Epilepsy and COVID-19: Associations and important considerations

Experiences of COVID-19 in an Australian community cohort of adults with epilepsy

A number of studies have been conducted on the effects of the COVID-19 pandemic on people with epilepsy (PWE), some showing increased seizures, poorer psychosocial states, and reductions in Quality of Life (QoL). During the latter stages of COVID-19, well before the UN declared an end to the state of emergency, our study was conducted in Australia of a sample of women and men ≥ 18 years. The study was based on Wave 6 of the Australian Epilepsy Longitudinal Study (AELS). It used mixed methods. Two main scales were used in the study, the QOLIE-31 for QoL and the MOS-8 for social support. The quantitative component of the study looked at QoL in relation to COVID-19 and found no QoL differences in those who contracted the virus. However, there was significantly lower QoL in those having difficulties in seeing a GP, for those with limited access to healthcare, and for those who had problems in gaining ASMs (anti-seizure medicines) and/or other medicines and being unvaccinated. Being younger and living in rental accommodation were most likely significant contributing factors. Those not being vaccinated were less than the proportion in the whole national population., The qualitative component focussed on reasons for being vaccinated or not. Overall, the responses to the question "Were you vaccinated?" demonstrated that people made informed decisions on vaccinations, taking into account their own health as well as protecting family and public health considerations.

Risk of COVID-19 infection and seizure exacerbation among patients with epilepsy during the peak of Omicron wave

OBJECTIVES

Existing data regarding the risk of COVID-19 infection and its effects on seizure control in patients with epilepsy (PWE) are inconclusive. Our research aims to investigate the PWE who are susceptible to COVID-19 and what factors contribute to seizure exacerbation.

METHODS

From Dec 28, 2022 to Feb 19, 2023, a cross-sectional questionnaire survey among adult PWE was conducted. The demographics, epilepsy-related information, COVID-19-related variables, and seizure outcomes after COVID-19 infection were collected. Multivariate logistic analyses were performed to determine the risk factors associated with COVID-19 infection and exacerbated seizures.

RESULTS

Of 1557 PWE, 829 (53.2%) were infected with COVID-19 and 136 (16.4%) developed seizure exacerbation after COVID-19 infection. Overweight/obesity (OR 1.372, 95% CI 1.075-1.753, p = 0.011), immunocompromised (OR 3.301, 95% CI 1.093-9.974, p = 0.031), active epilepsy (OR 1.700, 95% CI 1.378-2.097, p < 0.001), and antiseizure medication (ASM) polytherapy (OR 1.314, 95% CI 1.065-1.621, p = 0.011) were associated with COVID-19 infection. Active epilepsy (OR 4.696, 95% CI 2.568-8.586, p < 0.001) and fever-associated seizures (OR 4.298, 95%CI 2.659-6.946, p < 0.001) were associated with seizure exacerbation.

SIGNIFICANCE

PWE with overweight/obesity, immunocompromised, active epilepsy, and ASM polytherapy were at higher risk of COVID-19 infection. Once infected with COVID-19, seizures were exacerbated in PWE with active epilepsy and fever-associated seizures.

PLAIN LANGUAGE SUMMARY

Patients with epilepsy (PWE) do not appear to be more susceptible to COVID-19 infection than general population. Once infected with COVID-19, 16.4% of PWE had seizure exacerbation. The PWE who have experienced seizures within the past 12 months before infection tend to contract COVID-19 more often, and are more likely to experience seizure exacerbations following COVID-19 infection.

New-Onset Seizures and Seizure Worsening in the Course of COVID-19 Infection

INTRODUCTION

The aim of our study is to assess the clinical manifestations, investigation results, and outcomes in Bulgarian patients with seizures in the course of COVID-19 infection.

METHODS

We performed an open, prospective study during a 12-month period from January 2021 with the participation of 290 inpatients and outpatients with seizures who attended the Clinic of Neurology at the University Hospital in Plovdiv, Bulgaria. After a detailed anamnesis, they underwent neurological examination, EEG, neuroimaging, and lumbar puncture when needed. There was a prospective one-year follow-up regarding seizure frequency, EEG, and treatment.

RESULTS

In 18 (5.9%) patients, seizures were related to COVID-19 infection. Nine (3.1%) patients had new-onset seizures, and in nine (3.1%) participants with epilepsy, there was a worsening of seizure frequency. New-onset seizures were more likely to occur in people above 65 years of age, within one to two months from the infection diagnosis. In one participant, seizures were related to fever. The most common seizure types were generalized tonic-clonic and focal motor seizures with/without loss of awareness. Antiseizure medications were started in seven participants. Viral encephalopathy was confirmed in two patients, one of them died. EEG showed focal epileptiform activity in four participants. The one-year prospective observation showed a favorable outcome in five patients who were without seizures, had normal EEG, and three were without treatment. Seizure frequency increase or seizure recurrence was typically observed for a short period of time in the epilepsy group. EEG was worsened in one patient and treatment changes were needed in five participants.

CONCLUSION

In conclusion, our study results provide evidence about the progress and possible relationship between new-onset seizures and seizure worsening with COVID-19 infection.

Incidence, severity and outcomes of COVID-19 in age and gender matched adults with and without epilepsy in Moscow: A historical cohort study

OBJECTIVE

We hypothesized that PWE have an increased risk to acquire COVID-19. This was a historical cohort study to determine COVID-19 incidence, severity, mortality and risk factors in adults with active epilepsy (PWE) compared to residents of Moscow without epilepsy matched by age, gender, and region of residence - Moscow Community Comparisons (MCC).

METHODS

Subjects were derived from a cohort of adult PWE and a cohort of age- and gender-matched population-based MCC without epilepsy identified in 2018. Incidence of COVID-19 was compared in each cohort from 01.03.2020 through 28.02.21. Influence of age, gender, comorbidities, and for the PWE cohort, epilepsy type, seizure frequency, and number/class of antiseizure medications was evaluated using Pearson's chi-squared test and logistic regression analysis.

RESULTS

We found 887 COVID-19 positive people in the two cohorts: 156 in PWE (51.8 ± 19.7 years) and 731 in MCC (52.0 ± 17.3 years,). COVID-19 incidence was lower in PWE: 13.8 % versus 18.7 % in MCC (p = 0.0002). In PWE no specific epilepsy related variables influenced incidence. Despite no difference in severity distribution in PWE versus MCC, hospitalization rate (37.6 % versus 25.5 %, p = 0.002), disease duration (57.1 % versus 47.1, p = 0.023), and mortality (10.9% versus 4.2 %, p = 0.0009) were significantly higher in PWE. Age and number of comorbidities significantly influenced COVID-19 incidence, severity, duration, and outcomes in both cohorts.

SIGNIFICANCE

Incidence of COVID-19 in PWE in Moscow was significantly lower compared to MCC. Age and comorbidities were strongly associated with severity, duration and outcomes of COVID-19 for all infected persons. Higher mortality in PWE may be explained by a higher number of comorbidities.

The impact of the COVID-19 pandemic on a cohort of adults with epilepsy

OBJECTIVES

The aim of this study was to assess the direct and indirect impacts of the COVID-19 pandemic on adults with epilepsy in Glasgow.

METHODS

We used routinely collected data for a previously identified cohort of patients with epilepsy to evaluate access to scheduled and unscheduled care with quarterly rates of inpatient admissions, outpatient attendance and accident & emergency attendance calculated. Anti-seizure medication prescribing and persistence, incidence of anxiety and depression and deaths for a cohort of patients with epilepsy was evaluated prior to the pandemic in comparison to during the pandemic, from 2015 to 2021.

RESULTS

All-cause mortality and epilepsy related mortality showed a statistically significant reduction during the pandemic. Although overall rates of out-patient hospital attendance dropped during the early stages of the pandemic (and had not returned to pre-pandemic levels by the end of 2021) epilepsy-related services saw maintenance of patient contact as a result of a rapid adoption of telephone clinics. A significant decrease in overall mortality was observed in PWE during the pandemic compared to the pre-pandemic period. COVID-19 was the single commonest cause of death in PWE during the pandemic (61/453) and 160 patients (3.7%) had at least 1 admission to hospital for COVID-19. Anti-seizure medication (ASM) prescribing remained rates remained stable during the pandemic. During the pandemic an average of 38.8% of cohort patients were treated for depression and 16.3% for anxiety per quarter, 8.2% and 12.4% of whom had not been previously treated for these conditions respectively.

CONCLUSION

We have shown that during a national lockdown, in the context of a pandemic, mortality in patients with epilepsy has reduced, while out-patient services were delivered remotely, primarily via the telephone. The reasons for this remain unclear but suggest that some of the excess mortality in people with epilepsy may be potentially avoidable by changes in lifestyle.

The association between epilepsy and COVID-19: analysis based on Mendelian randomization and FUMA

Objective

A multitude of observational studies have underscored a substantial comorbidity between COVID-19 and epilepsy. This study was aimed at establishing a conclusive causal link between these two conditions.

Methods

We employed Mendelian randomization (MR) to evaluate the causal link between COVID-19 and epilepsy, as well as its focal and generalized subtypes. The GWAS for epilepsy and its subtypes database were abstracted from both FinnGen consortium and ILAE. Additionally, we leveraged functional mapping and annotation (FUMA) to integrate information from genome-wide association studies (GWAS) results.

Results

The MR analyses revealed that genetic liability to COVID-19 infection conferred a causal effect on epilepsy [FinnGen: OR: 1.5306; 95% confidence interval (CI): 1.1676-2.0062, PFDR (false discovery rate) = 0.0076; ILAE: OR: 1.3440; 95% CI: 1.0235-1.7649, PFDR = 0.0429], and generalized epilepsy (FinnGen: OR: 2.1155; 95% CI: 1.1734-3.8139, PFDR = 0.0327; ILAE: OR: 1.1245; 95% CI: 1.0444-1.2108, PFDR = 0.0114). Genetic liability to COVID-19 hospitalization conferred a causal effect on epilepsy (FinnGen: OR: 1.0934; 95% CI: 1.0097-1.1841, PFDR = 0.0422; ILAE: OR: 1.7381; 95% CI: 1.0467-2.8862, PFDR = 0.0451), focal epilepsy (ILAE: OR: 1.7549; 95% CI: 1.1063-2.7838, PFDR = 0.0338), and generalized epilepsy (ILAE: OR: 1.1827; 95% CI: 1.0215-1.3693, PFDR = 0.0406). Genetic liability to COVID-19 severity conferred a causal effect on epilepsy (FinnGen consortium: OR: 1.2454; 95% CI: 1.0850-1.4295, PFDR = 0.0162; ILAE: OR: 1.2724; 95% CI: 1.0347-1.5647, PFDR = 0.0403), focal epilepsy (FinnGen: OR: 1.6818; 95% CI: 1.1478-2.4642, PFDR = 0.0231; ILAE: OR: 1.6598; 95% CI: 1.2572-2.1914, PFDR = 0.0054), and generalized epilepsy (FinnGen: OR: 1.1486; 95% CI: 1.0274-1.2842, PFDR = 0.0335; ILAE: OR: 1.0439; 95% CI: 1.0159-1.0728, PFDR = 0.0086). In contrast, no causal linkage of epilepsy on COVID-19 was observed. Further, FUMA analysis identified six overlapping genes, including SMEK2, PNPT1, EFEMP1, CCDC85A, VRK2, and BCL11A, shared between COVID-19 and epilepsy. Tissue-specific expression analyses revealed that the disease-gene associations of COVID-19 were significantly enriched in lung, ovary, and spleen tissue compartments, while being significantly enriched in brain tissue for epilepsy.

Conclusion

Our study demonstrates that COVID-19 can be a contributing factor to epilepsy, but we found no evidence that epilepsy contributes to COVID-19.

Interaction between COVID-19 and epilepsy during the omicron surge: A cross-sectional survey conducted in China tertiary hospital

Objective

It is unclear whether patients with epilepsy are more susceptible to SARS-CoV-2 infection, whether they experience more severe manifestations of COVID-19, and whether seizures worsen after SARS-CoV-2 infection. Our study aims to explore these points and provide comprehensive and practical guidance for patients with epilepsy.

Methods

We designed a questionnaire to collect variables from epilepsy patients. We used the Chi-square test, Fisher's exact test, or Mann-Whitney U test to analyze differences between the two groups. Multiple logistic regressions were employed to determine the risk factors for relevant outcome variables.

Results

We identified a total of 181 patients, with 74% (n = 134) reporting COVID-19. The patients' educational level was found to be a risk factor for COVID-19 (OR = 0.33, 95% CI 0.14-0.80, P = 0.013). When comparing seizure frequency changes between epilepsy patients with and without COVID-19, no statistically significant difference was observed (P > 0.05). However, an increase in seizure frequency was significantly associated with higher levels of anxiety (P < 0.001) and depression (P < 0.005).

Conclusion

The risk of COVID-19 infection may be increased in patients with epilepsy. COVID-19 infection does not seem to worsen seizures in epilepsy patients. Patients with epilepsy rarely develop more severe clinical manifestations of COVID-19 after SARS-CoV-2 infection. During the COVID-19 pandemic, patients with epilepsy who also suffer from anxiety and depression may experience an increase in the frequency of their seizures.

Alterations in Seizure Frequency in Patients with Epilepsy Following Coronavirus Disease 2019

Background and Purpose

During the coronavirus disease 19 (COVID-19) pandemic, a considerable number of studies have focused on the difficulties for accessing the medical services and telemedicine-related issues. However, it is not clear whether COVID-19 affects the clinical course of epilepsy. Therefore, in the current study we aimed to assess the effects of COVID-19 infection on seizure frequency in patients with epilepsy (PWE).

Methods

We evaluated PWE who consecutively referred to the neurology clinics of 22 Bahman and Qaem hospitals, who had experienced a recent polymerase chain reaction-confirmed-COVID-19 infection. Data were collected through a pre-defined electronic questionnaire.

Results

A total of 104 patients were included. Females represented 52% of the population. The mean age of the patients was 36.73±17.87. Thirty-six patients (34%) reported increased seizure frequency. The mean age of the patients who had exacerbated seizure frequency was significantly lower than the non-exacerbated group (27.50±9.8 vs. 40.14±18.39; p=0.005). The number of the male patients were significantly higher in the exacerbated group (52% vs. 25%; p=0.014). The majority of exacerbated group had a history of drug resistance (44.4% vs. 8.5%; p=0.022). The number of epileptic seizures before COVID-19 infection was higher in the exacerbated (p=0.04).

Conclusions

About 34% of PWE experienced exacerbated epileptic seizures after COVID-19 infection. Male patients, young patients, patients with the history of drug resistance, and the patients who had higher seizure frequency were at increased risk for seizure exacerbation. Our results highlight the importance of screening, early diagnosis, and treatment in PWE.

COVID-19 and parents of children with epilepsy: Experiences and positive changes

Introduction

The aim of this study is to explore the ways that parents with children or adolescents with epilepsy (CAWE) experienced the restrictive measures, as well as the stressors and challenges that they had to face.

Methods

We employed an experiential approach and fifteen Greek-speaking parents answered to an in-depth semi-structured interview, during the second lockdown period. Data were analyzed through the Thematic Analysis (TA).

Results

The emerging themes were the challenges encountered in terms of medical monitoring, the "stay-home" impact on their everyday lives as a family, their psycho-emotional responses. More specifically, parents identified the irregular doctor appointments and their struggle to access the hospital services as the most important challenges. Moreover, parents reported that the "stay-home" impact has disrupted their children's daily routines among others. Finally, parents highlighted their emotional strain and worries experienced during the lockdown along with the positive changes that occurred.

Global landscape of COVID-19 and epilepsy research: A bibliometric analysis

Background

A large number of papers regarding coronavirus disease 2019 (COVID-19) and epilepsy have been published since the declaration of the COVID-19 pandemic. However, there is no bibliometric analysis on these papers. In this study, we aimed to analyze the bibliometric characteristics of these papers, thus identifying the trends and future directions of COVID-19 and epilepsy research.

Methods

Scientific papers regarding COVID-19 and epilepsy were retrieved through searches of the Web of Science Core Collection database. Title, authors, contributing institute, country, source journal, times cited, and additional information were extracted from each selected paper. Microsoft Excel 2019 and GraphPad Prism 8 were used to analyze the extracted data and export the bar charts and tables whilst VOSviewer software was used to perform and visualize co-authorship analysis and co-occurrence analysis of keywords.

Results

A total of 317 papers regarding COVID-19 and epilepsy were included in the final analysis. Epilepsy & Behavior published the largest number of papers (n = 84). J. Helen Cross and Naoto Kuroda were the most prolific authors (n = 13 each). The United States (n = 88) and the University of London (n = 23) were the country and organization with the most contributions, respectively. The strongest authors' collaborations were between Giovanni Assenza and Jacopo Lanzone and between J. Helen Cross and Nathalie Jette. Selected author keywords were organized into seven clusters, and the keywords in clusters 1 and cluster 4 had the largest average appearing year of any clusters.

Conclusion

This is the first bibliometric analysis of papers regarding COVID-19 and epilepsy. Our results showed that the United States was the leading country whilst J. Helen Cross was the most influential scholar in COVID-19 and epilepsy research. psychological consequences of COVID-19, and the safety of COVID-19 vaccines for people with epilepsy, are possible areas for future research on COVID-19 and epilepsy.

Long-term analysis of the effects of COVID-19 in people with epilepsy: Results from a multicenter on-line survey across the pandemic waves

PURPOSE

The worldwide pandemic caused by SARS-CoV-2 virus posed many challenges to the scientific and medical communities, including the protection and management of fragile populations. People with epilepsy (PWE) are a heterogenous group of subjects, with different treatment regimens and severity of symptoms. During the National lockdown, in Italy many patients with chronic conditions lost their regular follow-up program. The aim of this study was to investigate the impact of COVID-19 on their health status, from the start of the pandemic (March 2020) to July 2021 and one year later.

METHODS

We proposed an online questionnaire to subjects followed up at different epilepsy centers located in Milano, Monza & Lodi, three of Lombardy, Northern Italy, the most affected areas by the pandemic. Survey evaluated age, sex, characteristics of patients, type of epilepsy and therapies, COVID-19 diagnosis, vaccines, sleep quality, and anxiety status.

RESULTS

Among 178 analyzed surveys, 37 individuals reported symptoms of COVID-19 in closed contacts, including 9 with molecular diagnosis and 16 PWE performing the nasopharyngeal swab with 3 positive cases. One year later, 35 individuals reported at least one symptom overlapping with those typical of COVID-19, 8 received COVID-19 diagnosis, among which 6 were positive for SARS-CoV-2 infection. According to the sleep quality scale assessment, most PWE (52.3%) had poor sleep quality. Assessing anxiety status, 32 (38.1%) had a pathological score.

CONCLUSION

In this multicenter study, we observed that PWE do not appear to be at a higher risk of severe COVID-19. It will be fundamental monitoring this group to assess possible differences in long-COVID-19 and/or neuro-COVID-19 prevalence. On the other hand, our survey confirmed the impact of the pandemic on anxiety and quality of sleep in PWE. Thus, it is important to promptly recognize and treat psychological distress in PWE, because it could be a risk factor in seizure aggravation and quality-of-life deterioration. Telemedicine appears to be a useful tool to support patients with chronic diseases, such as epilepsy.

Exacerbation of Pre-existing Neurological Symptoms With COVID-19 in Patients With Chronic Neurological Diseases: An Updated Systematic Review

The neurotropism of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can potentially explain the worsening of symptoms in patients with a history of neurological conditions such as stroke, Parkinson's disease, Alzheimer's, and epilepsy. Several studies have reported that these pre-existing conditions may worsen with a higher frequency of flare-ups, thus resulting in a more significant risk of patient mortality. In this review, we sought to provide an overview of the relationship between pre-existing neurological disorders and COVID-19, focusing on whether the initial infection directly influenced the severity of symptoms. We systematically searched the electronic database PubMed (MEDLINE) and used specific keywords related to our aims from January 2020 to July 2022. All articles published on COVID-19 with keywords pertaining to pre-existing neurological diseases were retrieved and subsequently analyzed. After independent review, the data from 107 articles were selected and evaluated. After analyzing the data from selected articles reviewing the effect of COVID-19 on neurological conditions, we have documented the relationship between said pre-existing neurological diseases, showing an increased risk of hospitalization, admission length, worsening of symptoms, and even mortality in COVID-19 patients.

Hypoxia-inducible factor 1 alpha (HIF-1α) stimulated and P2X7 receptor activated by COVID-19, as a potential therapeutic target and risk factor for epilepsy

Based on available evidence, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a neuroinvasive virus. According to the centers for disease control and prevention (CDC), coronavirus disease 2019 (COVID-19) may cause epilepsy. In this line, COVID-19 can stimulate hypoxia-inducible factor-1 alpha (HIF-1α) and activate P2X7 receptor. Both HIF-1α and P2X7 receptors are linked to epileptogenesis and seizures. Therefore, in the current study, we suggested that COVID-19 may have a role in epileptogenesis and seizure through HIF-1α stimulation and P2X7 receptor activation. Consequently, pharmacological targeting of these factors could be a promising therapeutic approach for such patients.

COVID-19 outbreak in a psychiatric hospital: what makes it worse?

BACKGROUND

Psychiatric patients could be at risk of worse outcomes from COVID-19 than the general population. The primary objective of the present study was to describe the symptoms and clinical characteristics of COVID-19 patients living in long-term hospital for mental illness in Lebanon. The secondary objective was to evaluate the factors related to COVID-19 disease severity among these patients.

METHODS

A retrospective observational study was conducted from September 2020 to January 2021 at the Psychiatric Hospital of the Cross. The total number of COVID-19 patients in the infected floors is 410 out of 548. The outcome variable was the severity of COVID-19 illness classified into five categories: asymptomatic, mild, moderate, severe and critically ill.

RESULTS

The rate of infection in the affected floors was 74.81%. Almost half of the patients were asymptomatic (49.3%), 43.4% had hyperthermia and only 28.0% had tachycardia and 25.1% developed hypoxia. The multivariate regression analysis showed that higher temperature (ORa = 6.52), lower saturation (ORa = 0.88), higher BMI (ORa = 1.12), higher CRP (ORa = 1.01), being a female (ORa = 4.59), having diabetes (ORa = 8.11) or COPD (ORa = 10.03) were significantly associated with the increase of the COVID-19 severity.

CONCLUSIONS

The current study showed that a high rate of infection from COVID-19 was detected in a psychiatric hospital with the majority having asymptomatic to mild symptoms. Female psychiatric patients, desaturation, increase inflammation and comorbidities such as diabetes and COPD were associated with the severity of COVID-19 among psychiatric patients. Future studies are needed to better understand the causal relation of the factors with severity and long term effects or sequelae of the disease.

Experimental Models of SARS-COV-2 Infection in the Central Nervous System

Coronavirus disease 2019 (COVID-19) has raised serious concerns worldwide due to its great impact on human health and forced scientists racing to find effective therapies to control the infection and a vaccine for the virus. To this end, intense research efforts have focused on understanding the viral biology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for COVID-19. The ever-expanding list of cases, reporting clinical neurological complications in COVID-19 patients, strongly suggests the possibility of the virus invading the nervous system. The pathophysiological processes responsible for the neurological impact of COVID-19 are not fully understood. Some neurodegenerative disorders sometimes take more than a decade to manifest, so the long-term pathophysiological outcomes of SARS-CoV-2 neurotropism should be regarded as a challenge for researchers in this field. There is no documentation on the long-term impact of SARS-CoV-2 on the human central nervous system (CNS). Most of the data relating to neurological damage during SARS-CoV-2 infection have yet to be established experimentally. The purpose of this review is to describe the knowledge gained, from experimental models, to date, on the mechanisms of neuronal invasion and the effects produced by infection. The hope is that, once the processes are understood, therapies can be implemented to limit the damage produced. Long-term monitoring and the use of appropriate and effective therapies could reduce the severity of symptoms and improve quality of life of the most severely affected patients, with a special focus on those have required hospital care and assisted respiration.

Relevamiento sobre la atención médica en pacientes con epilepsia durante la pandemia del coronavirus

Introducción

La pandemia por el coronavirus 2019 significó un gran desafío para el sistema de salud. La demanda de camas de internación y de recursos destinados al tratamiento del coronavirus ha obligado al servicio sanitario a reorganizarse y al gobierno nacional a implementar estrictas medidas para disminuir la tasa de contagios.

Objetivo

El objetivo del trabajo se centró en determinar si se vio afectada la atención y el acceso a la medicación de los pacientes con epilepsia durante la cuarentena obligatoria.

Materiales y métodos

Se realizó un estudio transversal en 2 centros médicos de salud, uno público y otro privado, de la Ciudad Autónoma de Buenos Aires, Argentina. Se diseñó una encuesta en la plataforma Google Forms que se envió por correo electrónico entre abril y junio de 2020 a los pacientes con diagnóstico de epilepsia de ambas instituciones. Se incluyeron preguntas sobre características demográficas, vías de acceso al sistema de salud y cambios en la frecuencia de crisis comiciales.

Resultados

Se contactó a 488 pacientes, obteniendo una respuesta del 50,8%. Con respecto a la cobertura médica el 36,5% de los pacientes no contaban con ninguna. El 49,1% tuvo dificultades en el acceso a la medicación. El 29,7% de los pacientes contactados refirió aumento de frecuencia de crisis. Los métodos de contacto más utilizados con el sistema de salud fueron el correo electrónico (35%) y la vía telefónica (15,4%). El 59,6% obtuvo sus recetas por métodos alternativos al presencial, en tanto que el 13% refirió no tener acceso a ellas.

Conclusiones

Nuestros resultados reflejan la importancia de incorporar vías alternativas de comunicación ante situaciones especiales para garantizar la atención y el tratamiento de pacientes con enfermedades crónicas.

Impact of COVID-19 pandemic on epilepsy care in Japan: A national-level multicenter retrospective cohort study

OBJECTIVE

The impact of the coronavirus disease 2019 (COVID-19) pandemic on epilepsy care across Japan was investigated by conducting a multicenter retrospective cohort study.

METHODS

This study included monthly data on the frequency of (1) visits by outpatients with epilepsy, (2) outpatient electroencephalography (EEG) studies, (3) telemedicine for epilepsy, (4) admissions for epilepsy, (5) EEG monitoring, and (6) epilepsy surgery in epilepsy centers and clinics across Japan between January 2019 and December 2020. We defined the primary outcome as epilepsy-center-specific monthly data divided by the 12-month average in 2019 for each facility. We determined whether the COVID-19 pandemic-related factors (such as year [2019 or 2020], COVID-19 cases in each prefecture in the previous month, and the state of emergency) were independently associated with these outcomes.

RESULTS

In 2020, the frequency of outpatient EEG studies (-10.7%, p<0.001) and cases with telemedicine (+2,608%, p=0.031) were affected. The number of COVID-19 cases was an independent associated factor for epilepsy admission (-3.75*10-3 % per case, p<0.001) and EEG monitoring (-3.81*10-3 % per case, p = 0.004). Further, the state of emergency was an independent factor associated with outpatient with epilepsy (-11.9%, p<0.001), outpatient EEG (-32.3%, p<0.001), telemedicine for epilepsy (+12,915%, p<0.001), epilepsy admissions (-35.3%; p<0.001), EEG monitoring (-24.7%: p<0.001), and epilepsy surgery (-50.3%, p<0.001).

SIGNIFICANCE

We demonstrated the significant impact that the COVID-19 pandemic had on epilepsy care. These results support those of previous studies and clarify the effect size of each pandemic-related factor on epilepsy care.

COVID-19 and neurological sequelae: Vitamin D as a possible neuroprotective and/or neuroreparative agent

SARS-CoV-2, the etiological agent of the current COVID-19 pandemic, belongs to a broad family of coronaviruses that also affect humans. SARS-CoV-2 infection usually leads to bilateral atypical pneumonia with significant impairment of respiratory function. However, the infectious capacity of SARS-CoV-2 is not limited to the respiratory system, but may also affect other vital organs such as the brain. The central nervous system is vulnerable to cell damage via direct invasion or indirect virus-related effects leading to a neuroinflammatory response, processes possibly associated with a decrease in the activity of angiotensin II converting enzyme (ACE2), the canonical cell-surface receptor for SARS-CoV-2. This enzyme regulates neuroprotective and neuroimmunomodulatory functions and can neutralize both inflammation and oxidative stress generated at the cellular level. Furthermore, there is evidence of an association between vitamin D deficiency and predisposition to the development of severe forms of COVID-19, with its possible neurological and neuropsychiatric sequelae: vitamin D has the ability to down-modulate the effects of neuroinflammatory cytokines, among other anti-inflammatory/immunomodulatory effects, thus attenuating harmful consequences of COVID-19. This review critically analyzes current evidence supporting the notion that vitamin D may act as a neuroprotective and neuroreparative agent against the neurological sequelae of COVID-19.

The Psychological Flexibility in Epilepsy Questionnaire (PFEQ): Psychometric properties of the Persian version

The present study aimed to evaluate the psychometric properties of a Persian version of the Psychological Flexibility Epilepsy Questionnaire (P-PFEQ). Transcultural adaptation and validation of the Persian version of the PFEQ were performed using translation and back-translation with pilot testing (on 17 patients) and expert evaluation. Participants in the current study involved 100 patients with an EEG-verified epilepsy diagnosis and an average age of 30.96 years (SD ± 6.46) (63% were female). Data collection included a sociodemographic questionnaire, epilepsy-specific questionnaire, the Depression-Anxiety-stress scale (DASS-21), the Insomnia Severity Index (ISI), the 31-item Quality-of-Life questionnaire in Epilepsy (QOLIE-31), the Acceptance and Action Questionnaire (AAQ), the Committed Action Questionnaire (CAQ), and the short form of the Freiburg Mindfulness Inventory (FMI). Descriptive and inferential analyses were conducted by SPSS software V.26. The P-PFEQ demonstrated semantic, conceptual, and content validity in equivalence with the Swedish version. Based on Exploratory Factor Analysis (EFA), five items were eliminated and unidimensional scale of PFEQ with 12 items, explaining 50.38% of the total variance, was accepted. The scale showed good reliability through internal consistency (Cronbach's α of 0.9) and temporal stability on retest (n = 85, Intraclass correlation = 0.92). Convergent and divergent validity findings were acceptable for the P-PFEQ. The findings show that the P-PFEQ is a reliable and valid scale for assessing psychological flexibility in the Iranian patients with epilepsy. Also, it can be confidently recommended as a useful instrument in clinical practice.

Risk of COVID-19 Infection and of Severe Complications Among People With Epilepsy: A Nationwide Cohort Study

OBJECTIVE

To evaluate whether patients with epilepsy were more susceptible to coronavirus disease 2019 (COVID-19) infection and at greater risk of severe complications when infected with COVID-19 when compared with patients without epilepsy.

METHODS

We included participants who underwent at least one SARS-CoV-2 real-time reverse transcription polymerase chain reaction test between Jan 1 and June 4, 2020 from the Korean nationwide COVID-19 dataset. Epilepsy was defined according to the presence of diagnostic code in health claims data prior to the COVID-19 diagnosis. To investigate the association between epilepsy and the susceptibility or severe complications of COVID-19, a 1:6 ratio propensity score matching (PSM) and logistic regression analysis were performed. Severe complications with COVID-19 infection were defined as a composite of the incidence of mechanical ventilation, intensive care unit admission, and death within two months after COVID-19 diagnosis.

RESULTS

Among 212,678 study participants who underwent COVID-19 test, 3,919 (1.8%) had a history of epilepsy. After PSM, there was no significant difference in COVID-19 PCR positivity according to epilepsy history [odds ratio (OR): 0.86, 95% confidence interval (CI) 0.67-1.11]. Of the 7,713 individuals with confirmed COVID-19 infection, 72 (0.9%) had a history of epilepsy. Among the COVID-19 patients, the severe complications occurred in 444 (5.8%) individuals. After PSM, the presence of epilepsy was associated with occurrence of severe complications after COVID-19 infection [OR: 2.05, 95% CI: 1.04-4.04]. Mortality following COVID-19 infection did not differ according to the presence of epilepsy history [OR: 1.55, 95% CI: 0.65-3.70].

CONCLUSIONS

The presence of epilepsy was not associated with increased susceptibility to COVID-19 infection or mortality related to the infection. However, there was an increased risk of severe complications with COVID-19 in patients with epilepsy; therefore, careful management and monitoring may be necessary.

Understanding and managing the impact of the COVID-19 pandemic and lockdown on patients with epilepsy

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic represented a relevant issue for people with epilepsy (PwE). Medical care and social restrictions exposed PwE to a high risk of seizure worsening. Medical institutions answered to the pandemic assuring only emergency care and implementing a remote assistance that highlighted the technological obsolescence of the medical care paradigms for PwE.

AREA COVERED

We reviewed the literature on the COVID-19-related factors influencing the epilepsy course, from the evidence of seizure risk in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infected PwE to anti-Sars-Cov-2 drugs interactions with antiseizure medications and the perceived changes of seizures in PwE.

EXPERT OPINION

COVID-19 pandemic was a problematic experience for PwE. We must make treasure of the lessons learned during this period of social restrictions and employ the recent technological advances to improve PwE assistance, in particular telemedicine and electronic media for patients' education.

Recent advancements to enhance the therapeutic efficacy of antiepileptic drugs

Epilepsy is a multifactorial neurological disorder characterized by recurrent or unprovoked seizures. Over the past two decades, many new antiepileptic drugs (AEDs) were developed and are in use for the treatment of epilepsy. However, drug resistance, drug-drug interaction and adverse events are common problems associated with AEDs. Antiepileptic drugs must be used only if the ratio of efficacy, safety, and tolerability of treatment are favorable and outweigh the disadvantages including treatment costs. The application of novel drug delivery techniques could enhance the efficacy and reduce the toxicity of AEDs. These novel techniques aim to deliver an optimal concentration of the drug more specifically to the seizure focus or foci in the CNS without numerous side-effects. The purpose of this article is to review the recent advancements in antiepileptic treatment and summarize the novel modalities in the route of administration and drug delivery, including gene therapy, for effective treatment of epilepsy.

Considerations for continuing diet therapy in patients with epilepsy during the COVID-19 pandemic: A scoping review

Diet therapy is an option for managing patients with drug-resistant epilepsy (DRE). Diet therapies used for patients with epilepsy include the classic ketogenic diet, the modified Atkins diet, the medium chain triglyceride diet, and the low glycemic index diet. The effectiveness of diet therapy is highly dependent on dietary adherence. Coronavirus disease (COVID-19), a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has substantially impacted the lifestyles of people worldwide. Therefore, continuing a specific diet during the COVID-19 pandemic is expected to be difficult in some aspects. Here, based on the available literature, we summarize the perspectives for maintaining diet therapy during the COVID-19 pandemic, as a scoping review. Epileptologists and dieticians need to understand the difficulty of maintaining diet therapy during the COVID-19 pandemic. In addition, the education of patients and all stakeholders to continue diet therapy even during the current COVID-19 pandemic is crucial to control epileptic seizures. In conclusion, continuing diet therapy is not a matter only for patients during the COVID-19 pandemic, but medical staff should also help patients to overcome the problems associated with the pandemic by understanding their situations.

COVID-19 in Children with Down Syndrome: Data from the Trisomy 21 Research Society Survey

Adults with Down Syndrome (DS) are at higher risk for severe outcomes of coronavirus disease 2019 (COVID-19) than the general population, but evidence is required to understand the risks for children with DS, which is necessary to inform COVID-19 shielding advice and vaccination priorities. We aimed to determine the epidemiological and clinical characteristics of COVID-19 in children with DS. Using data from an international survey obtained from a range of countries and control data from the United States, we compared the prevalence of symptoms and medical complications and risk factors for severe outcomes between DS and non-DS paediatric populations with COVID-19. Hospitalised COVID-19 patients <18 years with DS had a higher incidence of respiratory symptoms, fever, and several medical complications from COVID-19 than control patients without DS <18 years. Older age, obesity, and epilepsy were significant risk factors for hospitalisation among paediatric COVID-19 patients with DS, and age and thyroid disorder were significant risk factors for acute respiratory distress syndrome. Mortality rates were low in all paediatric COVID-19 patients (with and without DS), contrasting with previous findings in adults with DS (who exhibit higher mortality than those without DS). Children with DS are at increased risk for more severe presentations of COVID-19. Efforts should be made to ensure the comprehensive and early detection of COVID-19 in this population and to identify children with DS who present comorbidities that pose a risk for a severe course of COVID-19. Our results emphasize the importance of vaccinating children with DS as soon as they become eligible.

Impact of the COVID-19 pandemic on people with epilepsy: Findings from the Brazilian arm of the COV-E study

The COVID-19 pandemic has had an unprecedented impact on people and healthcare services. The disruption to chronic illnesses, such as epilepsy, may relate to several factors ranging from direct infection to secondary effects from healthcare reorganization and social distancing measures.

OBJECTIVES

As part of the COVID-19 and Epilepsy (COV-E) global study, we ascertained the effects of COVID-19 on people with epilepsy in Brazil, based on their perspectives and those of their caregivers. We also evaluated the impact of COVID-19 on the care delivered to people with epilepsy by healthcare workers.

METHODS

We designed separate online surveys for people with epilepsy and their caregivers. A further survey for healthcare workers contained additional assessments of changes to working patterns, productivity, and concerns for those with epilepsy under their care. The Brazilian arm of COV-E initially collected data from May to November 2020 during the country's first wave. We also examined national data to identify the Brazilian states with the highest COVID-19 incidence and related mortality. Lastly, we applied this geographic grouping to our data to explore whether local disease burden played a direct role in difficulties faced by people with epilepsy.

RESULTS

Two hundred and forty-one people returned the survey, 20% were individuals with epilepsy (n = 48); 22% were caregivers (n = 53), and 58% were healthcare workers (n = 140). Just under half (43%) of people with epilepsy reported health changes during the pandemic, including worsening seizure control, with specific issues related to stress and impaired mental health. Of respondents prescribed antiseizure medication, 11% reported difficulty taking medication on time due to problems acquiring prescriptions and delayed or canceled medical appointments. Only a small proportion of respondents reported discussing significant epilepsy-related risks in the previous 12 months. Analysis of national COVID-19 data showed a higher disease burden in the states of Sao Paulo and Rio de Janeiro compared to Brazil as a whole. There were, however, no geographic differences observed in survey responses despite variability in the incidence of COVID-19.

CONCLUSION

Our findings suggest that Brazilians with epilepsy have been adversely affected by COVID-19 by factors beyond infection or mortality. Mental health issues and the importance of optimal communication are critical during these difficult times. Healthcare services need to find nuanced approaches and learn from shared international experiences to provide optimal care for people with epilepsy as the direct burden of COVID-19 improves in some countries. In contrast, others face resurgent waves of the pandemic.

Neuropsychiatric Disorders and COVID-19: What We Know So Far

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2) affects the central nervous system (CNS), which is shown in a significant number of patients with neurological events. In this study, an updated literature review was carried out regarding neurological disorders in COVID-19. Neurological symptoms are more common in patients with severe infection according to their respiratory status and divided into three categories: (1) CNS manifestations; (2) cranial and peripheral nervous system manifestations; and (3) skeletal muscle injury manifestations. Patients with pre-existing cerebrovascular disease are at a higher risk of admission to the intensive care unit (ICU) and mortality. The neurological manifestations associated with COVID-19 are of great importance, but when life-threatening abnormal vital signs occur in severely ill COVID-19 patients, neurological problems are usually not considered. It is crucial to search for new treatments for brain damage, as well as for alternative therapies that recover the damaged brain and reduce the inflammatory response and its consequences for other organs. In addition, there is a need to diagnose these manifestations as early as possible to limit long-term consequences. Therefore, much research is needed to explain the involvement of SARS-CoV-2 causing these neurological symptoms because scientists know zero about it.

COVID-19 and epilepsy: How are people with epilepsy in Brazil?

PURPOSE

During COVID-19 pandemic the global population is facing an important psychosocial distress. The aim of this study was to evaluate how people with epilepsy (PWE) in Brazil is dealing with the pandemic, in relation to seizure frequency, access to antiseizure medicines (ASM), medical follow-up, and well-being.

METHODS

An online questionnaire survey among PWE (group 1) and caregivers (group 2) was applied in the social networks of the Brazilian Association of Epilepsy, the official Brazilian chapter of the International Bureau for Epilepsy. The questionnaire was composed of 46 generic questions in four areas, namely, demographics and baseline clinical data as well as epilepsy and quality-of-life impact by COVID-19 pandemic based on the domains of the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) instrument.

RESULTS

The questionnaire was answered by 464 participants including 380 (81.9%) PWE (78.7% female; age 34.3 yrs.; ±9.76) and 84 (18.1%) caregivers (patients' age 14.1 yrs.; ±10.30). During the COVID-19 pandemic, 36.8% of PWE and 36.4% of caregivers reported difficulties in accessing the epilepsy healthcare provider, and visits occurred normally only in 29.7% of PWE and in 34.5% of the caregiveŕs group. Telehealth was not provided for 66.6% of group 1 and for 58.5% of group 2. Lack of availability of ASM was reported by 21.9% of PWE and 28.0% of caregivers in public dispensing units and by 19.2% and 17.8%, respectively, in private pharmacies. Increase in seizures during pandemic was mentioned by 26.3% and 27.9% of groups 1 and 2, respectively. Patients who had increase in seizure frequency had more frequently reported problems with treatment and in quality-of-life concepts. Fear of having a more severe COVID-19 presentation because of epilepsy was reported by 74.5% of PWE and by 89.8% of caregivers. Dissatisfaction with current health status was reported by 36.7% and 38.1% in groups 1 and 2, respectively, and that the support from others has decreased (56.1% and 66.1%, in groups 1 and 2) during the pandemic. The factors with higher Odds Ratio of increase in seizure frequency during pandemic were age >41 yrs., treatment in public healthcare system, drug-resistant epilepsy, adversities in getting ASM in public dispensing units, difficulties with prescription renewals, current financial problems and belief that epilepsy or ASM are risk factors for contracting COVID-19.

CONCLUSION

During COVID-19 pandemic in Brazil, PWE and caregivers reported increase in seizures in one-fourth of the patients and several difficulties, namely problems in accessing the healthcare system including ASM dispensation, telehealth, and fear of having a more severe COVID-19 because of epilepsy. There were also physical, psychological, and social concerns which affected quality-of-life-related aspects in this population. These facts may increase treatment gap in epilepsy in Brazil as well in other developing countries.

Convulsive Status Epilepticus in a Child With Controlled Epilepsy and Concurrent COVID-19 Infection: A Case Report and a Quick Review

The current unprecedented COVID-19 pandemic has been another step toward learning about the unique interaction between viral infections and human nervous system. Very few scientific papers explored neuroinvasive and neurotropic potentials of the SARS-CoV-2 virus in children. We report a child with convulsive status epilepticus and confirmed COVID-19 infection. Brief review of current available literature was discussed.

The impact of COVID-19 on patients with epilepsy

BACKGROUND

The COVID-19 pandemic and social distancing can have adverse impacts on adult people with epilepsy (PWE).

OBJECTIVE

To investigate the seizure frequency, the perceived well-being, and the presence of anxiety symptoms in PWE during the COVID-19 pandemic period.

METHODS

Data from a questionnaire on the repercussions of COVID-19 were analyzed in relation to the clinical variables of 114 PWE, with a significance level of p<0.05.

RESULTS

There were 26 cases of COVID-19 in PWE and/or family members (22.8%). During the pandemic period, 11 PWE (9.6%) reported an increase in seizures, but unrelated to COVID-19. Also, the number of crises in PWE with previous depressive disorders increased, with differences between epilepsies. Symptoms of depression, impaired well-being, and concern for their lifestyle were significant in PWE with a previous diagnosis of depression. Impaired well-being, increased anxiety, nervousness, and tiredness, and the concern with being infected were mentioned by a high number of PWE in the pandemic.

CONCLUSION

Seizure frequency increased during the pandemic period, a finding associated with clinical variables of epilepsy. PWE with depression had worse perceived well-being. Changes in well-being and increased anxiety and nervousness were frequent in the pandemic.

SARS-CoV-2 Infection: Symptoms of the Nervous System and Implications for Therapy in Neurological Disorders

In this paper, the neurological aspects of COVID-19 are presented, which may be of significance for physicians. Knowledge about the neurological symptoms of COVID-19 infection should help physicians in diagnoses and in taking appropriate precautions, as some manifestations can appear before typical pulmonary symptoms. Various mechanisms of SARS-CoV-2 neuroinvasion are discussed and symptoms are described, which can be subdivided into manifestations of the central nervous system (CNS) (headache, dizziness, stroke, impaired consciousness, encephalitis, meningitis, seizures) and peripheral nervous system (PNS) (characteristic hyposmia and hypogeusia, Guillain Barré syndrome, myalgia). Additionally, the implications of COVID-19 infection for treatment of patients with common neurological diseases and their management is presented. It can be concluded that neurological symptoms are part of a clinical spectrum of COVID-19 infection, involving the CNS and PNS. COVID-19 may influence decisions regarding the treatment of neurological disorders, especially those with an immune background.

Online Health Survey on Epileptic Children during Coronavirus Disease-2019 Pandemic

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2, and the outbreak is now rapidly spreading globally. The current administrative measures of lock-down, social distancing, and self-isolation are intended at reducing the spread of the viral infection, minimizing contacts between potentially infected individuals and healthy subjects. However, they can complicate the management of children with neurological illnesses by instigating or worsening concomitant anxiety and depression, hindering the interactions with physicians, and leading to shortages or inconsistent supply of medicines. OBJECTIVE: The current study aims to provide information on the medical care and wellbeing of children with epilepsy during COVID-19 pandemic and provide the best possible care for those children while avoiding visits to urgent care facilities and hospitalizations during the pandemic. METHODS: The current study was an observational cross-section survey study. One hundred twenty children with epilepsy following in the epilepsy clinic of Medical Research Center of Excellence, and epilepsy clinic at Neurology Department, Faculty of Medicine, Ain Shams University aged above 4 years were recruited. The authors designed a 22-items questionnaire to address impact of COVID-19 crisis on the care, seizure outcome, behavior of children, and concerns of their parents. The study was conducted during the period from May 2020 to November 2020. RESULTS: The study included 120 epileptic children, 47 males and 73 females, with age ranged from 4 to 17 years with mean age 8.34 ± 3.877 years. Before COVID pandemic, 18.3% of care providers had worries about epilepsy, while during the pandemic, 78.3% of them had the same worries. Twenty percent of the studied patients showed worsened sleep during the pandemic. Medical follow-up difficulties and drug access difficulties were found in 18.3% and 50% of the patients, respectively, during the pandemic. Child anxiety was 20% before the pandemic and 97.5% during the pandemic. Of the care providers, 95.8% were worried about their children of getting COVID 19. Thirty percent showed a need for psychological support, 76.7% for medical support, and 75% for information support about epilepsy. Medical support by phone or online during the pandemic was accepted by 80.8% of the caregivers. The study also showed that epileptic children with age ≤12 years needed more psychological support than those >12 years. All children without anxiety before the COVID-19 pandemic had anxiety during COVID-19 pandemic, while 87.5% of those with anxiety before COVID still had anxiety during the pandemic, signifying that COVID 19 pandemic increased the anxiety of the epileptic children significantly. CONCLUSION: The present study found no increase in seizure exacerbation during the outbreak of COVID-19. During the pandemic, worries of the care providers about progression of the frequency of seizure and epileptic children anxiety increased significantly. Physicians should offer health care facilities including medications and information as much as possible at home to keep children with epilepsy in good psychological and mental status as well as minimizing of risk of seizure exacerbation through adherence. Effective telemedicine tools will prove useful for the long-term management of these patients.

Neurologic Manifestations of COVID-19

Neurological manifestations of novel coronavirus disease (COVID-19) are reported to occur in as much as 37% of the affected patients. These manifestations range from headache and dizziness to altered mental status and consciousness, anosmia, ageusia, sensory disturbances, and stroke. The mechanisms by which the neurological symptoms arise are not yet determined but may either proceed as an indirect consequence of systemic hyperinflammation or result from the direct invasion of the virus to neural and glial cells. The neural invasion can explain both the retrograde pathway of encephalitis and the early manifestation of anosmia by invading the olfactory bulb. Moreover, in the case of attacking the brain stem, it may take part in the early apnea manifestation reported by patients. Additionally, neurotropism of the virus could be the cause of acute hemorrhagic encephalitis. Hyperinflammation can have acute and prolonged effects in the nervous system, such as acute demyelination and predisposition to multiple sclerosis. Moreover, the pro-inflammatory state contributes to hypercoagulation, which in turn could result in cerebrovascular injuries in COVID-19 patients. This chapter would discuss that the neurologic manifestations of the COVID-19 are to be looked at as a multifactorial entangled phenomenon.

The impact of the coronavirus disease (COVID-19) pandemic on outpatient epilepsy care: An analysis of physician practices in Germany

OBJECTIVE

To gain insight into epilepsy care during coronavirus disease (COVID-19) pandemic, we analyzed prescription data of a large cohort of persons with epilepsy (PWE) during lockdown in Germany.

METHODS

Information was obtained from the Disease Analyzer database, which collects anonymous demographic and medical data from practice computer systems of general practitioners (GP) and neurologists (NL) throughout Germany. We retrospectively compared prescription data for anti-seizure medication (ASM) and physicians' notes of "known" and "new" PWE from January 2020 until May 2020 with the corresponding months in the three preceding years 2017-2019. Adherence was estimated by calculating the proportion of patients with follow-up prescriptions within 90 days after initial prescriptions in January or February. We additionally analyzed hospital referrals of PWE. The significance level was set to 0.01 to adjust for multiple comparisons.

RESULTS

A total of 52,844 PWE were included. Anti-seizure medication prescriptions for known PWE increased in March 2020 (GP + 36%, NL + 29%; P < 0.01). By contrast, a decrease in prescriptions to known and new PWE was observed in April and significantly in May 2020 ranging from -16% to -29% (P < 0.01). The proportion of PWE receiving follow-up prescriptions was slightly higher in 2020 (73.5%) than in 2017-2019 (70.7%, P = 0.001). General practitioners and NL referred fewer PWE to hospitals in March 2020 (GP: -30%, P < 0.01; NL: -12%), April 2020 (GP: -29%, P < 0.01; NL: -37%), and May 2020 (GP: -24%, P < 0.01; NL: -16%).

CONCLUSION

Adherence of known PWE to ASM treatment appeared to remain stable during lockdown in Germany. However, this study revealed findings which point to reduced care for newly diagnosed PWE as well as fewer hospital admissions. These elements may warrant consideration during future lockdown situations.

Socio-economic impact on epilepsy outside of the nation-wide COVID-19 pandemic area

OBJECTIVE

To identify people with epilepsy (PWE) who required extensive care before the novel coronavirus disease 2019 (COVID-19) pandemic that had world-wide impacts on medical care and on socio-economic conditions.

METHODS

Consecutive PWE who were treated at the epilepsy center of Hiroshima University Hospital, which was located in the COVID-19 non-pandemic area, between March 2019 and August 2020 were enrolled. We evaluated clinical and socioeconomic factors that were associated with seizure exacerbation (an increase in seizure frequency) during the first 6 months after the COVID-19 pandemic started compared with the previous 6 months.

RESULTS

Among the 196 PWE who were evaluated (mean age was 37.8 ± 16.2 years), there were 33 PWE (16.8%) whose seizure frequency had increased after the pandemic began. People with epilepsy with a seizure increase showed a significant association with living alone (p < 0.001), a higher seizure frequency (p < 0.001), negative findings on MRI (p = 0.020), history of dissociative seizure (p < 0.001), mood disorders (p < 0.001), insomnia (p < 0.001), and high psychological stress levels (p = 0.024) at baseline compared with PWE without seizure exacerbation. Multivariate logistic regression analysis revealed that "living alone" (odds ratio (OR) 3.69; 95%CI 1.29-10.52), "high seizure frequency at baseline" (OR 4.53; 95%CI 1.63-12.57), and "comorbidity of insomnia" (OR 9.55; 95%CI 3.71-24.55) were independently associated with seizure exacerbation.

CONCLUSIONS

Even in the non-pandemic area, PWE had seizure exacerbation, suggesting that clinicians should screen patients' mental health before the outbreak to provide care, reduce the burden, and prevent social isolation in PWE. This should be addressed particularly in patients with medically refractory seizures with insomnia who live alone.

Correlation of Seizure Increase and COVID-19 Outbreak in Adult Patients with Epilepsy: Findings and Suggestions from a Nationwide Multi-centre Survey in China

OBJECTIVES

To investigate the impact of the COVID-19 outbreak on the behaviours, mental health and seizure control of adult patients with epilepsy (PWE) and to identify the correlation of seizure increase and the COVID-19 outbreak to guide the medical care of individuals with epilepsy during a public health crisis.

METHODS

This study was conducted at 28 centres from February 2020 to April 2020. Participants filled out a 62-item online survey including sociodemographic, COVID-19-related, epilepsy-related and psychological variables and were divided into two groups based on whether their seizure frequency increased during the COVID-19 pandemic. Chi-square tests and t-tests were used to test differences in significant characteristics. Multiple logistic regression analyses were used to identify risk factors for seizure worsening.

RESULTS

A total of 1,237 adult PWE were enrolled for analysis. Of this sample, 31 (8.33%) patients experienced an increase in seizures during the pandemic. Multivariate logistic regression suggested that feeling nervous about the pandemic (P < 0.05), poor quality of life (P = 0.001), drug reduction/withdrawal (P = 0.032), moderate anxiety during the COVID-19 outbreak (P = 0.046) and non-seizure free before the COVID-19 outbreak (P < 0.05) were independently related to seizure increase during the pandemic.

CONCLUSIONS

During the COVID-19 pandemic, PWE with poor quality of life and mental status, as well as AED reduction/withdrawal, were more likely to experience seizure increase. This observation highlights the importance of early identification of the population at high risk of seizure worsening and implementation of preventive strategies during the pandemic.

Persons with co-existing neurological disorders: Risk analysis, considerations and management in COVID-19 pandemic

Increasing reports of neurological symptoms in COVID-19 patient's warrant clinicians to adopt and define the standardized diagnostic and managing protocols in order to investigate the linkage of neurological symptoms in COVID-19. Encephalitis, anosmia, acute cerebrovascular disease and ageusia are some of the emerging neurological manifestations which are reported in several cohort studies on hospitalized patients with COVID-19. Although the COVID-19 pandemic is primarily associated with respiratory tract system but measures like lockdown and restricted physical movements to control the spread of this infection will certainly have neurobehavioural implications. Additionally, some of the patients with pre-existing neurological manifestations like epilepsy, Parkinson's and Alzheimer's disease are more prone to infection and demands extra as well as improvisation in their treatment therapy. In this review we have focused on the neurovirological clinical manifestations associated with COVID-19 pandemic. Although the prevalence of neurovirological manifestations is rare but increasing reports cannot be ignored and needs to be discussed thoroughly with respect to risk analysis and considerations for developing management strategy. This also helps in defining the burden of neurological disorders associated with COVID-19 patients.

Responses of people with epilepsy to the COVID-19 pandemic in the time of national lockdown

The aim of our study was to gather information on how people with epilepsy (PwE) responded to the COVID-19 pandemic during the national lockdown. An online questionnaire was therefore offered to the visitors of the Croatian Association for Epilepsy's website. The 22-items questionnaire was designed to acquire information from adults with epilepsy living in Croatia on demographic data, cognitive, emotional and behavioral responses to the pandemic, and communication problems between patients and their neurologists during the lockdown. Perceived anxiety and fears were expressed with the Likert scale (1-5) and the results of specific fears added to make the Total Fear Score. Results: Out of 186 respondents in total, only 2.8% did not comply with the lockdown measures, and all of those respondents stated that they did not feel any anxiety related to COVID-19. A canceled neurologist examination during the lockdown was significantly associated with pandemic-related anxiety (2.9 ± 1.28 vs. 2.3 ± 1.19, U = 3039, p = 0.001) and fears (Total Fear Score 31.4 ± 9.70 vs. 28.4 ± 9.79, U = 3341, p = 0.036), and 87.4% of respondents expressed the wish to communicate with their neurologist, either by phone/video call (53.0%) or email (34.4%). Conclusion: We think the results of our survey show that the responses from PwE point to a social responsibility appropriate for the existing situation. During future pandemics, telemedicine could have an important role in tackling the fears and anxieties caused by the cancelation of examinations, which corresponds to the wishes expressed by the great majority of our respondents.

Epilepsy and COVID-19: Updated evidence and narrative review

The coronavirus disease 2019 (COVID-19) outbreak started in Wuhan, China, in late 2019 and rapidly spread globally. Vaccines have recently been developed and are being administered in some countries, but their widespread use is not yet sufficient; the battle against COVID-19 is protracted and people need to adapt to living under the influence of this disease. Epilepsy is a common chronic neurological condition characterized by spontaneous recurrence of unprovoked seizures. Various effects of COVID-19 on epilepsy have been studied in recent months. As clinicians, we need to keep up with daily updates in the evidence regarding interactions between COVID-19 and epilepsy. This review article summarizes the current evidence. Prospective studies on epilepsy and COVID-19 remain lacking. Most articles have comprised case reports, case series, retrospective studies, and recommendations/opinions that do not include data. However, summarizing these articles can identify the demands for research into COVID-19 and epilepsy by clarifying what is known and what remains unclear from current research.

Multiple Neuroinvasive Pathways in COVID-19

COVID-19 is a highly infectious viral disease caused by the novel coronavirus SARS-CoV-2. While it was initially regarded as a strictly respiratory illness, the impact of COVID-19 on multiple organs is increasingly recognized. The brain is among the targets of COVID-19, and it can be impacted in multiple ways, both directly and indirectly. Direct brain infection by SARS-CoV-2 may occur via axonal transport via the olfactory nerve, eventually infecting the olfactory cortex and other structures in the temporal lobe, and potentially the brain stem. A hematogenous route, which involves viral crossing of blood-brain barrier, is also possible. Secondary mechanisms involve hypoxia due to respiratory failure, as well as aberrant immune response leading to various forms of encephalopathy, white matter damage, and abnormal blood clotting resulting in stroke. Multiple neurological symptoms of COVID-19 have been described. These involve anosmia/ageusia, headaches, seizures, mental confusion and delirium, and coma. There is a growing concern that in a number of patients, long-term or perhaps even permanent cognitive impairment will persist well after the recovery from acute illness. Furthermore, COVID-19 survivors may be at increased risk for developing neurodegenerative diseases years or decades later. Since COVID-19 is a new disease, it will take months or even years to characterize the exact nature, scope, and temporal extent of its long-term neurocognitive sequelae. To that end, rigorous and systematic longitudinal follow-up will be required. For this effort to succeed, appropriate protocols and patient registries should be developed and put in place without delay now.

Recalling the COVID-19 lockdown: Insights from patients with epilepsy

PURPOSE

The purpose of our study was to explore health changes among people with epilepsy (PWE) during a national COVID-19 lockdown in the context of patients' clinical characteristics and their experience of receiving epilepsy-related medical services.

METHODS

A questionnaire was distributed for adult PWE both online and at a tertiary epilepsy center after the end of a national lockdown in Lithuania. PWE were asked to evaluate their health status during the lockdown and estimate changes in their seizure patterns. Additional questions concerned the accessibility and quality of epilepsy-related consultations.

RESULTS

The study sample consisted of 143 PWE (59 [41.3%] male, mean age 35.1 ± 13.4 years), 94 (65.7%) completed the survey in person, 49 (34.3%) - online. A deterioration in reported physical and mental health during lockdown was observed (Z = -4.604, p < 0.0001 and Z = -4.253, p < 0.0001, respectively) and 22 (15.4%) PWE reported seizure exacerbation. In an ordinal logistic regression model (analysis of data from all participants), baseline seizure frequency (b = 0.413, p = 0.031), reported physical health before lockdown (b = -0.462, p = 0.031) and the ease of proper antiepileptic drug (AED) use during the imposed restrictions (b = -0.535, p = 0.006) were statistically significant variables associated with changes in seizure frequency. The latter were not affected by modifications in AED use (Mann-Whitney U = 1127.0, p = 0.307) irrespective of the data collection method. With teleconsultations being predominant during the lockdown, an overall decline in the quality of epilepsy-related consultations was observed (Z = -2.895, p = 0.004). Among all participants, 46 (32.2%) lost an epilepsy-related consultation or medical service because of the lockdown. This loss was found to be associated with seizure exacerbation (Mann-Whitney U = 1622.5, p = 0.046).

CONCLUSION

Our study indicates that a national COVID-19 lockdown may have led to worse seizure control and health status in some PWE. Easy access to AEDs and their appropriate use may be especially useful to prevent seizure exacerbation during strict COVID-19 restrictions. The quality and accessibility of remote epilepsy-related consultations was suboptimal and may require further improvement during disruption of in-person services.

Impact of COVID-19 pandemic in pediatric patients with epilepsy with neuropsychiatric comorbidities: A telemedicine evaluation

OBJECTIVE

The objective of this study was to evaluate care needs, emotional and behavioral changes, and parental stress indices in a cohort of pediatric patients with epilepsy with neurocognitive and emotional comorbidities at the time of the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This is a prospective observational study involving pediatric patients with epilepsy with neurocognitive and emotional comorbidities. Included patients were admitted to our hospital between August 2019 and February 2020 for epilepsy and neuropsychiatric assessment, and Child Behavior Checklist (CBCL) questionnaires were filled in by parents. Those patients and their families accepted to participate in a phone follow-up visit in April-May 2020 and to refill CBCL and Parenting Stress Index-Short Form (PSI-SF) questionnaires. Descriptive statistics for demographic and clinical data, CBCL questionnaire scores before and during the COVID-19 pandemic, and PSI-SF scores have been computed. Moreover, results of a short phone survey on the psychological burden during COVID lockdown have been reported.

RESULTS

This study provides the parental-proxy report of emotional and behavioral profile changes of 23 pediatric patients with epilepsy and neurocognitive and emotional comorbidities during the COVID-19 pandemic. Concerns for therapy monitoring at the time of lockdown emerged in 43% of families, and 30% of patients showed worries for an altered contact with the referring medical team. Patients with neurocognitive comorbidities were more likely to exhibit behavioral problems, especially externalizing problems compared with patients with a diagnosis of anxiety/depression.

CONCLUSION

Our data suggest the importance to monitor disease trajectory and behavior and affective symptoms with telehealth strategies to provide effective care to patients and their families.

Evaluating risk to people with epilepsy during the COVID-19 pandemic: Preliminary findings from the COV-E study

The COVID-19 pandemic has caused global anguish unparalleled in recent times. As cases rise, increased pressure on health services, combined with severe disruption to people's everyday lives, can adversely affect individuals living with chronic illnesses, including people with epilepsy. Stressors related to disruption to healthcare, finances, mental well-being, relationships, schooling, physical activity, and increased isolation could increase seizures and impair epilepsy self-management. We aim to understand the impact that COVID-19 has had on the health and well-being of people with epilepsy focusing on exposure to increased risk of seizures, associated comorbidity, and mortality. We designed two online surveys with one addressing people with epilepsy directly and the second for caregivers to report on behalf of a person with epilepsy. The survey is ongoing and has yielded 463 UK-based responses by the end of September 2020. Forty percent of respondents reported health changes during the pandemic (n = 185). Respondents cited a change in seizures (19%, n = 88), mental health difficulties (34%, n = 161), and sleep disruption (26%, n = 121) as the main reasons. Thirteen percent found it difficult to take medication on time. A third had difficulty accessing medical services (n = 154), with 8% having had an appointment canceled (n = 39). Only a small proportion reported having had discussions about epilepsy-related risks, such as safety precautions (16%, n = 74); mental health (29%, n = 134); sleep (30%, n = 140); and Sudden Unexpected Death in Epilepsy (SUDEP; 15%, n = 69) in the previous 12 months. These findings suggest that people with epilepsy are currently experiencing health changes, coupled with inadequate access to services. Also, there seems to be a history of poor risk communication in the months preceding the pandemic. As the UK witnesses a second COVID-19 wave, those involved in healthcare delivery must ensure optimal care is provided for people with chronic conditions, such as epilepsy, to ensure that avoidable morbidity and mortality is prevented during the pandemic, and beyond.

Cytokine storm induced by SARS-CoV-2 infection: The spectrum of its neurological manifestations

The new coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can trigger a hyperinflammatory state characterized by elevated cytokine levels known as hypercytokinemia or cytokine storm, observed most often in severe patients. Though COVID-19 is known to be a primarily respiratory disease, neurological complications affecting both the central and peripheral nervous systems have also been reported. This review discusses potential routes of SARS-CoV-2 neuroinvasion and pathogenesis, summarizes reported neurological sequelae of COVID-19, and examines how aberrant cytokine levels may precipitate these complications. Clarification of the pathogenic mechanisms of SARS-CoV-2 is needed to encourage prompt diagnosis and optimized care. In particular, identifying the presence of cytokine storm in patients with neurological COVID-19 manifestations will facilitate avenues for treatment. Future investigations into aberrant cytokine levels in COVID-19 patients with neurological symptoms as well as the efficacy of cytokine storm-targeting treatments will be critical in elucidating the pathogenic mechanisms and effective treatments of COVID-19.

Viral infections and their relationship to neurological disorders

The chronic dysfunction of neuronal cells, both central and peripheral, a characteristic of neurological disorders, may be caused by irreversible damage and cell death. In 2016, more than 276 million cases of neurological disorders were reported worldwide. Moreover, neurological disorders are the second leading cause of death. Generally, the etiology of neurological diseases is not fully understood. Recent studies have related the onset of neurological disorders to viral infections, which may cause neurological symptoms or lead to immune responses that trigger these pathological signs. Currently, this relationship is mostly based on epidemiological data on infections and seroprevalence of patients who present with neurological disorders. The number of studies aiming to elucidate the mechanism of action by which viral infections may directly or indirectly contribute to the development of neurological disorders has been increasing over the years but these studies are still scarce. Comprehending the pathogenesis of these diseases and exploring novel theories may favor the development of new strategies for diagnosis and therapy in the future. Therefore, the objective of the present study was to review the main pieces of evidence for the relationship between viral infection and neurological disorders such as Alzheimer's disease, Parkinson's disease, Guillain-Barré syndrome, multiple sclerosis, and epilepsy. Viruses belonging to the families Herpesviridae, Orthomyxoviridae, Flaviviridae, and Retroviridae have been reported to be involved in one or more of these conditions. Also, neurological symptoms and the future impact of infection with SARS-CoV-2, a member of the family Coronaviridae that is responsible for the COVID-19 pandemic that started in late 2019, are reported and discussed.

Impact of COVID-19 pandemic on pediatric patients with epilepsy - The caregiver perspective

The recent COVID-19 pandemic has disrupted care systems around the world. We assessed how the COVID-19 pandemic affected children with epilepsy in Italy, where lockdown measures were applied from March 8 to May 4, 2020. We compiled an Italian-language online survey on changes to healthcare and views on telehealth. Invitations were sent to 6631 contacts of all patients diagnosed with epilepsy within the last 5 years at the BambinoGesù Children's Hospital in Rome. Of the 3321 responses received, 55.6% of patients were seizure-free for at least 1 year before the COVID-19-related lockdown, 74.4% used anti-seizure medications (ASMs), and 59.7% had intellectual disability. Only 10 patients (0.4%) became infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Seizure frequency remained stable for most patients during the lockdown period (increased in 13.2%; decreased in 20.3%), and seizure duration, use of rescue medications, and adherence to treatment were unchanged. Comorbidities were more affected (behavioral problems worsened in 35.8%; sleep disorder worsened in 17.0%). Visits were canceled/postponed for 41.0%, but 25.1% had remote consultation during the lockdown period (93.9% were satisfied). Most responders (67.2%) considered continued remote consultations advantageous. Our responses support that patients/caregivers are willing to embrace telemedicine for some scenarios.

Examining the impacts of the COVID-19 pandemic on the well-being and virtual care of patients with epilepsy

OBJECTIVE

The emergence of SARS-CoV-2 (COVID-19) as a novel coronavirus resulted in a global pandemic that necessitated the implementation of social distancing measures. These public health measures may have affected the provision of care for patients with epilepsy. Social isolation may have also adversely affected well-being and quality of life due to informal and formal support networks becoming less accessible. The purpose of this qualitative study was to examine the lived experiences of patients with epilepsy and to see how their quality of life and healthcare has been affected by the COVID-19 pandemic.

METHODS

From April 27 to May 15, 2020 we performed remote interviews with 18 participants who had virtual appointments with their healthcare providers and were enrolled in the Calgary Comprehensive Epilepsy Program registry. Interviews were recorded and transcribed, after which transcripts were analyzed and coded into relevant themes using NVivo 12.

RESULTS

Three broad themes emerged throughout the interviews:1) impact of pandemic on informal and formal support systems; 2) impact of pandemic on healthcare provision; and 3) concerns about the impact of the pandemic on personal situations and society in the future. Participants reported anxiety and stress about decreased social engagement and activity cessations. Although face-to-face appointments were preferred, virtual care was well-received. Common concerns about the future included securing employment and burnout from balancing family responsibilities. Some patients also feared they would be stigmatized as society adapted to the situation.

SIGNIFICANCE

This study highlights the need for additional research in anticipation of the implementation of remote medicine in the management and treatment of epilepsy. It also highlights the tenacity of those living with epilepsy during difficult periods despite social and familial pressures. Raising awareness during this time about the lives and experiences of epilepsy patients can help challenge misconceptions and stigma in the workplace and wider society.

Death due to COVID-19 in a patient with diabetes, epilepsy, and gout comorbidities

There is evidence of increased incidence, rapid progression, and poor prognosis of COVID-19 in patients with underlying comorbidities such as diabetes and epilepsy. Developing effective treatment regimens for COVID-19 patients with multiple comorbidities is crucial, as patients' past medical history is an essential contributor to possible organ injuries in COVID-19 patients. Herein, we report a confirmed case of COVID-19 patient with a history of multiple underlying diseases, including diabetes, epilepsy, and gout. The patient developed multiple organ failure and died a week after intensive care unit (ICU) admission. Multiple organ failure is the most common cause of death in COVID-19 patients.

Is amiloride a promising cardiovascular medication to persist in the COVID-19 crisis?

In the ongoing coronavirus diseases-2019 (COVID-19) crisis that caused immense suffering and deaths, the choice of therapy for the prevention and life-saving conditions must be based on sound scientific evidence. Uncertainty and apprehension are exacerbated in people using angiotensin-converting enzyme (ACE) inhibitors to control their comorbidities such as hypertension and diabetes. These drugs are reported to result in unfavorable outcome as they tend to increase the levels of ACE2 which mediates the entry of SARS-CoV-2. Amiloride, a prototypic inhibitor of epithelial sodium channels (ENaC) can be an ideal candidate for COVID-19 patients, given its ACE reducing and cytosolic pH increasing effects. Moreover, its potassium-sparing and anti-epileptic activities make it a promising alternative or a combinatorial agent.