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Mustafa MS, Shafique MA, Aheed B, Ashraf F, Ali SMS, Iqbal MF, Haseeb A. The impact of ketogenic diet on drug-resistant epilepsy in children: A comprehensive review and meta-analysis. Ir J Med Sci 2024; 193:1495-1503. [PMID: 38315271 DOI: 10.1007/s11845-024-03622-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024]
Abstract
The ketogenic diet (KD), characterized by high-fat and low-carbohydrate intake, is currently gaining widespread popularity as a treatment for drug-resistant epilepsy (DRE). In addition to the traditional ketogenic diet, several variants have been introduced to enhance compliance and flexibility, such as the modified Atkins diet (MAD) and the low glycemic index diet (LGID). These adaptations aim to provide patients with more manageable and sustainable options while harnessing the potential therapeutic benefits of DRE. The objective of this study is to evaluate the efficacy and safety of the KD in pediatric patients who exhibit DRE. In this study, we conducted a thorough review of existing literature by searching Cochrane, Embase, Medline, and PubMed. Our approach involved predefined criteria for data extraction and the assessment of study quality. Eleven RCTs with 788 participants were included in this study. The pooled effect estimates revealed a significant association between dietary interventions and seizure frequency reduction of > 50% (OR 6.68, 96% CI 3.52, 12.67) and > 90% (OR 4.37, 95% CI 2.04, 9.37). Dietary interventions also increased the odds of achieving seizure freedom (OR 4.13, 95% CI 1.61, 10.60). The common adverse effects included constipation (39.07%) and vomiting (10%). In conclusion, dietary interventions, notably the KD, hold promise for pediatric DRE, reducing seizures and achieving freedom. These non-pharmacological options improve the quality of life of non-responsive and non-surgical patients. The KD has emerged as a potential therapeutic approach. Further research is needed to address the limitations and investigate their long-term effects.
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Affiliation(s)
- Muhammad Saqlain Mustafa
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Muhammad Ashir Shafique
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan.
| | - Bilal Aheed
- Department of Biochemistry, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Farheen Ashraf
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Syed Muhammad Sinaan Ali
- Department of Medicine, Liaquat National Hospital and Medical College, National Stadium Rd, Karachi, Karachi City, Sindh, 74800, Pakistan
| | - Muhammad Faheem Iqbal
- Department of Medicine, Dow University of Health Sciences, V246+X8C, Mission Rd, Nanak Wara Nanakwara, Karachi, Karachi City, Sindh, Pakistan
| | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
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Lamsal R, Yeh EA, Pullenayegum E, Ungar WJ. A Systematic Review of Methods Used by Pediatric Cost-Utility Analyses to Include Family Spillover Effects. PHARMACOECONOMICS 2024; 42:199-217. [PMID: 37945777 PMCID: PMC10810985 DOI: 10.1007/s40273-023-01331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND A child's health condition affects family members' health and well-being. However, pediatric cost-utility analysis (CUA) commonly ignores these family spillover effects leading to an incomplete understanding of the cost and benefits of a child's health intervention. Methodological challenges exist in assessing, valuing, and incorporating family spillover effects. OBJECTIVE This study systematically reviews and compare methods used to include family spillover effects in pediatric CUAs. METHODS A literature search was conducted in MEDLINE, Embase, EconLit, Cochrane collection, CINAHL, INAHTA, and the Pediatric Economic Database Evaluation (PEDE) database from inception to 2020 to identify pediatric CUAs that included family spillover effects. The search was updated to 2021 using PEDE. The data describing in which family members spillover effects were measured, and how family spillover effects were measured, incorporated, and reported, were extracted. Common approaches were grouped conceptually. Further, this review identified theories or theoretical frameworks used to justify approaches for integrating family spillover effects into CUA. RESULTS Of 878 pediatric CUAs identified, 35 included family spillover effects. Most pediatric CUAs considered family spillover effects on one family member. Pediatric CUAs reported eight different approaches to measure the family spillover effects. The most common method was measuring the quality-adjusted life years (QALY) loss of the caregiver(s) or parent(s) due to a child's illness or disability using an isolated approach whereby family spillover effects were quantified in individual family members separately from other health effects. Studies used four approaches to integrate family spillover effects into CUA. The most common method was to sum children's and parents/caregivers' QALYs. Only two studies used a theoretical framework for incorporation of family spillover effects. CONCLUSIONS Few pediatric CUAs included family spillover effects and the observed variation indicated no consensus among researchers on how family spillover effects should be measured and incorporated. This heterogeneity is mirrored by a lack of practical guidelines by Health Technology Assessment (HTA) agencies or a theoretical foundation for including family spillover effects in pediatric CUA. The results from this review may encourage researchers to develop a theoretical framework and HTA agencies to develop guidelines for including family spillover effects. Such guidance may lead to more rigorous and standardized methods for including family spillover effects and better-quality evidence to inform decision-makers on the cost-effectiveness of pediatric health interventions.
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Affiliation(s)
- Ramesh Lamsal
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor, Toronto, ON, M5G 0A4, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor, Toronto, ON, M5G 0A4, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor, Toronto, ON, M5G 0A4, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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Chan HY, Janssen LMM, Wijnen BFM, Hiligsmann M, Majoie MHJM, Evers SMAA. Economic evaluations of nonpharmacological treatments for drug-resistant epilepsy: A systematic review. Epilepsia 2023; 64:2861-2877. [PMID: 37545415 DOI: 10.1111/epi.17742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/08/2023]
Abstract
This study was undertaken to systematically identify and critically appraise all published full economic evaluations assessing the cost-effectiveness of nonpharmacological interventions for patients with drug-resistant epilepsy. The Population, Intervention, Comparison, Outcome, Study criteria was used to design search strategies for the identification and selection of relevant studies. Literature search was performed using the MEDLINE (via PubMed), Embase, International Health Technology Assessment, National Institute for Health Research Economic Evaluation Database, and Cost-Effectiveness Analysis Registry databases to identify articles published between January 2000 and May 2023. Web of Science was additionally used to perform forward and backward referencing. Title, abstract, and full-text screening was performed by two independent researchers. The Consensus Health Economic Criteria (CHEC) checklist and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 were applied for quality assessment. A total of 4470 studies were identified, of which 18 met our inclusion criteria. Twelve of the studies conducted model-based economic evaluation, and others were trial-based. Three studies showed that epilepsy surgery was cost-effective in adults, whereas this remained inconclusive for children (two positive, three negative). Three studies showed negative economic outcome for ketogenic diet in children. One of four studies showed positive results for self-management. For vagus nerve stimulation, one study showed positive results in adults and another one negative results in children. One recent study showed cost-effectiveness of responsive neurostimulation (RNS) in adults. Finally, one study showed promising but inconclusive results for deep brain stimulation (DBS). The mean scores for risk of bias assessment (based on CHEC) and for reporting quality (CHEERS 2022) were 95.8% and 80.5%, respectively. This review identified studies that assessed the cost-effectiveness of nonpharmacological treatments in both adults and children with drug-resistant epilepsy, suggesting that in adults, epilepsy surgery, vagus nerve stimulation, and RNS are cost-effective, and that DBS and self-management appear to be promising. In children, the cost-effectiveness of epilepsy surgery remains inconclusive. Finally, the use of ketogenic diet was shown not to be cost-effective. However, limited long-term data were available for newer interventions (i.e., ketogenic diet, DBS, and RNS).
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Affiliation(s)
- Hoi Yau Chan
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Luca M M Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Ben F M Wijnen
- Center of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - Mickaël Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
| | - Marian H J M Majoie
- Department of Research and Development, Epilepsy Center Kempenhaeghe, Heeze, the Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
- School of Health Professions Education, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Kempenhaeghe and Maastricht, the Netherlands
| | - Silvia M A A Evers
- Department of Health Services Research, Care and Public Health Research Institute, Maastricht, the Netherlands
- Center of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
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Guo Z, Zhong W, Zou Z. miR-98-5p Prevents Hippocampal Neurons from Oxidative Stress and Apoptosis by Targeting STAT3 in Epilepsy in vitro. Neuropsychiatr Dis Treat 2023; 19:2319-2329. [PMID: 37928166 PMCID: PMC10624118 DOI: 10.2147/ndt.s415597] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/09/2023] [Indexed: 11/07/2023] Open
Abstract
Purpose Epilepsy is a serious mental disease, for which oxidative stress and hippocampal neuron death after seizure is crucial. Numerous miRNAs are involved in epilepsy. However, the function of miR-98-5p in oxidative stress and hippocampal neuron death after seizure is unclear, which is the purpose of current study. Methods Magnesium ion (Mg2+)-free solution was used to establish the in vitro epilepsy model in hippocampal neurons. Oxidative stress was exhibited by measuring malondialdehyde (MDA) level and superoxide Dismutase (SOD) activity using enzyme-linked immune sorbent assay (ELISA) kits. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and flow cytometry were applied for the examination of neuron viability and apoptosis, respectively. Quantitative reverse-transcription polymerase chain reaction (qRT-PCR) and Western blot were used to evaluate the mRNA and protein levels of miR-98-5p and signal transducer and activator of transcription (STAT3), respectively. The relationship between miR-98-5p and STAT3 was predicted by TargetScan 7.2, and identified by dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay. Results miR-98-5p was decreased in the in vitro epileptic model of hippocampal neurons induced by Mg2+-free solution, whose overexpression rescued oxidative stress and neuron apoptosis in epileptic model. Moreover, overexpression of STAT3, one downstream target of miR-98-5p, partially eliminated the effects of miR-98-5p mimic. Conclusion We shed lights on a pivotal mechanism of miR-98-5p in regulating neuron oxidative stress and apoptosis after seizures, providing potential biomarkers for the diagnosis of epilepsy and therapeutic targets for the treatment of epilepsy.
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Affiliation(s)
- Zhizhuan Guo
- Department of Neurology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, People’s Republic of China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Wenwen Zhong
- Department of Rehabilitation Medicine, Huangshi Maternal and Child Health Hospital, Edong Medical Group, Huang Shi, Hubei, 435000, People’s Republic of China
| | - Zhengshou Zou
- Department of Neurology, Huangshi Central Hospital, Edong Medical Group, Huangshi, Hubei, 435000, People’s Republic of China
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Kregel M, Coulson S, Nabavi Nouri M, Sorzano R, Andrade A. Families' Knowledge Change in Paediatric Drug Resistant Epilepsy: A Novel Clinic Model. Seizure 2023; 108:116-126. [PMID: 37146515 DOI: 10.1016/j.seizure.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/17/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Epilepsy is a chronic condition that affects approximately 95,000 Ontarians, of whom approximately 15,000 are children under the age of 18. Drug resistant epilepsy (DRE) will affect around 30% of these children who will require more advanced care due to their medical complexities. The purpose of this study is to determine if receiving care in a paediatric Comprehensive Epilepsy Clinic (CEC) is associated with positive outcomes for children living with DRE and their families by looking at three health outcomes: 1) families' knowledge of their child's diagnosis and treatment plan, 2) navigational access to both the hospital and community epilepsy services, and 3) health behaviours. METHODS This was a prospective cohort study in which families of children diagnosed with DRE would be exposed to a CEC care model for the first time and followed for 6-months after enrollment. This was analyzed by utilizing surveys from new families at baseline and 6 months post receiving care within a CEC. RESULTS Results revealed a statistical significance in change of knowledge in families' knowing the type of epilepsy their child has and what epilepsy co-morbidities are. Families' also had a significant change in utilizing hospital epilepsy resources and knowing who to contact in the community and hospital for their epilepsy related questions. CONCLUSION A CEC model improves families' knowledge about epilepsy diagnosis and treatment plan, navigational access to both the hospital and community epilepsy services, and health behaviours.
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Affiliation(s)
- Michelle Kregel
- Children's Hospital, London Health Sciences, 800 Commissioners Rd E, London, Ontario N6A 5W9, Canada; Lawson Health Research Institute, 750 Baseline Rd E, London, Ontario N6C 2R5, Canada.
| | - Sherry Coulson
- Department of Paediatrics, Western University, 1151 Richmond St, London, Ontario N6A 5C1, Canada
| | - Maryam Nabavi Nouri
- Department of Paediatrics, Schulich School of Medicine & Dentistry, 1151 Richmond St, London, Ontario N6A 5C1, Canada
| | - Rochelle Sorzano
- Lawson Health Research Institute, 750 Baseline Rd E, London, Ontario N6C 2R5, Canada
| | - Andrea Andrade
- Department of Paediatrics, Schulich School of Medicine & Dentistry, 1151 Richmond St, London, Ontario N6A 5C1, Canada
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Wu ZD, Feng Y, Ma ZX, Liu Z, Xiong HH, Zhou ZP, Ouyang LS, Xie FK, Tang YM. MicroRNAs: protective regulators for neuron growth and development. Neural Regen Res 2023; 18:734-745. [DOI: 10.4103/1673-5374.353481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Carroll JH, Martin-McGill KJ, Cross JH, Hickson M, Williams E, Aldridge V, Collinson A. Core outcome set development for childhood epilepsy treated with ketogenic diet therapy: Results of a scoping review and parent interviews. Seizure 2022; 99:54-67. [PMID: 35598573 DOI: 10.1016/j.seizure.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/23/2022] [Accepted: 05/10/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Clinical trials on childhood epilepsy treated with ketogenic diet (KD) use a wide range of outcomes, however, patients and decision-makers often do not perceive the outcomes used as the most important. We sought parental opinion on outcomes of importance and compared these to outcomes reported in published research. METHODS Ethical approval (London-Surrey-REC19/LO/1680). A scoping review identified outcomes reported in previous studies of childhood epilepsy and KD. Parents were recruited from nine KD centres (UK), charities and social media (international), then interviewed (Jan-April 2020) to explore priority outcomes. Content analysis identified all outcomes in transcripts. Parent identified outcomes were compared with those in the scoping review. Outcomes were collated and grouped into domains according to the COMET Taxonomy. RESULTS Of 2663 articles;147 met inclusion criteria. 921 verbatim outcomes were sorted into 90 discrete outcomes, reduced to 70 in consultation with the study advisory group, then classified into 21 domains. Parents (n = 21) identified 39 outcomes as important from the scoping review and seven new outcomes. They prioritised both physiological and functional outcomes in contrast to past studies, which prioritised physiological outcomes. CONCLUSION Little consistency exists in the outcomes used in childhood epilepsy and KD research. Those traditionally used do not adequately reflect parents' important outcomes for their child. Clinical trials should consider the broader priorities of parents when choosing outcomes, in particular, functional outcomes. Identified outcomes will inform an international two-round Delphi-study with parent, professional and researcher participants to develop a core outcome set for this clinical area (COMET registration #1116).
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Affiliation(s)
| | | | - J Helen Cross
- Developmental Neurosciences, UCL, NIHR BRC Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mary Hickson
- Faculty of Health, University of Plymouth, Devon, United Kingdom
| | - Emma Williams
- Matthew's Friends, Lingfield, Surrey, United Kingdom
| | - Val Aldridge
- Matthew's Friends, Lingfield, Surrey, United Kingdom
| | - Avril Collinson
- Faculty of Health, University of Plymouth, Devon, United Kingdom
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Effects of Classic Ketogenic Diet in Children with Refractory Epilepsy: A Retrospective Cohort Study in Kingdom of Bahrain. Nutrients 2022; 14:nu14091744. [PMID: 35565714 PMCID: PMC9105742 DOI: 10.3390/nu14091744] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 12/11/2022] Open
Abstract
Background: The classic ketogenic diet (cKD) has been used worldwide as an effective therapy for children with drug-resistant epilepsy. However, there have been no studies performed in Middle Eastern countries in order to assess the efficacy, side effects, predictors of cKD response and factors mostly associated with diet adherence. This study aims to assess the efficacy of cKD ratios of 4:1 and 3:1 and their influence on growth and biochemical parameters, particularly lipid profile and liver function tests (LFTs), and the factors most associated with diet adherence in a cohort of children with drug-resistant epilepsy in Bahrain. Methods: Baseline and follow-up data related to patients’ demographic and biochemical variables, epilepsy episodes, diet history and anthropometric measurements were retrieved for a total of 24 children treated with cKD in Bahrain. Results: After 6 months cKD initiation, 58.3% were positive responders with >50% seizure rate reduction, and 33.3% became seizure-free at 12 months. After 6 months of intervention with cKD, the level of triglycerides and albumin had a significant (p < 0.05) average increase over time of +1.47 mmol/L and 4.3 g/L, respectively. Although the median values of total cholesterol and alanine transaminase increased, respectively, following cKD initiation, the difference over time was not statistically significant. The mean z-scores for weight, height, and body mass index (or weight-for-length) did not change significantly at 12 months follow-up. cKD duration was the highest correlated variable with cKD efficacy (r = 0.76), which was followed by age at cKD initiation (r = 0.47). The cKD was discontinued by 14 patients (58.3%) during the first follow-up period (6 months), which was mainly due to inefficacy (n = 8), poor compliance (n = 3), food refusal (n = 1), achieved required efficacy (n = 1) and death (n = 1). Conclusions: cKD is an effective treatment for patients with drug-resistant epilepsy, and positive response to cKD was the main factor that increased adherence to the diet. Although long-term cKD could increase the risk of dyslipidemia and hepatic problems, it appears safe for children. Consequently, close monitoring and emphasis on healthy fats is of high priority.
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Pizzo F, Collotta AD, Di Nora A, Costanza G, Ruggieri M, Falsaperla R. Ketogenic diet in pediatric seizures: a randomized controlled trial review and Meta-Analysis. Expert Rev Neurother 2022; 22:169-177. [PMID: 35144527 DOI: 10.1080/14737175.2022.2030220] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The ketogenic diet is a non-pharmacologic treatment option for children with drug-resistant epilepsy. This systematic review and meta-analysis aimed to assess the efficacy of the ketogenic diet on seizures frequency in children. METHODS We reviewed the literature using Cochrane, EMBASE, MEDLINE, and highly qualified journals. Randomized controlled trials were chosen to investigate the seizures-free regime or at least 50% seizures reduction after three months from the starting of the ketogenic diet or earlier. We have selected articles from January 2011 to January 2020. RESULTS Eight articles were eligible. The data show a significant reduction in seizure frequency in the dietary treatment pediatric population. The rate of a seizures-free regime or at least 50% seizures reduction was 48.31% of patients in the intervention group. Our overall meta-analysis underlined the significant efficacy. The KD group is 5.6 times more likely than the control group to have a 50% reduction of seizures after three months of the diet or earlier. QUADAS and AMSTAR assessments showed a low risk of bias and adequate accuracy. CONCLUSION The results show that the KD reduces seizure frequency in children with drug-refractory epilepsy. KD is an effective treatment option for children and adolescents with refractory epilepsy.
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Affiliation(s)
- Francesco Pizzo
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ausilia Desiree Collotta
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessandra Di Nora
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giuseppe Costanza
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, AOU "Policlinico", PO "G. Rodolico", Via S. Sofia, 87, 95128, Catania, Italy
| | - Raffaele Falsaperla
- General Pediatrics and Pediatric Acute and Emergency Unit,Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico-San Marco, San Marco Hospital, University of Catania, Catania, Italy
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Wang Y, Yang Z, Zhang K, Wan Y, Zhou Y, Yang Z. miR-135a-5p inhibitor protects glial cells against apoptosis via targeting SIRT1 in epilepsy. Exp Ther Med 2021; 21:431. [PMID: 33747170 PMCID: PMC7967866 DOI: 10.3892/etm.2021.9848] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022] Open
Abstract
Epilepsy is a common neurological disease that can induce severe physiological brain damage, including nerve cell apoptosis. MicroRNAs (miRs) have been widely investigated in epilepsy therapy. miR-135a-5p expression levels in children with temporal lobe epilepsy were found to be significantly increased. However, whether miR-135a-5p participates in epilepsy-induced cell apoptosis is not completely understood. In the present study, an in vitro model of epilepsy in BV2 microglia cells was induced using 6-µm kainic acid (KA). Reverse-transcription quantitative PCR was performed to analyze miR-135a-5p and sirtuin 1 (SIRT1) mRNA expression levels. Western blotting was performed to measure SIRT1 protein expression levels. BV2 cell proliferation and apoptosis were assessed by performing MTT assays and flow cytometry, respectively. A BCA protein assay kit was used to detect caspase-3 and caspase-9 activities. TargetScan and dual luciferase reporter assays were performed to investigate the interaction between miR-135a-5p and the 3'-untranslated region (UTR) of SIRT1. miR-135a-5p expression was significantly increased in the KA-induced in vitro model of epilepsy in BV2 microglia. miR-135a-5p inhibitor effectively promoted BV2 microglia proliferation and inhibited microglia apoptosis, whereas small interfering RNA targeting SIRT1 significantly repressed BV2 microglia proliferation and induced microglia apoptosis. In addition, the results demonstrated that the 3'-UTR of SIRT1 mRNA was targeted by miR-135a-5p, and SIRT1 knockdown attenuated miR-135a-5p inhibitor-mediated effects on epilepsy. In summary, the results of the present study identified the role of miR-135a-5p inhibitor pretreatment in protecting nerve cells against epilepsy-induced apoptosis and provided a novel strategy for the treatment of neural damage in seizures.
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Affiliation(s)
- Ying Wang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China.,Department of Pathology, School of Basic Medical Science, Central South University, P.R. China
| | - Zhiquan Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Kai Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Yi Wan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Yu Zhou
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Zhuanyi Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
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Christensen MG, Damsgaard J, Fink-Jensen A. Use of ketogenic diets in the treatment of central nervous system diseases: a systematic review. Nord J Psychiatry 2021; 75:1-8. [PMID: 32757903 DOI: 10.1080/08039488.2020.1795924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Studies have consistently shown that patients with epilepsy could benefit from ketogenic diets (KDs). Recent evidence suggests that KD could be used in the treatment of central nervous system (CNS) diseases. The aim of this systematic review was to investigate the use and efficacy of KD, modified Atkins diet (MAD) and medium-chain triglyceride (MCT) diet in infants, children, adolescents, and adults with CNS diseases. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Main databases, i.e. EMBASE, PubMed and PsycINFO, were searched on 4 December 2019. Only randomized clinical trials (RCTs) were included and only if they reported KD, MCT or MAD interventions on patients with CNS diseases. RESULTS Twenty-four publications were eligible for inclusion (n = 1221). Twenty-one publications concerned epilepsy, two concerned Alzheimer's disease (AD), and one concerned Parkinson's disease (PD). All studies regarding epilepsy reported of seizure reduction compared to baseline. MCT did not significantly change regional cerebral blood flow (rCBF) in patients with AD, but MAD significantly improved memory at 6 weeks (p = .03). KD significantly improved motor and nonmotor functions in patients with PD at 8 weeks (p < .001). There was a trend towards fewer adverse effects in MAD compared to KD. CONCLUSION In conclusion, various forms of KDs seem tolerable and effective as part of the treatment for epilepsy, AD and PD, although more investigation concerning the mechanism, efficacy and adverse events is necessary.
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Affiliation(s)
| | - Jakob Damsgaard
- Psychiatric Centre Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Anders Fink-Jensen
- Psychiatric Centre Copenhagen, University of Copenhagen, Copenhagen, Denmark
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Mir A, Albaradie R, Alamri A, AlQahtani M, Hany E, Hussain A, Joseph M, Bashir S. Incidence of potential adverse events during hospital-based ketogenic diet initiation among children with drug-resistant epilepsy. Epilepsia Open 2020; 5:596-604. [PMID: 33336130 PMCID: PMC7733660 DOI: 10.1002/epi4.12442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 08/23/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Due to the possibility of serious adverse events (AE), patients are commonly admitted to hospital for 3-5 days for ketogenic diet (KD) initiation. This study examined the incidence of potential AE during admission for KD initiation to investigate the possibility of safely initiating a KD at home. METHODS Children with drug-resistant epilepsy (DRE) who were admitted to hospital for 5 days for KD initiation were retrospectively studied. RESULTS A total of 66 children (59% female) were analyzed. The mean age at the initiation of the KD was 48.0 ± 38.4 months, and the mean weight was 14.6 ± 6.3 kg. The median number of anticonvulsant medications used at the time of KD initiation was 3. The etiology of the DRE was structural in 4.5%, hypoxic ischemic encephalopathy in 10.6%, genetic/metabolic in 31.8%, acquired in 10.6%, and unknown in 42.2%. The potential AE occurred in 28.7% of patients, including hypoglycemia (20%), hypoactivity (6.1%), somnolence (3%), and vomiting (7.6%). A univariate analysis of the clinical characteristics of the AE and no AE groups showed a statistically significant difference in weight (P = 0.003) and age (P = 0.033). The concurrent use of topiramate was found to have a near-significant association (P = 0.097) between the groups. The groups' urine ketone levels on all 5 days were compared, and a statistically significant difference was found on day 3 (P = 0.026). A statistically significant difference in the serum bicarbonate levels (P = 0.038) was found between the patients taking topiramate and those not taking it. SIGNIFICANCE The incidence of AE during admission for KD initiation was found to be low. The AE either required no intervention or were easily managed with simple interventions. Thus, in carefully selected patients, it may be possible to initiate a KD at home if the parents are adequately prepared and monitored.
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Affiliation(s)
- Ali Mir
- Department of Pediatric NeurologyNeuroscience CenterKing Fahad Specialist HospitalDammamSaudi Arabia
| | - Raidah Albaradie
- Department of Pediatric NeurologyNeuroscience CenterKing Fahad Specialist HospitalDammamSaudi Arabia
| | - Abdullah Alamri
- College of MedicineImam Abdulrahman Bin Faisal UniversityDammamSaudi Arabia
| | - Mohammed AlQahtani
- Department of Pediatric NeurologyNeuroscience CenterKing Fahad Specialist HospitalDammamSaudi Arabia
| | - Entisar Hany
- Department of NutritionKing Fahad Specialist HospitalDammamSaudi Arabia
| | - Aqeel Hussain
- Department of PediatricsKing Fahad Specialist HospitalDammamSaudi Arabia
| | - Mary Joseph
- Department of Pediatric NeurologyNeuroscience CenterKing Fahad Specialist HospitalDammamSaudi Arabia
| | - Shahid Bashir
- Department of Pediatric NeurologyNeuroscience CenterKing Fahad Specialist HospitalDammamSaudi Arabia
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Falsaperla R, D'Angelo G, Praticò AD, Mauceri L, Barbagallo M, Pavone P, Catanzaro S, Gitto E, Corsello G, Ruggieri M. Ketogenic diet for infants with epilepsy: A literature review. Epilepsy Behav 2020; 112:107361. [PMID: 33181904 DOI: 10.1016/j.yebeh.2020.107361] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 12/20/2022]
Abstract
The ketogenic diet (KD) is an established, nonpharmacological treatment for drug-resistant epilepsy (DRE). Actually, KD and its variants have been shown to be elective and resolute for patients with glucose transporter type 1 (GLUT1) deficiency. The aim of this review was to study the use of KD and its variants in infancy, including the neonatal age, and demonstrate the safety and efficacy of this treatment in patients with the age of 0-23 months affected by DRE already subjected to pharmacological approach attempts. A literature search was conducted using PubMed as the medical database source. We used the age limit of 0-23 months, and we considered only articles published between the years 2015 and 2018, in light of increasing interest worldwide in the use of KD and its variants to manage DRE. We included 52 publications: 1 Cochrane study, 22 retrospective studies, 9 prospective studies, 4 randomized controlled trials (RCTs), 12 clinical cases, and 4 clinical reviews. Literature data showed that KD and its variants are safe and useful in patients with the age of 0-23 months with DRE. Classical KD is of first choice in the treatment of GLUT1 deficiency. Earlier introduction of KD in GLUT1 promises a better outcome and a decrease in seizure frequency in these patients.
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Affiliation(s)
- Raffaele Falsaperla
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Gabriella D'Angelo
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology of Adult and Childhood "G. Barresi", University Hospital "G. Martino", Messina, Italy
| | - Andrea D Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Italy.
| | - Laura Mauceri
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Massimo Barbagallo
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Piero Pavone
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Stefano Catanzaro
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Italy
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology of Adult and Childhood "G. Barresi", University Hospital "G. Martino", Messina, Italy
| | - Giovanni Corsello
- Department of Maternal and Child Health, University of Palermo, Palermo, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Italy
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Sarlo GL, Kao A, Holton KF. Optimizing data collection in dietary therapy clinics for epilepsy: A recommendation for standardized data collection forms. Epilepsy Res 2020; 168:106488. [PMID: 33161311 DOI: 10.1016/j.eplepsyres.2020.106488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/22/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objectives of this study were to 1) examine medical records from one medium-sized dietary clinic as an example of data being collected clinically, 2) identify data limitations, and then 3) create standardized data collection forms with the long-term goals of improving clinical care and facilitating multicenter data analysis. METHODS A retrospective chart review was conducted at the Dietary Therapies for Epilepsy Clinic at Children's National Medical Center (CNMC) in Washington, D.C. Patients who initiated dietary therapy between 2015 and 2018 were assessed. Categorical variables were examined via Chi Square or Fisher's Exact tests and continuous variables were assessed via an independent t-test or Mann-Whitney U test, depending on normality. RESULTS Forty-two patients underwent dietary therapy initiation during this time period, but only 26 had follow-up visit data. Of these patients, 54% reported non-seizure symptom improvement(s), and only 16 had quantitative seizure frequency information available, with 63% being clinical responders. No significant associations were observed between patient or diet characteristics and seizure or non-seizure improvement. Some variables, such as seizure duration, seizure severity, beta-hydroxybutyrate, and dietary compliance were not typically included in the records and therefore could not be evaluated statistically. Variations in seizure type(s), etiology, and clinical diagnoses/syndromes also made it unfeasible to evaluate differences in improvement based on these variables. Standardized data collection forms were created to address these limitations and are included as appendices. SIGNIFICANCE The results suggest limitations with the clinical data currently being collected. Medium-sized clinics may not see enough patients to study specific epilepsy populations. Standardized patient forms could target these issues, thereby improving clinical care and expanding research opportunities. Future research can test these forms for clinical use and as a collection tool for larger scale research across clinics.
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Affiliation(s)
- Gabrielle L Sarlo
- Behavior, Cognition and Neuroscience Program, American University, Washington DC, United States
| | - Amy Kao
- Division of Neurophysiology, Epilepsy, and Critical Care, Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington DC, United States
| | - Kathleen F Holton
- Department of Health Studies, American University, Washington DC, United States; Center for Behavioral Neuroscience, American University, Washington DC, United States.
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Lynch S, Barry C, Douglass LM. Social and Economic Challenges to Implementing the Ketogenic Diet: A Case Series. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1713908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe ketogenic diet (KD) is a powerful therapeutic tool that can reduce seizure activity in patients with refractory epilepsy. However, dietary implementation can be difficult for patients and families due to the time and resource intensive nature of the diet. These challenges are particularly pronounced in economically disadvantaged or socially unstable patient populations. The first case of this series describes the successful implementation of KD in a low-income, homeless patient through the use of innovative KD recipes and access to social programs offered through Boston Medical Center. The second case illustrates the importance of consistent parental support to the success of KD and describes mechanisms used to improve familial support within a nonunified household. Collectively, these cases demonstrate ways by which health care providers can make this powerful dietary treatment accessible to low-resource patients.
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Affiliation(s)
- Sloan Lynch
- Division of Child Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Catherine Barry
- Division of Developmental and Behavioral Pediatrics, Boston Medical Center, Boston, Massachusetts, United States
| | - Laurie M. Douglass
- Division of Child Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
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Abstract
BACKGROUND Ketogenic diets (KDs) are high in fat and low in carbohydrates and have been suggested to reduce seizure frequency in people with epilepsy. Such diets may be beneficial for children with drug-resistant epilepsy. This is an update of a review first published in 2003, and last updated in 2018. OBJECTIVES To assess the effects of ketogenic diets for people with drug-resistant epilepsy. SEARCH METHODS For this update, we searched the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 26 April 2019) on 29 April 2019. The Cochrane Register of Studies includes the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), and randomised controlled trials (RCTs) from Embase, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We imposed no language restrictions. We checked the reference lists of retrieved studies for additional relevant studies. SELECTION CRITERIA RCTs or quasi-RCTs of KDs for people of any age with drug-resistant epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently applied predefined criteria to extract data and evaluated study quality. We assessed the outcomes: seizure freedom, seizure reduction (50% or greater reduction in seizure frequency), adverse effects, cognition and behaviour, quality of life, and attrition rate. We incorporated a meta-analysis. We utilised an intention-to-treat (ITT) population for all primary analyses. We presented the results as risk ratios (RRs) with 95% confidence intervals (CIs). MAIN RESULTS We identified 13 studies with 932 participants; 711 children (4 months to 18 years) and 221 adults (16 years and over). We assessed all 13 studies to be at high risk of performance and detection bias, due to lack of blinding. Assessments varied from low to high risk of bias for all other domains. We rated the evidence for all outcomes as low to very low certainty. Ketogenic diets versus usual care for children Seizure freedom (RR 3.16, 95% CI 1.20 to 8.35; P = 0.02; 4 studies, 385 participants; very low-certainty evidence) and seizure reduction (RR 5.80, 95% CI 3.48 to 9.65; P < 0.001; 4 studies, 385 participants; low-certainty evidence) favoured KDs (including: classic KD, medium-chain triglyceride (MCT) KD combined, MCT KD only, simplified modified Atkins diet (MAD) compared to usual care for children. We are not confident that these estimated effects are accurate. The most commonly reported adverse effects were vomiting, constipation and diarrhoea for both the intervention and usual care group, but the true effect could be substantially different (low-certainty evidence). Ketogenic diet versus usual care for adults In adults, no participants experienced seizure freedom. Seizure reduction favoured KDs (MAD only) over usual care but, again, we are not confident that the effect estimated is accurate (RR 5.03, 95% CI 0.26 to 97.68; P = 0.29; 2 studies, 141 participants; very low-certainty evidence). Adults receiving MAD most commonly reported vomiting, constipation and diarrhoea (very low-certainty evidence). One study reported a reduction in body mass index (BMI) plus increased cholesterol in the MAD group. The other reported weight loss. The true effect could be substantially different to that reported. Ketogenic diet versus ketogenic diet for children Up to 55% of children achieved seizure freedom with a classical 4:1 KD after three months whilst up to 85% of children achieved seizure reduction (very low-certainty evidence). One trial reported a greater incidence of seizure reduction with gradual-onset KD, as opposed to fasting-onset KD. Up to 25% of children were seizure free with MAD and up to 60% achieved seizure reduction. Up to 25% of children became seizure free with MAD and up to 60% experienced seizure reduction. One study used a simplified MAD (sMAD) and reported that 15% of children gained seizure freedom rates and 56% achieved seizure reduction. We judged all the evidence described as very low certainty, thus we are very unsure whether the results are accurate. The most commonly reported adverse effects were vomiting, constipation and diarrhoea (5 studies, very low-certainty evidence). Two studies reported weight loss. One stated that weight loss and gastrointestinal disturbances were more frequent, with 4:1 versus 3:1 KD, whilst one reported no difference in weight loss with 20 mg/d versus 10 mg/d carbohydrates. In one study, there was a higher incidence of hypercalcuria amongst children receiving classic KD compared to MAD. All effects described are unlikely to be accurate. Ketogenic diet versus ketogenic diet for adults One study randomised 80 adults (aged 18 years and over) to either MAD plus KetoCal during the first month with MAD alone for the second month, or MAD alone for the first month followed by MAD plus KetoCal for the second month. No adults achieved seizure freedom. More adults achieved seizure reduction at one month with MAD alone (42.5%) compared to MAD plus KetoCal (32.5%), however, by three months only 10% of adults in both groups maintained seizure reduction. The evidence for both outcomes was of very low certainty; we are very uncertain whether the effects are accurate. Constipation was more frequently reported in the MAD plus KetoCal group (17.5%) compared to the MAD only group (5%) (1 study, very low-certainty evidence). Diarrhoea and increase/change in seizure pattern/semiology were also commonly reported (17.5% to 20% of participants). The true effects of the diets could be substantially different to that reported. AUTHORS' CONCLUSIONS The evidence suggests that KDs could demonstrate effectiveness in children with drug-resistant epilepsy, however, the evidence for the use of KDs in adults remains uncertain. We identified a limited number of studies which all had small sample sizes. Due to the associated risk of bias and imprecision caused by small study populations, the evidence for the use of KDs was of low to very low certainty. More palatable but related diets, such as the MAD, may have a similar effect on seizure control as the classical KD, but could be associated with fewer adverse effects. This assumption requires more investigation. For people who have drug-resistant epilepsy or who are unsuitable for surgical intervention, KDs remain a valid option. Further research is required, particularly for adults with drug-resistant epilepsy.
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Affiliation(s)
- Kirsty J Martin-McGill
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Clinical Sciences and Nutrition, University of Chester, Chester, UK
| | - Rebecca Bresnahan
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Paul N Cooper
- Centre for Clinical Neurosciences, Salford Royal Hospitals NHS Trust, Salford, UK
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Boles S, Webster RJ, Parnel S, Murray J, Sell E, Pohl D. No improvement in quality of life in children with epilepsy treated with the low glycemic index diet. Epilepsy Behav 2020; 104:106664. [PMID: 31958641 DOI: 10.1016/j.yebeh.2019.106664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Up to 30% of children with epilepsy show a poor therapeutic response to pharmacologic treatment. Ketogenic diets, including the less strict low glycemic index treatment (LGIT), may improve seizure control in pharmacoresistant epilepsy. However, little is known about the quality of life (QoL) in children on LGIT. To explore psychosocial implications of the LGIT on pediatric patients and their caregivers, we have conducted a pilot study to explore the QoL of children and adolescents on the diet. METHODS Pediatric patients on LGIT and their parents completed standardized, validated QoL questionnaires (Pediatric Quality of Life Epilepsy Module), one retrospectively and one while being on LGIT. An additional questionnaire included two open-ended questions in order to gain a better understanding of personal experiences of families. RESULTS We enrolled six patients with epilepsy on LGIT between the age of 3 and 13 years. Self-reported QoL decreased in all adolescents, regardless of improvement in seizure control. Parent-reported QoL improved in three of six participants, remained stable in one, and decreased in two patients (both displayed no seizure improvement). Parents and adolescents reported positive experiences of trying new foods and being more health conscious, as well as negative themes such as social isolation and meal preparation difficulties. CONCLUSIONS The lack of improvement in patient-reported QoL points towards an overall negative impact of the LGIT on patient well-being, despite positive effects on seizure control. Our preliminary results indicate that the benefits of seizure control may subjectively be outweighed by adverse social effects of the LGIT. Families should be made aware of psychosocial risks of the diet. Whenever possible, children should be part of the therapeutic decision-making process. Larger prospective studies are required to fully assess the overall impact of the LGIT.
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Affiliation(s)
- Sama Boles
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Richard J Webster
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Sophie Parnel
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Julie Murray
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Erick Sell
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Daniela Pohl
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
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Ułamek-Kozioł M, Czuczwar SJ, Januszewski S, Pluta R. Ketogenic Diet and Epilepsy. Nutrients 2019; 11:nu11102510. [PMID: 31635247 PMCID: PMC6836058 DOI: 10.3390/nu11102510] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 09/25/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022] Open
Abstract
Currently available pharmacological treatment of epilepsy has limited effectiveness. In epileptic patients, pharmacological treatment with available anticonvulsants leads to seizure control in <70% of cases. Surgical intervention can lead to control in a selected subset of patients, but still leaves a significant number of patients with uncontrolled seizures. Therefore, in drug-resistant epilepsy, the ketogenic diet proves to be useful. The purpose of this review was to provide a comprehensive overview of what was published about the benefits of ketogenic diet treatment in patients with epilepsy. Clinical data on the benefits of ketogenic diet treatment in terms of clinical symptoms and adverse reactions in patients with epilepsy have been reviewed. Variables that could have influenced the interpretation of the data were also discussed (e.g., gut microbiota). The data in this review contributes to a better understanding of the potential benefits of a ketogenic diet in the treatment of epilepsy and informs scientists, clinicians, and patients—as well as their families and caregivers—about the possibilities of such treatment. Since 1990, the number of publications on attempts to treat drug-resistant epilepsy with a ketogenic diet has grown so rapidly that it has become a challenge to see the overall trajectory and major milestones achieved in this field. In this review, we hope to provide the latest data from randomized clinical trials, practice guidelines, and new research areas over the past 2 years.
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Affiliation(s)
- Marzena Ułamek-Kozioł
- Laboratory of Ischemic and Neurodegenerative Brain Research, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland.
- First Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland.
| | - Stanisław J Czuczwar
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland.
| | - Sławomir Januszewski
- Laboratory of Ischemic and Neurodegenerative Brain Research, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland.
| | - Ryszard Pluta
- Laboratory of Ischemic and Neurodegenerative Brain Research, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland.
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Outpatient initiation of the ketogenic diet in children with pharmacoresistant epilepsy: An effectiveness, safety and economic perspective. Eur J Paediatr Neurol 2019; 23:740-748. [PMID: 31300320 DOI: 10.1016/j.ejpn.2019.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/29/2019] [Accepted: 06/06/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Children with pharmacoresistant epilepsy usually receive ketogenic diet (KD) as an inpatient, which makes it an expensive treatment. OBJECTIVE To compare the effectiveness, safety, and costs of outpatient versus inpatient initiated KD. DESIGN Retrospective observational non-inferiority study. PATIENTS/SETTING Patients (1-18 years of age) who started KD either inpatient or outpatient. MAIN OUTCOME MEASURES Effectiveness was defined as ≥50% seizure reduction. Safety was measured by the numbers of emergency visits and complications. Economic impact was analyzed by calculating total costs of treatment. STATISTICAL ANALYSES Non-inferiority of outpatient initiation was tested using 95% confidence intervals of the differences in effectiveness and safety endpoints between groups with non-inferiority margins of 10%. Nonparametric bootstrap techniques were used to derive a 95% confidence interval for the mean difference in total costs between the groups. RESULTS Hundred and five patients started KD in the period 2001 to 2017: 43 inpatient and 62 outpatient. At three months, the KD was effective in 61% of outpatients versus 63% of inpatients. The KD was considered safe in 36% of the outpatients, as compared to 29% in the inpatients. Outpatient initiation was shown to be non-inferior to inpatient initiation in terms of safety. Total health care costs of outpatient initiation were € 2901, as compared to € 8195 of inpatient initiation per patient (mean difference € 5294, 95% CI; -€ 7653 to -€ 2935). CONCLUSIONS Our study suggests that outpatient KD initiation is no worse than inpatient initiation in terms of effectiveness and safety, while carrying lower health care costs.
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Liu D, Li S, Gong L, Yang Y, Han Y, Xie M, Zhang C. Suppression of microRNA‐141 suppressed p53 to protect against neural apoptosis in epilepsy by SIRT1 expression. J Cell Biochem 2018; 120:9409-9420. [PMID: 30548678 DOI: 10.1002/jcb.28216] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/15/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Ding Liu
- Department of Neurology The Third Xiangya Hospital of Central South University Changsha Hunan China
| | - Shu Li
- Department of Neurology The Third Xiangya Hospital of Central South University Changsha Hunan China
| | - Lina Gong
- Department of Neurology The Third Xiangya Hospital of Central South University Changsha Hunan China
| | - Yan Yang
- Department of Neurology The Third Xiangya Hospital of Central South University Changsha Hunan China
| | - Yaru Han
- Department of Neurology The Third Xiangya Hospital of Central South University Changsha Hunan China
| | - Miao Xie
- Department of Neurology The Third Xiangya Hospital of Central South University Changsha Hunan China
| | - Chen Zhang
- Department of Neurology The Third Xiangya Hospital of Central South University Changsha Hunan China
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Martin‐McGill KJ, Jackson CF, Bresnahan R, Levy RG, Cooper PN. Ketogenic diets for drug-resistant epilepsy. Cochrane Database Syst Rev 2018; 11:CD001903. [PMID: 30403286 PMCID: PMC6517043 DOI: 10.1002/14651858.cd001903.pub4] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ketogenic diets (KDs), being high in fat and low in carbohydrates, have been suggested to reduce seizure frequency in people with epilepsy. At present, such diets are mainly recommended for children who continue to have seizures despite treatment with antiepileptic drugs (AEDs) (drug-resistant epilepsy). Recently, there has been interest in less restrictive KDs, including the modified Atkins diet (MAD), and the use of these diets has extended into adult practice. This is an update of a review first published in 2003 and last updated in 2016. OBJECTIVES To assess the effects of KDs for drug-resistant epilepsy by reviewing the evidence from randomised controlled trials. SEARCH METHODS For the latest update we searched the Cochrane Epilepsy Group's Specialized Register (11 April 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 11 April 2017), MEDLINE (Ovid, 11 April 2017), ClinicalTrials.gov (11 April 2017) and the WHO International Clinical Trials Registry Platform (ICTRP, 11 April 2017). We imposed no language restrictions. We checked the reference lists of retrieved studies for additional reports of relevant studies. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials of ketogenic diets for people with drug-resistant epilepsy. DATA COLLECTION AND ANALYSIS Two review authors independently applied predefined criteria to extract data and assessed study quality. MAIN RESULTS We identified 11 randomised controlled trials (RCTs) that generated 15 publications.All trials applied an intention-to-treat analysis with varied randomisation methods. The 11 studies recruited 778 patients; 712 children and adolescents and 66 adults. We assessed all 11 studies to be at low to unclear risk of bias for the following domains: random sequence generation, allocation concealment and selective reporting. For the other domains (blinding, incomplete outcome data, other bias) assessments were varied (low, unclear and high risk of bias). We could not conduct a meta-analysis due to the heterogeneity of the studies and the quality of the evidence was low to very low (GRADE ratings).Reported rates of seizure freedom reached as high as 55% in a classical 4:1 KD group after three months and reported rates of seizure reduction reached as high as 85% in a classical 4:1 KD group after three months (GRADE rating low).One trial found no significant difference between the fasting-onset and gradual-onset KD for rates of seizure freedom, and reported a greater rate of seizure reduction in the gradual-onset KD group.Studies assessing the efficacy of the MAD reported seizure freedom rates of up to 25% and seizure reduction rates of up to 60% in children. One study used a simplified MAD (sMAD) and reported seizure freedom rates of 15% and seizure reduction rates of 56% in children. One study utilised a MAD in adults and reported seizure reduction rates of 35%, but no patients became seizure free (GRADE rating low).Adverse effects of the dietary interventions were experienced in all studies. The most commonly reported adverse effects were gastrointestinal syndromes. It was common that adverse effects were the reason for participants dropping out of trials (GRADE rating low). Other reasons for dropout included lack of efficacy and non-acceptance of the diet (GRADE rating low).Although there was some evidence for greater antiepileptic efficacy for a classical 4:1 KD over lower ratios, the classical 4:1 KD was consistently associated with more adverse effects.One study assessed the effect of dietary interventions on quality of life, cognition and behavioural functioning, reporting participants in the KD group to be more active, more productive and less anxious after four months, compared to the control group. However, no significant difference was found in quality-adjusted life years (QALYs) between the KD group and control group at four or 16 months (GRADE rating very low). AUTHORS' CONCLUSIONS The RCTs discussed in this review show promising results for the use of KDs in epilepsy. However, the limited number of studies, small sample sizes and the limited studies in adults, resulted in a low to very low overall quality of evidence.There were adverse effects within all of the studies and for all KD variations, such as short-term gastrointestinal-related disturbances and increased cholesterol. However, study periods were short, therefore the long-term risks associated with these adverse effects is unknown. Attrition rates remained a problem with all KDs and across all studies; reasons for this being lack of observed efficacy and dietary tolerance.Only one study reported the use of KDs in adults with epilepsy; therefore further research would be of benefit.Other more palatable but related diets, such as the MAD, may have a similar effect on seizure control as the classical KD, but this assumption requires more investigation. For people who have medically intractable epilepsy or people who are not suitable for surgical intervention, KDs remain a valid option; however, further research is required.
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Affiliation(s)
- Kirsty J Martin‐McGill
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
- The Walton Centre NHS Foundation TrustDietetics OfficeLower LaneLiverpoolUKL9 7LJ
| | - Cerian F Jackson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
| | - Rebecca Bresnahan
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyLower LaneLiverpoolUKL9 7LJ
| | - Robert G Levy
- The Croft Shifta Health CentreBelfield RoadRochdaleUKOL16 2UP
| | - Paul N Cooper
- Salford Royal Hospitals NHS TrustCentre for Clinical NeurosciencesHope HospitalStott LaneSalfordGreater ManchesterUKM6 8HD
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Suraev A, Lintzeris N, Stuart J, Kevin RC, Blackburn R, Richards E, Arnold JC, Ireland C, Todd L, Allsop DJ, McGregor IS. Composition and Use of Cannabis Extracts for Childhood Epilepsy in the Australian Community. Sci Rep 2018; 8:10154. [PMID: 29977078 PMCID: PMC6033872 DOI: 10.1038/s41598-018-28127-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 06/04/2018] [Indexed: 12/20/2022] Open
Abstract
Recent surveys suggest that many parents are using illicit cannabis extracts in the hope of managing seizures in their children with epilepsy. In the current Australian study we conducted semi-structured interviews with families of children with diverse forms of epilepsy to explore their attitudes towards and experiences with using cannabis extracts. This included current or previous users of cannabis extracts to treat their child's seizures (n = 41 families), and families who had never used (n = 24 families). For those using cannabis, extracts were analysed for cannabinoid content, with specific comparison of samples rated by families as "effective" versus those rated "ineffective". Results showed that children given cannabis extracts tended to have more severe epilepsy historically and had trialled more anticonvulsants than those who had never received cannabis extracts. There was high variability in the cannabinoid content and profile of cannabis extracts rated as "effective", with no clear differences between extracts perceived as "effective" and "ineffective". Contrary to family's expectations, most samples contained low concentrations of cannabidiol, while Δ9-tetrahydrocannabinol was present in nearly every sample. These findings highlight profound variation in the illicit cannabis extracts being currently used in Australia and warrant further investigations into the therapeutic value of cannabinoids in epilepsy.
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Affiliation(s)
- A Suraev
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - N Lintzeris
- Addiction Medicine, Central Clinical School, Faculty of Medicine, The University of Sydney, Sydney, 2006, Australia
- The Langton Centre, Drug and Alcohol Services, South East Sydney Local Health District, NSW Health, Surry Hills, 2010, Australia
| | - J Stuart
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R C Kevin
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R Blackburn
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - E Richards
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - J C Arnold
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
- Department of Pharmacology, Faculty of Medicine, University of Sydney, Sydney, NSW, 2006, Australia
| | - C Ireland
- Epilepsy Action Australia, Sydney, Australia
| | - L Todd
- Epilepsy Action Australia, Sydney, Australia
| | - D J Allsop
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - I S McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia.
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24
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El Rashidy OF, Nassar MF, El Gendy YG, Deifalla SM, Gaballa S. Experience with MAD on children with epilepsy in Egypt after classic KD failure. Acta Neurol Scand 2018; 137:195-198. [PMID: 29034969 DOI: 10.1111/ane.12856] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Modified Atkins diet (MAD) is a less restrictive type of ketogenic diet (KD) as compared to the classic one. The aim of this study was to evaluate the impact of 9 months MAD treatment on the growth and seizure control in patients with intractable epilepsy as well as the quality of life (QoL) of their mothers. SUBJECTS AND METHODS The study included 15 patients with intractable epilepsy who could not tolerate their classic KD management plan. From the 15 recruited cases, only seven patients completed this nine months prospective study. After neurological reassessment, the patients were prescribed MAD tailored from the local Egyptian ingredients. Arabic translation of the WHO Quality of life Instruments (WHOQOL-BREF) scale was calculated for the mothers initially and 9 months later. Daily seizure frequency with severity assessment by Chalfont scale was recorded as well as monthly weight and length throughout the study period. RESULTS Mothers 'QoL in all WHOQOL-BREF domains significantly improved (P < .001) after nine months follow-up coupled by significant decrease in Chalfont scores from 51.00 ± 15.45 to 20.57 ± 21.45 and daily seizure frequency from 13.29 ± 6.99 to 2.71 ± 3.68. Regarding anthropometric data, there was significant increase in patients' weight and length as well as in the z-score for weight and length. CONCLUSION After nine months of MAD, growth and seizure parameters significantly improved in the intractable epilepsy patients as well as their mothers& QoL. We thus recommend MAD as a more flexible alternative in intractable epilepsy patients who can not tolerate classic KD.
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Affiliation(s)
- O. F. El Rashidy
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - M. F. Nassar
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - Y. G. El Gendy
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - S. M. Deifalla
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
| | - S. Gaballa
- Pediatrics Department Children's Hospital Ain‐Shams University Cairo Egypt
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25
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Practice Paper of the Academy of Nutrition and Dietetics: Classic and Modified Ketogenic Diets for Treatment of Epilepsy. J Acad Nutr Diet 2017; 117:1279-1292. [DOI: 10.1016/j.jand.2017.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Indexed: 12/19/2022]
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26
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Wijnen BFM, Leenen LAM, de Kinderen RJA, van Heugten CM, Majoie MHJM, Evers SMAA. An economic evaluation of a multicomponent self-management intervention for adults with epilepsy (ZMILE study). Epilepsia 2017; 58:1398-1408. [DOI: 10.1111/epi.13806] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Ben F. M. Wijnen
- CAPHRI School for Public Health and Primary Care; Maastricht University; Maastricht The Netherlands
- Department of Health Services Research; Maastricht University; Maastricht The Netherlands
- Department of Research & Development; Epilepsy Center Kempenhaeghe; Heeze The Netherlands
| | - Loes A. M. Leenen
- CAPHRI School for Public Health and Primary Care; Maastricht University; Maastricht The Netherlands
- Department of Health Services Research; Maastricht University; Maastricht The Netherlands
- Department of Research & Development; Epilepsy Center Kempenhaeghe; Heeze The Netherlands
| | - Reina J. A. de Kinderen
- CAPHRI School for Public Health and Primary Care; Maastricht University; Maastricht The Netherlands
- Department of Health Services Research; Maastricht University; Maastricht The Netherlands
- Department of Research & Development; Epilepsy Center Kempenhaeghe; Heeze The Netherlands
| | - Caroline M. van Heugten
- Department of Psychiatry and Neuropsychology; MHENS, School for Mental Health and Neuroscience; Maastricht University Medical Center; Maastricht The Netherlands
- Department of Neuropsychology and Psychopharmacology; Maastricht University; Maastricht The Netherlands
| | - Marian H. J. M. Majoie
- Department of Research & Development; Epilepsy Center Kempenhaeghe; Heeze The Netherlands
- Department of Psychiatry and Neuropsychology; MHENS, School for Mental Health and Neuroscience; Maastricht University Medical Center; Maastricht The Netherlands
- Department of Neurology; Academic Center for Epileptology; Epilepsy Center Kempenhaeghe and Maastricht University Medical Center; Maastricht The Netherlands
- Faculty of Health, Medicine and Life Sciences; School of Health Professions Education; Maastricht University; Maastricht The Netherlands
| | - Silvia M. A. A. Evers
- CAPHRI School for Public Health and Primary Care; Maastricht University; Maastricht The Netherlands
- Department of Health Services Research; Maastricht University; Maastricht The Netherlands
- Trimbos Institute; Netherlands Institute of Mental Health and Addiction; Utrecht The Netherlands
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27
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Wijnen BF, de Kinderen RJ, Lambrechts DA, Postulart D, Aldenkamp AP, Majoie MH, Evers SM. Long-term clinical outcomes and economic evaluation of the ketogenic diet versus care as usual in children and adolescents with intractable epilepsy. Epilepsy Res 2017; 132:91-99. [DOI: 10.1016/j.eplepsyres.2017.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/14/2017] [Accepted: 03/12/2017] [Indexed: 11/30/2022]
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Decreased health care utilization and health care costs in the inpatient and emergency department setting following initiation of ketogenic diet in pediatric patients: The experience in Ontario, Canada. Epilepsy Res 2017; 131:51-57. [DOI: 10.1016/j.eplepsyres.2017.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 12/20/2016] [Accepted: 01/21/2017] [Indexed: 01/01/2023]
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29
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Wijnen BFM, van Mastrigt GAPG, Evers SMAA, Gershuni O, Lambrechts DAJE, Majoie MHJM, Postulart D, Aldenkamp BAP, de Kinderen RJA. A systematic review of economic evaluations of treatments for patients with epilepsy. Epilepsia 2017; 58:706-726. [PMID: 28098939 DOI: 10.1111/epi.13655] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2016] [Indexed: 11/29/2022]
Abstract
The increasing number of treatment options and the high costs associated with epilepsy have fostered the development of economic evaluations in epilepsy. It is important to examine the availability and quality of these economic evaluations and to identify potential research gaps. As well as looking at both pharmacologic (antiepileptic drugs [AEDs]) and nonpharmacologic (e.g., epilepsy surgery, ketogenic diet, vagus nerve stimulation) therapies, this review examines the methodologic quality of the full economic evaluations included. Literature search was performed in MEDLINE, EMBASE, NHS Economic Evaluation Database (NHS EED), Econlit, Web of Science, and CEA Registry. In addition, Cochrane Reviews, Cochrane DARE and Cochrane Health Technology Assessment Databases were used. To identify relevant studies, predefined clinical search strategies were combined with a search filter designed to identify health economic studies. Specific search strategies were devised for the following topics: (1) AEDs, (2) patients with cognitive deficits, (3) elderly patients, (4) epilepsy surgery, (5) ketogenic diet, (6) vagus nerve stimulation, and (7) treatment of (non)convulsive status epilepticus. A total of 40 publications were included in this review, 29 (73%) of which were articles about pharmacologic interventions. Mean quality score of all articles on the Consensus Health Economic Criteria (CHEC)-extended was 81.8%, the lowest quality score being 21.05%, whereas five studies had a score of 100%. Looking at the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), the average quality score was 77.0%, the lowest being 22.7%, and four studies rated as 100%. There was a substantial difference in methodology in all included articles, which hampered the attempt to combine information meaningfully. Overall, the methodologic quality was acceptable; however, some studies performed significantly worse than others. The heterogeneity between the studies stresses the need to define a reference case (e.g., how should an economic evaluation within epilepsy be performed) and to derive consensus on what constitutes "standard optimal care."
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Affiliation(s)
- Ben F M Wijnen
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Ghislaine A P G van Mastrigt
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Silvia M A A Evers
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Olga Gershuni
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Danielle A J E Lambrechts
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands.,Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marian H J M Majoie
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands.,Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Maastricht, The Netherlands.,MHENS School of Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands.,School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Debby Postulart
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Bert A P Aldenkamp
- Department of Research & Development, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands.,Department of Neurology, Academic Center for Epileptology, Epilepsy Center Kempenhaeghe & Maastricht University Medical Center, Maastricht, The Netherlands.,MHENS School of Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands.,Department of Behavioral Sciences, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - Reina J A de Kinderen
- Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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van Mastrigt GAPG, Hiligsmann M, Arts JJC, Broos PH, Kleijnen J, Evers SMAA, Majoie MHJM. How to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions: a five-step approach (part 1/3). Expert Rev Pharmacoecon Outcomes Res 2016; 16:689-704. [PMID: 27805469 DOI: 10.1080/14737167.2016.1246960] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Systematic reviews of economic evaluations are useful for synthesizing economic evidence about health interventions and for informing evidence-based decisions. Areas covered: As there is no detailed description of the methods for performing a systematic review of economic evidence, this paper aims to provide an overview of state-of-the-art methodology. This is laid out in a 5-step approach, as follows: step 1) initiating a systematic review; step 2) identifying (full) economic evaluations; step 3) data extraction, risk of bias and transferability assessment; step 4) reporting results; step 5) discussion and interpretation of findings. Expert commentary: The paper aims to help inexperienced reviewers and clinical practice guideline developers, but also to be a resource for experts in the field who want to check on current methodological developments.
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Affiliation(s)
- Ghislaine A P G van Mastrigt
- a CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences , Maastricht University , Maastricht , The Netherlands
| | - Mickaël Hiligsmann
- a CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences , Maastricht University , Maastricht , The Netherlands
| | - Jacobus J C Arts
- b Department of Orthopedics , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Pieter H Broos
- c Knowledge Institute of Medical Specialists , Utrecht , The Netherlands
| | - Jos Kleijnen
- d CAPHRI, School for Public Health and Primary Care, Department of Family Medicine, Faculty of Health, Medicine and Life Sciences , Maastricht University , Maastricht , The Netherlands
| | - Silvia M A A Evers
- a CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences , Maastricht University , Maastricht , The Netherlands.,e Trimbos Institute, Netherlands Institute of Mental Health and Addiction , Utrecht , The Netherlands
| | - Marian H J M Majoie
- f Department of Research and Development , Epilepsy Centre Kempenhaeghe , Heeze , The Netherlands.,g Department of Neurology, Academic Centre for Epileptology , Maastricht University Medical Centre , Maastricht , The Netherlands.,h School of Mental Health and Neuroscience , Maastricht University Medical Center , Maastricht , The Netherlands.,i School of Health Professions Education, Faculty of Health, Medicine and Life Sciences , Maastricht University , Maastricht , The Netherlands
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31
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Wijnen B, Van Mastrigt G, Redekop WK, Majoie H, De Kinderen R, Evers S. How to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions: data extraction, risk of bias, and transferability (part 3/3). Expert Rev Pharmacoecon Outcomes Res 2016; 16:723-732. [PMID: 27762640 DOI: 10.1080/14737167.2016.1246961] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION This article is part of the series "How to Prepare a Systematic Review (SR) of Economic Evaluations (EE) for Informing Evidence-based Healthcare Decisions" in which a five-step-approach for conducting a SR of EE is proposed. Areas covered: This paper explains the data extraction process, the risk of bias assessment and the transferability of EEs by means of a narrative review and expert opinion. SRs play a critical role in determining the comparative cost-effectiveness of healthcare interventions. It is important to determine the risk of bias and the transferability of an EE. Expert commentary: Over the past decade, several criteria lists have been developed. This article aims to provide recommendations on these criteria lists based on the thoroughness of development, feasibility, overall quality, recommendations of leading organizations, and widespread use.
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Affiliation(s)
- Bfm Wijnen
- a Department of Health Services Research, CAPHRI School of Public Health and Primary Care , Maastricht University , Maastricht , The Netherlands.,b Department of Research and Development , Epilepsy Centre Kempenhaeghe , Heeze , The Netherlands
| | - Gapg Van Mastrigt
- a Department of Health Services Research, CAPHRI School of Public Health and Primary Care , Maastricht University , Maastricht , The Netherlands
| | - W K Redekop
- c Department of Health Policy and Management, Institute for Medical Technology Assessment , Erasmus University Rotterdam , Rotterdam , The Netherlands
| | - Hjm Majoie
- b Department of Research and Development , Epilepsy Centre Kempenhaeghe , Heeze , The Netherlands.,d Department of Neurology, Academic Centre for Epileptology , Epilepsy Centre Kempenhaeghe and Maastricht University Medical Centre , Maastricht , The Netherlands.,f School of Mental Health and Neuroscience , Maastricht University Medical Center , Maastricht , The Netherlands.,g School of Health Professions Education, Faculty of Health, Medicine and Life Sciences , Maastricht University , Maastricht , The Netherlands
| | - Rja De Kinderen
- a Department of Health Services Research, CAPHRI School of Public Health and Primary Care , Maastricht University , Maastricht , The Netherlands
| | - Smaa Evers
- a Department of Health Services Research, CAPHRI School of Public Health and Primary Care , Maastricht University , Maastricht , The Netherlands.,e Department for Economic Evaluations , Trimbos Institute, Netherlands Institute of Mental Health and Addiction , Utrecht , The Netherlands
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Pasca L, De Giorgis V, Macasaet JA, Trentani C, Tagliabue A, Veggiotti P. The changing face of dietary therapy for epilepsy. Eur J Pediatr 2016; 175:1267-76. [PMID: 27586246 DOI: 10.1007/s00431-016-2765-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/07/2016] [Accepted: 08/19/2016] [Indexed: 01/01/2023]
Abstract
UNLABELLED Ketogenic diet is an established and effective non-pharmacologic treatment for drug-resistant epilepsy. Ketogenic diet represents the treatment of choice for GLUT-1 deficiency syndrome and pyruvate dehydrogenase complex deficiency. Infantile spasms, Dravet syndrome and myoclonic-astatic epilepsy are epilepsy syndromes for which ketogenic diet should be considered early in the therapeutic pathway. Recently, clinical indications for ketogenic diet have been increasing, as there is emerging evidence regarding safety and effectiveness. Specifically, ketogenic diet response has been investigated in refractory status epilepticus and encephalopathy with status epilepticus during sleep. New targets in neuropharmacology, such as mitochondrial permeability transition, are being studied and might lead to using it effectively in other neurological diseases. But, inefficient connectivity and impaired ketogenic diet proposal limit ideal availability of this therapeutic option. Ketogenic diet in Italy is not yet considered as standard of care, not even as a therapeutic option for many child neurologists and epileptologists. CONCLUSIONS The aim of this review is to revisit ketogenic diet effectiveness and safety in order to highlight its importance in drug-resistant epilepsy and other neurological disorders. WHAT IS KNOWN • Ketogenic diet efficacy is now described in large case series, with adequate diet compliance and side effects control. • Ketogenic diet is far from being attempted as a first line therapy. Its availability varies worldwide. What is New: • New pharmacological targets such as mitochondrial permeability transition and new epileptic syndromes and etiologies responding to the diet such as refractory status epilepticus are being pointed out. • Ketogenic diet can function at its best when used as a tailor-made therapy. Fine tuning is crucial.
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Affiliation(s)
- Ludovica Pasca
- Department of Child Neurology and Psychiatry, IRCCS "C. Mondino" National Neurological Institute, Pavia, Italy
| | - Valentina De Giorgis
- Department of Child Neurology and Psychiatry, IRCCS "C. Mondino" National Neurological Institute, Pavia, Italy.,Brain and Behaviour Department, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | | | - Claudia Trentani
- Human nutrition and eating disorder center, department of public health, experimental and forensic medicine, University of Pavia, Pavia, Italy
| | - Anna Tagliabue
- Human nutrition and eating disorder center, department of public health, experimental and forensic medicine, University of Pavia, Pavia, Italy
| | - Pierangelo Veggiotti
- Department of Child Neurology and Psychiatry, IRCCS "C. Mondino" National Neurological Institute, Pavia, Italy. .,Brain and Behaviour Department, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy.
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