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Macdonald-Laurs E, Dzau W, Warren AEL, Coleman M, Mignone C, Stephenson SEM, Howell KB. Identification and treatment of surgically-remediable causes of infantile epileptic spasms syndrome. Expert Rev Neurother 2024; 24:661-680. [PMID: 38814860 DOI: 10.1080/14737175.2024.2360117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Infantile epileptic spasms syndrome (IESS) is a common developmental and epileptic encephalopathy with poor long-term outcomes. A substantial proportion of patients with IESS have a potentially surgically remediable etiology. Despite this, epilepsy surgery is underutilized in this patient group. Some surgically remediable etiologies, such as focal cortical dysplasia and malformation of cortical development with oligodendroglial hyperplasia in epilepsy (MOGHE), are under-diagnosed in infants and young children. Even when a surgically remediable etiology is recognised, for example, tuberous sclerosis or focal encephalomalacia, epilepsy surgery may be delayed or not considered due to diffuse EEG changes, unclear surgical boundaries, or concerns about operating in this age group. AREAS COVERED In this review, the authors discuss the common surgically remediable etiologies of IESS, their clinical and EEG features, and the imaging techniques that can aid in their diagnosis. They then describe the surgical approaches used in this patient group, and the beneficial impact that early epilepsy surgery can have on developing brain networks. EXPERT OPINION Epilepsy surgery remains underutilized even when a potentially surgically remediable cause is recognized. Overcoming the barriers that result in under-recognition of surgical candidates and underutilization of epilepsy surgery in IESS will improve long-term seizure and developmental outcomes.
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Affiliation(s)
- Emma Macdonald-Laurs
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Winston Dzau
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Aaron E L Warren
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia
- Brigham and Women's Hospital, Harvard Medical School, Massachusetts, USA
| | - Matthew Coleman
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Cristina Mignone
- Department of Medical Imaging, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Sarah E M Stephenson
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine B Howell
- Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
- Neurosciences Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
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Coleman M, Pinares-Garcia P, Stephenson SE, Lee WS, Kooshavar D, Mclean CA, Howell KB, Leventer RJ, Reid CA, Lockhart PJ. Ectopic HCN4 Provides a Target Biomarker for the Genetic Spectrum of mTORopathies. Neurol Genet 2024; 10:e200135. [PMID: 38496361 PMCID: PMC10940058 DOI: 10.1212/nxg.0000000000200135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/05/2024] [Indexed: 03/19/2024]
Abstract
Background and Objectives Pathogenic variants in PI3K-AKT-mTOR pathway and GATOR1 complex genes resulting in hyperactivation of mechanistic target of rapamycin (mTOR) complex 1 are a major cause of drug-resistant epilepsy and focal cortical malformations (FCM). Resective neurosurgery is often required to achieve seizure control in patients with mTORopathies due to lack of effectiveness of nonsurgical therapies, including antiseizure medication and mTOR inhibitors. Elevated hyperpolarization-activated cyclic nucleotide-gated potassium channel isoform 4 (HCN4) has been proposed as a key marker in some mTOR-related brain malformations. This study aimed to investigate HCN4 as a biomarker in the brain across the genetic spectrum of mTORopathies in humans. Methods Our study investigated the relative steady-state levels and cellular localization of HCN4 in resected human brain tissue from 18 individuals with mTORopathies (3 individuals with tuberous sclerosis complex (TSC) due to TSC2 variants, 5 individuals with focal cortical dysplasia type IIA (FCD IIA) due to genetic variants in MTOR, AKT3, and PIK3CA, and 10 individuals with FCD IIB due to variants in TSC1, MTOR, RHEB, DEPDC5, or NPRL3). Results Elevated HCN4 was observed to be highly restricted to abnormal cell types (dysmorphic neurons and balloon cells) in brain tissue from all mTORopathy tissues (p < 0.0001) compared with those in controls, regardless of genetic cause or variant allele frequency. Elevated HCN4 was not observed in controls or individuals with non-mTOR-related focal epilepsy due to pathogenic variants in ATP1A3, SLC35A2, or FGFR1. Discussion HCN4 provides a biomarker for the genetic spectrum of mTORopathies and may present a potential therapeutic target for seizure control in mTOR-related epilepsy.
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Affiliation(s)
- Matthew Coleman
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Paulo Pinares-Garcia
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Sarah E Stephenson
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Wei Shern Lee
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Daniz Kooshavar
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Catriona A Mclean
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Katherine B Howell
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Richard J Leventer
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Christopher A Reid
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
| | - Paul J Lockhart
- From the Murdoch Children's Research Institute (M.C., S.E.S., W.S.L., D.K., K.B.H., R.J.L., P.J.L.); Department of Paediatrics (M.C., S.E.S., D.K., K.B.H., R.J.L., P.J.L.), University of Melbourne; The Florey Institute of Neuroscience and Mental Health (P.P.-G., C.A.R.), Parkville; Alfred Hospital (C.A.M.), Prahran; Department of Neurology (K.B.H., R.J.L.), The Royal Children's Hospital, Parkville; and Epilepsy Research Centre (C.A.R.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victory, Australia
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Chan HY, Janssen LMM, Wijnen BFM, Hiligsmann M, Majoie MHJM, Evers SMAA. Economic evaluations of nonpharmacological treatments for drug-resistant epilepsy: A systematic review. Epilepsia 2023; 64:2861-2877. [PMID: 37545415 DOI: 10.1111/epi.17742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/08/2023]
Abstract
This study was undertaken to systematically identify and critically appraise all published full economic evaluations assessing the cost-effectiveness of nonpharmacological interventions for patients with drug-resistant epilepsy. The Population, Intervention, Comparison, Outcome, Study criteria was used to design search strategies for the identification and selection of relevant studies. Literature search was performed using the MEDLINE (via PubMed), Embase, International Health Technology Assessment, National Institute for Health Research Economic Evaluation Database, and Cost-Effectiveness Analysis Registry databases to identify articles published between January 2000 and May 2023. Web of Science was additionally used to perform forward and backward referencing. Title, abstract, and full-text screening was performed by two independent researchers. The Consensus Health Economic Criteria (CHEC) checklist and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 were applied for quality assessment. A total of 4470 studies were identified, of which 18 met our inclusion criteria. Twelve of the studies conducted model-based economic evaluation, and others were trial-based. Three studies showed that epilepsy surgery was cost-effective in adults, whereas this remained inconclusive for children (two positive, three negative). Three studies showed negative economic outcome for ketogenic diet in children. One of four studies showed positive results for self-management. For vagus nerve stimulation, one study showed positive results in adults and another one negative results in children. One recent study showed cost-effectiveness of responsive neurostimulation (RNS) in adults. Finally, one study showed promising but inconclusive results for deep brain stimulation (DBS). The mean scores for risk of bias assessment (based on CHEC) and for reporting quality (CHEERS 2022) were 95.8% and 80.5%, respectively. This review identified studies that assessed the cost-effectiveness of nonpharmacological treatments in both adults and children with drug-resistant epilepsy, suggesting that in adults, epilepsy surgery, vagus nerve stimulation, and RNS are cost-effective, and that DBS and self-management appear to be promising. In children, the cost-effectiveness of epilepsy surgery remains inconclusive. Finally, the use of ketogenic diet was shown not to be cost-effective. However, limited long-term data were available for newer interventions (i.e., ketogenic diet, DBS, and RNS).
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Affiliation(s)
- Hoi Yau Chan
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Luca M M Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Ben F M Wijnen
- Center of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Marian H J M Majoie
- Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, the Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
- School of Health Professions Education, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Kempenhaeghe and Maastricht, the Netherlands
| | - Silvia M A A Evers
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
- Center of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
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Kitschen A, Aleknonytė-Resch M, Sakalytė G, Diederich F. Cost-effectiveness of surgical treatment compared to medical treatment in patients with drug-refractory epilepsy: A systematic review. Eur J Neurol 2023; 30:749-761. [PMID: 36371643 DOI: 10.1111/ene.15632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Approximately 30% of epilepsy patients develop a drug-refractory epilepsy, that is, seizures cannot be controlled with antiepileptic drugs. Surgery has been evaluated as an effective but costly form of treatment. The aim of this systematic review is to synthesize the available evidence on the cost-effectiveness of surgical treatment compared to medical treatment for these patients. METHOD A systematic literature search was performed in MEDLINE, Embase, PsycINFO, Cochrane Library and the National Health Service Economic Evaluation Database until September 2022. Title, abstract and full-text screening were conducted by two researchers. Original studies published in English or German analyzing the cost-effectiveness of surgical compared to medical treatment were included. Study characteristics, effectiveness measures, costs and incremental cost-effectiveness ratios (ICERs) were extracted. The quality of studies was assessed using the Drummond checklist. RESULTS Fourteen studies were included. Most studies evaluated surgery as cost-effective. The ICER per patient seizure free ranged from dominant to purchasing power parity US dollars (PPP-USD) 479,275. The ICER per 1% seizure reduction ranged from PPP-USD 227 to PPP-USD 342. The ICER per year without seizures was PPP-USD 4202 and the ICER per quality-adjusted life-year ranged from dominant to PPP-USD 90,874. The studies varied greatly in their methodology and time horizon. CONCLUSION Surgical treatment is cost-effective compared to medical treatment, especially when a lifetime horizon is adopted. It is concluded that all disease-specific costs should be considered over a long period when assessing the cost-effectiveness of epilepsy treatment. From an economic perspective, efforts should be made to improve access to surgical treatment for patients with drug-refractory epilepsy.
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Affiliation(s)
- Anne Kitschen
- Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Bremen, Germany
- Department of Philosophy, Politics and Economics, Witten/Herdecke University, Witten, Germany
| | - Milda Aleknonytė-Resch
- Department of Neurology, Kiel University, Kiel, Germany
- Institute of Medical Informatics and Statistics, Kiel University, Kiel, Germany
| | | | - Freya Diederich
- Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Bremen, Germany
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Widjaja E, Demoe L, Yossofzai O, Guttmann A, Tomlinson G, Rutka J, Snead OC, Sander B. Health Care System Costs Associated With Surgery and Medical Therapy for Children With Drug-Resistant Epilepsy in Ontario. Neurology 2022; 98:e1204-e1215. [PMID: 35169008 DOI: 10.1212/wnl.0000000000200026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/03/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Improvement in seizure control after epilepsy surgery could lead to lower health care resource use and costs, but it is uncertain whether this could offset the high costs related to surgery. This study aimed to evaluate phase-specific and cumulative long-term health care costs of surgery compared to medical therapy in children with drug-resistant epilepsy from the health care payer perspective. METHODS Children who were evaluated for epilepsy surgery and treated with surgery or medical therapy from 2003 to 2018 at the Hospital for Sick Children in Toronto were identified from chart review and linked to their health administrative databases in Ontario, Canada. Inverse probability of treatment weighting with stabilized weights was used to balance the baseline covariates between the 2 groups. Patients were assigned to presurgery, surgery, short-term (first 2 years), intermediate-term (2-5 years), and long-term (>5 years) postsurgery care phases on the basis of treatment trajectory. Phase-specific and cumulative long-term health care costs were evaluated. Costs were converted from Canadian to US dollars year 2018 value. RESULTS There were 372 surgical and 258 medical patients. Costs were higher in surgical than medical patients for presurgery (3 and 39 weeks), surgery, and short-term care phase, and the attributable costs of surgery per 7 patient-days were $1,602 (95% CI $1,438-$1,785), $172 (95% CI $147-$185), $19,819 (95% CI $18,822-$20,932), and $28 (95% CI $22-$32), respectively. Costs were lower in surgical patients for intermediate- and long-term care phase, and the attributable costs were -$72 (95% CI -$124 to -$35) and -$94 (95% CI -$129 to -$63), respectively. In surgical patients, costs were highest for surgery followed by presurgery care phase, with hospitalizations accounting for the highest cost component. In medical patients, costs increased gradually from presurgery to long-term care phase. Cumulative costs were higher for surgical than medical patients in the first 7 years after surgery, but from 8 years on, costs were lower for surgical patients. DISCUSSION This study demonstrated the long-term economic benefits of epilepsy surgery compared to medical therapy for the health care system with the use of real-world data, which would justify the high costs of surgery. The results will support future economic evaluation comparing minimally invasive treatment such as laser therapy to surgery.
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Affiliation(s)
- Elysa Widjaja
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada.
| | - Lindsay Demoe
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada
| | - Omar Yossofzai
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada
| | - Astrid Guttmann
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada
| | - George Tomlinson
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada
| | - James Rutka
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada
| | - O Carter Snead
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada
| | - Beate Sander
- From the Institute of Health Policy, Management and Evaluation (E.W., A.G., G.T., B.H.S.) and Leong Centre for Healthy Children (A.G.), University of Toronto; Diagnostic Imaging (E.W.), Division of Neurology (E.W., O.C.S.), Neurosciences and Mental Health (L.D., O.Y.), Division of Pediatric Medicine (A.G.), and Department of Neurosurgery (J.R.), Hospital for Sick Children; ICES (E.W., A.G., B.H.S.); Toronto Health Economics and Technology Assessment (THETA) Collaborative (G.T., B.H.S.), University Health Network; and Public Health Ontario (B.H.S.), Toronto, Ontario, Canada
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Patel AD, Beatty CW. Costs for Children With Drug-Resistant Epilepsy: Is Care Value Based? Neurology 2022; 98:475-476. [PMID: 35169005 DOI: 10.1212/wnl.0000000000200104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anup D Patel
- From the Division of Neurology (A.D.P., C.W.B.) and Center for Clinical Excellence (A.D.P.), Nationwide Children's Hospital; and Department of Pediatrics (A.D.P., C.W.B.), The Ohio State University College of Medicine, Columbus.
| | - Christopher W Beatty
- From the Division of Neurology (A.D.P., C.W.B.) and Center for Clinical Excellence (A.D.P.), Nationwide Children's Hospital; and Department of Pediatrics (A.D.P., C.W.B.), The Ohio State University College of Medicine, Columbus
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Parker JJ, Zhang Y, Fatemi P, Halpern CH, Porter BE, Grant GA. Antiseizure medication use and medical resource utilization after resective epilepsy surgery in children in the United States: A contemporary nationwide cross-sectional cohort analysis. Epilepsia 2022; 63:824-835. [PMID: 35213744 DOI: 10.1111/epi.17180] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Antiseizure drug (ASD) therapy can significantly impact quality of life for pediatric patients whose epilepsy remains refractory to medications and who experience neuropsychological side effects manifested by impaired cognitive and social development. Contemporary patterns of ASD reduction after pediatric epilepsy surgery across practice settings in the United States are sparsely reported outside of small series. We assessed timing and durability of ASD reduction after pediatric epilepsy surgery and associated effects on health care utilization. METHODS We performed a retrospective analysis of 376 pediatric patients who underwent resective epilepsy surgery between 2007 and 2016 in the United States using the Truven MarketScan database. Filled ASD prescriptions during the pre- and postoperative periods were compared. Univariate and multivariate analyses identified factors associated with achieving a stable discontinuation of or reduction in number of ASDs. Health care utilization and costs were systematically compared. RESULTS One hundred seventy-one patients (45.5%) achieved a >90-day ASD-free period after surgery, and 84 (22.3%) additional patients achieved a stable reduction in number of ASDs. Achieving ASD freedom was more common in patients undergoing total hemispherectomy (n = 21, p = .002), and less common in patients with tuberous sclerosis (p = .003). A higher number of preoperative ASDs was associated with a greater likelihood of achieving ASD reduction postoperatively (hazard ratio [HR]: 1.85, 95% confidence interval [CI]: 1.50-2.28), but was not associated with a significant difference in the likelihood of achieving ASD freedom (0.83, 95% CI: 0.49-1.39). Achieving an ASD-free period was associated with fewer hospital readmissions within the first year after surgery. SIGNIFICANCE Patterns of ASD use and discontinuation after pediatric epilepsy surgery provide an unbiased surgical outcome endpoint extractable from administrative databases, where changes in seizure frequency are not captured. This quantitative measure can augment traditional surgical outcome scales, incorporating a significant clinical parameter associated with improved quality of life.
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Affiliation(s)
- Jonathon J Parker
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Parastou Fatemi
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brenda E Porter
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, USA.,Division of Child Neurology, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA.,Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, California, USA
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8
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Bernstein J, Kashyap S, Kortz MW, Zakhary B, Takayanagi A, Toor H, Savla P, Wacker MR, Ananda A, Miulli D. Utilization of epilepsy surgery in the United States: A study of the National Inpatient Sample investigating the roles of race, socioeconomic status, and insurance. Surg Neurol Int 2021; 12:546. [PMID: 34877032 PMCID: PMC8645483 DOI: 10.25259/sni_824_2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/11/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Epilepsy is estimated to affect 70 million people worldwide and is medically refractory in 30% of cases. Methods: This is a retrospective cross-sectional study using a US database from 2012 to 2014 to identify patients aged ≥18 years admitted to the hospital with epilepsy as the primary diagnosis. The sampled population was weighted using Healthcare Cost and Utilization Project guidelines. Procedural ICD-9 codes were utilized to stratify the sampled population into two cohorts: resective surgery and implantation or stimulation procedure. Results: Query of the database yielded 152,925 inpatients, of which 8535 patients underwent surgical intervention. The nonprocedural group consisted of 76,000 White patients (52.6%) and 28,390 Black patients (19.7%) while the procedural group comprised 5550 White patients (64%) and 730 Black patients (8.6%) (P < 0.001). Patients with Medicare were half as likely to receive a surgical procedure (14.8% vs. 28.4%) while patients with private insurance were twice as likely to receive a procedure (53.4% vs. 29.3%), both were statistically significant (P < 0.01). Those in the lowest median household income quartile by zip code (<$40,000) were 68% less likely to receive a procedure (21.5% vs. 31.4%) while the highest income quartile was 133% more likely to receive a procedure (26.1% vs. 19.5%). Patients from rural and urban nonteaching hospitals were, by a wide margin, less likely to receive a surgical procedure. Conclusion: We demonstrate an area of need and significant improvement at institutions that have the resources and capability to perform epilepsy surgery. The data show that institutions may not be performing enough epilepsy surgery as a result of racial and socioeconomic bias. Admissions for epilepsy continue to increase without a similar trend for epilepsy surgery despite its documented effectiveness. Race, socioeconomic status, and insurance all represent significant barriers in access to epilepsy surgery. The barriers can be remedied by improving referral patterns and implementing cost-effective measures to improve inpatient epilepsy services in rural and nonteaching hospitals.
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Affiliation(s)
- Jacob Bernstein
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Samir Kashyap
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Michael W Kortz
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Bishoy Zakhary
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Ariel Takayanagi
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Harjyot Toor
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Paras Savla
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Margaret R Wacker
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Ajay Ananda
- Department of Neurosurgery, Kaiser Sunset Medical Center, Los Angeles, California, United States
| | - Dan Miulli
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
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9
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Youngerman BE, Mahajan UV, Dyster TG, Srinivasan S, Halpern CH, McKhann GM, Sheth SA. Cost-effectiveness analysis of responsive neurostimulation for drug-resistant focal onset epilepsy. Epilepsia 2021; 62:2804-2813. [PMID: 34458986 DOI: 10.1111/epi.17049] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We evaluated the incremental cost-effectiveness of responsive neurostimulation (RNS) therapy for management of medically refractory focal onset seizures compared to pharmacotherapy alone. METHODS We created and analyzed a decision model for treatment with RNS therapy versus pharmacotherapy using a semi-Markov process. We adopted a public payer perspective and used the maximum duration of 9 years in the RNS long-term follow-up study as the time horizon. We used seizure frequency data to model changes in quality of life and estimated the impact of RNS therapy on the annual direct costs of epilepsy care. The model also included expected mortality, adverse events, and costs related to system implantation, programming, and replacement. We interpreted our results against societal willingness-to-pay thresholds of $50 000, $100 000, and $200 000 per quality-adjusted life year (QALY). RESULTS Based on three different calculated utility value estimates, the incremental cost-effectiveness ratio (ICER) for RNS therapy (with continued pharmacotherapy) compared to pharmacotherapy alone ranged between $28 825 and $46 596. Multiple sensitivity analyses yielded ICERs often below $50 000 per QALY and consistently below $100 000/QALY. SIGNIFICANCE Modeling based on 9 years of available data demonstrates that RNS therapy for medically refractory epilepsy very likely falls within the range of cost-effectiveness, depending on method of utility estimation, variability in model inputs, and willingness-to-pay threshold. Several factors favor improved cost-effectiveness in the future. Given the increasing focus on delivering cost-effective care, we hope that this analysis will help inform clinical decision-making for this surgical option for refractory epilepsy.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Uma V Mahajan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Timothy G Dyster
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Shraddha Srinivasan
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Guy M McKhann
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Langeh U, Chawla P, Gupta GD, Singh S. A Novel Approach to Refractory Epilepsy by Targeting Pgp Peripherally and Centrally: Therapeutic Targets and Future Perspectives. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 19:741-749. [PMID: 32814543 DOI: 10.2174/1871527319999200819093109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/19/2020] [Accepted: 06/30/2020] [Indexed: 11/22/2022]
Abstract
Refractory epilepsy is a type of epilepsy involving seizures uncontrolled by first or second- line anticonvulsant drugs at a regular therapeutic dose. Despite considerable growth in epileptic pharmacotherapy, one-third of the patients are resistant to current therapies. In this, the mechanisms responsible for resistant epilepsy are either increased expulsion of antiepileptic drugs (AEDs) by multidrug resistance (MDR) transporters from the epileptogenic tissue or reduced sensitivity of drug in epileptogenic brain tissue. The difficulty to treat refractory epilepsy is because of drug resistance due to cellular drug efflux, use of drug monotherapy, and subtherapeutic dose administration. Increased expression of Pgp is also responsible for resistance epilepsy or refractory epilepsy. Increased glutamate expression via inhibition of cyclooxygenase-II (COX-II) enzyme also upregulate P-glycoprotein (Pgp) expression and augment instance of recurrent seizures. Peripheral and central inhibition of Pgp is a powerful tool to control this drug resistant epilepsy. Drug resistance primarily involves multidrug resistance (MDR1) gene responsible for encoding P-glycoprotein (Pg- P1 or MDR1). Currently, there is no drug under clinical practice which inhibits MDR1. The present review cites some drugs like Calcium Channel Blockers (CCBs), COX-II inhibitors, and glutamate receptors antagonists that inhibit P-gp. The exploitation of these targets may emerge as a beneficial approach for patients with drug-resistant epilepsy. The present review further highlights the mechanistic role of Pgp in drug-resistant epilepsy, glutamate role in drug efflux, and management approach.
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Affiliation(s)
- Urvashi Langeh
- Research Scholar, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab-142001, India
| | - Pooja Chawla
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, Moga, Punjab-142001, India
| | - Ghanshyam Das Gupta
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab-142001, India
| | - Shamsher Singh
- Neuroscience Division, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab-142001, India
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