbidities, maintenance and rescue therapies, and evolving disease‐modifying therapies) and nominated the 31‐member expert panel (ensuring international representation), which participated in two rounds of a Delphi process to gain consensus on diagnosis and management of DS. Results There was strong consensus that infants 2–15 months old, presenting with either a first prolonged hemiclonic seizure or first convulsive status epilepticus with fever or following vaccination, in the absence of another cause, should undergo genetic testing for DS. Panelists agreed on evolution of specific comorbidities with time, but less agreement was achieved on optimal management. There was also agreement on appropriate first‐ to third‐line maintenance therapies, which included the newly approved agents. Whereas there was agreement for recommendation of disease‐modifying therapies, if they are proven safe and efficacious for seizures and/or reduction of comorbidities, there was less consensus for when these should be started, with caregivers being more conservative than physicians. Significance This International DS Consensus, informed by both experienced global caregiver and physician voices, provides a strong overview of the impact of DS, therapeutic goals and optimal management strategies incorporating the recent therapeutic advances in DS, and evolving disease‐modifying therapies.
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Affiliation(s)
- Elaine C Wirrell
- Divisions of Child and Adolescent Medicine and Epilepsy Department of Neurology Mayo Clinic Rochester MN USA
| | | | - Kelly G Knupp
- Departments of Pediatrics and Neurology University of Colorado Anschutz Campus Aurora CO USA
| | | | - Rima Nabbout
- Reference Centre for Rare Epilepsies Department of Pediatric Neurology Necker–Enfants Malades Hospital, APHP, Member of European Reference Network EpiCARE, Institut Imagine, INSERM, UMR 1163 Université de Paris Paris France
| | - Ingrid Scheffer
- University of Melbourne Austin Health and Royal Children’s Hospital Florey Institute of Neuroscience and Mental Health Murdoch Children’s Research Institute Melbourne Australia
| | - Jo Wilmshurst
- Department of Paediatric Neurology Red Cross War Memorial Children’s Hospital Neuroscience Institute University of Cape Town South Africa
| | - Joseph Sullivan
- Departments of Neurology and Pediatrics Benioff Children’s Hospital University of California San Francisco CA USA
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Thompson K. Status epilepticus and early development: neuronal injury, neurodegeneration, and their consequences. Epilepsia Open 2022; 8 Suppl 1:S110-S116. [PMID: 35434910 PMCID: PMC10173843 DOI: 10.1002/epi4.12601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/07/2022] Open
Abstract
Evidence showing that the immature brain is vulnerable to seizure-induced damage has been accumulating for decades. Clinical data have always suggested that some early-life seizures are associated with negative sequelae, but clinical observations are frequently obscured by multiple uncontrolled contributing factors and can rarely establish causality. Determining with certainty that seizures, per se, can cause neuronal death and can irreversibly disrupt critical developmental processes, required the development of suitable model systems. Several experimental seizure models clearly show that the immature brain can sustain neuronal injury as a result of uncontrolled seizure activity and that even in the absence of observable neuronal death, the developing brain is selectively vulnerable to interruptions of required growth programs. Severe early-life seizures inhibit DNA, RNA, and protein synthesis, and they can reduce the accumulation of myelin and synaptic markers in the developing nervous system, leading to functional delays in development. Depending on the seizure pathway involved, and the developmental period under study, classic neurodegeneration, excitotoxicity, and apoptosis can result in permanent damage to critical neural networks in the temporal lobe and in many other brain regions. This conclusion is further supported by recent clinical studies showing that prolonged febrile status epilepticus can lead to hippocampal injury, which evolves into hippocampal atrophy and hippocampal sclerosis. A growing body of experimental data demonstrates that the metabolic compromise and cellular loss produced by seizures during critical phases of brain development negatively affect later hippocampal physiology including learning and memory functions in maturity.
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Affiliation(s)
- Kerry Thompson
- Occidental College Department of Biology, 1600 Campus Rd Los Angeles CA USA
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62
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Dravet syndrome in children - a population-based study. Epilepsy Res 2022; 182:106922. [DOI: 10.1016/j.eplepsyres.2022.106922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/06/2022] [Accepted: 04/05/2022] [Indexed: 11/03/2022]
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63
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Stenshorne I, Syvertsen M, Ramm-Pettersen A, Henning S, Weatherup E, Bjørnstad A, Brüggemann N, Spetalen T, Selmer KK, Koht J. Monogenic developmental and epileptic encephalopathies of infancy and childhood, a population cohort from Norway. Front Pediatr 2022; 10:965282. [PMID: 35979408 PMCID: PMC9376386 DOI: 10.3389/fped.2022.965282] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/07/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Developmental and epileptic encephalopathies (DEE) is a group of epilepsies where the epileptic activity, seizures and the underlying neurobiology contributes to cognitive and behavioral impairments. Uncovering the causes of DEE is important in order to develop guidelines for treatment and follow-up. The aim of the present study was to describe the clinical picture and to identify genetic causes in a patient cohort with DEE without known etiology, from a Norwegian regional hospital. METHODS Systematic searches of medical records were performed at Drammen Hospital, Vestre Viken Health Trust, to identify patients with epilepsy in the period 1999-2018. Medical records were reviewed to identify patients with DEE of unknown cause. In 2018, patients were also recruited consecutively from treating physicians. All patients underwent thorough clinical evaluation and updated genetic diagnostic analyses. RESULTS Fifty-five of 2,225 patients with epilepsy had DEE of unknown etiology. Disease-causing genetic variants were found in 15/33 (45%) included patients. Three had potentially treatable metabolic disorders (SLC2A1, COQ4 and SLC6A8). Developmental comorbidity was higher in the group with a genetic diagnosis, compared to those who remained undiagnosed. Five novel variants in known genes were found, and the patient phenotypes are described. CONCLUSION The results from this study illustrate the importance of performing updated genetic investigations and/or analyses in patients with DEE of unknown etiology. A genetic cause was identified in 45% of the patients, and three of these patients had potentially treatable conditions where available targeted therapy may improve patient outcome.
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Affiliation(s)
- Ida Stenshorne
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Marte Syvertsen
- Department of Neurology, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Anette Ramm-Pettersen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway
| | - Susanne Henning
- Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Elisabeth Weatherup
- Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Alf Bjørnstad
- Department of Children and Adolescents, Stavanger University Hospital, Stavanger Health Trust, Stavanger, Norway
| | - Natalia Brüggemann
- Department of Children and Adolescents, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Torstein Spetalen
- Department of Neurology, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Kaja K Selmer
- National Center for Epilepsy, Oslo University Hospital, Oslo, Norway.,Division of Clinical Neuroscience, Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Jeanette Koht
- Department of Neurology, Oslo University Hospital, Oslo, Norway
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