Effects of long-term antiepileptic drug monotherapy on vascular risk factors and atherosclerosis

Bidirectional association between abnormal cardiac conditions and epilepsy: A two-sample Mendelian randomization study

BACKGROUND

Observational studies have consistently indicated a significant correlation between abnormal cardiac conditions and epilepsy. However, the association and direction of this relationship remain a subject of debate. This study employs a two-sample bidirectional Mendelian randomization (MR) approach to investigate the association between abnormal cardiac conditions and epilepsy.

METHODS

Instrumental variables, represented by single nucleotide polymorphisms (SNPs) associated with epilepsy and various abnormal cardiac conditions, were derived from large-scale genome-wide association studies databases, including FinnGen and UK Biobank. Bidirectional MR analysis was conducted to estimate the association between epilepsy and abnormal cardiac conditions. Sensitivity analyses were performed using MR-Egger, weighted median, Inverse Variance Weighted, and MR pleiotropy residual sum and outlier methods.

RESULTS

The forward MR analysis suggested a potential positive effect of atrial fibrillation and flutter (AF) and valvular heart diseases (VHD) on the risk of epilepsy. Conversely, the reverse MR analysis indicated that epilepsy might increase the susceptibility to AF, VHD, and heart failure.

CONCLUSION

The findings support a bidirectional relationship between AF, VHD, and epilepsy, indicating that AF and VHD can elevate the risk of developing epilepsy, while epilepsy, in turn, can also increase the risk of developing AF and VHD. Furthermore, the study suggest that epilepsy may contribute to the development of heart failure. These results underscore the importance of screening for cardiac abnormalities in patients with epilepsy and vice versa, to better understand their clinical significance and potential as modifiable risk factors.

Association of first antiseizure medication with acute health care utilization in a cohort of adults with newly diagnosed epilepsy

OBJECTIVE

Epilepsy is primarily treated with antiseizure medications (ASMs). The recommendations for first ASM in newly diagnosed epilepsy are inconsistently followed, and we sought to examine whether nonrecommended first ASM was associated with acute care utilization.

METHODS

We conducted a retrospective cohort study of adults (≥18 years old) with newly diagnosed epilepsy (identified using validated epilepsy/convulsion International Classification of Diseases, Clinical Modification codes) in 2015-2019, sampled from Marketscan's Commercial and Medicare Databases. Exposure of interest was receipt of a non-guideline-recommended ASM, and the primary outcome was acute care utilization (an emergency department visit or hospitalization after the first ASM claim). Descriptive statistics characterized covariates, and multivariable negative binominal regression models were built adjusting for age, sex, Elixhauser Comorbidity Index, comorbid neurologic disease (e.g., stroke), and ASM polypharmacy.

RESULTS

Approximately 14 681 people with new epilepsy were prescribed an ASM within 1 year. The three most prescribed medications were levetiracetam (54%, n = 7912), gabapentin (10%, n = 1462), and topiramate (7%, n = 1022). Approximately 4% (n = 648) were prescribed an ASM that should be avoided, and ~74% of people with new epilepsy had an acute care visit during the follow-up period. Mean number of acute care visits during follow-up was 3.34 for "recommended" ASMs and 4.42 for ASMs that "should be avoided." Prescription of a recommended/neutral ASM as compared to an ASM that should be avoided was associated with reduced likelihood of acute care utilization (incidence rate ratio [IRR] = .85, 95% confidence interval [CI] = .77-.94). The recommended/neutral category of ASMs was not statistically significantly associated with seizure- or epilepsy-specific acute care utilization (IRR = .93, 95% CI = .79-1.09).

SIGNIFICANCE

Adults with new epilepsy are frequent users of acute care. There remain a proportion of persons with epilepsy prescribed ASMs that guidelines suggest avoiding, and these ASMs are associated with increased likelihood of emergency department visit or hospitalization. These findings reinforce the importance of optimizing the choice of first ASM in epilepsy.

The effect of the modified Atkins diet and anti-seizure medications on lipid marker levels in adults with epilepsy

OBJECTIVES

Some anti-seizure medications (ASMs) are known to induce liver enzymes and impact lipid values that include total cholesterol (TC), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), and triglyceride (TG). In addition, use of ketogenic diet therapies, including the modified Atkins diet (MAD), has also influenced lipids. Here, we explored the combined impact of enzyme inducing ASMs (EIASMs) and MAD on lipid values in adults with epilepsy.

METHODS

Diet-naïve adults with epilepsy who began MAD were divided into three groups based on ASM use: EIASMs, non-EIASMs, and those on no ASMs. Demographic information, epilepsy-specific clinical history, anthropometrics and lipid values were obtained through retrospective chart review at baseline and after a minimum of 12 months of MAD use.

RESULTS

Forty-two adults on MAD had baseline and follow up 12-month lipid outcomes. There was a significant increase in median levels of TC, LDL, non-HDL, and HDL after 12 months of MAD use. There was no change in median levels of TG. When separated according to ASM category, adults on non-EIASMs showed significant elevations in TC, HDL, and LDL after 12 months of MAD use. In contrast, adults on EIASMs only showed a significant increase in HDL after 12 months of MAD use.

DISCUSSION

The increase in atherogenic cholesterol levels observed after 12 months of MAD use was most pronounced in adults with epilepsy on non-EIASMs and not observed in adults with epilepsy on EIASMs despite a higher proportion of abnormal cholesterol levels at baseline in those on EIASMs.

Late onset epilepsy and stroke: Diagnosis, pathogenesis and prevention

The association of stroke and late-onset epilepsy (LOE) is discussed with special regard to its diagnosis, pathogenesis, and prevention. In addition to epidemiological data, including those from different age groups, the mechanisms for the development of acute symptomatic and remote symptomatic seizures are reviewed. The risk factors associated with seizures and post-stroke epilepsy (PSE) are considered, along with the methodological limitations of the study. For future research, the distinction between acute and remote symptomatic seizure before or after seven days from stroke onset should be reviewed because different acute symptomatic seizures (ASSs) themselves can entail a variable PSE risk. The definition of LOE by age is hitherto inconsistent. Comparing adult lifespan epochs, it is evident that stroke and seizures exhibit similar prevalence profiles. Young adulthood, old adulthood, and elderly epochs may be relevant for the differentiation of LOE subtype by age, vascular comorbidity, and other characteristics. A step-scheme strategy as a possible contribution to cerebrovascular prevention approaches is proposed.

Sex Differences in Adverse Effects of Antiseizure Medications in Adults with Epilepsy: A Systematic Review

BACKGROUND

Sex differences in epilepsy have been described in prevalence, seizure propensity and response to treatment. Therefore, taking into account sex-based differences in epilepsy is important for both diagnostic purposes and therapeutic considerations. However, little is known about sex differences in adverse effects of antiseizure medications (ASMs).

OBJECTIVES

We performed a systematic review searching for sex differences in adverse effects of ASMs in adult persons with epilepsy (PWE) as part of a wider project aimed to assess sex-based differences in efficacy and adverse effects of ASMs in PWE.

METHODS

We conducted a comprehensive literature search in the PubMed database. The search was conducted with no restriction on publication date, and all results up to April 2020 were included. We included articles written in English, Italian, Spanish, or French that evaluated adverse effects of one or more ASMs in PWE, with specific mention of the two sexes. When appropriate, Newcastle-Ottawa or Jadad scales were used to assess study quality.

RESULTS

Of 5164 identified studies, only 167 considered sex in the analysis and were therefore included. Significant sex-related differences were found in 58 of those studies. We found a consistently higher frequency of cutaneous adverse effects in females; higher risk of developing general adverse effects on different ASMs in females; stronger risk of adverse effects on bone metabolism in females, mainly on treatment with enzyme-inducing ASMs; a concordant higher risk of visual field loss was noted in males on vigabatrin; an overall worse lipid profile in males; as well as higher leptin levels and higher body mass index in females treated with various ASMs.

CONCLUSIONS

Our analysis has identified some important sex differences in the adverse effects of ASMs. Clinicians should be aware of these differences when informing patients about the risks associated with ASM treatment in PWE.

Increased cardiovascular risk in epilepsy

Epilepsy is associated with increased mortality. Cardiovascular disease confers a significant portion of this increased risk. Recently there is increased interest in the burden of cardiovascular mortality in people with epilepsy. This review discusses the most common cardiovascular risk factors and their association with epilepsy including obesity, diabetes mellitus, and hyperlipidemia. Hyperlipidemia related to the use of enzyme inducing anti-seizure medications is also discussed as a topic that is of particular importance to prescribers that have patients with comorbid cardiovascular risk and epilepsy. Heart rate variability (HRV) and its association with SUDEP is discussed as well as a contributor to vascular risk. Finally, the authors discuss a potential role for neurologists who treat epilepsy to engage closer with their patient's cardiovascular risk factors using available tools such as a the ASCVD score calculator to determine the overall risk of mortality, as well as acting upon this information to guide treatment approaches integrating the information provided in this review.

Post-stroke epilepsy: From clinical predictors to possible mechanisms

BACKGROUND

Stroke is the most common cause of newly diagnosed epilepsy in the elderly, ahead of degenerative disorders, brain tumors, and head trauma. Stroke accounts for 30-50% of unprovoked seizures in patients aged ≥ 60 years. This review discusses the current understanding of epidemiology, risk factors, mechanisms, prevention, and treatment opportunities for post-stroke epilepsy (PSE).

METHODS

We performed a literature search in the PubMed and Cochrane Library databases. The keywords "stroke, epilepsy", "stroke, seizure", "post-stroke seizure", "post-stroke epilepsy" were used to identify the clinical and experimental articles on PSE. All resulting titles and abstracts were evaluated, and any relevant article was considered. The reference lists of all selected papers and reference lists of selected review papers were manually analyzed to find other potentially eligible articles.

RESULTS

PSE occurs in about 6% of stroke patients within several years after the event. The main risk factors are cortical lesion, initial stroke severity, young age and seizures in acute stroke period (early seizures, ES). Other risk factors, such as a cardioembolic mechanism or circulation territory involvement, remain debated. The role of ES as a risk factor of PSE could be underestimated especially in young age. Mechanism of epileptogenesis may involve gliosis scarring, alteration in synaptic plasticity, etc.; and ES may enhance these processes. Statins especially in the acute period of stroke are possible agents for PSE prevention presumably due to their anticonvulsant and neuroprotection effects. Antiepileptic drugs (AED) monotherapy is enough for seizure prevention in most cases of PSE; but no evidence was found for its efficiency against epileptic foci formation. The growing interest in PSE has led to a notable increase in the number of published articles each year. To aid in navigating this expanding body of literature, several tables are included in the manuscript.

CONCLUSION

Further studies are needed for better understanding of the pathophysiology of PSE and searching the prevention strategies.

The Study of Carotid Artery Intima-Media Thickness in Children With Epilepsy on Anti-Epileptic Drugs

Objectives. To evaluate carotid artery intima-media thickness (CIMT) and lipid profile in children with epilepsy on long-term antiepileptic drug (AED) monotherapy. Methods. We included 60 children with epilepsy receiving valproate, carbamazepine, or levetiracetam monotherapy and 60 controls. A high-resolution B-mode ultrasound was used to measure (CIMT). Measurement of serum lipids was done. Results. Patients on valproate (0.44 ± 0.03, P ≤ .001), carbamazepine (0.43 ± 0.03with P ≤ .001), and levetiracetam (0.44 ± 0.02 with P ≤ .001) monotherapy showed significantly higher CIMT compared to controls. CIMT was correlated with age (P = .041, r = .112) AEDs{valproate (P = .005, r = .731), carbamazepine (P = .038, r = .365), and levetiracetam (P = .036, r = .155)}, duration of treatment (P = .001, r = .313), TC(P = .001, r = .192), TG (P = .014, r = .018), and LDL (P = .001, r = .219). HDL (P = .003, r = -.126). Seizure severity and Apo A1 were insignificantly involved. Conclusion. Long-term monotherapy with valproate, carbamazepine, and levetiracetam in epileptic children was associated with significant abnormalities in CIMT.

Lipid profile with eslicarbazepine acetate and carbamazepine monotherapy in adult patients with newly diagnosed focal seizures: post hoc analysis of a phase III trial and open-label extension study

Background

Antiseizure medications can have negative effects on plasma lipid levels.

Objectives

To evaluate plasma lipid changes in patients with newly diagnosed focal epilepsy treated with eslicarbazepine acetate (ESL) or controlled-release carbamazepine (CBZ-CR) monotherapy during a phase III, randomized, double-blind (DB) trial and 2 years of ESL treatment in an open-label extension (OLE).

Design

Post hoc analysis of a phase III trial and OLE study.

Methods

Proportions of patients with elevated levels of total cholesterol and low-density lipoprotein (LDL) cholesterol were assessed at DB baseline, OLE baseline (last visit of DB trial), and end of OLE.

Results

A total of 184 patients received ESL monotherapy during the OLE: 96 received ESL monotherapy in the DB trial and 88 patients received CBZ-CR monotherapy. The proportions of patients with elevated total cholesterol and LDL cholesterol increased significantly during the DB trial in those treated with CBZ-CR monotherapy [total cholesterol, +14.9% (p < 0.001); LDL cholesterol, +11.5% (p = 0.012)] but decreased significantly after switching to ESL monotherapy in the OLE [total cholesterol, -15.3% (p = 0.008); LDL cholesterol, -11.1% (p = 0.021)]. No significant changes were observed in those treated with ESL monotherapy during the DB trial and OLE. At the end of the DB trial, between-group differences (ESL-CBZ-CR) in the proportions of patients with elevated total and LDL cholesterol were -13.6% (p = 0.037) and -12.3% (p = 0.061), respectively; at the end of the OLE, these between-group differences were -6.0% (p = 0.360) and -0.6% (p = 1.000), respectively.

Conclusion

A lower proportion of patients with newly diagnosed focal epilepsy had increased levels of total and LDL cholesterol, compared to baseline, following monotherapy with ESL versus CBZ-CR; after switching from CBZ-CR to ESL, the proportions of patients with increased levels decreased significantly.

Registration

ClinicalTrials.gov NCT01162460/NCT02484001; EudraCT 2009-011135-13/2015-001243-36.

Topiramate treatment during the peripubertal period does not alter aortic endothelial function in female Wistar rats

AIMS

This study aimed to evaluate the short- and long-term adverse effects of blood pressure (BP), vascular endothelial function, and estrogen receptor (ERα and ERβ) modulation on endothelial function in female Wistar rats treated with topiramate (TPM), an antiepileptic drug, during the peripubertal period.

MATERIALS AND METHODS

Female Wistar rats were treated with TPM (41 mg/kg) or water (CTR group) by gavage from postnatal day (PND) 28 to 50 (peripubertal phase). At the end of the treatment, the TPM and CTR rats were divided into two groups and evaluated after 24 h or from PND 85 (adulthood). The rats were evaluated for: thoracic aorta reactivity to phenylephrine (Phenyl), acetylcholine (ACh), and sodium nitroprusside (SNP); aortic ring reactivity after ERα and ERβ antagonism; and BP.

KEY FINDINGS

It was observed that vascular response to Phenyl, ACh, and SNP was similar between TPM and CTR rats in the short- and long-term evaluations. In addition, the ER antagonism did not interfere with aortic contraction or relaxation in either TPM or CTR.

SIGNIFICANCE

Taken together, the results show that TPM treatment during the peripubertal period does not alter aortic endothelial function and its estrogen modulation via classic ER in female Wistar rats, suggesting that TPM treatment in this period is safe for the vascular system.

The effect of anti-seizure medications on lipid values in adults with epilepsy

PURPOSE

Certain anti-seizure medications (ASMs) adversely impact lipid values. Here, we explored the impact of ASMs on lipid values in adults with epilepsy.

METHODS

A total of 228 adults with epilepsy were divided into four groups based on ASMs used: strong EIASMs, weak EIASMs, non-EIASMs, and no ASMs. Demographic information, epilepsy-specific clinical history, and lipid values were obtained through chart review.

RESULTS

While there was no significant difference in lipid values between groups, there was a significant difference in the proportion of participants with dyslipidemia. Specifically, more participants exhibited elevated low-density lipoprotein (LDL) level in the strong EIASM group compared to the non-EIASM group (46.7% vs 18%, p < 0.05). In addition, more participants showed elevated LDL level in the weak EIASM group compared to the non-EIASM group (38% vs 18%, p < 0.05). Users of strong EIASMs showed greater odds of high LDL level (OR 5.734, p = 0.005) and high total cholesterol level (OR 4.913, p = 0.008) compared to users of non-EIASMs. When we analyzed the impact of individual ASMs used by more than 15% of the cohort on lipid levels, participants using valproic acid (VPA) showed lower high-density lipoprotein (p = 0.002) and higher triglyceride levels (p = 0.002) compared to participants not using VPA.

CONCLUSION

Our study demonstrated a difference in the proportion of participants with dyslipidemia between ASM groups. Thus, adults with epilepsy using EIASMs should have careful monitoring of lipid values to address the risk of cardiovascular disease.

Circadian rhythm of blood pressure in patients with drug-resistant mesial temporal lobe epilepsy

OBJECTIVE

To determine whether patients with drug-resistant mesial temporal lobe epilepsy present with an alteration in the autonomic circadian regulation of blood pressure.

METHODS

A prospective case‒control study was designed, with a case group comprising patients with drug-resistant mesial temporal lobe epilepsy and a control group comprising healthy volunteers. Twenty-four-hour outpatient blood pressure monitoring was performed to assess the existence of a normal (dipping) or altered (non-dipping) circadian pattern. In addition, analytical and ultrasound parameters (carotid intima-media thickness) of vascular risk and sleep quality were evaluated.

RESULTS

Twenty-four subjects were recruited in each study group, amongst whom no demographic differences or history of vascular risk were observed. A higher percentage of participants with a non-dipping pattern was observed in the group of patients with epilepsy (62.5% vs. 12.5, p = 0.001). In the case group, significant differences were also observed in carotid intima-media thickness, with a greater probability of presenting with pathological values (p = 0.022).

CONCLUSION

The results suggest a disorder of the central autonomic control of blood pressure in patients with drug-resistant mesial temporal lobe epilepsy, with a greater probability of developing an alteration of the circadian rhythm of blood pressure. This dysfunction may be a factor involved in the increased cardiovascular risk in this population.

Valproic acid as a radio-sensitizer in glioma: A systematic review and meta-analysis

Background

Histone deacetylase inhibitors (HDACi) including valproic acid (VPA) have the potential to improve radiotherapy (RT) efficacy and reduce treatment adverse events (AE) via epigenetic modification and radio-sensitization of neoplastic cells. This systematic review and meta-analysis aimed to assess the efficacy and AE associated with HDACi used as radio-sensitizers in adult solid organ malignancy patients.

Methods

A systematic review utilized electronic searches of MEDLINE(Ovid), Embase(Ovid), The Cochrane Library, and the International Clinical Trials Registry Platform to identify studies examining the efficacy and AEs associated with HDACi treatment in solid organ malignancy patients undergoing RT. Meta-analysis was performed with overall survival (OS) reported as hazard ratios (HR) as the primary outcome measure. OS reported as median survival difference, and AEs were secondary outcome measures.

Results

Ten studies reporting on the efficacy and/or AEs of HDACi in RT-treated solid organ malignancy patients met inclusion criteria. All included studies focused on HDACi valproic acid (VPA) in high-grade glioma patients, of which 9 studies (n = 6138) evaluated OS and 5 studies (n = 1055) examined AEs. The addition of VPA to RT treatment protocols resulted in improved OS (HR = 0.80, 95% CI 0.67-0.96). No studies focusing on non-glioma solid organ malignancy patients, or non-VPA HDACi met the inclusion criteria for this review.

Conclusions

This review suggests that glioma patients undergoing RT may experience prolonged survival due to HDACi VPA administration. Further randomized controlled trials are required to validate these findings. Additionally, more research into the use of HDACi radio-adjuvant treatment in non-glioma solid organ malignancies is warranted.

Epilepsy care in nursing facilities: Knowledge gaps and opportunities

Epilepsy in the elderly is a complex disease, often underdiagnosed, and inadequately treated. It requires a multi-disciplinary approach and care coordination especially if the patient resides in a nursing facility. Episodes of loss of consciousness falls, or amnestic events in those living in a nursing facility require a detailed description and an urgent assessment to rule out an epileptic seizure. Prompt recognition of seizures and the implementation of treatment protocols in those with recurrent seizures are needed to prevent unnecessary emergency visits. Although there is a myriad of antiseizure medications (ASM) to treat seizures, clinicians should be aware of common interactions, side effects, and changes in pharmacodynamics with age. There is a limited number of ASMs that have been properly studied in clinical trials to assess tolerability and efficacy in the elderly, and an over-reliance on enzyme-inducing ASMs. Strategies to improve the knowledge of health care providers include electronic resources, treatment protocols, and improving awareness of the efficacy, drug-drug interaction, and short-term and long-term monitoring of ASM side effects.

Diagnosis and Treatment of Poststroke Epilepsy: Where Do We Stand?

Purpose of Review

Stroke is the most common cause of seizures and epilepsy in older adults. This educational paper aims to give an update on current clinical aspects of diagnosis and treatment of poststroke epilepsy.

Recent Findings

Regarding epileptic seizures related to stroke, it is important to distinguish between acute symptomatic seizures and unprovoked seizures as they differ in their risk for seizure recurrence. In fact, after a single unprovoked poststroke seizure, a diagnosis of epilepsy can be made because there is a greater than 60% risk for further seizures. Clinical models that can predict the development of epilepsy after a stroke have been successfully established. However, treatment with anti-seizure medications is advised only after a first unprovoked poststroke seizure, as current treatments are not known to be effective for primary prevention. The management of poststroke epilepsy requires consideration of aspects such as age, drug-drug interactions and secondary vascular prophylaxis, yet evidence for the use of anti-seizure medications specifically in poststroke epilepsy is limited.

Summary

This text reviews the epidemiology and risk factors for poststroke epilepsy, explains the role of EEG and neuroimaging in patients with stroke and seizures and provides an overview on the clinical management of stroke-related acute symptomatic seizures and poststroke epilepsy.

Influence of Different Antiseizure Medications on Vascular Risk Factors in Children with Epilepsy

Many studies have proposed that plasma homocysteine levels are increased as a side effect with the prolonged use of antiseizure medications. This is associated with an increase in carotid intima media thickness; hence, it increases the threat of atherosclerosis at a young age. We aimed to assess serum levels of homocysteine in epileptic children on long-standing antiseizure medications and its association with increased occurrence of cardiovascular disease. The study included 60 epileptic children aged between 2 and 15 years old who visited our pediatric neurology outpatient clinic and 25 apparently healthy children served as a control group. All included children were subjected to careful history taking, clinical examination, anthropometric measures, laboratory investigations including serum homocysteine levels and lipid profile, along with radiological assessment involving carotid intima media thickness and carotid stiffness. Results demonstrated a significant increase in the serum levels of homocysteine, carotid intima media thickness, and carotid stiffness in children on monotherapy of old generation antiseizure medications and polytherapy than that in children on monotherapy of new generation antiseizure medications and control children. Epileptic children on old generation and polytherapy antiseizure medications have an increased risk for cardiovascular diseases and need follow up for early intervention when needed.

Topiramate treatment in Wistar rats during childhood induces sex-specific vascular dysfunction in adulthood

The present study determined whether treatment during childhood with topiramate (TPM), a new generation antiepileptic drug, results in altered aortic reactivity in adult male and female rats. We also sought to understand the role of endothelium-derived contractile factors in TPM-induced vascular dysfunction. Male and female Wistar rats were treated with TPM (41 mg/kg/day) or water (TPM vehicle) by gavage during childhood (postnatal day, 16-28). In adulthood, thoracic aorta reactivity to phenylephrine (phenyl), as well as aortic thickness and expression of cyclooxygenases (COX-1 and COX-2), NOX2, and p47^phox were evaluated. The aortic response to phenyl was increased in male and female rats from the TPM group when compared with the control group. In TPM male rats, the hyperreactivity to phenyl was abrogated by the inhibition of NADPH oxidase and COX-2, while in female rats, responses were restored only by inhibition of COX-2. In addition, TPM male rats presented aortic hypertrophy and increased expression of NOX-2 and p47phox, while TPM female rats showed increased COX-2 aortic expression. Taken together, for the first-time, the present study provides evidence that treatment with TPM during childhood causes vascular dysfunction in adulthood, and that the mechanism underlying the vascular effects of TPM is sex-specific.

Seizures and epilepsy in patients with ischaemic stroke

BACKGROUND

With the increased efficacy of stroke treatments, diagnosis and specific treatment needs of patients with post-stroke seizures (PSS) and post-stroke epilepsy have become increasingly important. PSS can complicate the diagnosis of a stroke and the treatment of stroke patients, and can worsen post-stroke morbidity. This narrative review considers current treatment guidelines, the specifics of antiseizure treatment in stroke patients as well as the state-of-the-art in clinical and imaging research of post-stroke epilepsy. Treatment of PSS needs to consider indications for antiseizure medication treatment as well as individual clinical and social factors. Furthermore, potential interactions between stroke and antiseizure treatments must be carefully considered. The relationship between acute recanalizing stroke therapy (intravenous thrombolysis and mechanical thrombectomy) and the emergence of PSS is currently the subject of an intensive discussion. In the subacute and chronic post-stroke phases, important specific interactions between necessary antiseizure and stroke treatments (anticoagulation, cardiac medication) need to be considered. Among all forms of prevention, primary prevention is currently the most intensively researched. This includes specifically the repurposing of drugs that were not originally developed for antiseizure properties, such as statins. PSS are presently the subject of extensive basic clinical research. Of specific interest are the role of post-stroke excitotoxicity and blood-brain barrier disruption for the emergence of PSS in the acute symptomatic as well as late (> 1 week after the stroke) periods. Current magnetic resonance imaging research focussing on glutamate excitotoxicity as well as diffusion-based estimation of blood-brain barrier integrity aim to elucidate the pathophysiology of seizures after stroke and the principles of epileptogenesis in structural epilepsy in general. These approaches may also reveal new imaging-based biomarkers for prediction of PSS and post-stroke epilepsy.

CONCLUSION

PSS require the performance of individual risk assessments, accounting for the potential effectiveness and side effects of antiseizure therapy. The use of intravenous thrombolysis and mechanical thrombectomy is not associated with an increased risk of PSS. Advances in stroke imaging may reveal biomarkers for PSS.

Carotid intima-media and epicardial adipose tissue thickness in adult patients with epilepsy taking anti-seizure medication and its long-term significance

OBJECTIVES

We investigated epicardial adipose tissue thickness (EATT), carotid intima-media thickness (CIMT), and lipid profile in adult patients with epilepsy (PWE) taking anti-seizure medication(s) (ASM) and compared with those of the healthy population. We also investigated whether duration of follow-up and number of ASM(s) (mono- vs. polytherapy) affect these risk factors.

METHODS

Twenty PWE older than 18 years of age were recruited at the outpatient epilepsy clinic and compared to twenty controls. Patients who were 18 years old and younger, those with cardiovascular risk factors, and patients with follow-up duration less than 2 years were excluded from the study.

RESULTS

Epicardial adipose tissue thickness and CIMT were thicker compared to controls. While patients' low-density lipoprotein (LDL) levels were higher than controls, and high-density lipoprotein (HDL) levels were lower, the levels were in normal ranges. Those patients with duration of follow-up more than five years had thicker EATT. The 5-year LDL was in normal ranges while HDL was abnormally low. Number of ASM(s) was not associated with increased risks of atherosclerosis. Increased CIMT in patients taking ASM(s) was independent of their lipid profile.

CONCLUSION

Anti-seizure medications contribute to accelerated atherosclerosis in people with epilepsy. Chronic use of ASMs may increase this chance. It is appropriate to use ASM(s) with lower chances of atherosclerosis in people with epilepsy and encourage them to change their lifestyle in order to modify cardiovascular risk factors. Meantime, it is reasonable to assess the risk of atherosclerosis periodically in these patients by noninvasive methods including lipid profile, CIMT, and EATT.

The correlation between carbamazepine and valproic acid monotherapy with serum adiponectin and carnitine

Antiepileptic drugs may cause systemic and metabolic side effects. The aim of our study was to investigate the effects of valproic acid and carbamazepine monotherapy used in the treatment of epilepsy patients on serum adiponectin and carnitine levels. The study included 60 patients, of which 30 patients receiving valproic acid monotherapy and 30 patients receiving carbamazepine monotherapy, who were followed up by the epilepsy outpatient clinic with the diagnosis of idiopathic epilepsy, and 30 healthy volunteers. Patients, who used drugs for at least 6 months, were selected. Venous blood samples were collected from the patients and healthy volunteers after their consent was obtained. Serum carnitine and adiponectin levels in the collected samples were measured using the ELISA method. Serum carnitine levels were 5166.55 ng/ml (± 1954.92) in patients receiving carbamazepine, 4224.56 ng/ml (± 2055.54) in patients using valproic acid, and 5802.64 ng/ml (± 3422.57) in the control group. Serum adiponectin levels were 13,606.51 ng/ml (± 5915.92) in patients using carbamazepine, 11,986.58 ng/ml (± 5367.82) in patients receiving valproic acid, and 14,033.43 ng/ml (± 5646.34) in the control group. In both groups, both serum carnitine and serum adiponectin levels were lower than the control group. There was a negative but insignificant correlation between the duration and dose of carbamazepine and valproic acid drug use and serum adiponectin and carnitine levels. There is a need for more extensive studies with larger sample size to investigate the effect of antiepileptic drugs used on serum adiponectin and carnitine levels.

Readmission for cardiac and non-cardiac causes among adults with epilepsy or multiple sclerosis - A nationwide analysis

PURPOSE

The aim of this study was to determine proportions of 30-day cardiac readmissions in adults with epilepsy compared to multiple sclerosis (MS) or those with neither condition. Predictors and causes of readmissions were also examined.

METHODS

We used the 2014 Nationwide Readmissions Database and ICD-9-CM codes to identify people with epilepsy, MS, and without epilepsy or MS. Multinomial logistic regressions were fitted to: (1) examine association between 30-day readmissions and epilepsy, MS or neither, and (2) to describe causes and predictors of 30-day readmission for cardiac readmissions in epilepsy.

RESULTS

Out of 6,870,508 adults admitted in 2014, 202,938 (2.98%) had epilepsy and 29,556 (0.45%) had MS. The proportion of 30-day readmission for epilepsy and MS were, respectively: (1) due to cardiac causes (0.17% vs. 0.13%); (2) due to other causes (13.89% vs. 10.61%). The odds of 30-day cardiac readmission in those with epilepsy and MS were lower compared to those without either condition (OR = 0.64, 95% CI 0.57-0.73, p < 0.0001; OR = 0.60, 95% CI 0.43-0.84, p = 0.003). Among those with epilepsy, increasing age (OR = 1.03, 95% CI 1.02-1.04, p < 0.0001) and a Charlson comorbidity index ≥1 (OR = 1.79, 95% CI 1.24-2.60, p = 0.002) were associated with higher odds of 30-day cardiac readmission. A higher proportion of those with epilepsy readmitted within 30-days due to cardiac causes died in hospital (10.09%) compared to those with MS (not reportable due to cell frequency <10) or without epilepsy or MS (5.61%).

CONCLUSION

Those admitted to a hospital and living with epilepsy had a higher proportion of cardiac readmissions and death in hospital when compared to those living with MS, and the determinants are likely multifactorial. These findings are important and need to be further explored to identify strategies to prevent readmissions due to any cause and treatments that could reduce mortality.

Effect of acute and chronic exposure to lovastatin on the anticonvulsant action of classical antiepileptic drugs in the mouse maximal electroshock-induced seizure model

Numerous studies indicate neuroprotective activity of statins, commonly used cholesterol lowering drugs in epilepsy and several other neurological diseases. Promising anti-convulsant and neuroprotective effects of statins, attributed to their anti-excitotoxic and anti-inflammatory action were reported in several animals' seizure models. To determine the effects of acute (single) and chronic (once daily for 7 consecutive days) administration of lovastatin on the protective activity of four classical antiepileptic drugs such as carbamazepine, phenobarbital, phenytoin and valproate in the mouse maximal electroshock seizure model. Seizure activity (maximal electroconvulsions) in mice were generated by alternating current delivered via ear-clip electrodes. Adverse-effect profile of lovastatin combinations with the tested antiepileptic drugs was assessed in the chimney test (motor performance). Total brain concentrations of antiepileptic drugs were evaluated with the fluorescence polarization immunoassay technique as a measure of the pharmacokinetic interaction between drugs. Lovastatin administered acutely or chronically (5-20 mg/kg) did not significantly affect the threshold for electroconvulsions in mice. Acute lovastatin (10 mg/kg) significantly enhanced the anticonvulsant effect of valproate, which was accompanied with a 34% significant increase in total brain concentration of valproate. Acute lovastatin in combination with phenytoin impaired motor performance by notably decreasing the TD50 value of phenytoin. Chronic lovastatin (10 mg/kg) markedly enhanced the anticonvulsant potential of phenytoin. Acute lovastatin increased anticonvulsant action of valproate but also significantly raised level of valproate in brain after combined administration suggesting pharmacokinetic nature of interaction. The combinations of chronic lovastatin combined with phenytoin can potentially enhance the anticonvulsant potency of phenytoin.

Atherogenic Risk Factors among Young Indian Adults with Epilepsy on Treatment with Phenytoin: Need for Novel Therapeutic Strategies

Background

Risk for the development of coronary heart disease and diabetes is found to be more among people with epilepsy especially when on treatment. Redox imbalance contributes to this risk especially in India as it is the diabetic capital of the world with higher prevalence of inflammation.

Objectives

The aim of this study was to evaluate atherogenic risk factors; dyslipidemia, oxidative stress, and systemic inflammation among young Indian adults with epilepsy on treatment with Phenytoin.

Material and Methods

Three groups of age and gender-matched young subjects were recruited. Group 1-Healthy control subjects, Group 2- Newly diagnosed epileptic young adults with recent epileptic seizures, Group 3- Epileptic adults on treatment with Phenytoin for more than 6 months were recruited.

Results

Dyslipidemia was found among the newly diagnosed epileptic subjects in comparison to healthy subjects. The LDL-cholesterol further increased, and HDL-cholesterol further decreased in the third group treated with Phenytoin. Body mass index of these treated epileptic subjects was more in comparison to healthy control. Low-grade inflammation as assessed by hsCRP and oxidative stress were significantly higher among the newly diagnosed epileptic subjects when compared to the healthy controls which further increased on treatment with phenytoin. We found dyslipidemia, oxidative stress, and low-grade inflammation among newly diagnosed epileptic subjects which further increased on treatment with Phenytoin for more than 6 months.

Conclusion

From this study, we conclude that dyslipidemia, oxidative stress and low-grade inflammation are identified among the newly diagnosed young adult Indian epileptic patients. Phenytoin treatment further augmented these complications.

Zonisamide Therapy Reduces Metabolic Consequences and Diminishes Nonalcoholic Fatty Liver Disease in Patients with Epilepsy

Antiepileptic drugs that can reduce aberrant metabolism are beneficial for patients. Zonisamide (ZNS) is a chemical with antiepileptic and antioxidant activities. Here, we evaluate the efficacy of ZNS therapy on reducing obesity and decreasing risks of vascular diseases and hepatic steatosis. Clinical and metabolic indicators including body weight, body mass index (BMI), serum lipid profiles, glycated hemoglobin (HbA1c), homocysteine, and an inflammatory marker, high-sensitivity C-reactive protein (hs-CRP), were assessed at baseline and at the end of 12 and 24 weeks of treatment. Nonalcoholic fatty liver disease was evaluated using the hepatic steatosis index (HSI). A body weight reduction of ≥5% was observed in 24.6% and 32.8% of patients after 12 and 24 weeks of ZNS treatment, respectively. After adjusting for age, sex, time, and the corresponding dependent variable at baseline, the generalized estimating equation analysis revealed that the body weight, BMI, serum levels of HbA1c, triglycerides, hs-CRP, and the index for HSI were significantly declined. These results suggest that ZNS provides benefits in patients with obesity and metabolic syndrome at high vascular risk.

Dietary and lifestyle behavior in adults with epilepsy needs improvement: a case-control study from northeastern Poland

BACKGROUND

Several factors predispose individuals with epilepsy to chronic diseases. Among them, nutrition and lifestyle factors have not been sufficiently studied. Therefore, the aim of this study was to evaluate patients with epilepsy in terms of diet, body composition and physical activity compared to healthy sex- and age-matched subjects to investigate whether there are risk factors for nutritional deficiencies and risk factors for the development of metabolic diseases.

METHODS

The case-control study involved 60 epileptic male and female volunteers and 70 healthy controls matched according to age and sex. Medical information was collected during the study, and a detailed questionnaire regarding eating and lifestyle habits was conducted. Physical activity was evaluated using the International Physical Activity Questionnaire (IPAQ). Nutritional status was assessed by bioelectric impedance. Venous blood samples were taken for lipid and 25-hydroxyvitamin D3 (25(OH)D3) analyses.

RESULTS

A tendency toward an increase in LDL cholesterol was found in the individuals with epilepsy. Significantly higher body fat and insignificantly higher visceral fat were found in epileptic men than in healthy men. In epileptic women, a tendency toward a lower lean body mass was found. Patients with epilepsy were more sedentary, consumed less cottage cheese, fruit, pulses, nuts and seeds, vitamin C and potassium, and consumed more sugar-sweetened soda, fat and sodium than healthy people. On a positive note, individuals with epilepsy consumed less coffee and alcoholic beverages. More than 80% of the epileptic volunteers had diets that were low in folic acid, vitamin D and calcium, but a similar tendency was observed in the healthy volunteers. A higher percentage of the patients with epilepsy had diets that were low in niacin, vitamin C and potassium than the control group (25% vs. 7, 50% vs. 31% and 73 vs. 56%, respectively). A significantly lower serum concentration of 25(OH)D3 was observed in epileptic individuals and was found to be positively modulated by physical activity.

CONCLUSIONS

The results indicate that several behavior-related habits, which may predispose epileptic people to cardiovascular disease, need to be improved. For this reason, patients with epilepsy should be provided with more comprehensive medical care, including advice on nutrition and physical activity.

Effects of long-term anti-seizure medication monotherapy on all-cause death in patients with post-stroke epilepsy: a nationwide population-based study in Taiwan

OBJECTIVE

We aim to compare the effect of long-term anti-seizure medication (ASM) monotherapy on the risk of death and new ischemic stroke in patients with post-stroke epilepsy (PSE).

PATIENTS AND METHODS

We identified all hospitalized patients (≥ 20 years) with a primary diagnosis of ischemic or hemorrhagic stroke from 2001 to 2012 using the National Health Insurance Research Database in Taiwan. The PSE cohort were defined as the stroke patients (1) who had no epilepsy and no ASMs use before the index stroke, and (2) who had epilepsy and ASMs use after 14 days from the stroke onset. The patients with PSE receiving ASM monotherapy were enrolled and were categorized into phenytoin, valproic acid, carbamazepine, and new ASM groups. We employed the Cox regression model to estimate the unadjusted and adjusted hazard ratios (HRs) with 95 % confidence intervals (CIs) of death and new ischemic stroke within 5 years across all groups, using the new ASM group as the reference.

RESULTS

Of 6962 patients with PSE using ASM monotherapy, 3917 (56 %) were on phenytoin, 1623 (23 %) on valproic acid, 457 (7 %) on carbamazepine, and 965 (14 %) on new ASMs. After adjusting for confounders, compared with new ASM users, phenytoin users had a higher risk of death in 5 years (HR: 1.64; 95 % CI: 1.06-2.55). On the other hand, all ASM groups showed a similar risk of new ischemic stroke in 5 years.

CONCLUSIONS

Among patients with PSE on first-line monotherapy, compared to new ASMs, use of phenytoin was associated with a higher risk of death in 5 years.

The effect of ketogenic diet on serum lipid concentrations in children with medication resistant epilepsy

BACKGROUND

Ketogenic diet (KD) is a valuable treatment option for patients with medication-resistant epilepsy. It is associated with a number of side effects. However limited data are available for the long-term effects of KD on serum lipid levels.

PURPOSE

The aim of this study was to investigate the long-term effects of KD on serum lipid concentrations in children with medication-resistant epilepsy in daily clinical practice.

METHOD

A total of 73 children (40 girls) aged 3 to 193 months (median, 53 months) with medication-resistant epilepsy who received a KD treatment for at least 12 months between 2014 and 2019 years were enrolled in the study. All children were started on a KD with 3:1 ratio which was then adjusted between 2:1 to 4:1 after the onset of KD as clinically necessary. Serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride concentrations and body mass index-standard deviation scores (BMI-SDS) were measured at onset and at 1, 6 and 12 months of treatment, and also in 40 of these patients they were measured at 18 and 24 months of treatment.

RESULTS

Dyslipidemia was observed in 71.2, 63, 63, 50, and 52.5% of the patients, at 1, 6, 12, 18, and 24 months, respectively. Median total cholesterol and triglyceride concentrations increased significantly at month-1, and although these high levels persisted for 24 months, the increase did not continue and showed a downward trend. However, this increase did not occur in the subset of patients with pre-existing dyslipidemia. Compared to baseline values, total cholesterol and triglyceride concentrations were higher at all time points, except 24-month cholesterol values. During the 24-month treatment period, BMI-SDS increased and the number of antiepileptic drugs decreased significantly.

CONCLUSION

Total cholesterol and triglyceride concentrations appear to increase during the first month of KD treatment, and although these high values persist for 24 months, the increase does not continue, on the contrary, it approaches the normal values by drawing a downward trend. However, cholesterol and triglyceride concentrations do not increase in the subset of patients with pre-existing dyslipidemia.

Protective effects of phenethyl isothiocyanate on foam cell formation by combined treatment of oxidized low-density lipoprotein and lipopolysaccharide in THP-1 macrophage

Accumulation of cholesterol-laden macrophage foam cells characteristic of early stage atherosclerotic lesions. Phenethyl isothiocyanate (PEITC) is a naturally occurring isothiocyanate found in cruciferous vegetables that has reported a variety of activities including antioxidant and anti-inflammatory properties. However, the protective effect of PEITC on foam cell formation and its precise mechanism is not yet clear. Therefore, we investigated whether PEITC suppresses foam cell formation and regulates the expression of genes related to lipid accumulation, cholesterol efflux, and inflammation in THP-1 derived-macrophages. We exposed THP-1 derived-macrophages to oxidized low-density lipoprotein (ox-LDL) (20 μg/mL) and lipopolysaccharide (LPS) (500 ng/ml) to mimic foam cell formation. Here, PEITC downregulated the expression of lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1), cluster of differentiation 36 (CD36), scavenger receptor A1 (SR-A1), and nuclear factor-κB (NF-κB), while upregulated ATP binding cassette subfamily A member 1 (ABCA1)/liver-X-receptor α (LXR-α)/peroxisome proliferator-activated receptor gamma (PPARγ) and sirtuin 1 (SIRT1) expression compared to co-treated with ox-LDL and LPS. Taken together, PEITC, at least in part, inhibits foam cell formation and reduces lipid accumulation in foam cells. Therefore, we suggest that PEITC may be a potential candidate for the treatment and prevention of vascular inflammation and atherosclerosis.

Autonomic Dysfunction Contributes to Impairment of Cerebral Autoregulation in Patients with Epilepsy

Patients with epilepsy frequently experience autonomic dysfunction and impaired cerebral autoregulation. The present study investigates autonomic function and cerebral autoregulation in patients with epilepsy to determine whether these factors contribute to impaired autoregulation. A total of 81 patients with epilepsy and 45 healthy controls were evaluated, assessing their sudomotor, cardiovagal, and adrenergic functions using a battery of autonomic nervous system (ANS) function tests, including the deep breathing, Valsalva maneuver, head-up tilting, and Q-sweat tests. Cerebral autoregulation was measured by transcranial Doppler examination during the breath-holding test, the Valsalva maneuver, and the head-up tilting test. Autonomic functions were impaired during the interictal period in patients with epilepsy compared to healthy controls. The three indices of cerebral autoregulation—the breath-holding index (BHI), an autoregulation index calculated in phase II of the Valsalva maneuver (ASI), and cerebrovascular resistance measured in the second minute during the head-up tilting test (CVR_2-min)—all decreased in patients with epilepsy. ANS dysfunction correlated significantly with impairment of cerebral autoregulation (measured by BHI, ASI, and CVR_2-min), suggesting that the increased autonomic dysfunction in patients with epilepsy may augment the dysregulation of cerebral blood flow. Long-term epilepsy, a high frequency of seizures, and refractory epilepsy, particularly temporal lobe epilepsy, may contribute to advanced autonomic dysfunction and impaired cerebral autoregulation. These results have implications for therapeutic interventions that aim to correct central autonomic dysfunction and impairment of cerebral autoregulation, particularly in patients at high risk for sudden, unexplained death in epilepsy.

Six-month effects of modified Atkins diet implementation on indices of cardiovascular disease risk in adults with epilepsy

BACKGROUND/AIMS

Ketogenic diet therapies (KDTs) offer a needed therapeutic option for patients with drug-resistant epilepsy. The current study investigated biochemical and anthropometric indices of cardiovascular disease (CVD) risk in adults with epilepsy treated with KDT over 6 months.

METHOD

65 adults with epilepsy naïve to diet therapy were enrolled in a prospective longitudinal study and instructed on modified Atkins diet (MAD) use. Seizure frequency, anthropometric measures, blood levels of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, apolipoproteins A1 and B, and lipoprotein sub-fractions were assessed at baseline, 3 months, and 6 months.

RESULTS

Subsequent to study enrollment, 34 participants were lost to follow-up, elected not to start, or stopped MAD prior to study completion, leaving a total of 31 participants in the study at 6 months. Compared to baseline, participants on MAD showed significant reductions in median seizure frequency/week, weight, body mass index, waist and hip circumference, and percent body fat at 3 and 6 months. Compared to baseline, participants on MAD for 3 months showed significantly increased levels of total, small and medium LDL particles, ApoB and ApoB/A1 ratio. At 6 months, only small LDL particles and ApoB levels remained elevated and levels of ApoA1 had risen, suggesting possible compensatory adaptation over time.

CONCLUSIONS

This study provides evidence demonstrating the efficacy and cardiovascular safety of 6 months of MAD use by adults with epilepsy. It also highlights an index of CVD risk - small LDL particles - that should be closely monitored..Trial registration: ClinicalTrials.gov identifier: NCT02694094..

Constipation and Its Associated Factors among Patients with Dementia

Constipation is one of the most frequent non-motor problems in older adults. As constipation is commonly ignored by dementia patients, it is not usually reported on time. Constipation has a serious impact on the activity of daily living and quality of life in dementia patients. The relationships between constipation, demographic variables, and the nutritional status of patients with dementia remain unknown. This study aimed to assess the possible factors associated with constipation. This cross-sectional study was conducted at the Kaohsiung Chang Gung Memorial Hospital from January to November 2019. This hospital is a medical center and the main referral hospital of southern Taiwan, serving 3 million inhabitants. In total, 119 patients with dementia were evaluated using the Rome III diagnostic criteria for functional constipation. There were 30 patients with dementia included in the constipation group and 89 patients with dementia included in the no constipation group. Mini-Nutritional Assessment and 3-day diet diary records were employed. The clinical dementia rating score was used to evaluate the severity of dementia in patients of the outpatient clinic. Approximately 25.2% of dementia patients had constipation. Patients in the dementia with constipation group were older, had severer dementia, and displayed a lower water intake. After multivariable adjustment, low liquid consumption was the predictor of constipation among patients with dementia. The findings support the clinical recommendations to treat constipation with an increased liquid intake, but not exercise, in dementia patients.

Seizure-Induced Oxidative Stress in Status Epilepticus: Is Antioxidant Beneficial?

Epilepsy is a common neurological disorder which affects patients physically and mentally and causes a real burden for the patient, family and society both medically and economically. Currently, more than one-third of epilepsy patients are still under unsatisfied control, even with new anticonvulsants. Other measures may be added to those with drug-resistant epilepsy. Excessive neuronal synchronization is the hallmark of epileptic activity and prolonged epileptic discharges such as in status epilepticus can lead to various cellular events and result in neuronal damage or death. Unbalanced oxidative status is one of the early cellular events and a critical factor to determine the fate of neurons in epilepsy. To counteract excessive oxidative damage through exogenous antioxidant supplements or induction of endogenous antioxidative capability may be a reasonable approach for current anticonvulsant therapy. In this article, we will introduce the critical roles of oxidative stress and further discuss the potential use of antioxidants in this devastating disease.

Impact of enzyme-inducing anti-epilepsy drugs on lipid levels in elderly patients with epilepsy

It has been speculated that patients with epilepsy in elderly is increasing. The effect of enzyme-inducing antiepileptic drugs (EIAED) on lipid metabolism is well known. However, the study in elderly subjects has been rarely conducted. Furthermore, it has not been directly assessed whether EIAED use causes the change of lipid levels from normal range to abnormal range. Adult patients with epilepsy (235 on EIAED, 213 on non-EIAED) were divided by age (20-64, 65-74 and 75 over years old). Longitudinal change (before starting AED, in 3 and 6 months after starting AED) of serum total cholesterol (TC), triglyceride (TRIG), HDL cholesterol (HDL-C), LDL cholesterol (LDL-C) and non-HDL cholesterol (non-HDL-C) were retrospectively analyzed using mixed models. The risk of change of lipid levels from normal range to abnormal range was also assessed by logistic regression analysis. Comparison between patients with EIAED use (EIAED group) and patients with non-EIAED use (non-EIAED group) revealed significant differences. non-EIAED group was set as reference. Differences in least square mean (LSM), 95 % confidence interval (CI) and P value in analysis of LDL-C and non-HDL-C levels (1 × 10^-2) were as follows: 0.23 (0.10 ∼ 0.36), P < 0.001, 0.22 (0.09 ∼ 0.33), P = 0.001 in patients with age 65-74. In patients of age over 75, those were 0.08 (0.01 ∼ 0.15), P = 0.038, 0.17 (0.07 ∼ 0.26), P < 0.001, respectively. In patients with age 65-74, odds ratios (ORs) (95 % CI) in change of TC, LDL and non-HDL-C level from normal range to abnormal range were 32.28 (1.83-567.05), 48.43 (2.69-869.05), 12.04 (1.29-111.88), respectively. In patients with age 75 over, odds ratios (ORs) (95 % CI) in change of TC, LDL and non-HDL-C level from normal range to abnormal range were 46.02 (2.77-762.89), 5.53 (1.27-23.94), 2.38 (1.01-10.76), respectively. EIAED use had significant impact on changes in lipid levels in elderly patients. Furthermore, we could assess the impact of switching AED from EIAED to levetiracetam (LEV) in 36 patients including elderly. Switching AED from EIAED to LEV had significant impact in reducing TC, TRIG, LDL-C and non-HDL-C in both younger adult and elderly patients.

Effect of valproic acid on overall survival in patients with high-grade gliomas undergoing temozolomide: A nationwide population-based cohort study in Taiwan

High-grade gliomas (HGGs) are a rapidly progressive and highly recurrent group of primary brain tumors. Despite aggressive surgical resection with chemoradiotherapy, prognoses remained poor. Valproic acid (VPA), a histone deacetylase inhibitor has shown the potential to inhibit glioma cell growth in vitro through several diverse mechanisms. However clinical studies regarding the effect of VPA on HGGs are limited. This study aimed to investigate whether using VPA in patients with HGGs under temozolomide (TMZ) would lead to a better overall survival (OS).We used the Taiwan National Health Insurance Research database to conduct this population-based cohort study. A total of 2379 patients with HGGs under TMZ treatment were included and were further classified into VPA (n = 1212, VPA ≥ 84 defined daily dose [DDD]) and non-VPA (n = 1167, VPA < 84 DDD) groups. Each patient was followed from 1998 to 2013 or until death. A Cox proportional hazard regression was performed to evaluate the effect of VPA and OS.The VPA group had a longer mean OS time compared with the non-VPA group (OS: 50.3 ± 41.0 vs 42.0 ± 37.2 months, P < .001). In patients between 18 and 40 years old, the difference is most significant (OS: 70.5 ± 48.7 vs 55.1 ± 46.0, P = .001). The adjusted hazard ratio is 0.81 (95% confidence interval, 0.72-0.91) for the VPA group relative to the non-VPA group.VPA at over 84 DDD improved OS in HGGs TMZ treatment.

The Epileptic Heart: Concept and clinical evidence

Sudden unexpected death in epilepsy (SUDEP) is generally considered to result from a seizure, typically convulsive and usually but not always occurring during sleep, followed by a sequence of events in the postictal period starting with respiratory distress and progressing to eventual cardiac asystole and death. Yet, recent community-based studies indicate a 3-fold greater incidence of sudden cardiac death in patients with chronic epilepsy than in the general population, and that in 66% of cases, the cardiac arrest occurred during routine daily activity and without a temporal relationship with a typical seizure. To distinguish a primarily cardiac cause of death in patients with epilepsy from the above description of SUDEP, we propose the concept of the "Epileptic Heart" as "a heart and coronary vasculature damaged by chronic epilepsy as a result of repeated surges in catecholamines and hypoxemia leading to electrical and mechanical dysfunction." This review starts with an overview of the pathophysiological and other lines of evidence supporting the biological plausibility of the Epileptic Heart, followed by a description of tools that have been used to generate new electrocardiogram (EKG)-derived data in patients with epilepsy that strongly support the Epileptic Heart concept and its propensity to cause sudden cardiac death in patients with epilepsy independent of an immediately preceding seizure.

Medication Use and the Risk of Newly Diagnosed Diabetes in Patients with Epilepsy

Epilepsy is a common neurological disorder that affects millions of people worldwide. Patients with epilepsy generally require long-term antiepileptic therapy and many of them receive polypharmacy. Certain medications, including older-generation antiepileptic drugs, have been known to predispose patients to developing diabetes. Although data mining techniques have become widely used in healthcare, they have seldom been applied in this clinical problem. Here, the authors used association rule mining to discover drugs or drug combinations that may be associated with newly diagnosed diabetes. Their findings indicate in addition to the most common culprits such as phenytoin and valproic acid, prescriptions containing carbamazepine, oxcarbazepine, or lamotrigine may be related to the development of newly diagnosed diabetes. These mined rules are useful as guidance to both clinical practice and future research.

Effects of valproic acid and levetiracetam monotherapy on carotid intima-media and epicardial adipose tissue thickness in non-obese children with epilepsy

OBJECTIVE

The aim of the study was to investigate the risk of subclinical atherosclerosis independent from obesity and high blood lipid levels in pediatric patients with idiopathic epilepsy receiving valproic acid or levetiracetam monotherapy by evaluating carotid intima-media thickness (CIMT) and Epicardial adipose tissue thickness (EATT).

METHODS

A total of 75 patients (38 males, 37 females; mean age 127.2 ± 37.9 months) with epilepsy receiving either valproic acid or levetiracetam monotherapy for more than 12 months (Epilepsy Group) and 75 sex, age, body mass index (BMI) matched healthy children (40 males, 35 females; mean age 133.8 ± 38.7 months) (Control Group) were included in the study. The mean duration of therapy was 27.6 ± 10.5 months. Serum lipid levels (total cholesterol, triglycerides, low density lipoprotein, high density lipoprotein) and CIMT-EATT of the patients and controls were assessed. Also, epilepsy group were divided according to antiepileptic drugs (valproic acid group and levetiracetam group).

RESULTS

The CIMT was determined as 0.6 ± 0.08 mm in epilepsy group and 0.49 ± 0.15 mm in control group (p < 0.001). The EATT was measured as 5.96 ± 0.8 mm in epilepsy group and 3.7 ± 0.5 mm in control group (p < 0.001). Of epileptic patients, 45 were using valproic acid monotherapy and 30 were on levetiracetam monotherapy. There was no significant difference in terms of CIMT between valproic acid and levetiracetam groups (0.61 ± 0.09 mm vs. 0.57 ± 0.07 mm; p = 0.07). EATT measurements were significantly higher in valproic acid group compared to levetiracetam group (6.14 ± 0.8 mm vs. 5.7 ± 0.7 mm; p = 0.02). CIMT and EATT values were not associated with the dosage and duration of each antiepileptic drug.

CONCLUSION

Non-obese children with epilepsy receiving valproic acid or levetiracetam monotherapy might have an increased risk for developing subclinical atherosclerosis despite normal lipid levels. The effect of valproic acid was more evident especially on EATT.

Epilepsy in the elderly: Unique challenges in an increasingly prevalent population

Elderly individuals (aged at least 60 or 65 years) represent a rapidly growing segment of the population. The incidence and prevalence of epilepsy is higher in this age group than in any other. Diagnosing epilepsy in the elderly can be challenging because the causes and clinical manifestations of seizures often differ as compared with younger individuals. Particular differential diagnoses, such as syncope and amyloid spells, are commonly encountered in the elderly population. A diagnosis of epilepsy has important implications in the older adult, many of which already present a variety of concomitant complex medical problems, such as cognitive impairment, comorbid cerebrovascular disease, and frailty. The treatment of epilepsy in the elderly is complicated by a variety of factors related to aging, including physiological changes, medical comorbidities, and polypharmacy. In this narrative review, we will address the descriptive epidemiology, clinical presentation, differential diagnosis, diagnostic evaluation, treatment, and prognosis of epilepsy in the elderly individual.

Pharmacological Treatment of Epilepsy in Elderly Patients

The incidence and prevalence of epilepsy are highest in elderly people, and the etiologies of epilepsy in the elderly differ from those in other age groups. Moreover, diagnosing and treating epilepsy in elderly people may be challenging due to differences in clinical characteristics and physiological changes associated with aging. This review focuses on the pharmacological treatment of epilepsy in elderly patients.

Elevated Blood C-Reactive Protein Levels in Patients With Epilepsy: A Systematic Review and Meta-Analysis

Background: In recent years, increasing attention has been paid to the association between C-reactive protein (CRP) levels and epilepsy. However, studies concerning CRP levels in epilepsy have also yielded conflicting results. Thus, the objective of the present study is to systematically review the evidence and conduct a meta-analysis to investigate CRP levels in epileptic patients compared with healthy controls.

Methods: A systematic search of PubMed, EMBASE, and the Cochrane Library was performed for eligible studies. Standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were used as a measure to assess the association between CRP and epilepsy.

Results: In total, 16 case–control studies were included in the present meta-analysis, which comprised 1918 individuals. Combined results indicated that epileptic patients had significantly increased CRP levels in peripheral blood compared with healthy controls (SMD = 0.43; 95% CI: 0.19–0.67). In addition, subgroup analyses by age demonstrated that significant differences in blood CRP levels between epileptic patients and healthy controls could be found in adults (SMD = 0.47; 95% CI: 0.21–0.73) but not children (SMD = 0.26; 95% CI: −0.48–0.99).

Conclusion: The present meta-analysis shows that the CRP levels in peripheral blood were significantly increased in epileptic patients compared to healthy controls, indicating a significant association between inflammation and epilepsy. Epileptic seizures may be associated with the inflammatory response.

Mood stabilisers and risk of stroke in bipolar disorder

BACKGROUND

Research on the risk of stroke following the use of mood stabilisers specific to patients with bipolar disorder is limited.AimsIn this study, we investigated the risk of stroke following the exposure to mood stabilisers in patients with bipolar disorder.

METHOD

Data for this nationwide population-based study were derived from the Taiwan National Health Insurance Research Database. Among a retrospective cohort of patients with bipolar disorder (n = 19 433), 609 new-onset cases of stroke were identified from 1999 to 2012. A case-crossover study design utilising 14-day windows was applied to assess the acute exposure effect of individual mood stabilisers on the risk of ischaemic, haemorrhagic and other types of stroke in patients with bipolar disorder.

RESULTS

Mood stabilisers as a group were significantly associated with the increased risk of stroke in patients with bipolar disorder (adjusted risk ratio, 1.26; P = 0.041). Among individual mood stabilisers, acute exposure to carbamazepine had the highest risk of stroke (adjusted risk ratio, 1.68; P = 0.018), particularly the ischaemic type (adjusted risk ratio, 1.81; P = 0.037). In addition, acute exposure to valproic acid elevated the risk of haemorrhagic stroke (adjusted risk ratio, 1.76; P = 0.022). In contrast, acute exposure to lithium and lamotrigine did not significantly increase the risk of any type of stroke.

CONCLUSIONS

Use of carbamazepine and valproic acid, but not lithium and lamotrigine, is associated with increased risk of stroke in patients with bipolar disorder.Declaration of interestNone.

Epilepsy in the Elderly: Treatment and Consideration of Comorbid Diseases

Epilepsy is the third most common neurological disorder affecting older adults after stroke and dementia, and the incidence of epilepsy is increasing rapidly in this population. A further increase in the incidence and prevalence of epilepsy is expected in aging societies. The establishment of a correct differential diagnosis between epilepsy and other seizure disorders that are common in the elderly is crucial. The symptoms of seizures in the elderly may be different from those in younger populations. The diagnosis is difficult, probably because of nonspecific characteristics, short-term symptoms, and absence of witnesses. There are three important issues in the treatment of epilepsy in the elderly: changes in pharmacokinetic parameters, polytherapy (including non-antiepileptic and antiepileptic drugs), and susceptibility to adverse drug effects. Antiepileptic drugs (AEDs) with fewer adverse effects, including cognitive effects, and AEDs without significant pharmacokinetic drug interactions are needed. Several studies found that stroke was strongly associated with a high incidence of early seizures and epilepsy. Stroke is also one of the major causes of status epilepticus. Cortical involvement and large lesions are strongly associated with the development of seizures and epilepsy. The severity of the initial neurological deficit is a strong clinical predictor of seizures after ischemic stroke. The optimal quality of life of dementia patients cannot be achieved without a proper diagnosis of coexisting epilepsy.