The epidemiology of epilepsy in Europe - a systematic review

Differences in obsessive-compulsive symptom dimensions between patients with epilepsy with obsessive-compulsive symptoms and patients with OCD

Clinical correlates of obsessive-compulsive symptoms (OCS) were evaluated in 100 adult consecutive outpatients with epilepsy, using the Obsessive-Compulsive Inventory (OCI-R), Beck Depression Inventory (BDI), Dissociative Experiences Scale (DES-II), and the Schizotypal Personality Questionnaire (SPQ). Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) was applied to determine the types and severity of OCS to the 45 patients with epilepsy who were over 21 points on the OCI-R scale and 30 patients who were with diagnosed obsessive-compulsive disorder (OCD) among the patients in the psychiatry outpatient clinic, as a control group. As a result, it was found that patients with epilepsy with OCS tend to have more symmetry/exactness obsessions and compulsions, whereas patients with OCD had significantly more contamination/cleaning and aggressiveness obsessions and compulsions. In addition, OCS was found to be significantly higher in temporal lobe epilepsy (TLE) and extratemporal epilepsy than generalized epilepsy. However, OCS were correlated with depression, dissociation, and schizotypy in patients with epilepsy, while only depression was predictive when regression analysis was performed for OCS. This study is the first study to compare patients with OCD with patients with epilepsy in terms of the nature of OCS and first identified the differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD.

Economic Value of Adjunctive Brivaracetam Treatment Strategy for Focal Onset Seizures in Finland

Introduction

There is an unmet need for well-tolerated antiepileptic drugs (AEDs) that effectively control focal onset seizures. This study aimed to evaluate the economic value of new AEDs in the treatment of focal onset seizure, with or without secondary generalization, in Finnish adults and adolescents with epilepsy, comparing brivaracetam with perampanel as adjunctive AEDs.

Methods

Economic value was assessed using cost-utility analysis. Periods of AED initiation, titration, response assessment (seizure freedom, ≥ 50% reduction, no response), switching in no response or treatment-emergent adverse events (TEAEs), and death were simulated using a discrete-event simulation model. Responses and switching were simulated based on a comprehensive Bayesian network meta-analysis. The primary modeled outcome was the 3%/year discounted incremental cost-effectiveness ratio (ICER). Discounted quality-adjusted life-years (QALYs), payer costs (year 2017 Euro) per patient, and net monetary benefit (NMB) were secondary outcomes. Probabilistic and comprehensive deterministic sensitivity analyses were conducted.

Results

Brivaracetam was more efficacious and had fewer TEAEs than perampanel and other AEDs. Modeled average 5-year QALYs and costs were 3.671 and €28,297 for brivaracetam and 3.611 and €27,979 for perampanel, respectively. The resulting ICER for brivaracetam versus perampanel was only €5345/QALY gained in a deterministic base case scenario. Brivaracetam had a positive NMB and high probability of cost-effectiveness of €1190 and 71% or €1944 and 80% with the assumed willingness to pay of €25,358 or €38,036/QALY gained, respectively. The primary result was robust, with a positive NMB persistent in all sensitivity analysis scenarios. When switching from brivaracetam to perampanel was excluded from the modeling or switching from perampanel to brivaracetam was included, brivaracetam was cost-saving and more effective than perampanel (dominant).

Conclusion

These simulated comparisons demonstrated that brivaracetam was more effective and potentially also more affordable than perampanel. Thus, brivaracetam is likely a cost-effective and net beneficial alternative to perampanel for treatment of focal onset seizures.

Plain Language Summary

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Electronic supplementary material

The online version of this article (10.1007/s12325-019-01155-6) contains supplementary material, which is available to authorized users.

Awareness and current knowledge of epilepsy

Epilepsy is a severe neural disorder that affects approximately fifty million individuals globally. Despite the fact that for most of the people with epilepsy, convulsions are better controlled by current accessible antiepileptic medicines, yet there are more than 30% of individuals affected with medically intractable epilepsy and around 30-40% of all patients with epilepsy affected by many adverse reactions and convulsion resistance to the present antiepileptic drugs. Consequently, various scientists attempt to develop new strategies to treat epilepsy, for instance, to find out novel antiepileptic ingredients from traditional medicines. This work aims to present a complete summary of natural medicines prescribed as antiepileptic agents all over the world by ethnic groups and different tribes. We undertook an extensive bibliographic analysis by searching peer reviewed papers and classical textbooks and further consulting well accepted worldwide scientific databases. We carried out PubMed, EMbase and CENTRAL searches by means of terms such as "antiepileptic" and "anti-convulsant" activity of plants. Medicinal plants have been prescribed to treat epilepsy and have been recognized as antiepileptic medicines. In this review, a variety of herbs have been reviewed for thorough studies such as Cuminum cyminum, Butea monosperma, Solanum americanum, Anacyclus pyrethrum, Leonotis leonurus, Elaeocarpus ganitrus and Angelica archangelica. This paper shows that it was high time experimental studies are increased to obtain novel potential active principles from medicinal plants. Plant extracts and their chemical constituents should be further evaluated to clarify their mechanisms of action. This paper provides a solid base upon which to further investigate the clinical efficacy of medicinal plants that are both currently prescribed by physicians as traditional antiepileptic agents, but also could be effective as an antiepileptic drug with further research and study.

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

Background

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

Objective

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

Methods

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

Result

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

Conclusion

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

Customized multigene panels in epilepsy: the best things come in small packages

Over the past 10 years, the increasingly important role played by next-generation sequencing panels in the genetic diagnosis of epilepsy has led to a growing list of gene variants and a plethora of new scientific data. To date, however, there is still no consensus on what constitutes the "ideal panel design," or on the most rational criteria for selecting the best candidates for gene-panel analysis, even though both might optimize the cost-benefit ratio and the diagnostic efficiency of customized gene panels. Even though more and more laboratories are adopting whole-exome sequencing as a first-tier diagnostic approach, interpreting, "in silico," a set of epilepsy-related genes remains difficult. In the light of these considerations, we performed a systematic review of the targeted gene panels for epilepsy already reported in the available scientific literature, with a view to identifying the best criteria for selecting patients for gene-panel analysis, and the best way to design an "ideal," gold-standard panel that includes all genes with an established role in epilepsy pathogenesis, as well as those that might help to guide decisions regarding specific medical interventions and treatments. Our analyses suggest that the usefulness and diagnostic power of customized gene panels for epilepsy may be greatest when these panels are confined to rationally selected, relatively small, pools of genes, and applied in more carefully selected epilepsy patients (those with complex forms of epilepsy). A panel containing 64 genes, which includes the 45 genes harboring a significant number of pathogenic variants identified in previous literature, the 32 clinically actionable genes, and the 21 ILAE (International League Against Epilepsy) recommended genes, may represent an "ideal" core set likely able to provide the highest diagnostic efficiency and cost-effectiveness and facilitate gene prioritization when testing patients with whole-exome/whole-genome sequencing.

ABCB1 Polymorphisms and Drug-Resistant Epilepsy in a Tunisian Population

Background

Epilepsy is one of the most common neurological disorders with about 30% treatment failure rate. An interindividual variations in efficacy of antiepileptic drugs (AEDs) make the treatment of epilepsy challenging, which can be attributed to genetic factors such as ATP-Binding Cassette sub-family B, member1 (ABCB1) gene polymorphisms.

Objective

The main objective of the present study is to evaluate the association of ABCB1 C1236T, G2677T, and C3435T polymorphisms with treatment response among Tunisian epileptic patients.

Materials and Methods

One hundred epileptic patients, originated from north of Tunisia, were recruited and categorized into 50 drug-resistant and 50 drug-responsive patients treated with antiepileptic drugs (AEDs) as per the International League Against Epilepsy. DNA of patients was extracted and ABCB1 gene polymorphisms studied using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method.

Results

The C1236T, G2677T, and C3435T polymorphisms were involved into AED resistance. Significant genotypic (C1236T TT (p ≤ 0.001); G2677T TT (p = 0.001); C3435T TT (p ≤ 0.001)) and allelic associations (C1236T T (3.650, p ≤ 0.001); G2677TT (1.801, p = 0.044); C3435T T (4.730, p ≤ 0.001)) with drug resistance epilepsy (DRE) were observed. A significant level of linkage disequilibrium (LD) was also noted between ABCB1 polymorphisms. Patients with the haplotypes CT and TT (C1236T-G2677T); GT, TC, and TT (G2677T-C3435T); CT and TT (C1236T-C3435T); CTT, TTC, TGT, and TTT (C1236T-G2677T-C3435T) were also significantly associated to AED resistance.

Conclusions

The response to antiepileptics seems to be modulated by TT genotypes, T alleles, and the predicted haplotypes for the tested SNPs in our population. Genetic analysis is a valuable tool for predicting treatment response and thus will contribute to personalized medicine for Tunisian epileptic patients.

Family history increases the risk of late seizures after stroke

OBJECTIVE

To assess the association between a family history of epilepsy and risk of late poststroke seizures (LPS).

METHODS

This register-based cohort study was based on adult patients from the Swedish Stroke Register (Riksstroke) with stroke from 2001 to 2012 and no prior epilepsy. LPS (>7 days after stroke) and epilepsy were ascertained in cases and in their first-degree biological relatives by cross-referencing Riksstroke, the Multi-Generation Register, and the National Patient Register.

RESULTS

Of 86,550 patients with stroke, a family history of epilepsy was detected in 7,433 (8.6%), and LPS (>7 days after stroke) occurred in 7,307 (8.4%). The survival-adjusted risk of LPS was higher in patients with compared to those without a family history of epilepsy: 6.8% (95% confidence interval [CI] 6.2%-7.4%) vs 5.9% (95% CI 5.7%-6.1%) at 2 years and 9.5% (95% CI 8.7%-10.3%) vs 8.2% (95% CI 8.0%-8.4%) at 5 years. In a Cox model adjusted for age, sex, and stroke type, the hazard ratio (HR) for LPS in patients with stroke with ≥1 relative with epilepsy was 1.18 (95% CI 1.09-1.28). The increased HR remained significant with adjustments for stroke severity and in multiple sensitivity analyses. A higher risk for patients with stroke with >1 relative with epilepsy was also seen but was not significant in all Cox models.

CONCLUSIONS

Although stroke characteristics remain the most important risk factors for LPS, having a first-degree relative with epilepsy also increases the risk in a multivariate analysis. The findings highlight the need for family history assessment in patients with stroke and the need for future studies on genetic vulnerability and environmental factors that may aid in the identification of at-risk individuals.

Patients' knowledge on epilepsy and SUDEP improves after a semi-structured health interview

BACKGROUND

Patients' education is the most relevant contributor to patient self-management of epilepsy. We aimed to assess the acquisition of knowledge after a semi-structured interview.

METHODS

We performed a quasi-experimental prospective study with a cohort of patients with epilepsy admitted for prolonged video electroencephalogram (VEEG). We measured patients' baseline knowledge with a 10-item true-false test (test A). Then, a qualified nurse carried out a semi-structured interview. We measured acquired knowledge with another 10-item true-false exam (test B), prior to VEEG discharge and after a 3- to 5-month follow-up, and we compared the difference between the scores in test A and test B. Finally, we conducted a satisfaction and suitability survey on the interview at follow-up.

RESULTS

Thirty-two patients participated, half were women. Their median age was 39.5, and the median length of schooling was 14 years. The median time since epilepsy onset was 13 years, 75% had suffered tonic-clonic seizures. The median score on test A was 7, while the median score on test B was 8.5 (p < 0.001) both at VEEG discharge and after follow-up. After the interview, 84.4% of participants reported that they were very satisfied with the information received; 87.5% stated that they had not previously heard about SUDEP (sudden unexpected dead in epilepsy); and 93.8% considered it important to receive detailed information about SUDEP.

CONCLUSIONS

Patient education through a semi-structured comprehensive interview improves knowledge of patients with epilepsy about their disease. The calm atmosphere and the qualified nursing working at VEEG units make them an appropriate setting for talking about epilepsy and its risks, including SUDEP.

[Febrile seizures, epilepsy, migraine, diabetes, and heart disease as well as measles, chicken pox, and whooping cough in children and adolescents in Germany : Results from KiGGS Wave 2]

Trends of frequent chronic diseases and health problems, e.g. allergic diseases, have already been published based on the KiGGS Wave 2 study as part of the health monitoring of children and adolescents in Germany. The present work complements these findings with results on less frequent noncommunicable diseases and the trend of communicable, vaccine-preventable diseases.Information from parents about diagnoses and diseases of their 0‑ to 17-year-old children from the representative cross-sectional survey KiGGS Wave 2 (2014-2017) are compared with those from the KiGGS baseline survey (2003-2006) and KiGGS Wave 1 (2009-2012).The current KiGGS results show almost unchanged prevalences for the noncommunicable diseases epilepsy, migraine, and heart disease. However, the data from KiGGS Wave 2 are supportive of an increased prevalence of diabetes mellitus, which nevertheless continues to be relatively rare and predominantly type 1 diabetes in children and adolescents.The decline in measles, chicken pox, and whooping cough diseases related to changes in vaccination recommendations shows that preventive measures can effectively benefit children and adolescents.However, the data on vaccine-preventable diseases indicate regionally varying immunity gaps in certain age groups, so the prevention potential of the vaccination recommendations of the Standing Vaccination Commission (STIKO) at the Robert Koch Institute does not seem to have been sufficiently exploited.

[Sudden unexpected death in epilepsy (SUDEP) : Epidemiology, cardiac and other risk factors]

Sudden unexpected death in epilepsy (SUDEP) is one of the most frequent epilepsy-related causes of death. The incidence of SUDEP is estimated to be approximately 1.2/1000 person-years (PY); however, it varies considerably depending on disease-specific and demographic factors. The estimated incidence of SUDEP in children seems to be significantly lower (0.22/1000 PY) than in adults but recent studies in children (>12 years) indicated a similar incidence to that of adults. Based on these estimations, approximately 700 SUDEP cases would be expected in Germany annually but no reliable data or epidemiological studies on SUDEP are available. Various risk factors and predictors for SUDEP have been investigated, e.g. age, seizure frequency, number of antiepileptic drugs, non-compliance and comorbidities, with sometimes contradictory results. This is understandable given that the exact mechanisms of SUDEP are unclear; however, it is very likely that the frequency of (nocturnal) generalized tonic-clonic seizures is the most important risk factor. Nocturnal monitoring of seizures (using devices) or the presence of another person at night may represent important factors to reduce the risk of SUDEP. Thus, seizure control and seizure monitoring are, according to current knowledge, the most important factors to avoid SUDEP. Some recent studies have contributed to a better understanding of possible pathomechanisms of SUDEP; however, further research is needed to identify predictive clinical factors and biomarkers and in particular to prevent SUDEP.

Management of epilepsy in brain tumors

Epilepsy in brain tumors (BTE) may require medical attention for a variety of unique concerns: epileptic seizures, possible serious adverse effects of antineoplastic and antiepileptic drugs (AEDs), physical disability, and/or neurocognitive disturbances correlated to tumor site. Guidelines for the management of tumor-related epilepsies are lacking. Treatment is not standardized, and overall management might differ according to different specialists. The aim of this document was to provide directives on the procedures to be adopted for a correct diagnostic-therapeutic path of the patient with BTE, evaluating indications, risks, and benefits. A board comprising neurologists, epileptologists, neurophysiologists, neuroradiologists, neurosurgeons, neuro-oncologists, neuropsychologists, and patients' representatives was formed. The board converted diagnostic and therapeutic problems into seventeen questions. A literature search was performed in September-October 2017, and a total of 7827 unique records were retrieved, of which 148 constituted the core literature. There is no evidence that histological type or localization of the brain tumor affects the response to an AED. The board recommended to avoid enzyme-inducing antiepileptic drugs because of their interference with antitumoral drugs and consider as first-choice newer generation drugs (among them, levetiracetam, lamotrigine, and topiramate). Valproic acid should also be considered. Both short-term and long-term prophylaxes are not recommended in primary and metastatic brain tumors. Management of seizures in patients with BTE should be multidisciplinary. The panel evidenced conflicting or lacking data regarding the role of EEG, the choice of therapeutic strategy, and timing to withdraw AEDs and recommended high-quality long-term studies to standardize BTE care.

Trends in sodium valproate prescriptions among children aged 0 to 14 years between 2010 and 2016: A study based on the French National Health Insurance Database

PURPOSE

After a huge campaign of information on the teratogenic risk of sodium valproate (VPA) having taken place in France we aimed to evaluate the trend of its prescriptions in young epileptic girls.

METHOD

Using the French National Health Insurance Database we searched for patients aged 0-14 years being supplied an antiepileptic drug (AED) between 2010 and 2016.

RESULTS

113,362 children received at least one AED, 61,259 boys and 52,103 girls. Compared to 2010-2014 years, VPA was less prescribed in 2016 as first AED (29% vs 37.3% respectively). The difference between the two periods was greater for girls (-41%) than for boys (-12%).

CONCLUSION

The changing trend of VPA as first AED prescribed, particularly in girls, reflects published evidence in terms of safety.

Treatment of Seizures in Children and Adults in the Emergency Medical System of the City of Zurich, Switzerland - Midazolam vs. Diazepam - A Retrospective Analysis

INTRODUCTION

Seizures count to critical situations emergency medical systems (EMS) are confronted with.

OBJECTIVES

Evaluation of a modified treatment algorithm (MTAS-EMS) using diazepam and midazolam due to a supply bottleneck of iv lorazepam in 2012.

METHODS

Retrospective study where data from patients treated for seizures by the EMS of the city of Zurich were analyzed. Effectiveness of the MTAS-EMS and i.v. diazepam in children and adults was compared with respect of cessation of seizure without recurrence over the period until arrival at the hospital. The chi-square and Fisher's exact test were used to compare categorical data. The Student's t-test and Mann Whitney test were used to compare numerical data. p-values < 0.05 are considered significant.

RESULTS

Of 584 documented missions, 165 treated patients (126 adults and 39 children) were included. 115 patients (80 adults and 35 children) were treated according the MTAS-EMS. Cessation of seizure was achieved in 85% of the adults and in 97% of the children, if all options of the MTAS-EMS were used. The first dose of nasal midazolam was more successful in children compared to adults (p = 0.012). In adults, the single dose of i.v. diazepam terminated the seizure in 98% (p = 0.001) compared to 57% for the single dose of iv and 64% for nasal midazolam.

CONCLUSIONS

The treatment success of the MTAS-EMS is high. However, in adults the single dose of i.v. diazepam is as successful as the completely used MTAS-EMS and seems to be superior to the single dose iv and nasal midazolam.

What really matters? A mixed methods study of treatment preferences and priorities among people with epilepsy in the UK

The widening range of treatment options for epilepsy, and their potential outcomes, mean decisions about treatment for people with epilepsy (PWE) are often complex. While antiepileptic drugs (AEDs) represent the mainstay of treatment, other potential nondrug interventions are gaining in importance. These treatments all have the potential for harming those using them, as well as bringing benefits. This study examined the views and experiences of PWE about a range of treatment options. We used both qualitative and quantitative approaches - a series of depth-narrative interviews, followed by a large-scale survey. Treatment options and healthcare priorities deemed important by at least 10% of interview participants were then addressed as a series of statements in the follow-on survey questionnaire. Quantitative responses supported healthcare priorities identified through the qualitative interviews. The key goal of treatment among study participants was to be able to live 'a normal life'. Important physical, psychological, and life benefits of treatment were identified - most being the direct consequence of improved seizure control. One psychological benefit, reduced worry, was also identified as an important treatment goal. All participants viewed AEDs as appropriate first-line treatment; and since adverse effects of AEDs had implications for individual levels of daily function and wellbeing, their appropriate management was considered important. In contrast, surgery was almost always regarded as the treatment of last resort. Despite lack of research evidence supporting their use, participants were interested in complementary therapies as adjunctive treatment and a means of coping with having epilepsy, with yoga and meditation of particular interest. An important finding was the desire for targeted services to help with memory problems, as was the call to increase availability of psychological/counseling services. Our findings emphasize the importance of providing treatment responsive to the life context of individual patients. They highlight not only the level of demand for specific treatment options, but also the need for high-quality evidence to support future investment in their provision.

Educational and health outcomes of children and adolescents receiving antiepileptic medication: Scotland-wide record linkage study of 766 244 schoolchildren

BACKGROUND

Childhood epilepsy can adversely affect education and employment in addition to health. Previous studies are small or highly selective producing conflicting results. This retrospective cohort study aims to compare educational and health outcomes of children receiving antiepileptic medication versus peers.

METHODS

Record linkage of Scotland-wide databases covering dispensed prescriptions, acute and psychiatric hospitalisations, maternity records, deaths, annual pupil census, school absences/exclusions, special educational needs, school examinations, and (un)employment provided data on 766,244 children attending Scottish schools between 2009 and 2013. Outcomes were adjusted for sociodemographic and maternity confounders and comorbid conditions.

RESULTS

Compared with peers, children on antiepileptic medication were more likely to experience school absence (Incidence Rate Ratio [IRR] 1.43, 95% CI: 1.38, 1.48), special educational needs (Odds ratio [OR] 9.60, 95% CI: 9.02, 10.23), achieve the lowest level of attainment (OR 3.43, 95% CI: 2.74, 4.29) be unemployed (OR 1.82, 95% CI: 1.60, 2.07), be admitted to hospital (Hazard Ratio [HR] 3.56, 95% CI: 3.42, 3.70), and die (HR 22.02, 95% CI: 17.00, 28.53). Absenteeism partly explained poorer attainment and higher unemployment. Girls and younger children on antiepileptic medication had higher risk of poor outcomes.

CONCLUSIONS

Children on antiepileptic medication fare worse than peers across educational and health outcomes. In order to reduce school absenteeism and mitigate its effects, children with epilepsy should receive integrated care from a multidisciplinary team that spans education and healthcare.

The Use of Caffeine by People with Epilepsy: the Myths and the Evidence

PURPOSE OF REVIEW

Caffeine is the most widely consumed central nervous stimulant. For people with epilepsy, it is often unclear whether drinking coffee carries a risk of triggering seizures.

RECENT FINDINGS

The relationship between caffeine, seizures, epilepsy, and anti-seizure drugs is not fully understood. Clinical studies are scarce. In animal models, caffeine can increase seizure susceptibility but can also protect from seizures. Effects seem dose-dependent and are influenced by the duration of intake and the developmental stage at which caffeine exposure started. Caffeine reduces the efficacy of several anti-seizure medications, especially topiramate. It is unclear how these findings, mainly from animal studies, can be translated to the clinical condition. At present, there is no evidence to advise people with epilepsy against the use or overuse of caffeine. Until clinical studies suggest otherwise, caffeine intake should be considered as a factor in achieving and maintaining seizure control in epilepsy.

Long-term efficacy and safety of lacosamide and levetiracetam monotherapy in elderly patients with focal epilepsy: A retrospective study

OBJECTIVES

Epilepsy management in elderly patients is often complex because of several concomitant comorbidities that may limit the use of some antiepileptic drugs (AEDs). Levetiracetam (LEV) is a second-generation AED widely used in elderly patients with epilepsy while lacosamide (LCM), which has been recently approved in European Union (EU) as monotherapy for the treatment of focal onset seizures, is affected by a scarcity of data in such frail population. This study is aimed at assessing the efficacy and the tolerability of LCM as monotherapy in elderly patients affected by focal onset epilepsy compared with those receiving LEV.

METHODS

A retrospective chart review of patients aged ≥65 years suffering from focal onset seizures, with or without secondary generalization on LCM monotherapy or LEV monotherapy, was performed. Data regarding demographic characteristics, seizure type and etiology, LCM and LEV daily dose, number of lifetime AEDs, seizure frequency at baseline and at 12 months of follow-up, and seizure freedom rates were reported.

RESULTS

In this observational retrospective study, 22 patients on LCM (10 males, 12 females, mean age: 76.23 ± 7.5) and 24 patients on LEV (10 males, 14 females, mean age: 73.58 ± 6.39) were enrolled. Mean LCM daily dose was 204.51 ± 88.51 mg and mean LEV daily dose was 1281.25 ± 378.15 mg. All patients had comorbidities on chronic treatment. At 12 months of follow-up, mean monthly seizure frequency reduced from 4.23 ± 8.53 to 0.33 ± 0.9 (p < .001) in LCM group and from 2.29 ± 6.11 to 0.2 ± 0.81 (p < .001) in LEV group. Furthermore, 16/22 (72.7%) LCM patients were seizure-free at 12 months of follow-up while seizure freedom was achieved by 17/24 (70.8%) patients in LEV group.

DISCUSSION AND CONCLUSION

Epilepsy management in elderly patients is often challenging. In this retrospective real-life study, the efficacy and the tolerability of LCM as monotherapy was favorable even at low doses in older patients and comparable with LEV with a high rate of long-term seizure freedom. Considering the frequent comorbidities and the risk of drug-drug interactions, LCM monotherapy may be a valuable option in elderly patients with focal onset epilepsy because of its favorable pharmacokinetic profile.

Herbal medicine for epilepsy seizures in Asia, Africa and Latin America: A systematic review

RELEVANCE

More than 70 million people suffer epilepsy worldwide. Low availability of anti-epileptic drugs, side-effects and drug-resistant epilepsy affect the quality of life of persons with epilepsy in countries with a poorly developed health system. Herbal medicine is frequently used for this neurological condition.

OBJECTIVES

The main objective was to provide a detailed analysis of Herbal Medicine used for neurological conditions related with epilepsy in Asia, Africa and Latin America. More broadly, this study aims to highlight species with assessed efficacy (cross-cultural use, pharmacological effects on models of epileptic seizures) and safety (toxicological data in laboratory) information, in order to point out species of interest for further studies. A critical assessment of models used in pharmacological evaluations was done.

MATERIALS AND METHODS

The systematic search for Herbal Medicine treatments for epilepsy was performed considering all the articles published until February 2017 through three scientific databases. It was made with MeSH terms and free text defining the epilepsy seizures and plant species. We included studies carried out in Asia, Africa and Latin America. All articles reporting the use of Herbal Medicine to treat epilepsy seizures and/or their pharmacological evaluation were retained for further analysis.

RESULTS

The search yielded 1886 articles, from 30 countries. Hundred and six articles published between 1982 and 2017 were included, corresponding to a total of 497 use reports for 351 plant species belonging to 106 families. Three hundred and seventy seven use reports corresponding to 264 species in ethnopharmacological surveys and 120 evaluation reports corresponding to 107 species were noted. Twenty-nine reports, for 29 species, combined both ethnopharmacological and pharmacological evaluation. Fifty eight studies originated from Africa, 35 studies from Asia and 18 from Latin America. Highest use report was noted for rhizomes of Acorus calamus L. (12 use report in 1 country) and leaves of Bacopa monnieri (L.) Wettst. (8 use report in 2 countries). Therefore these species display the highest use convergence. Regarding pharmacological evaluation most studied species were: Leonotis leonurus (L.) R.Br. (4 evaluation reports in 1 country), Uncaria rhynchophylla (Miq.) Miq. ex Havil. (3 evaluation reports in 2 countries) and Calotropis gigantea (L.) Dryand. (3 evaluation reports in 1 country). In vivo models of chronic epilepsy were more relevant than in vitro models or chemical models inducing acute seizures for pharmacological assessment.

CONCLUSION

Species with the highest use report were not those with pharmacological evaluation. It will be pertinent to assess the pharmacological effects and safety of medicinal plants used mostly by traditional healers on predictive models of seizures.

A meta-analysis of levetiracetam for randomized placebo-controlled trials in patients with refractory epilepsy

OBJECTIVE

The objective of this study was to investigate the efficacy and safety profile of levetiracetam as add-on therapy in patients with refractory epilepsy.

METHODS

Web of Science, MEDLINE (Ovid and PubMed), Cochrane Library, EMBASE, and Google Scholar were systematically searched to identify potential eligible randomized controlled trials by two reviewers independently. Pooled estimates of risk ratios (RRs) for 50%, 75%, and 100% reduction from baseline were calculated using the fixed-effect model or random-effect model. Quality of included studies was assessed with the Cochrane Collaboration's Risk of Bias tool. Serious adverse events and withdrawals induced by interventions and the most common side effects were analyzed.

RESULTS

Seventeen trials with a total of 3,205 participants were included in this meta-analysis, including 14 trials for adulthood and three trials for children. Pooled estimates suggested that levetiracetam was an effective anti-epileptic drug at 1,000-3,000 mg/day (RR =2.00 for 1,000 mg/day, RR =2.68 for 2,000 mg/day, RR =2.18 for 3,000 mg/day) for adults and 60 mg/kg/day (RR =2.00) for children compared to placebo in terms of 50% reduction from baseline. Likewise, as for seizure freedom rate, levetiracetam had an advantage over placebo at 1,000-3,000 mg/day (RR =5.84 for 1,000 mg/day, RR =4.55 for 2,000 mg/day, RR =4.57 for 3,000 mg/day, respectively) for adults and 60 mg/kg/day (RR =4.52) for children. Regarding safety profile, patients treated with levetiracetam had significantly higher occurrence than placebo for somnolence, asthenia, dizziness, infection, nasopharyngitis, anxiety, and irritability; however, most studies reported that these adverse events were mild and transient.

CONCLUSION

Levetiracetam is an effective anti-epileptic drug for both adults and children with generalized or partial-onset refractory seizures at 1,000-3,000 or 60 mg/kg/day, with a favorable adverse event profile.

Self-Management education for adults with poorly controlled epILEpsy [SMILE (UK)]: a randomised controlled trial

BACKGROUND

Epilepsy is a common neurological condition resulting in recurrent seizures. Research evidence in long-term conditions suggests that patients benefit from self-management education and that this may improve quality of life (QoL). Epilepsy self-management education has yet to be tested in a UK setting.

OBJECTIVES

To determine the effectiveness and cost-effectiveness of Self-Management education for people with poorly controlled epILEpsy [SMILE (UK)].

DESIGN

A parallel pragmatic randomised controlled trial.

SETTING

Participants were recruited from eight hospitals in London and south-east England.

PARTICIPANTS

Adults aged ≥ 16 years with epilepsy and two or more epileptic seizures in the past year, who were currently being prescribed antiepileptic drugs.

INTERVENTION

A 2-day group self-management course alongside treatment as usual (TAU). The control group received TAU.

MAIN OUTCOME MEASURES

The primary outcome is QoL in people with epilepsy at 12-month follow-up using the Quality Of Life In Epilepsy 31-P (QOLIE-31-P) scale. Other outcomes were seizure control, impact of epilepsy, medication adverse effects, psychological distress, perceived stigma, self-mastery and medication adherence. Cost-effectiveness analyses and a process evaluation were undertaken.

RANDOMISATION

A 1 : 1 ratio between trial arms using fixed block sizes of two.

BLINDING

Participants were not blinded to their group allocation because of the nature of the study. Researchers involved in data collection and analysis remained blinded throughout.

RESULTS

The trial completed successfully. A total of 404 participants were enrolled in the study [SMILE (UK), n = 205; TAU, n = 199] with 331 completing the final follow-up at 12 months [SMILE (UK), n = 163; TAU, n = 168]. In the intervention group, 61.5% completed all sessions of the course. No adverse events were found to be related to the intervention. At baseline, participants had a mean age of 41.7 years [standard deviation (SD) 14.1 years], and had epilepsy for a median of 18 years. The mean QOLIE-31-P score for the whole group at baseline was 66.0 out of 100.0 (SD 14.2). Clinically relevant levels of anxiety symptoms were reported in 53.6% of the group and depression symptoms in 28.0%. The results following an intention-to-treat analysis showed no change in any measures at the 12-month follow-up [QOLIE-31-P: SMILE (UK) mean: 67.4, SD 13.5; TAU mean: 69.5, SD 14.8]. The cost-effectiveness study showed that SMILE (UK) was possibly cost-effective but was also associated with lower QoL. The process evaluation with 20 participants revealed that a group course increased confidence by sharing with others and improved self-management behaviours.

CONCLUSIONS

For people with epilepsy and persistent seizures, a 2-day self-management education course is cost-saving, but does not improve QoL after 12-months or reduce anxiety or depression symptoms. A psychological intervention may help with anxiety and depression. Interviewed participants reported attending a group course increased their confidence and helped them improve their self-management.

FUTURE WORK

More research is needed on self-management courses, with psychological components and integration with routine monitoring.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57937389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 21. See the NIHR Journals Library website for further project information.

Quality of life and correlating factors in children, adolescents with epilepsy, and their caregivers: A cross-sectional multicenter study from Germany

PURPOSE

To identify factors correlating with poorer quality of life (QoL) in children and adolescents with epilepsy and regarding QoL and depression of their caregivers in Germany.

METHOD

A cross-sectional multicenter study on QoL and depression was performed in two representative German states (Hessen and Schleswig-Holstein). Variance analysis, linear regression, and bivariate correlation were used to identify correlating factors for poorer QoL and symptoms of depression.

RESULTS

Data from 489 children and adolescents (mean age 10.4 ± 4.2 years, range 0.5-17.8; 54.0% male) and their caregivers were collected. We identified missing seizure freedom (p = 0.046), concomitant diseases (p = 0.007), hospitalization (p = 0.049), recent status epilepticus (p = 0.035), living in a nursing home or with foster parents (p = 0.049), and relevant degree of disability (p = 0.007) to correlate with poorer QoL in children and adolescents with epilepsy. Poorer QoL of caregivers was associated with longer disease duration (p = 0.004), non-idiopathic (mainly structural-metabolic) epilepsy (p = 0.003), ongoing seizures (p = 0.003), concomitant diseases (p = 0.003), relevant disability (p = 0.003), or status epilepticus (p = 0.003) as well as with unemployment of the primary caretaker (p = 0.010). Symptoms of depression of caregivers were associated with non-idiopathic epilepsy (p = 0.003), concomitant diseases (p = 0.003), missing seizure freedom (p = 0.007), status epilepticus (p = 0.004), or a relevant disability (p = 0.004) of their ward. A poorer QoL value of the children and adolescents correlated with a poorer QoL value of the caregivers (p < 0.001).

CONCLUSIONS

Epilepsy shows a considerable impact on QoL and symptoms of depression. Early and effective therapy should focus on reduction of seizure frequency and the probability for developing status epilepticus. Furthermore, comprehensive care should pay attention at comorbidities, consequences of disability and dependency on others.

Prevalence and burden of epilepsy in Nigeria: A systematic review and meta-analysis of community-based door-to-door surveys

BACKGROUND

Studies on prevalence of epilepsy in Nigeria yielded figures ranging between 3.1 and 37 per 1000, giving one of the widest variations in prevalence of epilepsy world over. In order to accurately estimate clinical and public health impacts of epilepsy in Nigeria, robust and reliable epidemiological data are required for an appropriate estimation of logistical, economical, and social impacts of epilepsy.

OBJECTIVE

The objectives of the study were to determine, using meta-analysis, the prevalence of epilepsy by pooling data from community-based door-to-door surveys conducted in various parts of Nigeria, explore the existing variation in prevalence of epilepsy in Nigeria along geopolitical regions and settlement setting of the country, and then evaluate the burden of epilepsy in Nigeria.

METHODS

Prevalence estimates were derived from a random effects meta-analysis of observational studies reporting the prevalence of epilepsy in Nigeria. The derived estimate for the prevalence of epilepsy was applied to the total populations in Nigeria to give an estimated burden of epilepsy in Nigeria.

RESULT

Nine community-based door-to-door surveys, with quality data from different regions in Nigeria, were included. I-squared (I²) heterogeneity was 88.5%. Random effects model (REM) estimate of overall prevalence of epilepsy from the studies was 8 per 1000 (95% confidence interval (95% CI): 6-10). The prevalence was highest (11 per 1000) in the south western part of the country. It was also higher among the rural (15 per 1000 people) than the urban (6 per 1000) dwellers. The burden of epilepsy in Nigeria, based on the prevalence estimate was 1,280,000 persons (95% CI: 960,000-1,600,000 persons).

CONCLUSION

In Nigeria, the estimated prevalence of epilepsy is 8 per 1000 people indicating a substantial burden of the disease in the country.

Epilepsy and interictal epileptiform activity in patients with autism spectrum disorders

PURPOSE

The purpose of this study was to determine the prevalence of epilepsy and subclinical epileptiform abnormalities in children with autism spectrum disorder (ASD), and to investigate its effects on core autistic symptoms and adaptive behavior skills.

METHODS

Patients with diagnosis of ASD who met full criteria on Autism Diagnostic Interview-Revised (ADI-R) were included in the study. Adaptive behavior skills were assessed by Vineland Adaptive Behavior Scale-II (VABS-II). Clinical assessment for epilepsy and video electroencephalography (EEG) (v-EEG) examinations during wakefulness and/or sleep were prospectively performed in all patients.

RESULTS

A total of 112 patients with diagnosis of ASD of mean age 6.58 ± 3.72 were included in the study. Based on clinical and v-EEG assessments, three groups of patients were defined: 1) patients with epilepsy (n = 17; 15.2%); 2) patients with epileptiform discharges in absence of clinical seizures (n = 14; 12.5%); 3) patients without epilepsy and without epileptiform discharges (n = 81; 72.3%). There were no significant differences between three groups of patients on ADI-R subscores. Speech development was also not significantly related to epilepsy. There was a slight tendency of the VABS-II motor skills score to be higher in the group of patients with autism without clinical diagnosis of epilepsy and without subclinical epileptiform discharges (p < 0.05) in comparison with the two other groups. According to this tendency, we might claim that patients with higher scores on motor skills could have 0.88 times lower odds for having epileptiform EEG activity.

CONCLUSIONS

According to our results, we were not able to detect differences in the ADI-R between the three populations with ASD, all with unknown etiology. Epilepsy, as well as subclinical epileptic discharges, showed small effects on Motor Skills in patients with autism, and had no effect on adaptive behavior Communication/Socialization/Daily Living Skills.

An ambispective cohort study on treatment outcomes of patients with epilepsy in a tertiary epilepsy center in Rwanda and recommendations for improved epilepsy care

OBJECTIVE

Because outcome data inform and drive healthcare decisions and improvement of patient care, this study aimed to gain a deep understanding of sociodemographic profiles and treatment outcomes of newly presenting and recently diagnosed persons living with epilepsy (PwE) at a tertiary epilepsy center in Rwanda.

METHODS

In June 2016 (T1), as a first stage of this single-center cohort study, an ambispective chart review was conducted on baseline sociodemographic and disease characteristics of PwE using a structured questionnaire. Missing data were obtained by phone interview. In 2017, follow-up data were collected by phone interview on treatment outcomes after 15-months (T2).

RESULTS

Of 406 PwE screened, 235 were included at T1 and outcomes on 166 PwE were obtained at T2. More than 70% were <20 years of age, with a male preponderance. A high number of patients were aged ≥20 years, were single (67.4%), unemployed (41.5%), and had no formal education or primary level education (53.9%), possibly reflecting stigma. A mean delay in diagnosis since first seizure increased with age at first seizure, amounting to 3 years for patients aged ≥20 years. At T2, 69.6% of 166 patients who could be contacted reported no seizures in the previous month. Valproate monotherapy was the most frequently prescribed treatment. At T2, 47% had discontinued treatment, which was often not recommended by a physician, despite medical insurance coverage in >90% of patients. Only 19% reported an adverse event. Marked and partial improvement in quality of life (QoL) was reported by, respectively, 50.9% and 32.7% of patients.

SIGNIFICANCE

Encouraging results on improved seizure control and QoL were observed at follow-up. The treatment gap remains high due to loss to follow-up and treatment discontinuation. In this article, we discuss needs and recommendations for improving patient care, requiring concerted efforts of stakeholders at all levels of the healthcare system.

Epilepsy at different ages-Etiologies in a Norwegian population

The causes of epilepsy are age related, but confirmative data from population-based studies are scarce. Our aim was to describe the typical causes of epilepsy in the different age groups of a defined population. The study was cross-sectional, based on a review of all medical files containing a diagnostic code for epilepsy at Drammen Hospital from 1999-2013. Drammen Hospital serves the population of Buskerud County, with 272 228 residents (as of January 1, 2014), including 1771 people with active epilepsy. This group of persons with active epilepsy was divided into different age groups with the causes of epilepsy mapped in each group. The proportion with unknown etiology ranged from 27% (age 5-9) to 41% (age 10-19). Structural-metabolic epilepsy and perinatal insults were the leading causes of epilepsy in the age group 5-9 (46%), whereas disturbances of brain development dominated in the youngest (23% in patients ≤4 years old). In the group comprising persons with epilepsy ≥60 years old, stroke was the most common cause of epilepsy (44%). Despite recent advances in research and technology, a large number of patients in all age groups (including the youngest) still have an unknown cause of epilepsy. We conclude that an effort must be made to improve the diagnostics for and understanding of the causes of epilepsy across all ages.

Diagnostic yield of genetic tests in epilepsy: A meta-analysis and cost-effectiveness study

OBJECTIVE

To compare the cost-effectiveness of genetic testing strategies in patients with epilepsy of unknown etiology.

METHODS

This meta-analysis and cost-effectiveness study compared strategies involving 3 genetic tests: chromosomal microarray (CMA), epilepsy panel (EP) with deletion/duplication testing, and whole-exome sequencing (WES) in a cost-effectiveness model, using "no genetic testing" as a point of comparison.

RESULTS

Twenty studies provided information on the diagnostic yield of CMA (8 studies), EP (9 studies), and WES (6 studies). The diagnostic yield was highest for WES: 0.45 (95% confidence interval [CI]: 0.33-0.57) (0.32 [95% CI: 0.22-0.44] adjusting for potential publication bias), followed by EP: 0.23 (95% CI: 0.18-0.29), and CMA: 0.08 (95% CI: 0.06-0.12). The most cost-effective test was WES with an incremental cost-effectiveness ratio (ICER) of $15,000/diagnosis. However, after adjusting for potential publication bias, the most cost-effective test was EP (ICER: $15,848/diagnosis) followed by WES (ICER: $34,500/diagnosis). Among combination strategies, the most cost-effective strategy was WES, then if nondiagnostic, EP, then if nondiagnostic, CMA (ICER: $15,336/diagnosis), although adjusting for potential publication bias, the most cost-effective strategy was EP ± CMA ± WES (ICER: $18,385/diagnosis). While the cost-effectiveness of individual tests and testing strategies overlapped, CMA was consistently less cost-effective than WES and EP.

CONCLUSION

WES and EP are the most cost-effective genetic tests for epilepsy. Our analyses support, for a broad population of patients with unexplained epilepsy, starting with these tests. Although less expensive, CMA has lower yield, and its use as the first-tier test is thus not supported from a cost-effectiveness perspective.

Age, sex and ethnic differentials in the prevalence and control of epilepsy among Sri Lankan children: a population-based study

OBJECTIVE

To estimate the prevalence of childhood epilepsy in Sri Lanka by different age groups (0-5, 6-10 and 11-16 years), sex and ethnicity, and to describe the types and outcomes of epilepsy.

DESIGN AND PATIENTS

A population-based, cross-sectional study was conducted in the district considered to be ethnically most balanced in Sri Lanka. A door-to-door survey was performed in the 0-5 year age group (60 geographically defined areas as clusters; 19 children per cluster), and a school-based survey in the 6-16 year age group (150 classes as clusters; 25 children per cluster). The screened children with epilepsy were reviewed individually for confirmation of the diagnosis of epilepsy, typing of the underlying epilepsy syndrome and assessment of control. The same group of children were re-evaluated 1 year later to reconfirm the syndromic diagnosis and to assess the stability of control of epilepsy.

RESULTS

The overall prevalence of childhood epilepsy was 5.7 per 10 000 children aged 0-16 years (95% CI: 38 to 87). It was higher with younger ages (73.4 per 10 000 children aged 0-5 years; 55.1 per 10 000 children aged 6-10 years and 50.4 per 10 000 children aged 11-16 years). A male dominance was noted in both age groups. In each age group, the prevalence was highest in children of Sinhalese ethnicity. Symptomatic focal epilepsy was the single most common group of epilepsy in both age groups. Majority of children remained well controlled on medications.

CONCLUSION

The findings indicate a relatively high burden of epilepsy among children in Sri Lanka, however, these were comparable to the burden of disease reported from other countries in the region.

Comorbidity Burden in Adults With Autism Spectrum Disorders and Intellectual Disabilities-A Report From the EFAAR (Frailty Assessment in Ageing Adults With Autism Spectrum and Intellectual Disabilities) Study

Background: Autism spectrum disorder (ASD) is an early-onset and lifelong neurodevelopmental condition frequently associated with intellectual disability (ID). Although emerging studies suggest that ASD is associated with premature ageing and various medical comorbidities, as described for ID, data are scarce. Objectives: To determine the comorbidity burden and its association with distinct clinical presentation in terms of ASD severity, adaptive skills, level of autonomy, and drug exposure in a well-phenotyped sample of individuals with ASD-ID-the EFAAR (Frailty Assessment in Ageing Adults with Autism Spectrum and Intellectual Disabilities) cohort. Methods: A total of 63 adults with ASD-ID, with a mean age of 42.9 ± 15.1 years, were recruited from 2015 to 2017 from nine specialized institutions. They underwent detailed clinical examinations, including screening for comorbidities, ASD severity [Childhood Autism Rating Scale (CARS)], adaptive functioning [Vineland Adaptive Behavior Scale II (VABS-II)], autonomy [activities of daily living (ADLs)], and drug use [polypharmacy and the Drug Burden Index (DBI)]. The comorbidity burden was evaluated using the Cumulative Illness Rating Scale (CIRS-G) and its sub-scores [the severity index (CIRS-SI) and severe comorbidity (CIRS-SC)]. Results: We found a large range of comorbidities, including gastrointestinal disorders and mental and neurological diseases. Overall, 25% of our ASD-ID sample had chronic kidney disease with the associated increased cardiovascular risk factors. The comorbidity burden was high (mean CIRS-G total score of 10.6 ± 4.8), comparable with that observed among patients older than those in our population hospitalized in geriatric departments. Furthermore, the comorbidity burden positively correlated with age, decreased autonomy, and polypharmacy. Conclusion: The severity of the comorbidity burden associated with premature ageing in adults with ASD and ID highlight their crucial need of personalized medical care.

The Impact of Pediatric Epilepsy on Children and Families: A Multicenter Cross-Sectional Study

Background and Objectives:

Epilepsy is considered one of the most prevalent causes of morbidity in children. The aim of this study is to determine how epilepsy impacts the lives of children with epilepsy and their families.

Methods:

A translated version of the “Impact of Pediatric Epilepsy Scale” (IPES) questionnaire was completed by the 80 mothers of children with epilepsy, recruited at three hospitals in Jeddah, Saudi Arabia This is a validated self-administered questionnaire used to assess the impact of epilepsy on the lives of the child and family, as well as the quality of life (QoL) of the child.

Results:

The mean age of children epilepsy was 6.32 years (SD = 3.22). The mean IPES score was 6.28 (SD = 8.42) and the mean child’s QoL was 2.85 (SD= 0.83). 87.5% of the mothers rated their child’s QoL as low. IPES score was significantly associated with cause of seizure (β=0.259; 95%-CI= 0.263 - 10.334; p = 0.039). Child’s QoL was significantly associated with frequency of seizure (β=0.251; 95%-CI= 0.016 - 0.568; p= 0.039) and child’s nationality (β=-0.270; 95%-CI -0.252, -0.013; p= 0.031).

Conclusions:

Pediatric epilepsy may have a greater impact on the lives of the child and the family when it is not comorbid with cerebral palsy. Quality of life tends to be lower for non-Saudi children, and children with more frequent seizures. Therefore, these groups may need more support in managing the impact that epilepsy has on their daily functioning and quality of life.

Incidence of Childhood Epilepsy in Estonia

The aim of this prospective epidemiological study was to establish the incidence rate of childhood epilepsy in Estonia, to describe the clinical spectrum and to identify etiology of childhood epilepsy. The overall incidence rate was 86.3/100 000. The incidence rate was the highest (141.9/100 000) in the age group from 5 to 9 years. Specific electroclinical syndromes were identified in 22.8% of cases. Structural or metabolic etiology was identified in 20.0% of cases, presumed genetic origin was identified in 33.9% of cases, and in 46.1% of cases the cause of epilepsy remained unknown. The incidence rate of childhood epilepsy in Estonia (86.3/100 000) is similar to the other European countries. In comparison with the results of the first epidemiological study of childhood epilepsy in Estonia (incidence rate 45/100 000; Beilmann et al), the incidence rate in this study is almost 2 times higher, what can be explained with better case collection and improved diagnostic modalities in Estonia.

Control of excessive neural circuit excitability and prevention of epileptic seizures by endocannabinoid signaling

Progress in research on endocannabinoid signaling has greatly advanced our understanding of how it controls neural circuit excitability in health and disease. In general, endocannabinoid signaling at excitatory synapses suppresses seizures by inhibiting glutamate release. In contrast, endocannabinoid signaling promotes seizures by inhibiting GABA release at inhibitory synapses. The physiological distribution of endocannabinoid signaling molecules becomes disrupted with the development of epileptic focus in patients with mesial temporal lobe epilepsy and in animal models of experimentally induced epilepsy. Augmentation of endocannabinoid signaling can promote the development of epileptic focus at initial stages. However, at later stages, increased endocannabinoid signaling delays it and suppresses spontaneous seizures. Thus, the regulation of endocannabinoid signaling at specific synapses that cause hyperexcitability during particular stages of disease development may be effective for treating epilepsy and epileptogenesis.

Parental age and risk of epilepsy: A nationwide register-based study

OBJECTIVE

This study aims to examine the association between maternal age, paternal age, and parental age difference at the time of birth and the risk of epilepsy in the offspring.

METHODS

We carried out a prospective population-based register study of all singletons born in Denmark between 1981 and 2012. Cox regression was used to estimate hazard ratios (HRs) of epilepsy and their corresponding 95% confidence intervals (CIs), adjusted for relevant confounders.

RESULTS

We followed 1 587 897 individuals for a total of ~25 million person-years and identified 21 797 persons with epilepsy during the study period. An excess risk of epilepsy was found in individuals born to mothers younger than 20 years (HR = 1.17, 95% CI = 1.07-1.29) and born to parental couples where paternal age exceeded maternal age by at least 5 years. The risk of epilepsy increased with increasing parental age gap and was highest when the father was ≥15 years older than the mother (adjusted HR = 1.28, 95% CI = 1.16-1.41). In contrast to maternal age, we found that paternal age did not independently contribute to offspring epilepsy risk, once we accounted for the parental age difference (P = .1418). The observed associations with maternal age and parental age gap were invariant to epilepsy subtypes, but were modified by age of epilepsy onset, with the effect being most pronounced in the first 10 years of the child's life.

SIGNIFICANCE

Maternal age and parental age gap, but not paternal age, were associated with the offspring's risk of epilepsy. Our results do not support the hypothesis that de novo mutations associated with advanced paternal age increase the risk of epilepsy in the offspring.

A Review of the New Antiepileptic Drugs for Focal-Onset Seizures in Pediatrics: Role of Extrapolation

Most antiepileptic drugs (AEDs) receive regulatory approval for children years after the drug is available in adults, encouraging off-label use of the drug in children and hindering attempts to obtain quality pediatric data in controlled trials. Extrapolating adult efficacy data to pediatrics can reduce the time between approval in adults and that in children. To extrapolate efficacy from adults to children, several assumptions must be supported, such as (1) a similar disease progression and response to interventions in adults and children, and (2) similar exposure response in adults and children. The Pediatric Epilepsy Academic Consortium for Extrapolation (PEACE) addressed these assumptions in focal-onset seizures (FOS), the most common seizure type in both adults and children. PEACE reviewed the biological and clinical evidence that supported the assumptions that children with FOS have a similar disease progression and response to intervention as adults with FOS. After age 2 years, the pathophysiological underpinnings of FOS and the biological milieu in which seizures are initiated and propagated in children, seizure semiology, electroencephalographic features, etiology and AED response to FOS in children are similar to those in adults with FOS. PEACE concluded that extrapolation of efficacy data in adults to pediatrics in FOS is supported by strong scientific and clinical evidence. However, safety and pharmacokinetic (PK) data cannot be extrapolated from adults to children. Based on extrapolation, eslicarbazepine is now approved for children with FOS, down to age 4 years. Perampanel, lacosamide and brivaracetam are now undergoing PK and safety studies for the purposes of extrapolation down to age 2 or 4 years. When done in conjunction with PK and safety investigations in children, extrapolation of adult data from adults to children can reduce the time delay between approval of effective and safe AEDs in adults and approval in children.

Epilepsy, headache, and abdominal pain after shunt surgery for idiopathic normal pressure hydrocephalus: the INPH-CRasH study

OBJECTIVE

Adverse events related to shunt surgery are common and might have a negative effect on outcome in patients with idiopathic normal pressure hydrocephalus (INPH). The authors’ objectives were to establish the frequencies of epilepsy, headache, and abdominal pain and determine their impact on patient quality of life (QOL), in long-term follow-up after shunt surgery for INPH.

METHODS

One hundred seventy-six shunt-treated patients with INPH (mean age 74 years) and 368 age- and sex-matched controls from the population were included. The mean follow-up time after surgery was 21 months (range 6–45 months). Each participant answered a questionnaire regarding present frequency and severity of headache and abdominal pain. Confirmed diagnoses of epilepsy and all prescriptions for antiepileptic drugs (AEDs) before and after shunt surgery for INPH were gathered from national registries. Equivalent presurgical and postsurgical time periods were constructed for the controls based on the date of surgery (the division date for controls is referred to as virtual surgery). All registry data covered a mean period of 6 years (range 3–8 years) before surgery/virtual surgery and 4 years (range 2–6 years) after surgery/virtual surgery. Provoked epileptic seizures were excluded. Patient QOL was assessed with the EuroQoL 5-dimension 5-level instrument.

RESULTS

Epilepsy was more common in shunt-treated patients with INPH than in controls (4.5% vs 1.1%, respectively; p = 0.023), as was treatment with AEDs (14.8% vs 7.3%, respectively; p = 0.010). No difference was found between the populations before surgery/virtual surgery (epilepsy, 2.3% [INPH] vs 1.1% [control], p = 0.280; AED treatment, 8.5% [INPH] vs 5.4% [control], p = 0.235). New-onset epilepsy and new AED treatment after surgery/virtual surgery were more common in INPH (epilepsy, 2.3% [INPH] vs 0.0% [control], p = 0.011; AED, 8.5% [INPH] vs 3.3% [control], p = 0.015). At follow-up, more patients with INPH than controls experienced headache several times per month or more often (36.1% vs 11.6%, respectively; p < 0.001). Patients with INPH and unilateral headache had more right-sided headaches than controls (p = 0.038). Postural headache was experienced by 16% (n = 27 of 169) of the patients with INPH. Twenty percent (n = 35) of the patients with INPH had persistent abdominal pain. Headache was not correlated to lower QOL. The study was underpowered to draw conclusions regarding QOL in patients with INPH who had epilepsy and abdominal pain, but the finding of no net difference in mean QOL indicates that no correlation between them existed.

CONCLUSIONS

Epilepsy, headache, and abdominal pain are common in long-term follow-up in patients after shunt surgery for INPH and are more common among patients with INPH than in the general population. All adverse events, including mild and moderate ones, should be considered during postoperative follow-ups and in the development of new methods for shunt placement.

Hippocampal deep brain stimulation: persistent seizure control after bilateral extra-cranial electrode fracture

Hippocampal deep brain stimulation (DBS) can provide an effective alternative for intractable temporal lobe epilepsy. In this case report, we describe a peculiar outcome after a post-traumatic wire-disconnection of a bilateral hippocampal DBS device. The patient presented a postoperative long-term significant reduction in seizure frequency even with an absent electric stimulation. This case gives the possibility to consider alternatives in epilepsy surgery, based on stimulation interference (lesional or electrical disturbing) in the epileptogenic zone.

Association of Omega-3 Fatty Acid and Epileptic Seizure in Epileptic Patients: A Systematic Review

The evidence on the association between omega-3 consumption and epileptic seizure is inconsistent. Therefore, we have conducted this systematic review to clarify the possible relationship. Original articles were searched in electronic databases (PubMed, Scopus, Google Scholar, Cochrane, and Ovid) and by reviewing the reference lists of retrieved articles. The main evaluated outcome was the epileptic seizures. We included the English language studies that reported the original data on the effect of omega-3 on epileptic human patients. We included the nine articles with 230 patients in the present systematic review. The mean ± standard deviation age of them was about 31.01 ± 14.99 years. The average of study duration was 22 ± 15.27 weeks. Omega-3 fatty acid supplements were defined as the sum of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) (1100 mg/d); as the sum of EPA, DHA, and alpha-linolenic acid (5 g/d); and as the sum of EPA alone (565 mg/d) in different studies. Among the nine studies, four studies reported a significant positive association between omega-3 fatty acids and epileptic seizures. However, power and quality of these studies are low, and we cannot consider the beneficial effect of omega-3 on seizures. In addition, five studies did not reveal any significant effect. Majority of the included studies did not show a significant association between omega-3 and epileptic seizure in epileptic patients, but further studies are necessary. It is controversial whether omega-3 fatty acids can produce positive effects on epileptic patients or not.

Prevalence of idiopathic epilepsy among school children in Gharbia Governorate, Egypt

BACKGROUND

Epilepsy is one of the most common neurological disorders among children. Data about its prevalence in Egypt is limited. Our aim was to study the prevalence of idiopathic epilepsy among school children in Gharbia governorate, Egypt.

SUBJECTS AND METHODS

A Cross-sectional school-based survey study was conducted; a validated screening questionnaire was distributed among urban and rural primary and preparatory school children. Students with suspected epilepsy were subjected to clinical evaluation, Electroencephalogram (EEG), and neuroimaging.

RESULTS

9545 students completed the questionnaire, of whom 69 children proved to have idiopathic epilepsy. The lifetime prevalence of idiopathic epilepsy among school students aged 6-14 years was 7.2/1000. Higher prevalence was reported in males (7.7/1000) and in children from urban areas (8.25/1000). Generalized seizures were observed in 56.5% of the children with epilepsy, whereas focal seizures were present in 43.5%. Thirty-four (49.27%) children were diagnosed with specific childhood epileptic syndrome: 25 children had benign childhood epilepsy with centrotemporal spikes and nine children had typical childhood absence epilepsy. Treatment gap is around 12.5% in the studied children. Family history of epilepsy and parental consanguinity were evident in 73.9% and 21.7% of the epileptic children, respectively. The odds ratio for idiopathic epilepsy in children with family history of epilepsy was 23.9.

CONCLUSION

The prevalence of idiopathic epilepsy among school students aged 6-14 years in Gharbia Governorate was 7.2/1000. The reported prevalence is similar to the prevalence of epilepsy in other Arab countries, but lower than the prevalence in Upper Egypt and in most developing countries.

Prevalence of epilepsy in China between 1990 and 2015: A systematic review and meta-analysis

Background

Epilepsy is a major neurological disorder that affects approximately 65 million people worldwide. Globally, the burden of epilepsy is not evenly distributed, with more than 80% of sufferers residing in low– and middle–income countries. This study estimates the burden of epilepsy in mainland China from 1990 to 2015 and explores the variations of burden by age and gender.

Methods

We conducted a systematic review of the peer–reviewed literature from 1990 to 2015 using Chinese and English academic databases (CNKI, WanFang, VIP and PubMed) to identify population–based prospective studies on the prevalence of epilepsy in mainland Chinese. Multilevel mixed–effects logistic regression was used to estimate the prevalence of lifetime epilepsy (LTE), and restricted cubic regression splines were applied to model the functional forms of the non–linear effects of age and LTE prevalence. Random–effect meta–analysis was used to obtain the pooled prevalence of 1–year active epilepsy (AE), 2–year AE and 5–year AE separately. To estimate the number of people with LTE and AE in the years 1990, 2000, and 2015, LTE and AE prevalence were multiplied by the total population of mainland China of the corresponding year.

Findings

Analyses were conducted using 39 prevalence studies that met the inclusion criteria and comprised 77 separate data points (37 on LTE, 16 on 1–year AE, 12 on 2–year AE and 12 on 5–year AE). In 1990, the prevalence of LTE ranged from 1.31‰ (95% CI = 0.85–2.00) in the 0–4 age group to 2.42‰ (95% confidence interval CI = 1.60–3.65) in the 30–34 age group. By 2015, the LTE prevalence had increased to 4.57‰ (95% CI = 2.52–8.27) in the 0–4 group and 8.43‰ (95% CI = 4.71–15.04) in the 30–34 group. Over the 25–year period, the overall prevalence of LTE had steadily increased by 259%, from 1.99‰ (95% CI = 1.31–3.02) in 1990 to 7.15‰ (95% CI = 3.98–12.82) in 2015. The rates of increase were similar across the whole age spectrum, fluctuating around 250%. Between 1990 and 2015, the total number of people with LTE in mainland China increased by 328%, from 2.30 million (95% CI = 1.51–3.49) in 1990 to 9.84 million (95% CI = 5.48–17.64) in 2015. The pooled 1–year, 2–year, and 5–year AE prevalence were 3.79‰ (95% CI = 3.31–4.34), 4.08‰ (95% CI = 3.41–4.89) and 4.19‰ (95% CI = 3.42–5.15).

Conclusions

The burden of LTE in China has increased substantially between 1990 and 2015, with the prevalence of LTE having more than doubled and the number of people with LTE more than tripled. The large amount of AE cases in China calls for optimal management and treatment. More high–quality epidemiological studies on LTE and AE prevalence are still needed.

A Survey of Epilepsy-related Knowledge, Attitudes and Practices of Home Healthcare Nurses in the San-in Region of Japan

Background

Comprehensive care is necessary for people with epilepsy (PWE) to lead a fulfilling life at home and in the community. The purpose of this study was to determine the epilepsy-related knowledge, attitudes and practices of home healthcare nurses (HHNs) in the San-in region of Japan.

Methods

A questionnaire survey was conducted by mail of 546 HHNs working in Tottori and Shimane Prefectures. The questionnaire assessed the epilepsy-related knowledge, attitudes and practices of HHNs. For the analysis, simple and cross tabulation of questionnaire responses were conducted, and the chi-squared test was used for statistical testing.

Results

A total of 285 HHNs participated in the study. Of the respondents, 43.9% had experience taking care of PWE in a home healthcare nursing setting. Regarding the cause of epilepsy, in descending order the percentage of correct responses were 86.7% for stroke, 85.3% for head injury, and only 13.3% for dementia. Concerning how to respond to an epileptic seizure, almost all respondents answered correctly, but 29.8% gave the incorrect answer of "place something inside the mouth." Regarding the practices of HHNs in relation to caring for PWE, nurses scored 52.0% for collaborating with the attending physician, indicating the need for improvement. The score for "provide information about social resources" was low at 18.4%. Of the respondents, 95.8% answered that epilepsy-related knowledge and technical skills were necessary for home healthcare nursing practice, and 87.7% were interested in participating in a workshop on epilepsy.

Conclusion

The study revealed an inadequate level of knowledge of epilepsy with dementia and corresponding epileptic seizures, a low awareness of nursing care in collaboration with physicians, and the importance of providing information about social resources. There is a need to offer information and education on the latest knowledge about epilepsy to HHNs.