Health-related quality of life after epilepsy surgery: A prospective, controlled follow-up on the Iranian population

Experiences of adults living with refractory epilepsy and their views and expectations on receiving results from whole genome sequencing

INTRODUCTION

Researchers, clinicians and patients are turning to new innovations in research and clinical practice to further their knowledge in the genetic domain and improve diagnostics or treatment. However, with increased knowledge in genetics, societal issues may arise. Being conscious of these issues is crucial in order to implement standardized and efficient testing on a wider scale that is accessible to a greater number of individuals while simultaneously returning test results, including incidental findings, in a timely manner.

METHODS

Within the framework of a genomics research project, we invited 20 participants who suffer from refractory epilepsy to provide insight on their personal experiences with epilepsy, as well as their thoughts on receiving Whole Genome Sequencing (WGS) results and with whom they would feel comfortable sharing these results with.

RESULTS

All participants had their own unique experience with epilepsy, such as how they handled their diagnosis, their struggles following the diagnosis, the healthcare services they received, how they shared their diagnosis with others, and how they managed stigmatization from others. Most participants would be eager to know their WGS results, whether the results be related to epilepsy (n = 19), response to pharmaceutical drugs including AEDs (n = 16), comorbidities (n = 19) and incidental findings (n = 15).

CONCLUSION

Our findings reinforce the need to improve access to genetic testing for epilepsy patients in clinical settings. Furthermore, while acquiring more genetic knowledge (i.e. WGS) about epilepsy can provide answers for the affected population, it also requires the simultaneous involvement of several medical disciplines, with greater emphasis on genetic and psychological counseling.

Impact of epilepsy surgery on quality of life: Systematic review and meta-analysis

Improved quality of life (QoL) is an important outcome goal following epilepsy surgery. This study aims to quantify change in QoL for adults with drug-resistant epilepsy (DRE) who undergo epilepsy surgery, and to explore clinicodemographic factors associated with these changes. We conducted a systematic review and meta-analysis using Medline, Embase, and Cochrane Central Register of Controlled Trials. All studies reporting pre- and post-epilepsy surgery QoL scores in adults with DRE via validated instruments were included. Meta-analysis assessed the postsurgery change in QoL. Meta-regression assessed the effect of postoperative seizure outcomes on postoperative QoL as well as change in pre- and postoperative QoL scores. A total of 3774 titles and abstracts were reviewed, and ultimately 16 studies, comprising 1182 unique patients, were included. Quality of Life in Epilepsy Inventory-31 item (QOLIE-31) meta-analysis included six studies, and QOLIE-89 meta-analysis included four studies. Postoperative change in raw score was 20.5 for QOLIE-31 (95% confidence interval [CI] = 10.9-30.1, I2  = 95.5) and 12.1 for QOLIE-89 (95% CI = 8.0-16.1, I2  = 55.0%). This corresponds to clinically meaningful QOL improvements. Meta-regression demonstrated a higher postoperative QOLIE-31 score as well as change in pre- and postoperative QOLIE-31 score among studies of cohorts with higher proportions of patients with favorable seizure outcomes. At an individual study level, preoperative absence of mood disorders, better preoperative cognition, fewer trials of antiseizure medications before surgery, high levels of conscientiousness and openness to experience at the baseline, engagement in paid employment before and after surgery, and not being on antidepressants following surgery were associated with improved postoperative QoL. This study demonstrates the potential for epilepsy surgery to provide clinically meaningful improvements in QoL, as well as identifies clinicodemographic factors associated with this outcome. Limitations include substantial heterogeneity between individual studies and high risk of bias.

Influence of Clinical Factors on the Quality of Life in Romanian People with Epilepsy-A Follow-Up Study in Real-Life Clinical Practice

BACKGROUND

This study aimed to assess the influence of various clinical factors on the quality of life perception of patients with epilepsy over a follow-up period in current clinical practice.

METHODS

Thirty-five PWE evaluated via video-electro-encephalography in the Clinical Hospital of Psychiatry and Neurology in Brasov, Romania, were included, and the quality of life was assessed using the Romanian version of the QOLIE-31-P questionnaire.

RESULTS

At baseline, the mean age was 40.03 (±14.63) years; the mean duration of epilepsy was 11.46 (±12.90) years; the mean age at the first seizure was 28.57 (±18.72); and the mean duration between evaluations was 23.46 (±7.54) months. The mean (SD) QOLIE-31-P total score at the initial visit (68.54 ±15.89) was lower than the mean (SD) QOLIE-31-P total score at the follow-up (74.15 ± 17.09). Patients with epileptiform activity recorded via video-electro-encephalography, using polytherapy, those with uncontrolled seizures, and those with one or more seizures per month had statistically significantly lower QOLIE-31-P total scores at baseline and follow-up. Multiple linear regression analyses revealed seizure frequency as a significant inverse predictor of quality of life in both evaluations.

CONCLUSIONS

The QOLIE-31-P total score was improved during the follow-up period, and medical professionals should use instruments to evaluate quality of life and identify patterns while trying to improve the outcomes of patients with epilepsy.

Association between antiseizure medications and quality of life in epilepsy: A mediation analysis

OBJECTIVE

The relationship between antiseizure medications (ASMs), which improve health outcomes by controlling seizures, and health-related quality of life (HRQOL) is poorly understood and may involve intermediate variables. We evaluated the potential mediators of the association between ASMs and HRQOL.

METHODS

Data are from an outpatient registry of adult patients with epilepsy seen at the Foothills Medical Center, Calgary, Alberta, Canada. Quality of life was measured using the 10-item Quality of Life in Epilepsy, and depression was measured using the Neurological Disorders Depression Inventory for Epilepsy. Propensity score matching was used to adjust for covariate imbalance between patients who received a single ASM (monotherapy) and those who received two or more ASMs (polytherapy) due to confounding. Mediation analysis was used to estimate the mediating effects of depression and ASM side effects on the association between patients' ASM polytherapy and HRQOL.

RESULTS

Of 778 patients included in this analysis, 274 (35.2%) were on two or more ASMs. Patient-reported depression and ASM side effects jointly mediated the association between ASMs and HRQOL; these mediators accounted for 42% of the total average effect of ASM polytherapy ( β  = -13.6, 95% confidence interval = -18.2 to -8.6) on HRQOL.

SIGNIFICANCE

These findings highlight the importance of managing depression and ASM side effects for improving health outcomes of patients requiring treatment with ASMs. Intervention programs aimed at improving HRQOL of patients with epilepsy need to target these potential mediators.

Clinical outcome of selective amygdalectomy in a series of patients with resistant temporal lobe epilepsy

Background:

Selective amygdalohippocampectomy is one of the main approaches for treating medial temporal lobe epilepsy (TLE). We herewith describe seven cases of amygdala lesions treated with selective amygdalectomy with the hippocampus saving procedure. Furthermore, we explain the trans-middle temporal gyrus transventricular approach for selective amygdalectomy.

Methods:

We studied patients with TLE who underwent selective amygdalectomy with hippocampal saving procedure between March 2012 and July 2018. We preferred the trans-middle temporal gyrus transventricular approach. We adopted pterional craniotomy with extensive exposure of the base and posterior of the temporal lobe. The posterior margin of resection in the intraventricular part of the amygdala was considered the inferior choroidal point. Medially anterior part of the uncus was resected until reaching the ambient cistern. We applied the transcortical transventricular approach for selective amygdalectomy in all patients.

Results:

We present 11 cases having an amygdala lesion in our series, seven of whom underwent selective amygdalectomy with hippocampal sparing. Nine patients had neoplastic lesions, and in two of them, gliosis was evident. Total resection of the lesion was achieved in all cases based on postoperative magnetic resonance imaging. No unusual complication or surgically-related new neurological deficit occurred.

Conclusion:

We consider the resection of the amygdala until the inferior choroidal point sufficient for the disconnection of its circuits, which results in more effective control of seizures and reduction of surgery time and complications.

Markers of Neuroinflammation and Apoptosis in the Temporal Lobe of Patients with Drug-Resistant Epilepsy

Abstract

Current antiepileptic strategies aim to normalize the interaction of the excitatory and inhibitory systems, which is ineffective in treating patients with drug-resistant epilepsy. Neuroinflammatory processes in the epileptic focus and its perifocal area can trigger apoptosis and also contribute to the development of drug resistance. The level of pro- and anti-apoptotic proteins (p-NF-kB, TNF-α, p53, FAS, caspase-3, caspase-9) was analyzed in intraoperative biopsies of the temporal lobe gray and white matter in the brain of patients with drug-resistant epilepsy. An increased level of pro-apoptotic proteins was revealed in the cortex and perifocal area’s white matter against the background of an imbalance of protective anti-apoptotic proteins. It appears that the activation of the extrinsic pathway of apoptosis occurs in the perifocal area, while in the epileptic focus, there are proteins responsible for the activation of the anti-apoptotic survival pathways. Active neuroinflammation in the epileptic focus and perifocal area of the temporal lobe may contribute to the development of the resistance to antiepileptic drugs and the progression of neurodegeneration in such patients.

Postoperative Evaluation of the Quality of Life, Depression, and Anxiety of Temporal Lobe Epilepsy Cohort: A Single Institute Experience in Indonesia

Background: Besides seizure control, quality of life (QoL) should be considered as an equally important outcome for epilepsy surgery service providers. The paucity of QoL reports from developing countries has enlarged the representation gap between wealthy countries and countries with fewer resources. In this study, we evaluated postoperative QoL in the Indonesian drug-resistant epilepsy cohort where the epilepsy surgery service faces limited resource availability.

Methods: We evaluated the QoL in patients with temporal lobe epilepsy who underwent surgery in our epilepsy surgery center in Semarang, Indonesia, from 2001 until 2015. The follow–up period started in 2018 through 2019. Postoperative QoL, depression, and anxiety were evaluated with self-reporting questionnaires including the Quality of Life in Epilepsy Inventory-31, Beck Depression Inventory-II, and Zung Self-Rating Anxiety Scales.

Results: Forty returned questionnaires were included in the analysis (male 25, 62.5%; mean age 27.6 ± 9.05 years). The seizure-free cohort (n = 22, 55.0%) reported higher scores in most QoL dimensions particularly adjustment, overall QoL, and seizure worry compared to those with persistent seizures. The overall QoL level was correlated with seizure freedom and surgery type. QoL dimensions were negatively correlated with anxiety and depression levels.

Conclusions: Postoperative seizure freedom was a major factor of postoperative QoL level. Besides seizure freedom, anxiety and depression levels were also negatively correlated with QoL levels in the Indonesian population.

Knowledge, attitude, and barriers for epilepsy surgery: A survey among resident doctors in a tertiary care center in India

BACKGROUND

Knowledge and attitude of doctors toward epilepsy surgery are essential for management and timely referral of people with Drug refractory epilepsy (DRE). This study aimed at analyzing knowledge, attitude, and barriers for epilepsy surgery among medical residents.

METHODS

A survey consisting of 16 statements in a Likert-like scale and one open-ended question was conducted among residents joining different postgraduate courses after MBBS (GR) and super-specialty courses after MD (PG) within 2 months of joining the institute. PGs with a postgraduate degree in internal medicine, pediatrics, or psychiatry were included. Demographic data were analyzed using descriptive statistics. Difference in response to the survey statements was analyzed using independent t test.

RESULTS

115 participated in the survey of which 97 were GRs. Participants belonged to 22 different states and 3 were foreign nationals. 45% of participants did not know the definition of DRE. There was a difference of opinion among GRs and PGs regarding surgery as a treatment option for epilepsy and feasibility of epilepsy surgery in children (p < .05). PGs were more confident in treating PWE and preferred to refer people with DRE to a higher center early (p < .05). Lack of knowledge was the commonest barrier for epilepsy surgery.

CONCLUSION

A substantial number of participants lacked the basic knowledge of DRE and epilepsy surgery. Lack of knowledge was perceived to be the commonest barrier for epilepsy surgery. Dissemination of basic knowledge and development of protocols for identification and referral of people with DRE are the need of the hour.

Epilepsy Research in Mali: A Pilot Pharmacokinetics Study on First-Line Antiepileptic Drug Treatment

Background and Purpose

The indication and benefit of plasma level of antiepileptic (AEDs) has been debating in the monitoring of people living with epilepsy and the epilepsy treatment gap has largely been documented in developed countries. This study was aimed to highlight the epilepsy treatment gap between rural and urban Mali.

Methods

We conducted a pilot study on AEDs treatment from September 2016 to May 2019. For 6 months, 120 children and young adults living with epilepsy (rural site, 90; urban site, 30) received phenobarbital, valproic acid and/or carbamazepine. At our rural study site, we determined the AED plasma levels, monitored the frequency, severity and the duration of seizure, and administered monthly the McGill quality of life questionnaire. At our urban study site, each patient underwent an electroencephalogram and brain computed tomography scan without close monitoring.

Results

At the rural study site, patients were mostly on monotherapy; AED levels at 1 month (M1) (n=90) and at 3 months (M3) (n=27) after inclusion were normal in 50% at M1 versus 55.6% at M3, low in 42.2% at M1 versus 33.3% at M3 and high in 7.8% at M1 versus 11.1% at M3. AED levels at M1 and at M3 were significantly different p<0.0001. By M3, seizures (n=90) were <1/month in 26.7%, and lasted less than 1 minute in 16.7%. After a yearlong follow up, all 90 patients reported a good or excellent quality of life. At our urban study site, patients (n=30) were on carbamazepine and valproid acid in 66.67% and monotherapy (carbamazepine) in 33.33%. By November 2018, only six out 30 patients (on bi-therapy) were still taking their medications.

Conclusions

Epilepsy diagnostic and treatment are a real concern in Mali. Our data showed appropriate AED treatment with close follow up resulted in a better quality of life of patients in rural Mali. We will promote the approach of personalized medicine in AED treatment in Mali.