Clinically important change in quality of life in epilepsy

Establishing the minimum clinically important difference of the Quality of Life in Childhood Epilepsy Questionnaire

OBJECTIVE

To estimate the minimum clinically important difference (MCID) for the parent-reported 55-item Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-55) and its shortened 16-item version, QOLCE-16.

METHODS

Data came from 74 children with epilepsy (CWE) (ages 4-10, mean age = 8 [SD = 1.8]) enrolled in the Making Mindfulness Matter in Epilepsy (M3-E) trial, a pilot, parallel randomized-controlled trial of a mindfulness-based intervention. Both anchor-based and distribution-based methods were used to estimate MCID values for the QOLCE-55 and QOLCE-16. For the anchor-based approach, the Patient Centered Global Ratings of Change (PCGRC) scale and linear regression analysis were used to estimate the MCID. For the distribution-based approach, .5 SD of the health-related quality of life (HRQOL) change score distribution was used to estimate the MCID.

RESULTS

For the QOLCE-55, the MCID obtained using an anchor-based approach was 10 points and using a distribution-based method was 6 points. For the QOLCE-16, the MCID obtained using an anchor-based method was 13 points and using a distribution-based method was 7 points.

SIGNIFICANCE

This is the first study to estimate MCID values for the QOLCE-55 and the QOLCE-16. It has been well documented that CWE are at risk of experiencing psychological, behavioral, and cognitive impairments, which can negatively impact their HRQOL. Reporting MCID values for the QOLCE-55 and QOLCE-16 is important in determining whether changes in HRQOL observed are meaningful to CWE themselves, as a key factor in shaping the nature of epilepsy care delivered.

Enhancing quality of life in epilepsy with a digital intervention (emyna): Results of the ELAINE randomized controlled trial

OBJECTIVE

Despite the availability of pharmacological treatment for seizures, people with epilepsy (PwE) commonly experience impairments in quality of life (QoL). Given the limited access to psychosocial treatments for PwE, digital interventions could bridge treatment gaps and help improve QoL. The objective of this study was to examine the effectiveness of emyna, a fully automated digital intervention based on cognitive behavioral therapy (CBT) techniques, in improving health-related QoL among PwE who reported impairments in QoL. A previous trial showed that emyna was effective in improving depressive symptoms among PwE with a comorbid depressive disorder, but its effects on QoL among PwE without comorbid depression remain unknown.

METHODS

A pragmatic randomized controlled trial was conducted with N = 438 PwE (mean age = 37.5, 70.3% women, physician-verified diagnoses) who were assigned to the intervention group (n = 216), which used emyna alongside treatment as usual (TAU), or the control group (n = 222), which received TAU only. QoL and secondary outcomes such as general self-efficacy, medication adherence, general distress, and epilepsy-related work and social adjustment were assessed at baseline, 3 months, and 6 months. The primary outcome was QoL assessed with the Quality of Life in Epilepsy [QOLIE-31] total score at 3 months post-randomization.

RESULTS

Findings from the intent-to-treat analyses showed that after 3 months, participants in the intervention group experienced significant and clinically relevant improvements in health-related QoL compared to the control group (baseline-adjusted group difference = 4.5; 95% CI = [2.0, 6.9], p < 0.001; Cohen's d = 0.32). Effects on secondary outcomes did not reach statistical significance.

SIGNIFICANCE

This study extends previous research by demonstrating that emyna facilitates improvements in QoL in a diverse group of PwE treated in routine care settings. This CBT-based digital intervention therefore presents a convenient and cost-effective addition to healthcare providers' treatment repertoire.

PLAIN LANGUAGE SUMMARY

In our study, we tested a digital program called emyna, which conveys cognitive behavioral therapy (CBT) techniques to help improve the quality of life for people living with epilepsy. We found that those who used emyna alongside their usual treatments felt better about their quality of life compared to those who did not use the program. Emyna offers a new, convenient way for people with epilepsy to manage their condition, which can be used alongside currently available treatments.

An observational time-series study on the behavioral effects of adjunctive artisanal cannabidiol use by adults with treatment resistant epilepsies

BACKGROUND

For approximately 30% of people with epilepsy, seizures are not well-controlled by anti-seizure medication (ASM). This condition, called treatment resistant epilepsy (TRE), is associated with increased morbidity and mortality, and substantially impacts the quality of life of both the individual and their family. Non-responsiveness to ASMs leads many people with TRE to seek alternative therapies, such as cannabinoid-based medication, particularly cannabidiol (CBD), with or without medical or professional advice. This is due in part to widespread reporting in the media about the benefits of CBD for seizures in some forms of epilepsy.

METHODS

Adults with TRE, opting to add CBD to their existing treatment regime, completed this prospective, observational, longitudinal, quasi-experimental, time-series study. We hypothesized that adjunctive CBD use would positively impact participants' quality of life and psychological well-being in comparison to a baseline period without CBD use. Participants were followed for a period of approximately six months - for approximately one month of baseline prior to the initiation of CBD use and approximately five months after the initiation of CBD use. Participants provided urine samples and completed behavioral questionnaires that assessed quality of life, anxiety/depression, and adverse events during baseline and at two times during CBD use.

RESULTS

Complete case analyses (n = 10) showed a statistically significant improvement in quality of life, a statistically significant decrease in anxiety symptoms, and a statistically significant decrease in the experience of adverse events over time (p < 0.05). Improvements noted in the experience of depression symptoms did not reach statistical significance. Urinalysis revealed the majority of participants had no CBD/metabolites in their system at the beginning of the study, and confirmed the presence of CBD/metabolites in participants' urine after CBD was added to their treatment regime. Analysis of missing data using multiple imputation supported the findings of the complete case analysis.

INTERPRETATION

For a small group of individuals with TRE of varying etiologies, adjunctive use of artisanal CBD was associated with improvements in the behavioral and psychological symptoms of TRE, as well as improved medication tolerability.

Neuropsychological Rehabilitation for Epilepsy in India: Looking Beyond the Basics

BACKGROUND

Neuropsychological Rehabilitation (NR) helps manage cognitive deficits in epilepsy. As internationally developed programs have limited applicability to resource-limited countries, we developed a program to bridge this gap. This 6-week caregiver-assisted, culturally suitable program has components of (1) psychoeducation, (2) compensatory training, and, (3) cognitive retraining and is called EMPOWER (Indigenized Home Based Attention and Memory Rehabilitation Program for Adult Patients with Drug Refractory Epilepsy). Its efficacy needs to be determined.

METHODS

We carried out an open-label parallel randomized controlled trial. Adults aged 18-45 years with Drug Refractory Epilepsy (DRE), fluency in Hindi and or English, with impaired attention or memory (n = 28) were randomized to Intervention Group (IG) and Control Group (CG). The primary outcomes were objective memory (Auditory Verbal Learning Test), patient and caregiver reported everyday memory difficulties (Everyday Memory Questionnaire-Revised), number of memory aids in use, depression (Hamilton Depression Rating Scale), anxiety (Hamilton Anxiety Rating Scale) and quality of life (Quality of Life in Epilepsy-31). Intention to treat was carried out for group analysis. In the absence of norms necessary for computing Reliable Change Indices (RCIs), a cut-off of +1.0 Standard Deviation (SD) was utilized to identify clinically meaningful changes in the individual analysis of objective memory. A cut-off of 11.8 points was used for quality of life. Feedback and program evaluation responses were noted.

RESULTS

The majority of the sample comprised DRE patients with temporal lobe epilepsy who had undergone epilepsy surgery. Group analysis indicated improved learning (p = 0.013), immediate recall (p = 0.001), delayed recall (p < 0.001), long-term retention (p = 0.031), patient-reported everyday memory (p < 0.001), caregiver-reported everyday memory (p < 0.001), anxiety (p = 0.039) and total quality of life (p < 0.001). Individual analysis showed improvement in 50 %, 64 %, 71 %, 57 %, and 64 % of patients on learning, immediate recall, delayed recall, long-term retention, and total quality of life respectively. Despite improvements, themes indicative of a lack of awareness and understanding of cognitive deficits were identified. Overall, the program was rated favorably by patients and caregivers alike.

CONCLUSION

NR shows promise for patients with DRE, however larger studies are warranted. The role of cognition in epilepsy needs to be introduced at the time of diagnosis to help lay the foundation for education and acceptance.

German questionnaires assessing quality of life and psycho-social status in people with epilepsy: Reliable change and intercorrelations

OBJECTIVES

People with epilepsy (PWE) not only suffer from seizures but also from various psycho-social issues containing facets such as social functioning, anxiety, depression or stigmatization, and consequently quality of life. (1) Assessing reliable change of these issues is crucial to evaluate their course and potential treatment effects. As most psycho-social self-report questionnaires have been validated in separate samples, their clinical-socio-demographic differences may limit the comparability and generalizability of the scales' internal consistency, which is important for the reliable change index (RCI). Using a co-normalized approach, we provide the internal consistency and RCIs for a large set of questionnaires targeting quality of life (QOLIE-31-P), depressive symptoms (NDDI-E), anxiety (GAD-7), seizure severity (LSSS), subjective antiseizure medication adverse events (LAEP), stigma, epilepsy-related fear, and restrictions in daily life (PESOS), and subjective cognition (FLei). As for some German versions of these measures, psychometric data is still missing, we also add important information for the German language area. (2) In addition, knowledge about intercorrelations of these constructs is needed to shape questionnaire usage and treatment approaches. We thus investigate associations of these scales and compare weighted and unweighted subscales of the QOLIE-31-P.

METHODS

In our prospective study, 202 adult in-patients of the Epilepsy-Center Berlin-Brandenburg with a reliable diagnosis of epilepsy filled out a set of self-report questionnaires between 03/2018 and 03/2021. We calculated Cronbach's α, RCIs, and bivariate intercorrelations and compared the respective correlations of weighted and unweighted scales of the QOLIE-31-P.

RESULTS

For most of the scales, good to excellent internal consistency was identified. Furthermore, we found intercorrelations in the expected directions with strong links between scales assessing similar constructs (e.g., QOLIE-31-P Cognition and FLei), but weak relationships between measures for different constructs (e.g., QOLIE-31-P Seizure worry and FLei). The QOLIE-31-P Total score was highly correlated with most of the other scales. Some differences regarding their correlational patterns for weighted and unweighted QOLIE-31-P scales were identified.

CONCLUSIONS

Psycho-social constructs share a large amount of common variance, but still can be separated from each other. The QOLIE-31-P Total score represents an adequate measure of general psycho-social burden.

Improvement in health perception but not quality of life with an antiseizure medication intervention in people with epilepsy in Guinea: A cohort study

BACKGROUND

This study assesses perceptions of quality of life (QOL) and overall health in people with epilepsy (PWE) in Guinea after a clinical intervention providing modified and new antiseizure medicine (ASM) regimens.

METHODS

Participants 12 years and older diagnosed with active epilepsy were prospectively and consecutively enrolled at two health centers in the Republic of Guinea (one urban, one rural) in 2022. 95% of participants were prescribed new/increased ASM doses, and interviewed for QOL and overall health perceptions at enrollment and three- and six-month follow ups. Univariate and linear mixed models were used to evaluate effects on QOL and overall health over time.

RESULTS

The mean QOLIE-31 score (±SD) among 148 Guinean PWE (82 male, 66 female; mean age 27.3; 137 with >1 seizure in prior year) was 51.7 ± 12.8 at enrollment, 57.6 ± 16.0 after three months (n = 116), and 52.2 ± 9.9 after six months (n = 87). Overall health scores were 53.1 ± 26.9, 72.6 ± 21.5, and 65.7 ± 20.2 respectively. After three months, PWE had improved overall health and QOLIE-31 scores (p<0.0001, p = 0.003), but these improvements persisted for overall health and not QOLIE-31 after six months (p = 0.001, p = 0.63). Seizure freedom (prior 30 days) was 26% initially, and 62 (42%) of the remaining PWE experiencing seizures achieved seizure freedom at either the first or second follow-ups.

CONCLUSIONS

A noticeable discrepancy exists between Guinean PWE's self-rated perceptions of QOL and overall health. Purely clinical interventions may not be sufficient to improve QOL, especially in people that experience severe, previously-untreated epilepsy in lower income settings.

Resective Epilepsy Surgery, QUality of life and Economic evaluation (RESQUE): the change in quality of life after resective epilepsy surgery-protocol for a multicentre, prospective cohort study

INTRODUCTION

Resective epilepsy surgery is often seen as a last resort when treating drug-resistant epilepsy. Positive results on quality of life (QoL) and economic benefits after surgery argue for a less restrictive attitude towards epilepsy surgery for drug-resistant epilepsy. QoL and economic benefits are country-dependent. The objective of the Resective Epilepsy Surgery, QUality of life and Economic evaluation (RESQUE) trial is to evaluate the change in QoL before and after epilepsy surgery in Dutch people with drug-resistant epilepsy. The results will form part of an economic evaluation of epilepsy surgery in people with epilepsy (PWE) in The Netherlands.

METHODS AND ANALYSIS

A longitudinal prospective multicentre cohort study involving 100 PWE undergoing epilepsy surgery between 2019 and 2025 is being performed in three Dutch academic hospitals. Excluded are PWE who have a lower level of intelligence (TIQ<70) or who do not master the Dutch language. Before surgery and 3, 6, 12 and 24 months after surgery, PWE receive validated online questionnaires (QOLIE-31, EQ-5D, iMCQ and iPCQ) on QoL, cost of care, expectations and satisfaction. Primary outcome is the change in QoL. Secondary outcomes are change in generic QoL, seizure reduction (International League Against Epilepsy Outcome Classification), medical consumption, productivity, the correlation between QoL and seizure reduction and expectation of and satisfaction with the surgery.

ETHICS AND DISSEMINATION

The study design has been approved by the Medical Ethics Review Committee (METC) of Maastricht UMC+ (2019-1134) and the Amsterdam UMC (vu). At the time of writing, UMC Utrecht is in the process of considering approval. The study will be conducted according to the Dutch Medical Research Involving Human Subjects Act and the Declaration of Helsinki. The results will be publicly disclosed and submitted for publication in international peer-reviewed scientific journals. There is no veto on publication by the involved parties.

TRIAL REGISTRATION

NL8278; Pre-results.

Minimal Clinically Important Difference (MCID) in Patient-Reported Outcome Measures for Neurological Conditions: Review of Concept and Methods

The concept of the minimal clinically important difference (MCID) emerged from the recognition that statistical significance alone is not enough to determine the clinical relevance of treatment effects in clinical research. In many cases, statistically significant changes in outcomes may not be meaningful to patients or may not result in any tangible improvements in their health. This has led to a growing emphasis on the importance of measuring patient-reported outcome measures (PROMs) in clinical trials and other research studies, in order to capture the patient perspective on treatment effectiveness. MCID is defined as the smallest change in scores that is considered meaningful or important to patients. MCID is particularly important in fields such as neurology, where many of the outcomes of interest are subjective or based on patient-reported symptoms. This review discusses the challenges associated with interpreting outcomes of clinical trials based solely on statistical significance, highlighting the importance of considering clinical relevance and patient perception of change. There are two main approaches to estimating MCID: anchor-based and distribution-based. Anchor-based approaches compare change scores using an external anchor, while distribution-based approaches estimate MCID values based on statistical characteristics of scores within a sample. MCID is dynamic and context-specific, and there is no single 'gold standard' method for estimating it. A range of MCID thresholds should be defined using multiple methods for a disease under targeted intervention, rather than relying on a single absolute value. The use of MCID thresholds can be an important tool for researchers, neurophysicians and patients in evaluating the effectiveness of treatments and interventions, and in making informed decisions about care.

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

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

Impact of educational actions on the quality of life of patients with epilepsy: A randomised controlled trial

INTRODUCTION

Epilepsy is a common and disabling disease for patients and their families. The care of these patients is no longer limited to the simple control of seizures, but considers, in a more global way, their quality of life (QOL). Improving the QOL is precisely one of the main objectives of therapeutic education. The aim of this study was to evaluate the impact of educational actions on the global QOL of patients with epilepsy.

MATERIALS AND METHODS

This study was carried out between October 2016 and August 2018. 80 patients were included over 18 years old with an epileptic condition diagnosed for at least 6 months and treated in the University Hospital of Caen Normandy in France. They were randomised to either the control group with usual care or the experimental group with the group educational sessions. The overall score for the QOLIE-31 survey was assessed from the inclusion (M0) and 6 months late.

RESULTS

At the M0 mark, the score of the control group (58.1 ± 12.3) was significantly lower than that of the experimental group (61.1 ± 14.3). After 6 months, the overall QOL score, was significantly higher for the experimental group compared to the control group (p = 0.002). In the experimental group, the overall score went from 61.1 ± 14.3-69 ± 14.2 and in the control group it went from 58.1 ± 12.3-58 ± 16.2.

DISCUSSION

The quality-of-life overall score for patients having participated in educational actions provided by epilepsy specialist nurses improved significantly. Complementary research is necessary to assess the sustainability of these effects and interactions with the caregivers.

Quality of life and functional limitations in persons with epilepsy

OBJECTIVE

Epilepsy can reduce quality of life (QOL), functionality, and social participation, but these effects have not been adequately quantified in large, population-based, controlled studies. We sought to evaluate the impact of epilepsy on patients' QOL and employment outcomes.

METHODS

In this cross-sectional study we used nationally representative, pooled data from the Medical Expenditure Panel Survey (MEPS) household component files for 2010-2018. MEPS is a population-based survey of U.S. community-dwelling persons. We included respondents with condition file records for epilepsy. We also analyzed respondents with records for seizure. The primary outcomes were short form-12 physical and mental health scores. Secondary outcomes included self-rated health status, employment status, educational attainment, school/household/work limitations, and missed workdays. We compared these outcomes between persons with epilepsy (PWE) and age- and gender-matched controls.

RESULTS

We identified 1078 people with epilepsy, 2344 seizure cases, and 3422 cases of either condition (persons with epilepsy and/or seizures). Epilepsy was associated with a decrease of - 4.0 (95% CI: -5.1 to -2.8) points in SF-12 physical health scores and - 3.1 (95% CI: -4.2 to -1.9) in SF-12 mental health scores. Epilepsy was also associated with decreases in the likelihood of reporting good/very good/excellent health status (-13.3 [95% CI: -16.1 to -10.4] percentage points). Epilepsy was also associated with adverse employment-related outcomes. Specifically, PWE were 17.9 (95% CI: 14.3-21.4) percentage points more likely to report that they had work or household limitations. The associations between outcomes and epilepsy were, in most cases, larger than those between outcomes and other common, chronic conditions.

SIGNIFICANCE

Epilepsy is associated with worse quality of life and employment-related outcomes. Interventions should aim to improve functioning and patients' ability to maintain employment.

Cognitive decline and quality of life after resective epilepsy surgery

OBJECTIVES

The objectives of this study were to examine the association between cognitive decline and quality of life (QoL) change in a large sample of individuals with drug-resistant epilepsy who underwent resective surgery and to examine whether the association between cognitive decline and QoL is differentially affected by seizure classification outcome (Engel Class 1 vs. 2-4) or side of surgery (left vs. right hemisphere).

MATERIALS AND METHODS

The sample comprised 224 adults (ages ≥ 18) with drug-resistant focal epilepsy treated with resective surgery who underwent comprehensive pre-operative and post-operative evaluations including neuropsychological testing and the Quality of Life in Epilepsy Inventory - 31 between 1991 and 2020. Linear mixed-effects models were fit to examine subject-specific trajectories and assess the effects of time (pre- to post-operative), cognitive decline (number of measures that meaningfully declined), and the interaction between time and cognitive decline on pre- to post-operative change in QoL.

RESULTS

Increases in QoL following resection were observed (B = -10.72 [SE = 1.22], p < .001; mean difference between time point 1 and time point 2 QoL rating = 8.11). There was also a main effect of cognitive decline on QoL (B = -.85 [SE = .27], p = .002). Follow-up analyses showed that the number of cognitive measures that declined was significantly associated with post-surgical QoL, (r = -.20 p = .003), but not pre-surgical QoL, (r = -.04 p = .594), and with pre-to post-surgery raw change in QoL score, (r = -.18 p = .009). A cognitive decline by time point interaction was observed, such that those who had greater cognitive decline had less improvement in overall QoL following resection (B = .72 [SE = .27], p = .009). Similar results were observed within the Engel Class 1 outcome subgroup. However, within the Engel Class 2-4 outcome subgroup, QoL improved following resection, but there was no main effect of cognitive decline or interaction between cognitive decline and time point on QoL change. There was no main effect of resection hemisphere on overall QoL, nor were there interactions with hemisphere by time, hemisphere by cognitive decline, or hemisphere by time by cognitive decline.

CONCLUSIONS

Quality of life improves following epilepsy surgery. Participants who had cognitive decline across a greater number of measures experienced less improvement in QoL post-operatively overall, but there was no clear pattern of domain-specific cognitive decline associated with change in QoL. Our results indicate that cognitive decline in a diffuse set of cognitive domains negatively influences post-operative QoL, particularly for those who experience good seizure outcomes (i.e., seizure freedom), regardless of the site or side of resection.

Quality of life after epilepsy surgery: How domain-specific cognitive changes impact QOL within the context of seizure outcome

PURPOSE

Neurosurgery is an effective treatment option for pharmacoresistant epilepsy. Although post-surgical seizure freedom is considered the primary goal of epilepsy surgery, other factors that impact Quality of Life (QOL) are also important to consider, including post-surgical cognitive changes. This study aimed to examine the impact of post-surgical cognitive changes on QOL in the context of seizure outcomes.

METHODS

Participants were 196 adults with focal epilepsy who underwent either frontal (n = 27) or temporal (n = 169) lobe resection. Each participant completed pre- and post-surgical neuropsychological evaluations, and cognitive composites were constructed for the following domains: language, attention/processing speed, memory, executive function, and visuospatial skill. The Quality of Life in Epilepsy (QOLIE-10) questionnaire was used to assess QOL. Seizure outcome was determined by seizure status six months post-surgery.

RESULTS

Eighty-one percent of patients were seizure-free post-surgery and generally reported improved QOL. While a significant portion of patient's demonstrated declines in language and verbal memory following surgery, only a decline in verbal memory was associated with worse QOL; however, this relationship was no longer significant after controlling for seizure outcome. Instead, reduced post-surgical QOL was primarily observed in those who experienced both seizure recurrence and a decline in executive function. Notably, depression was a significant covariate in all of the models.

CONCLUSIONS

The findings from this study improve our ability to counsel patients about the trade-off between cognitive decline and seizure remittance in the greater context of overall QOL. Reassuringly, it appears that QOL is improved regardless of cognitive changes when patients have good seizure outcomes. However, for those that experience a "double hit" (i.e., cognitive decline without seizure remission), post-surgical QOL may be reduced. Changes in depression also appear to play a crucial role in QOL outcomes.

Quality of Life in Adult Patients With Epilepsy in Lebanon: A Cross-Sectional Study

BACKGROUND

Epilepsy is a chronic and heterogeneous neurological disorder that impairs the quality of life (QOL) of sufferers and affects their mental health in many aspects. Few studies have been conducted in the Middle East, especially in Lebanon, on the QOL of patients with epilepsy. The aim of our study is to assess the burden of epilepsy on the life of adult patients in Lebanon and measure the impact of sociodemographic and clinical factors on the QOL.

MATERIALS AND METHODS

A total of 47 patients from several neurology clinics were included in our study and asked to fill out a questionnaire including the sociodemographic variables and epilepsy-related factors. We used the Quality of Life in Epilepsy Scale-31 (QOLIE-31), which is a 31-question form covering seven attributes of the QOL; overall QOL, emotional wellbeing, social functioning, cognition, energy, seizure worry and medication effects, to assess the QOL of adult patients with epilepsy. Analysis was conducted using SPSS program version 23.

RESULTS

The mean age of our sample was 37.54 years, 53.2% of which were males. The majority were unemployed, educated, and belonging to the medium socioeconomic level. The highest subscale score was for the social functioning subscale with a mean of 74.49±25.89 and the lowest subscale score was for seizure worry with a mean of 55.81±27.14. Employment status, nationality, and socioeconomic level were shown to be associated with the QOL scores. There were no correlations between the clinical factors and the QOL scores.

CONCLUSION

 Sociodemographic factors, namely Lebanese nationality, employment status, and socioeconomic level, were associated with better QOL, reflected by the significant associations between the following parameters and the QOL scores (p-value<0.05), highlighting the positive influence of social support on the outcome of the disease. However, epilepsy-related clinical features did not show any correlation with the QOL and its subscales.

Perioperative levetiracetam for seizure prophylaxis in seizure-naive brain tumor patients with focus on neurocognitive functioning

INTRODUCTION

In seizure-naive brain tumor patients, the efficacy of perioperative prophylactic antiepileptic drug treatment remains controversial. In case of administration, the common preferred drug is levetiracetam (LEV) because of its favorable pharmacological profile. Research to date has not sufficiently determined how LEV affects cognition in the short term, as is the case in the perioperative period. The objective of this prospective study was to examine the neurocognitive functioning of seizure-naive brain tumor patients after receiving LEV perioperatively.

METHODS

Fortythree patients with supratentorial brain tumor scheduled for surgery received LEV three days before until six days after surgery as seizure prophylaxis. Cognitive functioning (NeuroCogFX), LEV plasma-levels, hematotoxicity, side-effects, as well as health-related quality of life (HRQoL, Qolie31), were recorded preoperatively before (Baseline) and after onset of LEV (Pre-Op), 4-6 days postoperatively (Post-Op) and 21 days postoperatively (Follow-Up).

RESULTS

No significant changes in cognitive functioning and HRQoL were seen after onset of preoperative LEV. There was a significant improvement of NeuroCogFX total-score at Follow-Up (p = 0.004) compared to Baseline. The overall-score Qolie31 showed simultaneous improvement patterns as cognitive functioning (p < 0.001). The most frequent side effect related to study drug was somnolence (in 28.6% of patients).

CONCLUSIONS

A significant improvement of cognitive functioning, as well as an improvement in HRQoL, were detected postoperatively. This is presumably due to the debulking effect of the surgery. Nevertheless, LEV has no detrimental effect on cognitive functioning in the perioperative phase in seizure-naive brain tumor patients.

TRIAL REGISTRATION

This study was registered prospectively (Date: 25/11/2015; EudraCT: 2015-003,916-19).

Effectiveness of a Self-Management Program to Improve Cognition and Quality of Life in Epilepsy: A Pragmatic, Randomized, Multicenter Trial

BACKGROUND AND OBJECTIVES

We conducted a multisite, pragmatic replication trial at 4 New England epilepsy centers to determine the effectiveness of Home-Based Self-Management and Cognitive Training Changes Lives (HOBSCOTCH) in a real-world setting and to assess feasibility of a virtual intervention.

METHODS

HOBSCOTCH is an 8-session intervention addressing cognitive impairment and quality of life (QoL) for people with epilepsy (PWE). Participants were recruited from epilepsy centers in 4 states and block-randomized into the following groups: in-person HOBSCOTCH (H-IP), virtual HOBSCOTCH (H-V), and waitlist control. Outcome measures were assessed for all groups at baseline, 3 months, and 6 months; intervention groups received long-term follow-up at 9 and 12 months.

RESULTS

A total of 108 participants were recruited, of whom 85 were included in this analysis (age at baseline 47.5 ± 11.5 years; 68% female). Participants completing the in-person intervention (H-IP) had a 12.4-point improvement in QoL score compared with controls (p < 0.001). Pairwise comparisons found a 6.2-point treatment effect for subjective cognition in the H-IP group (p < 0.001). There were no meaningful group differences in objective cognition or health care utilization at any time points and the treatment effect for QoL diminished by 6 months. The virtual intervention demonstrated feasibility but did not significantly improve outcomes compared with controls. Within-group analysis found improvements in QoL for both H-V and H-IP.

DISCUSSION

This study replicated the effectiveness of the HOBSCOTCH program in improving QoL for PWE. The study was conducted prior to the COVID-19 pandemic, but the distance-delivered intervention may be particularly well-suited for the current environment. Future research will explore modifications designed to improve the efficacy of H-V and the sustainability of HOBSCOTCH's treatment effect.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov (NCT02394509).

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that in-person HOBSCOTCH delivery improved subjective measures of cognition in persons with epilepsy.

Minimum clinically important difference (MCID) of the personal impact of epilepsy scale (PIES)

INTRODUCTION

The Personal Impact of Epilepsy Scale (PIES) assesses patient functional status in subscales of (1) seizure impact, (2) medication effects, (3) mood & social status, and (4) overall quality of life. This study was designed to determine the Minimal Clinically Important Change (MCID) in PIES subscale and total scores that demonstrate improvement.

METHODS

To ascertain the correspondence of PIES score change and clinical status change (improved, same, worse) in each PIES subscale and total score, we used two distinct retrospective anchor-based assessments of clinical status (patient self-assessment and trained rater assessment) across two clinic visits. Mean PIES scores were compared between clinical status groups, controlling for days between visits and initial clinical status. Personal Impact of Epilepsy Scale score change was quantified for each group to determine MCID. A small prospective proof-of-concept study was conducted in a separate subject group.

RESULTS

Patient self-report anchor analysis demonstrated lower (better) PIES scores in the "improved" group vs the "worse" group on the mood & social subscale (p < .001) and total score (p = .002), with a similar trend on the seizure subscale (p = 0.056). Clinical rater anchor analysis demonstrated lower PIES scores in the "improved" vs "worse" group in the mood & social subscale (p = .029) and a trend in total score (p = .082). For the "improved" group, the reduction in PIES scores between visits averaged across both anchor analyses was 8.14% for subscales and 8.67% for total score.

DISCUSSION/CONCLUSION

Reduction of 8% on a PIES subscale or total score indicates meaningful improvement in patient clinical status, and is designated the MCID for this instrument. Personal Impact of Epilepsy Scale can be useful in day-to-day clinical care and as an outcome metric in clinical research.

Impact of exercise as a complementary management strategy in people with epilepsy: A randomized controlled trial

OBJECTIVE

To measure the impact of 12 weeks of physical exercise as complementary management strategy on quality of life (QOL) in people with epilepsy (PWE).

METHODS

In a parallel-group, randomized controlled study with blinded outcome assessment, PWE of 18-65 years old, smartphone users were randomized into two groups. The exercise group was advised minimum 150 min per week of moderate-intense aerobic activity, as per current WHO recommendation [1], in addition to standard medical care; the control group received only standard medical care. QOL was assessed using Quality of Life in Epilepsy (QOLIE-31) inventory [2,3]; physical activity, with Global Physical Activity Questionnaire version 2 (GPAQ), and Pedometer Step Counter (a smartphone-based activity tracker application), at baseline and after 12 weeks. Body weight, body mass index, seizure frequency, and stigma scores (Epilepsy Stigma Scale Austin and colleagues) [4] were also noted.

RESULTS

One hundred and seventeen PWE were recruited (58 exercise, 59 control). Although there was an improvement in the physical activity correlates after 12 weeks compared to mean values at baseline, the differences were not significant between the groups. The total QOL mean scores at baseline in the exercise and control groups were 64.9 and 63.7 (p = 0.597) and after 12 weeks, 68.4 and 66.9 (p = 0.660), respectively. However, intragroup comparison of energy/fatigue score in the exercise group showed significant change with a p value of 0.009 and intragroup comparison of Overall QOL score in the control group showed a significant change with a p value of 0.003. Similar improvement was seen in stigma scores (p = 0.500) and seizure frequency (p = 0.388) at 12 weeks in exercise and control groups. After 12 weeks, mean values of METS ((metabolic equivalents) were 794.81 and 714.27 (p = 0.159), steps per day were 4018.32 and 3730.0 (p = 0.314), calories spent per day were 173.85 and 159.68 (p = 0.320 and distance walked per day in meters were 2576.52 and 2198.42 (p = 0.072), in the exercise and control groups, respectively.

SIGNIFICANCE

Regular physical activity for at least 150 min per week, in the form of moderate-intense aerobic exercises resulted in positive yet non-significant improvement of QOL, seizure frequency, and stigma in PWE.

Neurostimulation in People with Drug-Resistant Epilepsy: Systematic Review and Meta-Analysis from the ILAE Surgical Therapies Commission

OBJECTIVE

Summarize the current evidence on efficacy and tolerability of vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) through a systematic review and meta-analysis.

METHODS

We followed the PRISMA reporting standards and searched Ovid Medline, Ovid Embase, and the Cochrane Central Register of Controlled Trials. We included published randomized controlled trials (RCT) and their corresponding open-label extension studies, as well as prospective case series, with ≥ 20 participants (excluding studies limited to children). Our primary outcome was the mean (or median when unavailable) percentage decrease in frequency, as compared to baseline, of all epileptic seizures at last follow-up. Secondary outcomes included proportion of treatment responders and proportion with seizure freedom.

RESULTS

We identified 30 eligible studies, six of which were RCTs. At long-term follow-up (mean 1.3 years), five observational studies for VNS reported a pooled mean percentage decrease in seizure frequency of 34.7% (95% CI: -5.1, 74.5). In the open-label extension studies for RNS, the median seizure reduction was 53%, 66%, and 75% at two, five, and nine years of follow-up, respectively. For DBS, the median reduction was 56%, 65%, and 75% at two, five, and seven years, respectively. The proportion of individuals with seizure freedom at last follow-up increased significantly over time for DBS and RNS while a positive trend was observed for VNS. Quality of life was improved in all modalities. The most common complications included hoarseness, cough and throat pain for VNS and implant site pain, headache, and dysesthesia for DBS and RNS.

SIGNIFICANCE

Neurostimulation modalities are an effective treatment option for drug resistant epilepsy, with improving outcomes over time and few major complications. Seizure reduction rates among the three therapies were similar during the initial blinded phase. Recent long-term follow-up studies are encouraging for RNS and DBS but are lacking for VNS.

Developing a Conceptual Disease Model of Patient Experiences and Identifying Patient-Reported Clinical Outcome Assessments for Use in Trials of Treatments for Focal Onset Seizures

PURPOSE

To identify concepts important to understanding the experiences of adults with focal onset seizures (FOS) and evaluate clinical outcome assessments (COAs) for measuring these concepts in clinical trials of treatments for FOS.

METHODS

A search of published qualitative research, clinical trials, and approved product labels for FOS treatments was performed to develop a conceptual disease model (CDM) of patients' experience of living with FOS. Concepts of interest (COI) were selected, and a second literature search was conducted to identify COAs measuring these concepts. Ten COAs were selected and reviewed to document their development process, evidence of measurement properties, and methods for interpreting change scores using criteria proposed in regulatory guidelines for patient-reported outcomes to support label claims.

RESULTS

Concepts identified from the published literature (13 articles, 1 conference abstract), 24 clinical trials, and 8 product labels were included in a novel CDM. Impacts on physical, cognitive, and social and emotional function were chosen as COI for evaluating treatment outcomes for FOS; the additional concept of social support and coping strategies was chosen to understand patients' lived experiences. From 51 unique COAs identified, 10 were selected based on their potential coverage of the COI; some symptom severity and health-related quality of life (HRQoL) COAs covered multiple COI. Of these 10, 8 COAs evaluated impacts/limitations on physical function, 8 measured social and emotional impacts, and 5 assessed social support and coping strategies. While most assessments had gaps in evidence validating their measurement properties, 2 COAs measuring symptom severity and 1 COA measuring HRQoL had evidence confirming their potential utility in clinical trials to support label claims.

CONCLUSION

This research provides insights into the experience of patients with FOS and identifies COAs that measure concepts considered to support endpoints in clinical trials for FOS.

Prospective multisite cohort study of patient-reported outcomes in adults with new-onset seizures

Objective

New‐onset seizures affect up to 10% of people over their lifetime, however, their health economic impact has not been well‐studied. This prospective multicenter study will collect patient‐reported outcome measures (PROMs) from adults with new‐onset seizures seen in six Seizure Clinics across Melbourne, Australia and The University of Colorado, USA.

Methods

Approximately 450 eligible patients will be enrolled in the study at or following their initial attendance to Seizure Clinics at the study hospitals. Inclusion criteria for the study group are those with new‐onset acute symptomatic seizures, new‐onset unprovoked seizures, and new‐onset epilepsy. Inclusion criteria for the three comparator groups are those with noncardiac syncope, those with psychogenic nonepileptic seizures, as well as published PROMs data from the Australian general population. Exclusion criteria are those aged less than 18 years, those with a preexisting epilepsy diagnosis, and those with intellectual disabilities or other impairments which would preclude them from comprehending and completing the questionnaires. Patients will complete eight online questionnaires regarding the effect that their seizures (or seizure mimics) have had on various aspects of their life. These questionnaires will be readministered at 6 and 12 months. Patients with new‐diagnosis epilepsy will also be asked to share the reasons why they have accepted or declined antiseizure medications.

Analysis

Primary outcome measures will be quality of life, work productivity, informal care needs, and mood, at baseline compared to 6 and 12 months later for those with new‐onset seizures and comparing these outcomes to those in the three comparator groups. Secondary outcomes include mapping of QoLIE‐31 to the EQ‐5D‐5L in epilepsy, modelling indirect costs of new‐onset seizures, and exploring why patients may or may not wish to take antiseizure medications.

Significance

These data will form an evidence‐base for future studies that examine the effectiveness of various healthcare interventions for new‐onset seizure patients.

Ethics and dissemination

This study is approved by the Alfred Health Human Research Ethics Committee (SERP: 52 538, Alfred HREC: 307/19), the Austin Health Human Research Ethics Committee (HREC/59148/Austin‐2019), and the Colorado Multiple Institutional Review Board (COMIRB) (COMIRB #20‐3028).

ANZCTR trial registration number

ACTRN12621000908831.

The Influence of Telemedicine and Compassionate Care on the Quality of Life and Mental Health of Patients with Epilepsy in Northeastern China During the COVID-19 Crisis

Purpose

To understand the influence of telemedicine and compassionate care on the quality of life and mental health of patients with epilepsy (PWE) in northeastern China during the COVID-19 crisis.

Patients and Methods

Physicians in the epilepsy department conducted a questionnaire survey on PWE on February 2020. The Quality Of Life In Epilepsy-31 (QOLIE-31), Generalized Anxiety Disorder 7-Item Scale (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) were used. The intervention (IG) group received compassionate care and follow-up through telemedicine equipment every week, while the nonintervention (NIG) group did not receive. The questionnaire survey was conducted again three month later.

Results

Ninety patients were recruited: mean age 39.91±15.57 in the IG, 37.39±11.69 in the NIG, 46 (51.1%) were men. Twenty patients had difficulty in purchasing antiepileptic drugs (AEDs). Seven patients reported seizure in the last 1 month. Only 1 patient (2.2%) consulted the emergency department. Up to 84 patients’ lives were affected. Fifteen (33.3%) of the IG and 20 (44.4%) of the NIG patients stated that their family income had decreased, and among them, 13 (28.9%) in the IG group and 10 (22.2%) in the NIG group stated that they were unemployed. 3 months later, the interaction between groups and time of QOLIE-31 was significant, F (1, 88) = 16.996, p<0.001; the interaction between group and time on the PHQ-9 was significant, F (1, 88)= 14.992, p<0.001; the interaction between group and time on the QAD-7 was significant, F (1, 88)= 6.026, p<0.001.

Conclusion

Our study found that during the COVID-19 outbreak, when patients were in a lockdown, telemedicine and compassionate care were effective and successful in managing PWE in northeastern China. It is a valid method to decrease anxiety and depression and improve the patients’ quality of life. Further research is necessary about compassionate care methods for PWE.

Personality changes in patients suffering from drug-resistant epilepsy after surgical treatment: a 1-year follow-up study

OBJECTIVE

To determine changes in dimensions of personality in a sample of patients suffering from drug-resistant epilepsy at the 1-year follow-up following surgery, compared to non-surgically treated controls.

METHODS

We conducted a prospective comparative controlled study, including drug-resistant epilepsy surgery candidates. Demographic, psychiatric, neurological, and psychological data were recorded. Presurgical and 12-months follow-up evaluations were performed. Personality dimensions were measured by the NEO Five-Factor Inventory, Revised version (NEO-FFI-R), anxiety and depression symptoms were assessed by the Hospital Anxiety and Depression Scale (HADS: HADA-Anxiety and HADD-Depression), psychiatric evaluations were performed using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis-I disorders classification. Statistical analysis consisted of comparative tests, correlation analysis, and the stepwise multiple regression test (ANOVA).

RESULTS

A 1-year follow-up was completed by 70 out of 80 patients. Through the study, the surgical group decreased in neuroticism and increased in agreeableness. The controls increased in consciousness, and these changes were predicted by the earlier age of epilepsy onset and lesser score in HADD at the baseline. No personality changes were associated with seizure frequency. The presurgical evaluation concluded that both groups had no differences in demographic, psychiatric, or neurological variables with the only exception being for the number of seizures per month, which was higher in the surgical group. Psychiatric comorbidity in patients was associated with their higher degree of neuroticism and agreeableness at the baseline. Comparing control and surgical groups at the one-year follow-up, the agreeableness personality variable was higher in the surgical group, and as expected, HADS scores were higher in the control group, and seizure frequency was also higher in the control group.

SIGNIFICANCE

Higher agreeableness was the most relevant difference in personality dimensions in patients who underwent surgical treatment compared with the non-surgical treatment group. After surgery patients decreased in neuroticism and increased in agreeableness scores.

A feasibility study to assess social stress and social support in patients enrolled in a cannabidiol (CBD) compassionate access program

Cannabidiol (CBD) trials offer an opportunity to examine social factors that shape outcomes of patients with treatment-resistant epilepsy. Prior research of patients treated with CBD for epilepsy describes financial struggles of these patients/families and the association between socioeconomic status and patient-centered outcomes. However, social determinants of health in this population are still poorly understood, mainly due to data scarcity. This study aimed to establish feasibility of assessing social stress, social support, and religious participation and their associations with outcomes (perceived health, quality of life, and mood) in patients treated with CBD for epilepsy. Data were collected during 2015-2018 through structured face-to face interviews with patients/caregivers in a CBD compassionate access/research program in the southern United States. Adult (ages 19-63; n = 65) and pediatric (ages 8-19; n = 46) patients or their caregivers were interviewed at the time of enrollment in the study. Social stress was assessed with stressful life events, perceived stress, epilepsy-related discrimination, and economic stressors; social support with the Interpersonal Support Evaluation List [ISEL]-12; and religious participation with frequency of religious attendance. The results showed economic stressors to be associated with poor overall health, but no associations were noted between stress, support, and religious participation measures and quality of life or mood. Despite a robust data collection plan, completeness of the data was mixed. We discuss lessons learned and directions for future research and identify potential refinements to social data collection in people with treatment-resistant epilepsy during clinical trials.

Quality of life long after temporal lobe epilepsy surgery

OBJECTIVES

To identify variables independently associated with a meaningful improvement in QOL long after surgical treatment of drug-resistant MTLE-HS patients.

MATERIAL & METHODS

We prospectively evaluated 72 consecutive MTLE-HS surgically treated patients and analyzed pre and post-surgical variables independently associated with a meaningful improvement in QOL evaluated by the Quality of Life in Epilepsy-31 (QOLIE-31) overall score, and its domain scores determined at follow-up after 36 to 131 months (mean 93 months) after surgery.

RESULTS

The mean overall QOLIE-31 score and its subdomain scores improved significantly after surgery (p < 0.01), and 55 patients (76.4%) had a meaningful QOL improvement. Being seizure-free (Engel IA) after surgery showed a non-significant association (OR 2.63, CI 95% 0.53 to 13.05, p = 0.23) and lower depressive symptoms a significant association (OR 4.15, CI 95% 1.19 to 14.53, p = 0.03) with meaningful improvement of QOL.

CONCLUSIONS

Patients with MTLE-HS who underwent epilepsy surgery show a sustained, meaningful improvement in their QOL. Pre-surgical variables do not predict long-term QOL improvement after surgery. Lower levels of depressive symptoms at postoperative evaluation are associated with meaningful QOL improvement.

Relationships between cognitive function, seizure control, and self-reported leisure-time exercise in epilepsy

Exercise may be a strategy for improvement of cognitive deficits commonly present in people with idiopathic generalized epilepsies (IGE). We investigated the relationship between cognition and level of physical exercise in leisure (PEL) in people with IGE who have been seizurefree for at least 6 months (IGE-) as compared to those who have not been seizurefree (IGE+) and healthy controls (HCs). We hypothesized that higher level of physical exercise is associated with better cognitive functioning in patients with IGE and HCs, and that seizure control affects both PEL levels and cognitive functioning in patients with IGE. We recruited 75 participants aged 18-65: 31 people with IGE (17 IGE-, 14 IGE+) and 44 HCs. Participants completed assessments of quality of life (SF-36), physical activity levels (Baecke questionnaire and International Physical Activity Questionnaire (IPAQ)) and cognition (Montreal Cognitive Assessment (MoCA), Hopkins Verbal Learning Test - Revised (HVLT), and flanker task). Group differences (HCs vs. IGE; HCs vs. IGE+ vs. IGE-) were assessed. Pearson correlations examined linear relationships between PEL and cognitive performance. Groups were similar in age and sex. Compared to HCs, patients with IGE had higher body mass index, fewer years of education, and consistently scored worse on all measures except flanker task accuracy on incongruent trials. When examining IGE- and IGE+ subgroups, compared to HCs, both had higher body mass index, and fewer years of education. Healthy controls scored significantly better than one or both of the IGE groups on SF-36 scores, PEL levels, IPAQ activity level, MoCA scores, HVLT learning and long-delay free-recall scores, and flanker task accuracy on congruent trials. Among patients with IGE, there were no significant differences between age of epilepsy onset, duration of epilepsy, number of anti-seizure drugs (ASDs) currently being used, or the group distribution of type of IGE. In the combined sample (IGE+, IGE- and HCs), PEL positively correlated with MoCA scores (Pearson's r = 0.238; p = 0.0397) and with flanker task accuracy on congruent trials (Pearson's r = 0.295; p = 0.0132). Overall, patients with IGE performed worse than HCs on cognitive and physical activity measures, but the cognitive impairments were more pronounced for IGE+, while physical exercise levels were less for patients with IGE regardless of seizure control. While positive relationships between leisure-time PEL and cognitive performance are promising, further investigations into how exercise levels interact with cognitive functioning in epilepsy are needed.

Risk Factors for Seizure Worsening After Epilepsy Surgery in Children and Adults: A Population-Based Register Study

BACKGROUND

Increased seizure frequency and new-onset tonic-clonic seizures (TCS) have been reported after epilepsy surgery.

OBJECTIVE

To analyze potential risk factors for these outcomes in a large cohort.

METHODS

We studied prospectively collected data in the Swedish National Epilepsy Surgery Register on increased seizure frequency and new-onset TCS after epilepsy surgery 1990-2015.

RESULTS

Two-year seizure outcome was available for 1407 procedures, and data on seizure types for 1372. Increased seizure frequency at follow-up compared to baseline occurred in 56 cases (4.0%) and new-onset TCS in 53 (3.9%; 6.6% of the patients without preoperative TCS). Increased frequency was more common in reoperations compared to first surgeries (7.9% vs 3.1%; P = .001) and so too for new-onset TCS (6.7% vs 3.2%; P = .017). For first surgeries, binary logistic regression was used to analyze predictors for each outcome. In univariable analysis, significant predictors for increased seizure frequency were lower age of onset, lower age at surgery, shorter epilepsy duration, preoperative neurological deficit, intellectual disability, high preoperative seizure frequency, and extratemporal procedures. For new-onset TCS, significant predictors were preoperative deficit, intellectual disability, and nonresective procedures. In multivariable analysis, independent predictors for increased seizure frequency were lower age at surgery (odds ratio (OR) 0.70 per increasing 10-yr interval, 95% CI 0.53-0.93), type of surgery (OR 0.42 for temporal lobe resections compared to other procedures, 95% CI 0.19-0.92), and for new-onset TCS preoperative neurological deficit (OR 2.57, 95% CI 1.32-5.01).

CONCLUSION

Seizure worsening is rare but should be discussed when counseling patients. The identified risk factors may assist informed decision-making before surgery.

Would people living with epilepsy benefit from palliative care?

Palliative care (PC) is an approach to the care of persons living with serious illness and their families that focuses on improving quality of life and reducing suffering by addressing complex medical symptoms, psychosocial needs, spiritual well-being, and advance care planning. While PC has traditionally been associated with hospice care for persons with cancer, there is now recognition that PC is relevant to many noncancer diagnoses, including neurologic illness, and at multiple points along the illness journey, not just end of life. Despite the recent growth of the field of neuropalliative care there has been scant attention paid to the relevance of PC principles in epilepsy or the potential for PC approaches to improve outcomes for persons living with epilepsy and their families. We believe this has been a significant oversight and that PC may provide a useful framework for addressing the many sources of suffering facing persons living with epilepsy, for engaging patients and families in challenging conversations, and to focus efforts to improve models of care for this population. In this manuscript we review areas of significant unmet needs where a PC approach may improve patient and family-centered outcomes, including complex symptom management, goals of care, advance care planning, psychosocial support for patient and family and spiritual well-being. When relevant we highlight areas where epilepsy patients may have unique PC needs compared to other patient populations and conclude with suggestions for future research, clinical, and educational efforts.

A live-online mindfulness-based intervention for children living with epilepsy and their families: protocol for a randomized controlled trial of Making Mindfulness Matter©

BACKGROUND

Epilepsy extends far beyond seizures; up to 80% of children with epilepsy (CWE) may have comorbid cognitive or mental health problems, and up to 50% of parents of CWE are at risk for major depression. Past research has also shown that family environment has a greater influence on children's and parents' health-related quality of life (HRQOL) and mental health than epilepsy-related factors. There is a pressing need for low-cost, innovative interventions to improve HRQOL and mental health for CWE and their parents. The aim of this randomized controlled trial (RCT) is to evaluate whether an interactive online mindfulness-based intervention program, Making Mindfulness Matter (M3), can be feasibly implemented and whether it positively affects CWE's and parents' HRQOL and mental health (specifically, stress, behavioral, depressive, and anxiety symptoms).

METHODS

This parallel RCT was planned to recruit 100 child-parent dyads to be randomized 1:1 to the 8-week intervention or waitlist control and followed over 20 weeks. The intervention, M3, will be delivered online and separately to parents and children (ages 4-10 years) in groups of 4-8 by non-clinician staff of a local community epilepsy agency. The intervention incorporates mindful awareness, social-emotional learning skills, and positive psychology. It is modeled after the validated school-based MindUP program and adapted for provision online and to include a parent component.

DISCUSSION

This RCT will determine whether this online mindfulness-based intervention is feasible and effective for CWE and their parents. The proposed intervention may be an ideal vector to significantly improve HRQOL and mental health for CWE and their parents given its low cost and implementation by community epilepsy agencies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04020484 . Registered on July 16, 2019.

Theory driven analysis of social class and health outcomes using UK nationally representative longitudinal data

BACKGROUND

Social class is frequently used as a means of ranking the population to expose inequalities in health, but less often as a means of understanding the social processes of causation. We explored how effectively different social class mechanisms could be measured by longitudinal cohort data and whether those measures were able to explain health outcomes.

METHODS

Using a theoretically informed approach, we sought to map variables within the National Child Development Study (NCDS) to five different social class mechanisms: social background and early life circumstances; habitus and distinction; exploitation and domination; location within market relations; and power relations. Associations between the SF-36 physical, emotional and general health outcomes at age 50 years and the social class measures within NCDS were then assessed through separate multiple linear regression models. R2 values were used to quantify the proportion of variance in outcomes explained by the independent variables.

RESULTS

We were able to map the NCDS variables to the each of the social class mechanisms except 'Power relations'. However, the success of the mapping varied across mechanisms. Furthermore, although relevant associations between exposures and outcomes were observed, the mapped NCDS variables explained little of the variation in health outcomes: for example, for physical functioning, the R2 values ranged from 0.04 to 0.10 across the four mechanisms we could map.

CONCLUSIONS

This study has demonstrated both the potential and the limitations of available cohort studies in measuring aspects of social class theory. The relatively small amount of variation explained in the outcome variables in this study suggests that these are imperfect measures of the different social class mechanisms. However, the study lays an important foundation for further research to understand the complex interactions, at various life stages, between different aspects of social class and subsequent health outcomes.

Assessing Cognitive Change and Quality of Life 12 Months After Epilepsy Surgery-Development and Application of Reliable Change Indices and Standardized Regression-Based Change Norms for a Neuropsychological Test Battery in the German Language

Objective

The establishment of patient-centered measures capable of empirically determining meaningful cognitive change after surgery can significantly improve the medical care of epilepsy patients. Thus, this study aimed to develop reliable change indices (RCIs) and standardized regression-based (SRB) change norms for a comprehensive neuropsychological test battery in the German language.

Methods

Forty-seven consecutive patients with temporal lobe epilepsy underwent neuropsychological assessments, both before and 12 months after surgery. Practice-effect-adjusted RCIs and SRB change norms for each test score were computed. To assess their usefulness, the presented methods were applied to a clinical sample, and binary logistic regression analyses were conducted to model the odds of achieving improvement in quality of life (QOL) after surgery.

Results

The determined RCIs at 90% confidence intervals and the SRB equations for each test score included in the test battery are provided. Cohen’s kappa analyses revealed a moderate mean agreement between the two measures, varying from slight to almost perfect agreement across test scores. Using these measures, a negative association between improvement in QOL and decline in verbal memory functions after surgery was detected (adjusted odds ratio = 0.09, p = 0.006).

Significance

To the best of our knowledge, this study is the first to develop RCIs and SRB change norms necessary for the objective determination of neuropsychological change in a comprehensive test battery in the German language, facilitating the individual monitoring of improvement and decline in each patients’ cognitive functioning and psychosocial situations after epilepsy surgery. The application of the described measures revealed a strong negative association between improvement in QOL and decline in verbal memory functions after surgery.

Memory response and neuroimaging correlates of a novel cognitive rehabilitation program for memory problems in epilepsy: A pilot study

BACKGROUND

Memory deficits are very common in epilepsy, but no standard of care exists to effectively manage them.

OBJECTIVE

We assessed effectiveness of cognitive rehabilitation (CR) on memory and neural plasticity in people with epilepsy (PWE) reporting memory impairments.

METHODS

Nine PWE completed 6 weekly sessions adapted from 2 generic CR programs enriched with information regarding epilepsy. Participants completed neuropsychological, mood, and quality of life (QOLIE-31) measures prior and after completion of CR; 5/9 participants also completed pre- and post-CR fMRI while performing a verbal paired associates learning task. FMRI data were analyzed using group spatial independent components analysis methods; paired t-tests compared spatial activations for pre-/post-CR.

RESULTS

Improvements were seen in immediate recall in Rey Auditory Verbal Learning Task, QOLIE-31, and read word recognition in paired associates task (all p's≤0.05). FMRI changes comparing pre-to-post CR were noted through increased activation in the left inferior frontal gyrus (IFG) and anterior cingulate and decreased activation in the left superior temporal gyrus; also noted were decreased activations in the default mode network (DMN), right cingulate, right middle temporal gyrus, right supramarginal gyrus, and increased DMN activation in the left cuneus.

CONCLUSIONS

This study demonstrates feasibility of conducting CR program in PWE with fMRI as a mechanistic biomarker. Improvements in cognition and cortical plasticity await confirmation in larger samples.

A feasibility assessment of functioning and quality-of-life patient-reported outcome measures in adult epilepsy clinics: A systematic review

OBJECTIVE

The objective of the study was to identify functioning and quality-of-life (QOL) patient-reported outcome measurements (PROMs) feasible for use in the waiting room of adult epilepsy clinics.

MATERIAL AND METHODS

We searched PubMed and Web of Science for articles on in English, Spanish, Portuguese, Italian, and French published by the end of February 15th, 2019. We screened retrieved titles and abstracts looking for publications that reported the use of PROMs to measure functioning and QOL in epilepsy. The authors, clinical experts, and patient advocates from the Epilepsy Foundation of America conceptualized a set of desirable feasibility attributes for PROMs implementation in the waiting room of adult epilepsy clinics. These attributes included brief time for completion (i.e., ≤3 min), free cost, coverage of four minimum QOL domains and respective facets, and good evidence of psychometric properties. We defined QOL domains according to the World Health Organization's classification and created psychometric appraisal criteria based on the Food and Drug Administration's (FDA) Guidance.

RESULTS

Eighteen candidate instruments were identified and compared with respect to desirable attributes for use in adult epilepsy clinics. We found that the Quality-of-life in epilepsy (QOLIE)-10 and Patient-Reported Outcome Measurement Information System-10 (PROMIS-10) were the most feasible PROMs for implementation in adult epilepsy clinics based on our criteria. The QOLIE-10 and PROMIS-10 still lack ideal evidence of responsiveness in people with epilepsy.

CONCLUSION

This is the first systematic review that aimed to assess feasibility properties of available functioning and QOL PROMs. The QOLIE-10 and PROMIS-10 are potentially feasible instruments for implementation in the waiting room of adult epilepsy clinics. Further studies assessing the responsiveness of these PROMs are needed and will contribute to the selection of the most appropriate instrument for longitudinal use in adult epilepsy clinical practice.

Epilepsy, impaired functioning, and quality of life in patients with tuberous sclerosis complex

OBJECTIVE

To estimate health-related quality of life (HRQoL) in patients with tuberous sclerosis complex (TSC) and associated manifestations and to identify potential factors associated with HRQoL in this population of patients.

METHODS

We performed a retrospective chart review of adults with TSC who attended the outpatient clinic of the University Medical Center Utrecht in the Netherlands from 1990 to 2015 (N = 363; on average 33.6 years of follow-up). HRQoL data were assessed in 2012 using the Health Utility Index version 3 (HUI-3) questionnaire completed by patients or caregivers (N = 214 with HUI score and ≥1 TSC manifestation, including renal angiomyolipomas [rAMLs], subependymal giant cell astrocytoma [SEGA], or epilepsy).

RESULTS

Of 214 patients in the study sample, 171 had TSC-associated epilepsy (with or without rAML/SEGA), 37 had TSC and rAML (without epilepsy or SEGA), and 6 had other combinations of manifestations. The median HUI score for the 214 patients with ≥1 TSC manifestation was 0.51 (-0.371 to 1 scale, 1 = perfect health, 0 = death, <0 = worse than death). Among all components used to build the overall HUI score, the cognition component had the lowest score (mean = 0.47; 0-1 scale). Patients with TSC-epilepsy had significantly lower overall HUI than patients with TSC and rAML only (median HUI = 0.31 vs 0.95, P < .05), especially those who were in refractory state for prolonged periods of time (median HUI = -0.11 among patients with seizures during the entire duration of their follow-up time). In multivariate analyses, severe impairment of daily functioning was the strongest predictor of HRQoL decrement (adjusted HUI difference between patients with severe vs. no impairment = -0.55, P < .05).

SIGNIFICANCE

This study showed that TSC-related epilepsy is associated with lower HUI, especially for patients who have refractory seizures for prolonged periods of time. Early and effective interventions to control or reduce seizures and preserve patients' cognitive functions may help to improve patients' quality of life.

Do distance-delivery group interventions improve depression in people with epilepsy?

About one-third of people with epilepsy experience comorbid depression. The present study examined outcomes of a distance-delivery group intervention program designed to improve emotional well-being. Participants were 55 adults with epilepsy and self-reported depressive symptoms who were randomly assigned to take part in either a mindfulness-based cognitive behavioral therapy (CBT) program (UPLIFT, n = 20), an epilepsy information and self-management program (EpINFO, n = 24) that served as an active control group, or a wait-list control (WLC) group (n = 11). The Quick Inventory of Depressive Symptomatology (QIDS), Neurological Disorders Depression Inventory for Epilepsy (NDDIE), and the psychological health subscale of the World Health Organization Quality of Life (WHOQOL-BREF) scale were used to assess depression and psychological quality of life before and after treatment, and at short-term (six months) and long-term follow-up (one year) upon program completion. From pre- to posttreatment, a main effect of time was found, with participants in both the UPLIFT and EpINFO groups having reported to a similar degree a significant decrease in depressive symptoms and improved psychological health, improvements that were not seen in the WLC group. The time by group interaction effect was not significant. The effects seen at posttreatment in the UPLIFT and EpINFO groups remained at six months and one year after treatment. These data suggest that distance-delivery group intervention programs are effective at improving depression and psychological quality of life, with the EpINFO program offering benefits similar to the UPLIFT program.

Establishing Credibility for Medical Marijuana: The Proposed Prometheus Dispensary Registry for Botanical Cannabis

A previous commentary in INNOVATIONS in Pharmacy argued that, given the lack of evidence for outcomes in medical marijuana, outside of a handful of randomized clinical trials and even fewer observational studies, good clinical practice points to the need for monitoring patients who received cannabis through certified medical marijuana dispensaries. The commentary noted the lack of standards for monitoring cannabis patients and the lack of feedback from the dispensary to providers. Botanical cannabis administration was occurring in, effectively, an evidence vacuum. More to the point, dispensary owners and investors seem uninterested in establishing a robust evidence base for cannabis outcomes. Given the range of conditions and symptoms presented by patients, to include the prevalence of multiple symptoms together with the range of potential cannabis formulations, dosing regimens and delivery options, a failure to monitor patients over the course of their exposure to cannabis in not acceptable. The purpose of this commentary is to report on a proposed on-line registry structure proposed by Prometheus Research for medical marijuana dispensaries in the US. The registry tracks and reports on patients over the course of treatment with botanical cannabis with the focus on severe or chronic non-cancer pain, severe nausea, persistent muscle spasms and seizures, together with prevalent comorbidities - fatigue, anxiety, depression and sleep. This is the first time a registry has been developed for dispensaries in the United States as a model for a robust evidence base to support botanical cannabis as a therapy option.

Predictors of meaningful improvement in quality of life after selective amygdalohippocampectomy in Chinese patients with refractory temporal lobe epilepsy: A prospective study

PURPOSE

Our aim was to determine the independent predictors of minimum clinically important difference (MCID) in quality of life (QOL) after selective amygdalohippocampectomy (SAH) among Chinese patients with refractory mesial temporal lobe epilepsy (MTLE).

METHODS

We conducted a prospective study and enrolled 50 consecutive patients with refractory MTLE who underwent SAH after their presurgical evaluations. The variables independently associated with MCID in the Quality of Life in Epilepsy Inventory-31 (QOLIE-31) overall score 1 year after SAH were analyzed by multiple binary logistic regression analysis.

RESULTS

Significant improvements in the QOLIE-31 overall score and all subscale scores were observed after SAH (p < 0.001). Among 50 patients with refractory MTLE, 78% reached the criteria for MCID of QOL overall score after SAH. In the multiple binary logistic regression model, the presurgical independent predictors of significant improvement by MCID in QOL were absence of depression diagnosis (adjusted odds ratio [OR] = 8.391, 95% confidence interval [CI] = 1.240-56.776, p = 0.029) and good cognitive function (adjusted OR = 8.427, 95% CI = 1.115-63.670, p = 0.039); the postoperative independent predictor was seizure freedom (adjusted OR = 8.477, 95% CI = 1.195-60.122, p = 0.032). The sensitivity and specificity for significant improvement in the QOL were 97.4% and 45.5% respectively, with an overall model accuracy of 86.0%.

CONCLUSIONS

Presurgical depression, cognitive function, and postsurgical seizure freedom are independent predictors for meaningful improvement in QOL after SAH among the Chinese patients with refractory MTLE. Preoperative evaluation of patients with refractory MTLE should consider the cognitive dysfunction and psychological disorders.

A protocol for a randomised controlled, double-blind feasibility trial investigating fluoxetine treatment in improving memory and learning impairments in patients with mesial temporal lobe epilepsy: Fluoxetine, Learning and Memory in Epilepsy (FLAME trial)

BACKGROUND

People with temporal lobe epilepsy (TLE) report significant problems with learning and memory. There are no effective therapies for combatting these problems in people with TLE, resulting in an unmet therapeutic need. The lack of treatment is, in part, due to a poor understanding of the neurobiology underlying these memory deficits. We know that hippocampal neurogenesis, a process believed to be important in learning and memory formation, is permanently reduced in chronic TLE, and this may go some way to explain the learning and memory impairments seen in people with TLE.The common anti-depressant drug fluoxetine has been shown to stimulate neurogenesis both in the healthy brain and in neurological diseases where neurogenesis is impaired. In an animal model of TLE, administration of fluoxetine was found to restore neurogenesis and improve learning on a complex spatial navigational task. We now want to test this effect in humans by investigating whether administration of fluoxetine to people with TLE can improve learning and memory.

METHODS

This is a single-centre randomised controlled, double-blind feasibility trial. We plan to recruit 20 participants with a diagnosis of TLE and uni-lateral hippocampal sclerosis, confirmed by 3T MRI. Eligible participants will undergo baseline assessments of learning and memory prior to being randomised to either 20 mg/day fluoxetine or matching placebo for 60 days. Follow-up assessments will be conducted after 60 days of trial medication and then again at 60 days after cessation of trial medication. Feasibility will be assessed on measures of recruitment, retention and adherence against pre-determined criteria.

DISCUSSION

This trial is designed to determine the feasibility of conducting a double-blind randomised controlled trial of fluoxetine for the treatment of learning and memory impairments in people with TLE. Data collected in this trial will inform the design and utility of any future efficacy trial involving fluoxetine for the treatment of learning and memory in people with TLE.

TRIAL REGISTRATION

EudraCT 2014-005088-34, registered on May 18, 2015.

Quality of life after switching to generic levetiracetam - A prospective comparative study

BACKGROUND

Improved quality of life (QoL) is one of the most important objectives in the treatment of epilepsy. Recent prospective, clinical studies proved no significant differences between brand antiepileptic drugs (AEDs) and their generic equivalents in terms of seizure control, pharmacokinetics, or safety. In this study, we focused on possible changes in QoL and adverse events in connection with generic substitution of levetiracetam (LEV).

METHODS

This was a prospective, naturalistic, two-cohort, twin-center study. After a baseline period of 10 weeks, outpatients with epilepsy on stable treatment with Keppra® either continued on this brand (reference group, n = 16) or switched to generic LEV (1A Pharma®) (study group, n = 16) for an eight-week study period. The Quality of Life in Epilepsy Inventory-31 (QOLIE-31) and an adverse events' questionnaire were administered at inclusion, after baseline, and at the end of the study period. The study protocol included a close clinical follow-up with repeated LEV serum concentration measurements and nurse-led outpatient visits.

RESULTS

Clinically relevant improvements in overall QOLIE-31 scores according to minimally important change (MIC) estimates were seen in both groups. QOLIE-31 subscales in both groups showed significantly less worry about seizures at the end of the study compared to scores at inclusion (study group: p = 0.01; reference group: p = 0.02). No significant deterioration in QoL or adverse events were observed following generic substitution. No switchbacks occurred.

CONCLUSIONS

We found reduced seizure worries over time among people with epilepsy allocated to either generic switch or continued treatment with brand LEV. We hypothesize that the nurse-led structured follow-up had an impact on seizure worries and switchback rates because of reduced nocebo effects. Further studies on generic AED substitution, focusing on psychological outcome measures, are warranted to test this supposition.

Quality of life in adults enrolled in an open-label study of cannabidiol (CBD) for treatment-resistant epilepsy

Treatment-resistant epilepsy (TRE) is associated with low quality of life (QOL). Cannabidiol (CBD) may improve QOL, but it is unclear if such improvements are independent of improvements in seizure control. Our aim was to compare QOL at baseline and after 1 year of treatment with CBD. We hypothesized that QOL would improve independent of changes in seizure frequency (SF) or severity, mood, or adverse events. We assessed QOL using Quality of Life in Epilepsy-89 (QOLIE-89) in an open-label study of purified CBD (Epidiolex®) for the treatment of TRE. All participants received CBD, starting at 5 mg/kg/day and titrated to 50 mg/kg/day in increments of 5 mg/kg/day. We collected QOLIE-89 in adult participants at enrollment and after 1 year of treatment, or at study exit if earlier. We analyzed if the change in QOLIE-89 total score could be explained by the change in SF, seizure severity (Chalfont Seizure Severity Scale, CSSS), mood (Profile of Moods States, POMS), or adverse events (Adverse Event Profile, AEP). Associations among the variables were assessed using bivariate tests and multiple regression. Fifty-three participants completed enrollment and follow-up testing, seven at study termination. Mean QOLIE-89 total score improved from enrollment (49.4 ± 19) to follow-up (57 ± 21.3; p = .004). We also saw improvements in SF, POMS, AEP, and CSSS (all p ≤ .01). Multivariable regression results showed QOLIE-89 at follow-up associated with improvements in POMS at follow-up (p = .020), but not with AEP, CSSS, or SF (p ≥ .135). Improvement in QOL after treatment with CBD is associated with better mood but not with changes in SF, seizure severity, or AEP. Cannabidiol may have beneficial effects on QOL and mood that are independent of treatment response.

Health-related quality of life in Veterans with epileptic and psychogenic nonepileptic seizures

RATIONALE

Health-related quality of life (HRQoL) is compromised in civilians with epileptic seizures (ES) or psychogenic nonepileptic seizures (PNES). U.S. Veterans are a distinct patient group with regard to gender, age, and background. We studied HRQoL in Veterans and asked the following: (1) Is there a difference in HRQoL in Veterans with ES vs. PNES?; (2) What factors influence HRQoL in each group?; (3) What factors influenced the difference between seizure groups?

METHODS

We studied consecutive Veterans entering the epilepsy monitoring units (EMUs) of three VA Epilepsy Centers of Excellence. Patients underwent continuous video-EEG monitoring. Seizure diagnoses followed established criteria. Health-related quality of life was measured with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Evaluations included the Structured Clinical Interview for Diagnostic and Statistical Manual-IV (DSM IV), the posttraumatic stress disorder (PTSD) Checklist (PCL), the Beck Depression Inventory II (BDI-II), and the Minnesota Multiphasic Personality Inventory-2 Restructured form (MMPI-2RF). Between-group differences were tested with Wilcoxon tests. Nested regression analysis was used to evaluate the influence of demographic, social, military, seizure-related, and psychological factors on QOLIE-31 scores.

RESULTS

The median QOLIE-31 total score was 14 points lower in Veterans with PNES vs. ES (p < 0.001; Cohen's d = 0.73). Within each seizure group, psychological factors accounted for ≥50% of the variance in QOLIE scores while combined demographic, social, and seizure-related factors accounted for 18% (group with ES) and 7% (PNES). Psychological measures, particularly PCL and the BDI-II scores, accounted for all of the difference in QOLIE-31 total scores between Veterans with ES and those with PNES.

CONCLUSIONS

Health-related quality of life as measured by the QOLIE-31 is worse in Veterans with PNES as compared with those with ES. Psychological factors account for the most of the variance in QOLIE-31 scores regardless of seizure type and also account for the difference between groups with PNES and ES. Demographic, military, social, and seizure-related factors have minimal influence on HRQoL. These results in U.S. Veterans are similar to those found in civilians despite differences in patient age, gender, and background.

A comparison of the reliability and validity of SF-6D, EQ-5D and HUI3 utility measures in patients with schizophrenia and patients with depression in Singapore

There is limited evidence of a direct comparison of the psychometric performance of generic preference-based measures in patients with mental illness in an Asian patient population. The current study aimed to compare the test-retest reliability, convergent and known-group validity and magnitude of change in scores of the EuroQol Five-Dimension, Health Utility Index Mark 3 (HUI3) and Short-Form Six-Dimension (SF-6D) measures in patients with depression and patients with schizophrenia spectrum disorder. 500 patients were recruited from a tertiary psychiatric institution in Singapore. The Schizophrenia Quality of Life Scale (SQLS), 8-item Patient Health Questionnaire, Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and Positive and Negative Syndrome Scale were also included. In the schizophrenia sample, the SF-6D was found to have higher test-retest validity, convergent validity with SQLS domain scores, known-group validity and magnitude of change in scores over 6-month follow up than other measures. In the depression sample, the HUI3 was found to have higher test-retest reliability, convergent validity with Q-LES-Q, known group validity and magnitude of change in scores than other measures. Results suggest that the SF-6D and HUI3 to be more suitable as a utility measure for patients with schizophrenia and depression in an Asian patient population.

Measuring Health-Related Quality of Life in Tuberous Sclerosis Complex - Psychometric Evaluation of Three Instruments in Individuals With Refractory Epilepsy

Tuberous sclerosis complex (TSC) is a rare genetic disease associated with significant disease burden and considerable impact on health-related quality of life (HRQL). Currently no disease-specific clinical outcome assessments evaluate HRQL in individuals with TSC. A multi-center phase III study EXIST-3 (NCT01713946) assessed the efficacy and safety of two trough exposure ranges (Low exposure, LE: 3-7 ng/mL and high exposure, HE: 9-15 ng/mL) of adjunctive everolimus in patients aged 2-65 years with TSC and refractory partial-onset seizures (N = 366). Three age-specific HRQL measures were included as secondary endpoints including: quality of life in childhood epilepsy (QOLCE; caregiver-report for aged 2- < 11), the Quality of Life in Epilepsy Inventory for Adolescents-48 (QOLIE-AD-48; self-report, aged ≥ 11- < 18), and the Quality of Life in Epilepsy Inventory-31-Problems (QOLIE-31-P; self-report, aged ≥ 18). Intellectual ability was evaluated using the Wechsler Non-Verbal (WNV) Scale of Ability. Post hoc analyses were performed on the core phase primary data from EXIST-3 to evaluate the psychometric properties of the HRQL measures and calculate meaningful change estimates. Results showed that a significant subset of the trial sample (4-21 year olds) scored in the intellectual disability range, as assessed by the WNV. Psychometric analyses of the three epilepsy measures (including reliability, validity, and ability to detect change) supported the appropriateness for use in TSC. Distribution-based meaningful change estimates were generated for each HRQL measure, with estimates for the QOLIE-31-P total score largely consistent with the published literature. To our knowledge, this is the first evaluation using clinical trial data to establish the psychometric properties of the QOLCE, QOLIE-AD-48, and QOLIE-31-P for use in individuals with TSC. These findings increase confidence in the measures as valid and reliable for use in clinical trials and future research in patients with TSC.

Hippocampal deep brain stimulation: persistent seizure control after bilateral extra-cranial electrode fracture

Hippocampal deep brain stimulation (DBS) can provide an effective alternative for intractable temporal lobe epilepsy. In this case report, we describe a peculiar outcome after a post-traumatic wire-disconnection of a bilateral hippocampal DBS device. The patient presented a postoperative long-term significant reduction in seizure frequency even with an absent electric stimulation. This case gives the possibility to consider alternatives in epilepsy surgery, based on stimulation interference (lesional or electrical disturbing) in the epileptogenic zone.

Establishing minimally important differences for the American Shoulder and Elbow Surgeons score and the Western Ontario Rotator Cuff Index in patients with full-thickness rotator cuff tears

BACKGROUND

The American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Rotator Cuff Index (WORC) are frequently used measures in clinical research for patients with rotator cuff tears (RCTs). The minimally important differences (MIDs) for these measures have not been established in patients with RCTs. The purpose of this study was to establish the MIDs for patients with known RCTs treated both surgically or nonsurgically.

METHODS

We included 222 subjects with full-thickness RCTs. The WORC and ASES were collected at baseline and at 4, 8, 16, 32, 48, and 64 weeks, as was an end of study form with questions about change in the condition after treatment. We calculated anchor-based and distribution-based MIDs. We used regression modeling to determine change in MIDs as predicted by several variables.

RESULTS

For the anchor-based method, we found an MID of 21.9 for the ASES and -282.6 for the WORC. When using the distribution-based method of ½ and ⅓ the standard deviation, we arrived at an MID of 26.9 and 17.9 points for the ASES and -588.7 and -392.5 points for the WORC. No variables predicted MID changes.

CONCLUSION

This is the first study to report MIDs for the ASES and WORC in a population of patients with only full-thickness RCTs. This information will directly improve our ability to determine when patients with RCTs are changing in a meaningful manner and accurately power clinical studies using these outcome measures.

Quality of life one year after epilepsy surgery

BACKGROUND

The aim of surgery for medically intractable epilepsy was to achieve seizure freedom and improve overall quality of life (QOL) in patients. This investigation looked at changes in QOL one year after epilepsy surgery and the relationship of changes to mood, language, and seizure outcomes.

METHOD

Depressive symptoms, QOL, and naming were measured in 25 patients with temporal lobe epilepsy before and one year after dominant temporal lobe resection. The Quality of Life in Epilepsy-89 (QOLIE-89), Beck Depression Inventory II (BDI-II), and Boston Naming Test (BNT) were used, respectively, and seizure outcome was reported according to the Engel classifications. Minimum clinically important differences (MCID) and reliable change indices (RCI) were used to assess the proportion of patients who achieved meaningful improvement or worsening in the respective areas of functioning, and the relationship between outcomes was evaluated. Changes on the 17 individual items of the QOLIE-89 were also assessed.

RESULTS

Overall, there was a significant improvement in QOL, reduction in depressive symptoms, and decline in naming one year after surgery. Positive clinically important improvement in QOL was achieved in 76% of patients, meaningful reduction of depressive symptoms was achieved in 20%, and clinically important naming declines were observed in 48% of the cohort. Sixteen patients were seizure-free one year after surgery, but there was no significant correlation between changes in QOL and seizure outcome, depressive symptoms, or naming.

CONCLUSION

The results in the reported cohort of patients showed that surgical treatment of temporal lobe epilepsy in the dominant hemisphere resulted in clinically meaningful improvement in overall QOL and declines in naming but no significant reduction of mood disturbance.

Epilepsy and adverse quality of life in surgically resected meningioma

OBJECTIVES

Meningiomas are common intracranial tumors, and despite surgery or therapy with anti-epileptic drugs (AEDs), many patients suffer from seizures. Epilepsy has a significant impact on quality of life (QoL) in non-tumor populations, but the impact of epilepsy on QoL in patients with meningioma is unknown. Our aim was to evaluate the impact of epilepsy on QoL in patients that have undergone resection of a benign meningioma.

MATERIALS AND METHODS

We recruited meningioma patients without epilepsy (n=109), meningioma patients with epilepsy (n=56), and epilepsy patients without meningioma (n=64). QoL was measured with the Short Form 36 version 2 (SF-36), the Functional Assessment of Cancer Therapy (FACT-BR), and the Liverpool Adverse Events Profile (LAEP). Regression analyses identified significant determinants of QoL.

RESULTS

Patients with meningioma and epilepsy had poorer QoL scores than meningioma patients without epilepsy in all measures. In FACT-BR, this difference was significant. Multiple regression analyses demonstrated that current AED use had a greater impact on QoL scores than recent seizures. Other variables associated with impaired QoL included depression, unemployment, and meningioma attributed symptoms.

CONCLUSIONS

Epilepsy has a negative impact on quality of life in patients with benign meningioma. AED use is correlated with impaired QoL and raised LAEP scores, suggesting that AEDs and adverse effects may have led to impaired QoL in our meningioma patients with epilepsy. The severity of epilepsy in our meningioma population was comparatively mild; therefore, a more conservative approach to AED therapy may be indicated in an attempt to minimize adverse effects.