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Bosch AT, Sander JW, Thijs RD. Antiseizure Medications and Sudden Unexpected Death in Epilepsy: An Updated Review. CNS Drugs 2024; 38:807-817. [PMID: 39112912 PMCID: PMC11377662 DOI: 10.1007/s40263-024-01112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 09/06/2024]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is responsible for most epilepsy-related deaths. It is mainly related to unwitnessed nocturnal convulsions, either focal to bilateral or generalised tonic-clonic seizures (TCS). Targeted preventive strategies are currently lacking as underlying mechanisms are largely unknown. Antiseizure medications (ASMs) modulate SUDEP risk through seizure reduction, but it is yet undetermined whether individual ASMs or other medications could also influence the internal SUDEP cascade. Seizure detection devices (SDD) may offer an alternative strategy by preventing TCS from being unwitnessed. Here, we critically evaluated the current evidence on the influence of ASMs, non-epilepsy concomitant drugs and SDD on SUDEP occurrence. We found no robust evidence for the effect of starting ASMs on SUDEP beyond TCS control, but we found some indications of a protective effect for polytherapy. We found no signs that specific ASMs exert a risk for SUDEP. One study suggested a possible protective effect of levetiracetam requiring further investigation. Only a few small studies addressed the association between non-epilepsy concomitant drugs and SUDEP, with no consistent effect for psychotropic medications and one more extensive study suggesting a lower risk among statin users. We only found indirect evidence indicating a protective effect for enhancing nocturnal supervision without explicitly addressing the impact of SDD on SUDEP occurrence. Further work is needed to explore the potential of ASMs and other interventions to modulate SUDEP risk, and they should accurately account for TCS frequency, polypharmacy and markers of non-adherence.
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Affiliation(s)
- Anemoon T Bosch
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
- UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, SL9 0RJ, UK
- Neurology Department, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands.
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.
- UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK.
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Shlobin NA, Thijs RD, Benditt DG, Zeppenfeld K, Sander JW. Sudden death in epilepsy: the overlap between cardiac and neurological factors. Brain Commun 2024; 6:fcae309. [PMID: 39355001 PMCID: PMC11443455 DOI: 10.1093/braincomms/fcae309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/21/2024] [Accepted: 09/25/2024] [Indexed: 10/03/2024] Open
Abstract
People with epilepsy are at risk of premature death, of which sudden unexpected death in epilepsy (SUDEP), sudden cardiac death (SCD) and sudden arrhythmic death syndrome (SADS) are the primary, partly overlapping, clinical scenarios. We discuss the epidemiologies, risk factors and pathophysiological mechanisms for these sudden death events. We reviewed the existing evidence on sudden death in epilepsy. Classification of sudden death depends on the presence of autopsy and expertise of the clinician determining aetiology. The definitions of SUDEP, SCD and SADS lead to substantial openings for overlap. Seizure-induced arrhythmias constitute a minority of SUDEP cases. Comorbid cardiovascular conditions are the primary determinants of increased SCD risk in chronic epilepsy. Genetic mutations overlap between the states, yet whether these are causative, associated or incidentally present is often unclear. Risk stratification for sudden death in people with epilepsy requires a multidisciplinary approach, including a review of clinical history, toxicological analysis and complete autopsy with histologic and, preferably, genetic examination. We recommend pursuing genetic testing of relatives of people with epilepsy who died suddenly, mainly if a post-mortem genetic test contained a Class IV/V (pathogenic/likely pathogenic) gene variant. Further research may allow more precise differentiation of SUDEP, SCD and SADS and the development of algorithms for risk stratification and preventative strategies.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- UCL Queen Square Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London WC1N 3BG, UK
| | - David G Benditt
- Cardiac Arrhythmia and Syncope Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands
- UCL Queen Square Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London WC1N 3BG, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
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3
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Ferrin M, Häge A, Swanson J, Wong KHTW, Dittmann RW, Banaschewski T, Coghill D, Santosh PJ, Romanos M, Simonoff E, Buitelaar JK. Medication adherence and persistence in children and adolescents with attention deficit hyperactivity disorder (ADHD): a systematic review and qualitative update. Eur Child Adolesc Psychiatry 2024:10.1007/s00787-024-02538-z. [PMID: 39105823 DOI: 10.1007/s00787-024-02538-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/15/2024] [Indexed: 08/07/2024]
Abstract
Low medication-adherence and persistence may reduce the effectiveness of ADHD-medication. This preregistered systematic review (PROSPERO CRD42020218654) on medication-adherence and persistence in children and adolescents with ADHD focuses on clinically relevant questions and extends previous reviews by including additional studies. We included a total of n = 66 studies. There was a lack of consistency in the measurement of adherence/persistence between studies. Pooling the medication possession ratios (MPR) and using the most common adherence definition (MPR ≥ 80%) indicated that only 22.9% of participants had good adherence at 12-month follow-up. Treatment persistence on medication measured by treatment duration during a 12-month follow-up averaged 170 days (5.6 months). Our findings indicate that medication-adherence and persistence among youth with ADHD are generally poor and have not changed in recent years. Clinicians need to be aware that various factors may contribute to poor adherence/persistence and that long-acting stimulants and psychoeducational programs may help to improve adherence/persistence. However, the evidence to whether better adherence/persistence contributes to better long-term outcomes is limited and requires further research.
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Affiliation(s)
- Maite Ferrin
- Child and Adolescent Mental Health Service, Barnet Enfield and Haringey NHS Trust, London, UK.
- ReCognition Health, London, UK.
| | - Alexander Häge
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - James Swanson
- Department of Pediatrics, University of California, Irvine, CA, USA
| | - Kirstie H T W Wong
- Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
- Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP, UK
| | - Ralf W Dittmann
- Paediatric Psychopharmacology, Dept of Child and Adolescent Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Heidelberg, Germany
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - David Coghill
- Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Paramala J Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, UK
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Center of Mental Health, University Hospital Wuerzburg, Würzburg, Germany
| | - Emily Simonoff
- Institute of Psychiatry, Psychology and Neuroscience and Maudsley NIHR Biomedical Research Centre, King's College London, London, UK
| | - Jan K Buitelaar
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
- Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, The Netherlands
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Girgis MMF, Farkasinszky G, Fekete K, Fekete I, Vecsernyés M, Bácskay I, Horváth L. Seriousness and outcomes of reported adverse drug reactions in old and new antiseizure medications: a pharmacovigilance study using EudraVigilance database. Front Pharmacol 2024; 15:1411134. [PMID: 39119609 PMCID: PMC11307265 DOI: 10.3389/fphar.2024.1411134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/04/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction: Epilepsy is a widespread disease requiring long-term drug treatment. The aim of this study was to collect information on reported suspected adverse drug reactions (sADRs) of antiseizure medications (ASMs) and study their seriousness and outcomes in various system organ classifications (SOCs). We intended to compare old and new ASMs' ADRs. Methods: Using EudraVigilance (EV) database, we extracted line listings of reported sADRs with different ASMs over the period from January 2012 to December 2021. The list of ASMs was compiled according to the Anatomical therapeutic chemical classification system. The Medical Dictionary for Regulatory Activities version 24.0 was used for determining the SOCs of individual reported preferred terms (PTs) sADRs. In addition, we calculated the Reporting Odds Ratio (ROR), 95% confidence interval (95% CI), p-value (statistically significant if p< 0.05) and chi-square statistics. Results: A total of 276,694 reports were contained in the exported line listings which included 1,051,142 individual sADRs reported as PTs such as seizure (3.49%), drug ineffective (2.46%), somnolence (1.32%), dizziness (1.29%) and represented four SOCs: nervous system disorders (19.26%), general disorders and administration site conditions (14.39%), psychiatric disorders (11.29%) and injury, poisoning and procedural complications (9.79). Among patients, the age group between 18 and 64 years had the highest percentage (52.40%), followed by those aged over 64 years (18.75%). Of all the reported PTs, 882,706 (83.98%) had reported seriousness. Old ASMs had a significant positive association with "caused/prolonged hospitalisation", "congenital anomaly", "disabling", "life threatening" and "results in death", while new ASMS with 'other medically important condition'. There were 386 (0.04%) PTs related to Sudden Unexpected Death in Epilepsy (SUDEP). Conclusion: In our study, we examined 10 years' reported sADRs of ASMs in the EV international database. The majority of PTs were serious. Old ASMs were generally more commonly associated with undesired outcomes and seriousness. Considering their expected seriousness and outcomes, the safety profile of the different ASMs, can play a cardinal role in the selection of ASMs.
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Affiliation(s)
- Michael Magdy Fahmy Girgis
- Department of Pharmaceutical Surveillance and Economy, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Gergely Farkasinszky
- Division of Nuclear Medicine and Translational Imaging, Department of Medical Imaging, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Klára Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklós Vecsernyés
- Department of Pharmaceutical Surveillance and Economy, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Ildikó Bácskay
- Healthcare Industry Institute, University of Debrecen, Debrecen, Hungary
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - László Horváth
- Department of Pharmaceutical Surveillance and Economy, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
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Vilella L, Miyake CY, Chaitanya G, Hampson JP, Omidi SJ, Ochoa-Urrea M, Talavera B, Mancera O, Hupp NJ, Hampson JS, Rani MRS, Lacuey N, Tao S, Sainju RK, Friedman D, Nei M, Scott CA, Gehlbach B, Schuele SU, Ogren JA, Harper RM, Diehl B, Bateman LM, Devinsky O, Richerson GB, Zhang GQ, Lhatoo SD. Incidence and Types of Cardiac Arrhythmias in the Peri-Ictal Period in Patients Having a Generalized Convulsive Seizure. Neurology 2024; 103:e209501. [PMID: 38870452 DOI: 10.1212/wnl.0000000000209501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Generalized convulsive seizures (GCSs) are the main risk factor of sudden unexpected death in epilepsy (SUDEP), which is likely due to peri-ictal cardiorespiratory dysfunction. The incidence of GCS-induced cardiac arrhythmias, their relationship to seizure severity markers, and their role in SUDEP physiopathology are unknown. The aim of this study was to analyze the incidence of seizure-induced cardiac arrhythmias, their association with electroclinical features and seizure severity biomarkers, as well as their specific occurrences in SUDEP cases. METHODS This is an observational, prospective, multicenter study of patients with epilepsy aged 18 years and older with recorded GCS during inpatient video-EEG monitoring for epilepsy evaluation. Exclusion criteria were status epilepticus and an obscured video recording. We analyzed semiologic and cardiorespiratory features through video-EEG (VEEG), electrocardiogram, thoracoabdominal bands, and pulse oximetry. We investigated the presence of bradycardia, asystole, supraventricular tachyarrhythmias (SVTs), premature atrial beats, premature ventricular beats, nonsustained ventricular tachycardia (NSVT), atrial fibrillation (Afib), ventricular fibrillation (VF), atrioventricular block (AVB), exaggerated sinus arrhythmia (ESA), and exaggerated sinus arrhythmia with bradycardia (ESAWB). A board-certified cardiac electrophysiologist diagnosed and classified the arrhythmia types. Bradycardia, asystole, SVT, NSVT, Afib, VF, AVB, and ESAWB were classified as arrhythmias of interest because these were of SUDEP pathophysiology value. The main outcome was the occurrence of seizure-induced arrhythmias of interest during inpatient VEEG monitoring. Moreover, yearly follow-up was conducted to identify SUDEP cases. Binary logistic generalized estimating equations were used to determine clinical-demographic and peri-ictal variables that were predictive of the presence of seizure-induced arrhythmias of interest. The z-score test for 2 population proportions was used to test whether the proportion of seizures and patients with postconvulsive ESAWB or bradycardia differed between SUDEP cases and survivors. RESULTS This study includes data from 249 patients (mean age 37.2 ± 23.5 years, 55% female) who had 455 seizures. The most common arrhythmia was ESA, with an incidence of 137 of 382 seizures (35.9%) (106/224 patients [47.3%]). There were 50 of 352 seizure-induced arrhythmias of interest (14.2%) in 41 of 204 patients (20.1%). ESAWB was the commonest in 22 of 394 seizures (5.6%) (18/225 patients [8%]), followed by SVT in 18 of 397 seizures (4.5%) (17/228 patients [7.5%]). During follow-up (48.36 ± 31.34 months), 8 SUDEPs occurred. Seizure-induced bradycardia (3.8% vs 12.5%, z = -16.66, p < 0.01) and ESAWB (6.6% vs 25%; z = -3.03, p < 0.01) were over-represented in patients who later died of SUDEP. There was no association between arrhythmias of interest and seizure severity biomarkers (p > 0.05). DISCUSSION Markers of seizure severity are not related to seizure-induced arrhythmias of interest, suggesting that other factors such as occult cardiac abnormalities may be relevant for their occurrence. Seizure-induced ESAWB and bradycardia were more frequent in SUDEP cases, although this observation was based on a very limited number of SUDEP patients. Further case-control studies are needed to evaluate the yield of arrhythmias of interest along with respiratory changes as potential SUDEP biomarkers.
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Affiliation(s)
- Laura Vilella
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Christina Y Miyake
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Ganne Chaitanya
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Johnson P Hampson
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Shirin Jamal Omidi
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Manuela Ochoa-Urrea
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Blanca Talavera
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Oscar Mancera
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Norma J Hupp
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Jaison S Hampson
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - M R Sandhya Rani
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Nuria Lacuey
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Shiqiang Tao
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Rup K Sainju
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Daniel Friedman
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Maromi Nei
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Catherine A Scott
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Brian Gehlbach
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Stephan U Schuele
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Jennifer A Ogren
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Ronald M Harper
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Beate Diehl
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Lisa M Bateman
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Orrin Devinsky
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - George B Richerson
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Guo-Qiang Zhang
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
| | - Samden D Lhatoo
- From the Departament de Medicina (L.V.), Universitat Autònoma de Barcelona, Spain; NINDS Center for SUDEP Research (CSR) (L.V., G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., R.K.S., D.F., M.N., C.A.S., B.G., S.U.S., R.M.H., B.D., L.M.B., O.D., G.B.R., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Neurology (L.V.), Hospital del Mar, Barcelona, Spain; Division of Cardiology (C.Y.M.), Department of Pediatrics, Texas Children's Hospital, and Department of Molecular Physiology and Biophysics (C.Y.M.), Baylor College of Medicine, Houston, TX; Department of Neurology (G.C., J.P.H., S.J.O., M.O.-U., B.T., O.M., N.J.H., J.S.H., M.R.S.R., N.L., S.T., G.-Q.Z., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; University of Iowa Carver College of Medicine (R.K.S., B.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.A.S., B.D.), University College London, United Kingdom; Department of Neurology (S.U.S.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (R.M.H.), and Department of Neurobiology (J.A.O.), University of California, Los Angeles; and Cedars-Sinai Medical Center (L.M.B.), Los Angeles, CA
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Aurlien DB, Taubøll E. Antiseizure medication and SUDEP - a need for unifying methodology in research. Front Neurol 2024; 15:1385468. [PMID: 38694773 PMCID: PMC11061368 DOI: 10.3389/fneur.2024.1385468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/03/2024] [Indexed: 05/04/2024] Open
Abstract
The risk of sudden unexpected death in epilepsy (SUDEP) increases with the frequency of generalized tonic-clonic seizures. Carbamazepine (CBZ) and lamotrigine (LTG) have been suggested to increase the risk. However, the prevailing viewpoint is that the choice of antiseizure medication (ASM) does not influence the occurrence. We have explored the approach to addressing this question in relevant studies to evaluate the validity of the conclusions reached. A systematic search was performed in PubMed to identify all controlled studies on SUDEP risk in individuals on CBZ or LTG. Studies were categorized according to whether idiopathic generalized epilepsy (IGE) or females were considered separately, and whether data were adjusted for seizure frequency. Eight studies on CBZ and six studies on LTG were identified. For CBZ, one study showed a significantly increased risk of SUDEP without adjustment for seizure frequency. Another study found significantly increased risk after statistical adjustment for seizure frequency and one study found increased risk with high blood levels. Five other studies found no increase in risk. For LTG, one study showed a significantly increased risk in patients with IGE as opposed to focal epilepsy, and another study showed a significantly increased risk in females. None of the subsequent studies on LTG and none of the studies on CBZ considered females with IGE separately. Taken together the available studies suggest that LTG, and possibly CBZ, may increase occurrence of SUDEP when used in females with IGE. Additional studies with sub-group analysis of females with IGE are needed.
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Affiliation(s)
- Dag Bruheim Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Donner E, Devinsky O, Friedman D. Wearable Digital Health Technology for Epilepsy. N Engl J Med 2024; 390:736-745. [PMID: 38381676 DOI: 10.1056/nejmra2301913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
- Elizabeth Donner
- From the Division of Neurology, Hospital for Sick Children, and the Department of Paediatrics, University of Toronto - both in Toronto (E.D.); and the Epilepsy Center, Department of Neurology, New York University Grossman School of Medicine, New York (O.D., D.F.)
| | - Orrin Devinsky
- From the Division of Neurology, Hospital for Sick Children, and the Department of Paediatrics, University of Toronto - both in Toronto (E.D.); and the Epilepsy Center, Department of Neurology, New York University Grossman School of Medicine, New York (O.D., D.F.)
| | - Daniel Friedman
- From the Division of Neurology, Hospital for Sick Children, and the Department of Paediatrics, University of Toronto - both in Toronto (E.D.); and the Epilepsy Center, Department of Neurology, New York University Grossman School of Medicine, New York (O.D., D.F.)
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Cohen JM, Alvestad S, Suarez EA, Schaffer A, Selmer RM, Havard A, Bateman BT, Cesta CE, Zoega H, Odsbu I, Huybrechts KF, Kjerpeseth LJ, Straub L, Leinonen MK, Bjørk MH, Nørgaard M, Gissler M, Ulrichsen SP, Hernandez-Diaz S, Tomson T, Furu K. Comparative Risk of Major Congenital Malformations With Antiseizure Medication Combinations vs Valproate Monotherapy in Pregnancy. Neurology 2024; 102:e207996. [PMID: 38165339 PMCID: PMC10870741 DOI: 10.1212/wnl.0000000000207996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Valproate should be avoided in pregnancy, but it is the most effective drug for generalized epilepsies. Alternative treatment may require combinations of other drugs. Our objectives were to describe first trimester use of antiseizure medication (ASM) combinations that are relevant alternatives to valproate and determine whether specific combinations were associated with a lower risk of major congenital malformations (MCM) compared with valproate monotherapy. METHODS We conducted a population-based cohort study using linked national registers from Denmark, Finland, Iceland, Norway, and Sweden and administrative health care data from the United States and New South Wales, Australia. We described first trimester use of ASM combinations among pregnant people with epilepsy from 2000 to 2020. We compared the risk of MCM after first trimester exposure to ASM combinations vs valproate monotherapy and low-dose valproate plus lamotrigine or levetiracetam vs high-dose valproate (≥1,000 mg/d). We used log-binomial regression with propensity score weights to calculate adjusted risk ratios (aRRs) and 95% CIs for each dataset. Results were pooled using fixed-effects meta-analysis. RESULTS Among 50,905 pregnancies in people with epilepsy identified from 7.8 million total pregnancies, 788 used lamotrigine and levetiracetam, 291 used lamotrigine and topiramate, 208 used levetiracetam and topiramate, 80 used lamotrigine and zonisamide, and 91 used levetiracetam and zonisamide. After excluding pregnancies with use of other ASMs, known teratogens, or a child diagnosed with MCM of infectious or genetic cause, we compared 587 exposed to lamotrigine-levetiracetam duotherapy and 186 exposed to lamotrigine-topiramate duotherapy with 1959 exposed to valproate monotherapy. Pooled aRRs were 0.41 (95% CI 0.24-0.69) and 1.26 (0.71-2.23), respectively. Duotherapy combinations containing low-dose valproate were infrequent, and comparisons with high-dose valproate monotherapy were inconclusive but suggested a lower risk for combination therapy. Other combinations were too rare for comparative safety analyses. DISCUSSION Lamotrigine-levetiracetam duotherapy in first trimester was associated with a 60% lower risk of MCM than valproate monotherapy, while lamotrigine-topiramate was not associated with a reduced risk. Duotherapy with lamotrigine and levetiracetam may be favored to treat epilepsy in people with childbearing potential compared with valproate regarding MCM, but whether this combination is as effective as valproate remains to be determined. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in people with epilepsy treated in the first trimester of pregnancy, the risk of major congenital malformations is lower with lamotrigine-levetiracetam duotherapy than with valproate alone, but similar with lamotrigine-topiramate.
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Affiliation(s)
- Jacqueline M Cohen
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Silje Alvestad
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth A Suarez
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Andrea Schaffer
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Randi M Selmer
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Alys Havard
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Brian T Bateman
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Carolyn E Cesta
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Helga Zoega
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Ingvild Odsbu
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Krista F Huybrechts
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Lars J Kjerpeseth
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Loreen Straub
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Maarit K Leinonen
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Marte-Helene Bjørk
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Mette Nørgaard
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Mika Gissler
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Sinna P Ulrichsen
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Sonia Hernandez-Diaz
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Torbjörn Tomson
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
| | - Kari Furu
- From the Department of Chronic Diseases (J.M.C., R.M.S., I.O., L.J.K., K.F.) and Centre for Fertility and Health (J.M.C., K.F.), Norwegian Institute of Public Health, Oslo; Department of Clinical Medicine (S.A., M.-H.B.), University of Bergen, Norway; National Center for Epilepsy (S.A.), Oslo University Hospital, Norway; Division of Pharmacoepidemiology and Pharmacoeconomics (E.A.S., B.T.B., K.F.H., L.S.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Center for Pharmacoepidemiology and Treatment Science (E.A.S.), Rutgers Institute of Health, Health Care Policy and Aging Research & Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; School of Population Health (A.S., A.H., H.Z.) and National Drug and Alcohol Research Centre (A.H.), Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Bennett Institute for Applied Data Science (A.S.), Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom; Department of Anesthesiology, Perioperative, and Pain Medicine (B.T.B.), Stanford University, Stanford, CA; Centre for Pharmacoepidemiology (C.E.C., I.O.), Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Centre of Public Health Sciences (H.Z.), Faculty of Medicine, University of Iceland, Reykjavik; Department of Knowledge Brokers (M.K.L., M.G.), Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Neurology (M.-H.B.), Haukeland University Hospital, Bergen, Norway; Department of Clinical Epidemiology (M.N., S.P.U.), Aarhus University Hospital and Aarhus University, Denmark; Research Centre for Child Psychiatry (M.G.), University of Turku, Finland; Region Stockholm (M.G.), Academic Primary Health Care Centre, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology (S.H.-D.), Harvard T.H. Chan School of Public Health, Boston, MA; and Department of Clinical Neuroscience (T.T.), Karolinska Institutet, Stockholm, Sweden
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9
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Smith J, Richerson G, Kouchi H, Duprat F, Mantegazza M, Bezin L, Rheims S. Are we there yet? A critical evaluation of sudden and unexpected death in epilepsy models. Epilepsia 2024; 65:9-25. [PMID: 37914406 DOI: 10.1111/epi.17812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/11/2023] [Accepted: 10/31/2023] [Indexed: 11/03/2023]
Abstract
Although animal models have helped to elaborate meaningful hypotheses about the pathophysiology of sudden and unexpected death in epilepsy (SUDEP), specific prevention strategies are still lacking, potentially reflecting the limitations of these models and the intrinsic difficulties of investigating SUDEP. The interpretation of preclinical data and their translation to diagnostic and therapeutic developments in patients thus require a high level of confidence in their relevance to model the human situation. Preclinical models of SUDEP are heterogeneous and include rodent and nonrodent species. A critical aspect is whether the animals have isolated seizures exclusively induced by a specific trigger, such as models where seizures are elicited by electrical stimulation, pharmacological intervention, or DBA mouse strains, or whether they suffer from epilepsy with spontaneous seizures, with or without spontaneous SUDEP, either of nongenetic epilepsy etiology or from genetically based developmental and epileptic encephalopathies. All these models have advantages and potential disadvantages, but it is important to be aware of these limitations to interpret data appropriately in a translational perspective. The majority of models with spontaneous seizures are of a genetic basis, whereas SUDEP cases with a genetic basis represent only a small proportion of the total number. In almost all models, cardiorespiratory arrest occurs during the course of the seizure, contrary to that in patients observed at the time of death, potentially raising the issue of whether we are studying models of SUDEP or models of periseizure death. However, some of these limitations are impossible to avoid and can in part be dependent on specific features of SUDEP, which may be difficult to model. Several preclinical tools are available to address certain gaps in SUDEP pathophysiology, which can be used to further validate current preclinical models.
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Affiliation(s)
- Jonathon Smith
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
| | - George Richerson
- Department of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Hayet Kouchi
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
| | - Fabrice Duprat
- University Cote d'Azur, Valbonne-Sophia Antipolis, France
- CNRS UMR 7275, Institute of Molecular and Cellular Pharmacology, Valbonne-Sophia Antipolis, France
- Inserm, Valbonne-Sophia Antipolis, France
| | - Massimo Mantegazza
- University Cote d'Azur, Valbonne-Sophia Antipolis, France
- CNRS UMR 7275, Institute of Molecular and Cellular Pharmacology, Valbonne-Sophia Antipolis, France
- Inserm, Valbonne-Sophia Antipolis, France
| | - Laurent Bezin
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
| | - Sylvain Rheims
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and Lyon 1 University, Lyon, France
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10
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Sveinsson O, Andersson T, Carlsson S, Tomson T. Type, Etiology, and Duration of Epilepsy as Risk Factors for SUDEP: Further Analyses of a Population-Based Case-Control Study. Neurology 2023; 101:e2257-e2265. [PMID: 37813583 PMCID: PMC10727222 DOI: 10.1212/wnl.0000000000207921] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/28/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES We conducted a nationwide case-control study in Sweden to investigate the risk of sudden unexpected death in epilepsy (SUDEP) in relation to epilepsy duration, epilepsy type, and etiology in combination with occurrence and frequency of tonic-clonic seizures (TCS) and nocturnal TCS. METHODS The study comprised 255 SUDEP cases and 1,148 epilepsy controls. Clinical information was obtained from medical records. The association between SUDEP and risk factors was estimated by odds ratios (ORs) with 95% CIs calculated by conditional logistic regression to account for matching by sex and calendar time. RESULTS The risk of SUDEP was elevated in people with focal (OR 1.48, 95% CI 1.00-2.20), generalized and focal (OR 3.51, 95% CI 1.55-7.96), or unknown (OR 2.43, 95% CI 1.29-4.57) vs generalized epilepsy type. Increased risk of SUDEP was also observed in relation to epilepsy with traumatic causes (OR 2.27, 95% CI 1.33-3.89 vs genetic etiology) or short duration (OR 1.71, 95% CI 1.01-2.87 for 0-5 vs 6-15 years duration). Among those with 1-3 TCS during the preceding year, structural epilepsy etiology was associated with a more than 10-fold increase 10.84 (4.85-24.27) in SUDEP risk compared with people with genetic epilepsy without TCS. The risk with ≥4 TCS the preceding year was similar among those with generalized and focal epilepsies. Those with ≥4 TCS had an OR of 210.73 (95% CI 28.40-∞) during years 0-5 compared with those free from TCS and an epilepsy duration of 6-15 years. The combination of short epilepsy duration (0-5 years) and nocturnal TCS conferred an OR of 45.99 (95% CI 12.19-173.61) compared with having longer duration (6-15 years) and being free from nocturnal TCS. DISCUSSION Although certain etiologies, such as post-traumatic epilepsy, seem to entail a higher SUDEP risk, our data indicate that frequent and nocturnal TCS carry a similar level of risk whether focal or generalized from onset. The tonic-clonic part of the seizure seems to be decisive for the fatal outcome. SUDEP risk associated with TCS is highest during the first years after the epilepsy diagnosis which calls for effective TCS treatment and vigilance from the onset of diagnosis.
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Affiliation(s)
- Olafur Sveinsson
- From the Faculty of Medicine (O.S.), University of Iceland, Reykjavik; Department of Neurology (O.S., T.T.), Karolinska University Hospital; Department of Clinical Neuroscience (O.S., T.T.), and Institute of Environmental Medicine (T.A., S.C.), Karolinska Institutet, Stockholm; and Center for Occupational and Environmental Medicine (T.A.), Stockholm County Council, Sweden.
| | - Tomas Andersson
- From the Faculty of Medicine (O.S.), University of Iceland, Reykjavik; Department of Neurology (O.S., T.T.), Karolinska University Hospital; Department of Clinical Neuroscience (O.S., T.T.), and Institute of Environmental Medicine (T.A., S.C.), Karolinska Institutet, Stockholm; and Center for Occupational and Environmental Medicine (T.A.), Stockholm County Council, Sweden
| | - Sofia Carlsson
- From the Faculty of Medicine (O.S.), University of Iceland, Reykjavik; Department of Neurology (O.S., T.T.), Karolinska University Hospital; Department of Clinical Neuroscience (O.S., T.T.), and Institute of Environmental Medicine (T.A., S.C.), Karolinska Institutet, Stockholm; and Center for Occupational and Environmental Medicine (T.A.), Stockholm County Council, Sweden
| | - Torbjörn Tomson
- From the Faculty of Medicine (O.S.), University of Iceland, Reykjavik; Department of Neurology (O.S., T.T.), Karolinska University Hospital; Department of Clinical Neuroscience (O.S., T.T.), and Institute of Environmental Medicine (T.A., S.C.), Karolinska Institutet, Stockholm; and Center for Occupational and Environmental Medicine (T.A.), Stockholm County Council, Sweden
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11
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Goldman M, Lucke-Wold B, Katz J, Dawoud B, Dagra A. Respiratory Patterns in Neurological Injury, Pathophysiology, Ventilation Management, and Future Innovations: A Systematic Review. EXPLORATORY RESEARCH AND HYPOTHESIS IN MEDICINE 2023; 8:338-349. [PMID: 38130817 PMCID: PMC10735242 DOI: 10.14218/erhm.2022.00081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Traumatic brain injuries (TBI), ischemic stroke, hemorrhagic stroke, brain tumors, and seizures have diverse and sometimes overlapping associated breathing patterns. Homeostatic mechanisms for respiratory control are intertwined with complex neurocircuitry, both centrally and peripherally. This paper summarizes the neurorespiratory control and pathophysiology of its disruption. It also reviews the clinical presentation, ventilatory management, and emerging therapeutics. This review additionally serves to update all recent preclinical and clinical research regarding the spectrum of respiratory dysfunction. Having a solid pathophysiological foundation of disruptive mechanisms would permit further therapeutic development. This novel review bridges experimental/physiological data with bedside management, thus allowing neurosurgeons and intensivists alike to rapidly diagnose and treat respiratory sequelae of acute brain injury.
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Affiliation(s)
| | | | | | - Bavly Dawoud
- Neurosurgical Resident, University of Illinois, Peoria Illinois, United States
| | - Abeer Dagra
- Research Assistant, University of Florida, Gainesville, United States
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12
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Faingold CL, Feng HJ. Response to Singh et al. 2023: It is premature for a unified hypothesis of sudden unexpected death in epilepsy: A great amount of research is still needed to understand the multisystem cascade. Epilepsia 2023; 64:2256-2259. [PMID: 37386865 PMCID: PMC10529268 DOI: 10.1111/epi.17698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023]
Abstract
In response to the comments by Singh and colleagues about our recent paper proposing a unified hypothesis of SUDEP, we definitely agree that more research is needed. This research should include studies in other models, including Dravet mice, emphasized by Singh et al. However, we strongly believe the hypothesis is timely, because it is based on the continuing progress on SUDEP-related research on serotonin (5-HT) and adenosine as well as neuroanatomical findings.We propose testing of 5-HT enhancing drugs, neurotoxicity blocking drugs, such as N-methyl-D-aspartate (NMDA) antagonists and periaqueductal gray (PAG) electrical stimulation for SUDEP prevention. There are FDA-approved drugs that enhance the action of 5-HT, including fluoxetine and fenfluramine, which is approved for Dravet syndrome. NMDA antagonists, including memantine and ketamine, are also approved for other disorders. PAG electrical stimulation, which is proposed to activate a suffocation alarm, is also approved to treat other conditions and is known to enhance respiration. Experiments using these methods are currently being carried out in animal studies. If these approaches are validated in SUDEP models, treatments could be evaluated relatively quickly in patients with epilepsy (PWE) who exhibit a biomarker for high SUDEP risk, such as peri-ictal respiratory abnormalities. An example of such a study is the ongoing clinical trial of a selective serotonin reuptake inhibitor in PWE. Although, gene-based therapies may ultimately become treatments of choice to prevent SUDEP, as Singh et al suggested, one or more of the approaches we proposed could become temporizing treatments before gene-based therapies can be available. Establishing genetic treatments would require extensive time for each of the genetic abnormalities associated with SUDEP, and too many PWE are likely to die in the meantime.The temporizing treatments may help to reduce the incidence of SUDEP sooner, which is urgently needed.
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Affiliation(s)
- Carl L. Faingold
- Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
- Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Hua-Jun Feng
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
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13
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Giussani G, Falcicchio G, La Neve A, Costagliola G, Striano P, Scarabello A, Mostacci B, Beghi E. Sudden unexpected death in epilepsy: A critical view of the literature. Epilepsia Open 2023; 8:728-757. [PMID: 36896633 PMCID: PMC10472423 DOI: 10.1002/epi4.12722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death, occurring in benign circumstances, in an individual with epilepsy, with or without evidence for a seizure and excluding documented status epilepticus in which postmortem examination does not reveal other causes of death. Lower diagnostic levels are assigned when cases met most or all of these criteria, but data suggested more than one possible cause of death. The incidence of SUDEP ranged from 0.09 to 2.4 per 1000 person-years. Differences can be attributed to the age of the study populations (with peaks in the 20-40-year age group) and the severity of the disease. Young age, disease severity (in particular, a history of generalized TCS), having symptomatic epilepsy, and the response to antiseizure medications (ASMs) are possible independent predictors of SUDEP. The pathophysiological mechanisms are not fully known due to the limited data available and because SUDEP is not always witnessed and has been electrophysiologically monitored only in a few cases with simultaneous assessment of respiratory, cardiac, and brain activity. The pathophysiological basis of SUDEP may vary according to different circumstances that make that particular seizure, in that specific moment and in that patient, a fatal event. The main hypothesized mechanisms, which could contribute to a cascade of events, are cardiac dysfunction (included potential effects of ASMs, genetically determined channelopathies, acquired heart diseases), respiratory dysfunction (included postictal arousal deficit for the respiratory mechanism, acquired respiratory diseases), neuromodulator dysfunction, postictal EEG depression and genetic factors.
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Affiliation(s)
- Giorgia Giussani
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | | | - Pasquale Striano
- IRCCS Istituto “Giannina Gaslini”GenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaGenovaItaly
| | - Anna Scarabello
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
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14
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Singh V, Ryan JM, Auerbach DS. It is premature for a unified hypothesis of sudden unexpected death in epilepsy: A great amount of research is still needed to understand the multisystem cascade. Epilepsia 2023; 64:2006-2010. [PMID: 37129136 DOI: 10.1111/epi.17636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/10/2023] [Accepted: 05/01/2023] [Indexed: 05/03/2023]
Affiliation(s)
- Veronica Singh
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Justin M Ryan
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - David S Auerbach
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
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15
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Celdran de Castro A, Nascimento FA, Beltran-Corbellini Á, Toledano R, Garcia-Morales I, Gil-Nagel A, Aledo-Serrano Á. Levetiracetam, from broad-spectrum use to precision prescription: A narrative review and expert opinion. Seizure 2023; 107:121-131. [PMID: 37023625 DOI: 10.1016/j.seizure.2023.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
Levetiracetam (LEV) is an antiseizure medication (ASM) whose mechanism of action involves the modulation of neurotransmitters release through binding to the synaptic vesicle glycoprotein 2A. It is a broad-spectrum ASM displaying favorable pharmacokinetic and tolerability profiles. Since its introduction in 1999, it has been widely prescribed, becoming the first-line treatment for numerous epilepsy syndromes and clinical scenarios. However, this might have resulted in overuse. Increasing evidence, including the recently published SANAD II trials, suggests that other ASMs are reasonable therapeutic options for generalized and focal epilepsies. Not infrequently, these ASMs show better safety and effectiveness profiles compared to LEV (partially due to the latter's well-known cognitive and behavioral adverse effects, present in up to 20% of patients). Moreover, it has been shown that the underlying etiology of epilepsy is significantly linked to ASMs response in particular scenarios, highlighting the importance of an etiology-based ASM choice. In the case of LEV, it has demonstrated an optimal effectiveness in Alzheimer's disease, Down syndrome, and PCDH19-related epilepsies whereas, in other etiologies such as malformations of cortical development, it may show negligible effects. This narrative review analyzes the current evidence related to the use of LEV for the treatment of seizures. Illustrative clinical scenarios and practical decision-making approaches are also addressed, therefore aiming to define a rational use of this ASM.
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Tan M, Allemann SS, Qin XS, D'Souza WJ. Adherence patterns in antiseizure medications influencing risk of sudden unexplained death in epilepsy: A data linkage study using dispensed prescriptions. Epilepsia 2023; 64:641-653. [PMID: 36617371 DOI: 10.1111/epi.17502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Medication adherence is considered an important risk factor for sudden unexpected death in epilepsy (SUDEP), although measurement accuracy is difficult. Using prescription dispensations, this study aims to estimate antiseizure medication (ASM) adherence and identify adherence patterns that influence epilepsy mortality. METHODS This is a retrospective cohort study of tertiary epilepsy outpatients seen at St Vincent's Hospital Melbourne, Victoria, Australia, from January 1, 2012 until December 31, 2017. Privacy-preserving data linkage with the Australian national prescription, death, and coroner's databases was performed. We fitted a four-cluster longitudinal group-based trajectory model for ASM adherence from recurring 90-day windows of prescription dispensations during a 3-year "landmark period" from January 1, 2012 to December 31, 2014, using the AdhereR package. We estimated the risk of SUDEP and all-cause death for each adherence pattern during an "observation period" from January 1, 2015 to December 31, 2017. The Cox proportional hazards and logistic regression models were adjusted for age, sex, socioeconomic status, epilepsy duration, comorbidity, drug resistance, and inadequate seizure control. RESULTS One thousand one hundred eighty-seven participants were observed for a median of 3.2 years (interquartile range = 2.4-4.0 years). We observed 66 deaths with 10 SUDEP cases during the observation period. We identified four patterns of ASM adherence: good, 51%; declining, 24%; poor, 16%; and very poor, 9%. Declining adherence was associated with an increased risk for SUDEP, with hazard ratio (HR) = 8.43 (95% confidence interval [CI] = 1.10-64.45) at 1 year and HR = 9.17 (95% CI = 1.16-72.21) at 3 years. Compared to no ASM therapeutic change, the addition of a second to fourth ASM offered increased protection against SUDEP in patients with continuing drug-resistant epilepsy. SIGNIFICANCE ASM nonadherence was observed in half of outpatients with epilepsy. A declining pattern of adherence, observed in a quarter of patients, was associated with more than eight times increased risk of SUDEP. Any ongoing medication interventions must include strategies to maintain and improve ASM adherence if we are to reduce the risk of SUDEP.
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Affiliation(s)
- Michael Tan
- Department of Medicine, University of Melbourne, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Samuel S Allemann
- Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
| | - Xiwen Simon Qin
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - Wendyl J D'Souza
- Department of Medicine, University of Melbourne, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
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17
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Whitney R, Sharma S, Ramachandrannair R. Sudden unexpected death in epilepsy in children. Dev Med Child Neurol 2023. [PMID: 36802063 DOI: 10.1111/dmcn.15553] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/20/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related mortality in children and adults living with epilepsy. The incidence of SUDEP is comparable in both children and adults; it is approximately 1.2 per 1000 person years. The pathophysiology of SUDEP is not well understood but may involve mechanisms such as cerebral shutdown, autonomic dysfunction, altered brainstem function, and cardiorespiratory demise. Risk factors for SUDEP include the presence of generalized tonic-clonic seizures, nocturnal seizures, possible genetic predisposition, and non-adherence to antiseizure medications. Pediatric-specific risk factors are not fully elucidated. Despite recommendations from consensus guidelines, many clinicians still do not follow the practice of counseling their patients about SUDEP. SUDEP prevention has been an area of important research focus and includes several strategies, such as obtaining seizure control, optimizing treatment regimens, nocturnal supervision, and seizure detection devices. This review discusses what is currently known about SUDEP risk factors and reviews current and future preventive strategies for SUDEP.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Suvasini Sharma
- Neurology Division, Department of Pediatrics, Lady Harding Medical College and Kalawati Saran Children Hospital, New Delhi, India
| | - Rajesh Ramachandrannair
- Division of Neurology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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18
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Nightscales R, Barnard S, Laze J, Chen Z, Tao G, Auvrez C, Sivathamboo S, Cook MJ, Kwan P, Friedman D, Berkovic SF, D'Souza W, Perucca P, Devinsky O, O'Brien TJ. Risk of sudden unexpected death in epilepsy (SUDEP) with lamotrigine and other sodium channel-modulating antiseizure medications. Epilepsia Open 2023. [PMID: 36648376 DOI: 10.1002/epi4.12693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE In vitro data prompted U.S Food and Drug Administration warnings that lamotrigine, a common sodium channel modulating anti-seizure medication (NaM-ASM), could increase the risk of sudden death in patients with structural or ischaemic cardiac disease, however, its implications for Sudden Unexpected Death in Epilepsy (SUDEP) are unclear. METHODS This retrospective, nested case-control study identified 101 sudden unexpected death in epilepsy (SUDEP) cases and 199 living epilepsy controls from Epilepsy Monitoring Units (EMUs) in Australia and the USA. Differences in proportions of lamotrigine and NaM-ASM use were compared between cases and controls at the time of admission, and survival analyses from the time of admission up to 16 years were conducted. Multivariable logistic regression and survival analyses compared each ASM subgroup adjusting for SUDEP risk factors. RESULTS Proportions of cases and controls prescribed lamotrigine (P = 0.166), one NaM-ASM (P = 0.80), or ≥2NaM-ASMs (P = 0.447) at EMU admission were not significantly different. Patients taking lamotrigine (adjusted hazard ratio [aHR] = 0.56; P = 0.054), one NaM-ASM (aHR = 0.8; P = 0.588) or ≥2 NaM-ASMs (aHR = 0.49; P = 0.139) at EMU admission were not at increased SUDEP risk up to 16 years following admission. Active tonic-clonic seizures at EMU admission associated with >2-fold SUDEP risk, irrespective of lamotrigine (aHR = 2.24; P = 0.031) or NaM-ASM use (aHR = 2.25; P = 0.029). Sensitivity analyses accounting for incomplete ASM data at follow-up suggest undetected changes to ASM use are unlikely to alter our results. SIGNIFICANCE This study provides additional evidence that lamotrigine and other NaM-ASMs are unlikely to be associated with an increased long-term risk of SUDEP, up to 16 years post-EMU admission.
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Affiliation(s)
- Russell Nightscales
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Sarah Barnard
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Neurology, New York University Grossman School of Medicine, New York, New York, USA
| | - Juliana Laze
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, USA
| | - Zhibin Chen
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Epidemiology, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gerard Tao
- Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia
| | - Clarissa Auvrez
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,NorthWestern Mental Health, Melbourne Health, Melbourne, Victoria, Australia
| | - Shobi Sivathamboo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mark J Cook
- Department of Medicine, St. Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Daniel Friedman
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, USA
| | - Samuel F Berkovic
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia.,Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Wendyl D'Souza
- Department of Medicine, St. Vincent's Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia.,Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Orrin Devinsky
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, USA
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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19
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Bauer J, Devinsky O, Rothermel M, Koch H. Autonomic dysfunction in epilepsy mouse models with implications for SUDEP research. Front Neurol 2023; 13:1040648. [PMID: 36686527 PMCID: PMC9853197 DOI: 10.3389/fneur.2022.1040648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/12/2022] [Indexed: 01/09/2023] Open
Abstract
Epilepsy has a high prevalence and can severely impair quality of life and increase the risk of premature death. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in drug-resistant epilepsy and most often results from respiratory and cardiac impairments due to brainstem dysfunction. Epileptic activity can spread widely, influencing neuronal activity in regions outside the epileptic network. The brainstem controls cardiorespiratory activity and arousal and reciprocally connects to cortical, diencephalic, and spinal cord areas. Epileptic activity can propagate trans-synaptically or via spreading depression (SD) to alter brainstem functions and cause cardiorespiratory dysfunction. The mechanisms by which seizures propagate to or otherwise impair brainstem function and trigger the cascading effects that cause SUDEP are poorly understood. We review insights from mouse models combined with new techniques to understand the pathophysiology of epilepsy and SUDEP. These techniques include in vivo, ex vivo, invasive and non-invasive methods in anesthetized and awake mice. Optogenetics combined with electrophysiological and optical manipulation and recording methods offer unique opportunities to study neuronal mechanisms under normal conditions, during and after non-fatal seizures, and in SUDEP. These combined approaches can advance our understanding of brainstem pathophysiology associated with seizures and SUDEP and may suggest strategies to prevent SUDEP.
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Affiliation(s)
- Jennifer Bauer
- Department of Epileptology and Neurology, RWTH Aachen University, Aachen, Germany,Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Orrin Devinsky
- Departments of Neurology, Neurosurgery and Psychiatry, NYU Langone School of Medicine, New York, NY, United States
| | - Markus Rothermel
- Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Henner Koch
- Department of Epileptology and Neurology, RWTH Aachen University, Aachen, Germany,*Correspondence: Henner Koch ✉
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20
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Efficacy and safety of traditional Chinese medicine for the treatment of epilepsy: A updated meta-analysis of randomized controlled trials. Epilepsy Res 2023; 189:107075. [PMID: 36603453 DOI: 10.1016/j.eplepsyres.2022.107075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/13/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of Traditional Chinese Medicine (TCM) in the treatment of epilepsy. METHODS A comprehensive search of the database in both Chinese and English was performed. Data from the selected studies were extracted and analyzed independently by two authors. RESULTS 30 randomized controlled trials (RCTs) were included in the meta-analysis with a total of 2471 patients. Among them, 4 trials (n = 235) focused on TCM monotherapy, while the other 26 trials (n = 2236) assessed the benefit of TCM as an add-on therapy to antiseizure medications (ASMs). For the efficacy, the meta-analysis found (1) The effective rate in TCM monotherapy group was higher than that in control group (OR = 4.92, 95 % CI: 2.29-10.57, Z = 4.08, P 0.0001); (2) The add-on of TCM also increased the effective rate (OR = 3.37, 95 % CI: 2.65-4.30, Z = 9.85, P 0.00001) and seizure freedom rate (OR = 1.93, 95 % CI: 1.53-2.44, Z = 5.58, P 0.00001). In terms of safety, the add-on of TCM reduced the rate of total adverse events (OR = 0.46, 95 % CI: 0.31-0.67, Z = 3.96, P 0.0001) as well as adverse events of the gastrointestinal and nervous system. 26 different TCM prescriptions were used in these included RCTs. Among them, the 5 most frequently used herbs were Acorus tatarinowii (19 out of 26), Glycyrrhiza uralensis (13 out of 26), Gastrodia elata (12 out of 26), Pinellia ternata (11 out of 26) and Poria cocos (11 out of 26). CONCLUSION This study suggested that TCM may be a relatively efficacious and safe clinical strategy for the treatment of epilepsy. Several limitations still exist, such as the risk of bias in the included studies, the diversified composition of TCM prescriptions, and the relatively low quality of study design.
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21
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Grinalds MS, Yoder C, Krauss Z, Chen AM, Rhoney DH. Scoping review of rational polytherapy in patients with drug-resistant epilepsy. Pharmacotherapy 2023; 43:53-84. [PMID: 36484111 PMCID: PMC10107532 DOI: 10.1002/phar.2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 12/14/2022]
Abstract
There is a paucity of literature regarding the optimal selection of combination antiseizure medications (ASMs) for drug-resistant epilepsy (DRE). The aim of this scoping review is to evaluate current evidence related to "rational polytherapy" among adults with DRE. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-SCr) guidelines, PubMed, ProQuest, CINAHL, and Cochrane databases were searched using DRE- and polytherapy-related keywords. The exclusion criteria applied included: non-English; non-human studies; non-research studies; participants less than 18 years; status epilepticus; ASM monotherapy; and certain ASMs. In Covidence, two researchers independently reviewed articles for inclusion at each phase, with a third resolving conflicts. Data were extracted, with quality appraisal using the Mixed Methods Appraisal Tool (MMAT). Of the 6477 studies imported for screening, 33 studies were included. Clinical, humanistic, and economic outcomes were reported by 26, 12, and one study, respectively. Common efficacy-related clinical outcomes included ≥50% reduction in seizure frequency (n = 14), seizure freedom (n = 14), and percent reduction in seizure frequency (n = 8). Common humanistic outcomes included quality of life (n = 4), medication adherence (n = 2), sleep-related outcomes (n = 2), and physician and patient global assessments (n = 2). The economic study reported quality-adjusted life years. The median MMAT score was 80 (range: 60-100). Two studies referenced the standard definition of DRE, whereas five studies did not specifically define DRE. Gaps in the literature include limited generalizability, minimal reports in pregnancy, and lack of optimal ASM combinations, among others. Strengths of the evidence include addressing a variety of outcomes. Inconsistent definitions of DRE, small sample sizes, and heterogeneity among studies limit the ability to draw meaningful conclusions. Optimal combinations of ASMs for rational polytherapy for DRE is unclear.
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Affiliation(s)
- McKenzie S Grinalds
- Pharmacy Practice Department, Cedarville University School of Pharmacy, Cedarville, Ohio, USA.,Miami Valley Hospital, Dayton, Ohio, USA
| | - Caleb Yoder
- Pharmacy Practice Department, Cedarville University School of Pharmacy, Cedarville, Ohio, USA
| | - Zach Krauss
- Pharmacy Practice Department, Cedarville University School of Pharmacy, Cedarville, Ohio, USA
| | - Aleda M Chen
- Pharmacy Practice Department, Cedarville University School of Pharmacy, Cedarville, Ohio, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, UNC, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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22
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Zhao H, Long L, Xiao B. Advances in sudden unexpected death in epilepsy. Acta Neurol Scand 2022; 146:716-722. [DOI: 10.1111/ane.13715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Haiting Zhao
- Department of Neurology Xiangya Hospital, Central South University Changsha China
- National Clinical Research Center for Geriatric Disorders Xiangya Hospital, Central South University Changsha China
- Clinical Research Center for Epileptic Disease of Hunan Province Central South University Changsha China
| | - Lili Long
- Department of Neurology Xiangya Hospital, Central South University Changsha China
- National Clinical Research Center for Geriatric Disorders Xiangya Hospital, Central South University Changsha China
- Clinical Research Center for Epileptic Disease of Hunan Province Central South University Changsha China
| | - Bo Xiao
- Department of Neurology Xiangya Hospital, Central South University Changsha China
- National Clinical Research Center for Geriatric Disorders Xiangya Hospital, Central South University Changsha China
- Clinical Research Center for Epileptic Disease of Hunan Province Central South University Changsha China
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23
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Haridas B, Chuang DT, Nei M, Kang JY. Sudden Unexpected Death in Epilepsy: Pathogenesis, Risk Factors, and Prevention. Semin Neurol 2022; 42:658-664. [PMID: 36223819 DOI: 10.1055/a-1960-1355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a tragic and unexpected cause of death in patients with a known diagnosis of epilepsy. It occurs in up to 6.3 to 9.3/1,000 patients with drug-resistant epilepsy. The main three risk factors associated with SUDEP are the presence of generalized tonic-clonic seizures, the presence of a seizure in the past year, and an intellectual disability. There are several mechanisms that can result in SUDEP. The most likely sequence of events appears to be a convulsive seizure, overactivation of the autonomic nervous system, cardiorespiratory dysfunction, and death. While the risk of SUDEP is relatively high in patients with drug-resistant epilepsy, studies indicate that more than 50% of patients and caregivers are unaware of the diagnosis. Counseling about the diagnosis and preventative measures at the time of diagnosis is important. There are numerous interventions that may reduce the risk of SUDEP, including conservative measures such as nocturnal surveillance with a bed partner (where applicable) and automated devices. Optimizing seizure control with antiseizure medications and surgical interventions can result in a reduced risk of SUDEP.
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Affiliation(s)
- Babitha Haridas
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David T Chuang
- Department of Neurology, Weill Cornell School of Medicine, New York, New York
| | - Maromi Nei
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
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24
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Multimorbidity and chronic co-prescription networks and potential interactions in adult patients with epilepsy: MorbiNet study. Neurol Sci 2022; 43:6889-6899. [DOI: 10.1007/s10072-022-06375-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/27/2022] [Indexed: 10/14/2022]
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25
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Kløvgaard M, Sabers A, Ryvlin P. Update on Sudden Unexpected Death in Epilepsy. Neurol Clin 2022; 40:741-754. [DOI: 10.1016/j.ncl.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Mesraoua B, Tomson T, Brodie M, Asadi-Pooya AA. Sudden unexpected death in epilepsy (SUDEP): Definition, epidemiology, and significance of education. Epilepsy Behav 2022; 132:108742. [PMID: 35623204 DOI: 10.1016/j.yebeh.2022.108742] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
People with epilepsy (PWE) may die suddenly and unexpectedly and without a clear under-lying pathological etiology; this is called SUDEP (sudden unexpected death in epilepsy). The pooled estimated incidence rate for SUDEP is 23 times the incidence rate of sudden death in the general population with the same age. Empowering healthcare professionals, PWE, and their care-givers with the appropriate knowledge about SUDEP is very important to enable efficient preventive measures in PWE. In the current narrative review, following a brief discussion on the definition, epidemiology, and risk factors for SUDEP, the authors discuss the importance of appropriately educating healthcare professionals, PWE, and their caregivers about SUDEP.
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Affiliation(s)
- Boulenouar Mesraoua
- Neurosciences Department, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar.
| | - Torbjorn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Martin Brodie
- Epilepsy Unit, University of Glasgow, Glasgow, Scotland, UK.
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
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27
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PAEDIATRIC SUDDEN UNEXPECTED DEATH IN EPILEPSY: FROM PATHOPHYSIOLOGY TO PREVENTION. Seizure 2022; 101:83-95. [DOI: 10.1016/j.seizure.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 11/22/2022] Open
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Gu L, Yu Q, Shen Y, Wang Y, Xu Q, Zhang H. The role of monoaminergic neurons in modulating respiration during sleep and the connection with SUDEP. Biomed Pharmacother 2022; 150:112983. [PMID: 35453009 DOI: 10.1016/j.biopha.2022.112983] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/04/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death among epilepsy patients, occurring even more frequently in cases with anti-epileptic drug resistance. Despite some advancements in characterizing SUDEP, the underlying mechanism remains incompletely understood. This review summarizes the latest advances in our understanding of the pathogenic mechanisms of SUDEP, in order to identify possible targets for the development of new strategies to prevent SUDEP. Based on our previous research along with the current literature, we focus on the role of sleep-disordered breathing (SDB) and its related neural mechanisms to consider the possible roles of monoaminergic neurons in the modulation of respiration during sleep and the occurrence of SUDEP. Overall, this review suggests that targeting the monoaminergic neurons is a promising approach to preventing SUDEP. The proposed roles of SDB and related monoaminergic neural mechanisms in SUDEP provide new insights for explaining the pathogenesis of SUDEP.
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Affiliation(s)
- LeYuan Gu
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qian Yu
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Yue Shen
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - YuLing Wang
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qing Xu
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - HongHai Zhang
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China; Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou 310006, China.
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Ingleby-Talecki L, van Dijkman SC, Oosterholt SP, Della Pasqua O, Winter C, Cunnington M, Rebar L, Forero-Schwanhaeuser S, Patel V, Cooper JA, Bahinski A, Chaudhary KW. Cardiac sodium channel inhibition by lamotrigine: in vitro characterization and clinical implications. Clin Transl Sci 2022; 15:1978-1989. [PMID: 35579204 PMCID: PMC9372421 DOI: 10.1111/cts.13311] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 11/26/2022] Open
Abstract
Lamotrigine, approved for use as an antiseizure medication as well as the treatment of bipolar disorder, inhibits sodium channels in the brain to reduce repetitive neuronal firing and pathological release of glutamate. The shared homology of sodium channels and lack of selectivity associated with channel blocking agents can cause slowing of cardiac conduction and increased proarrhythmic potential. The Vaughan‐Williams classification system differentiates sodium channel blockers using biophysical properties of binding. As such, Class Ib inhibitors, including mexiletine, do not slow cardiac conduction as measured by the electrocardiogram, at therapeutically relevant exposure. Our goal was to characterize the biophysical properties of NaV1.5 block and to support the observed clinical safety of lamotrigine. We used HEK‐293 cells stably expressing the hNaV1.5 channel and voltage clamp electrophysiology to quantify the potency (half‐maximal inhibitory concentration) against peak and late channel current, on‐/off‐rate binding kinetics, voltage‐dependence, and tonic block of the cardiac sodium channel by lamotrigine; and compared to clinically relevant Class Ia (quinidine), Ib (mexiletine), and Ic (flecainide) inhibitors. Lamotrigine blocked peak and late NaV1.5 current at therapeutically relevant exposure, with rapid kinetics and biophysical properties similar to the class Ib inhibitor mexiletine. However, no clinically meaningful prolongation in QRS or PR interval was observed in healthy subjects in a new analysis of a previously reported thorough QT clinical trial (SCA104648). In conclusion, the weak NaV1.5 block and rapid kinetics do not translate into clinically relevant conduction slowing at therapeutic exposure and support the clinical safety of lamotrigine in patients suffering from epilepsy and bipolar disorder.
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Affiliation(s)
| | | | | | | | | | | | - Linda Rebar
- GSK US Regulatory Affairs, Collegeville, PA 19426, USA
| | | | - Vickas Patel
- Former GSK Employee, Collegeville, PA 19426, USA
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Singh A, Woelfle R, Chepesiuk R, Southward C, Antflick J, Cowan K, Hum K, Ng M, Burneo JG, Suller Marti A. Canadian epilepsy priority-setting partnership: Toward a new national research agenda. Epilepsy Behav 2022; 130:108673. [PMID: 35367726 DOI: 10.1016/j.yebeh.2022.108673] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Health research agendas are often set by researchers or by industry and may not reflect the needs and priorities of end users. This priority-setting partnership (PSP) for epilepsy was undertaken to identify the most pressing unanswered questions about epilepsy and seizures from the perspective of people with epilepsy (PWE) and their care providers. METHODS Using the methodology developed by the James Lind Alliance (JLA), evidence uncertainties were gathered via online surveys from stakeholders across Canada. Submissions were formed into summary questions and checked against existing evidence to determine if they were true uncertainties. Verified uncertainties were then ranked by patients, caregivers, and healthcare providers and a final workshop was held to reach a consensus on the top 10 priorities. RESULTS The final top 10 list reflects the priority areas of focus for research as identified by the Canadian epilepsy community, including genetic markers for diagnosis and treatment, concerns about living with the long-term effects of epilepsy, and addressing knowledge gaps in etiology and treatment approaches. CONCLUSION This project represents the first systematic evidence of patient- and clinician-centered research priorities for epilepsy. The results of this priority-setting exercise provide an opportunity for researchers and funding agencies to align their agendas with the values and needs of the epilepsy community in order to improve clinical outcomes and quality of life (QOL) for PWE.
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Affiliation(s)
- Amaya Singh
- EpLink - The Epilepsy Research Program of the Ontario Brain Institute, Toronto, Ontario, Canada; Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada.
| | - Rebecca Woelfle
- EpLink - The Epilepsy Research Program of the Ontario Brain Institute, Toronto, Ontario, Canada; Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Katherine Cowan
- The James Lind Alliance, The Wessex Institute, University of Southampton, Southampton, United Kingdom
| | - Kathryn Hum
- EpLink - The Epilepsy Research Program of the Ontario Brain Institute, Toronto, Ontario, Canada; Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Marcus Ng
- Section of Neurology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jorge G Burneo
- Epilepsy Program, Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Neuroepidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ana Suller Marti
- Epilepsy Program, Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Paediatrics Department, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Neurosciences Program, Western University, London, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Sudden unexpected death in epilepsy (SUDEP) is a major contributor to premature mortality in people with epilepsy. This review provides an update on recent findings on the epidemiology of SUDEP, clinical risk factors and potential mechanisms. RECENT FINDINGS The overall risk rate of SUDEP is approximately 1 per 1000 patients per year in the general epilepsy population and that children and older adults have a similar incidence. Generalized convulsive seizures (GCS), perhaps through their effects on brainstem cardiopulmonary networks, can cause significant postictal respiratory and autonomic dysfunction though other mechanisms likely exist as well. Work in animal models of SUDEP has identified multiple neurotransmitter systems, which may be future targets for pharmacological intervention. There are also chronic functional and structural changes in autonomic function in patients who subsequently die from SUDEP suggesting that some SUDEP risk is dynamic. Modifiable risks for SUDEP include GCS seizure frequency, medication adherence and nighttime supervision. SUMMARY Current knowledge of SUDEP risk factors has identified multiple targets for SUDEP prevention today as we await more specific therapeutic targets that are emerging from translational research studies.
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Affiliation(s)
- Daniel Friedman
- NYU Grossman School of Medicine, Department of Neurology, 223 East 34th Street, New York, New York, USA
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Bacq A, Roussel D, Bonduelle T, Zagaglia S, Maletic M, Ribierre T, Adle‐Biassette H, Marchal C, Jennesson M, An I, Picard F, Navarro V, Sisodiya SM, Baulac S. Cardiac Investigations in Sudden Unexpected Death in DEPDC5-Related Epilepsy. Ann Neurol 2022; 91:101-116. [PMID: 34693554 PMCID: PMC9299146 DOI: 10.1002/ana.26256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Germline loss-of-function mutations in DEPDC5, and in its binding partners (NPRL2/3) of the mammalian target of rapamycin (mTOR) repressor GATOR1 complex, cause focal epilepsies and increase the risk of sudden unexpected death in epilepsy (SUDEP). Here, we asked whether DEPDC5 haploinsufficiency predisposes to primary cardiac defects that could contribute to SUDEP and therefore impact the clinical management of patients at high risk of SUDEP. METHODS Clinical cardiac investigations were performed in 16 patients with pathogenic variants in DEPDC5, NPRL2, or NPRL3. Two novel Depdc5 mouse strains, a human HA-tagged Depdc5 strain and a Depdc5 heterozygous knockout with a neuron-specific deletion of the second allele (Depdc5c/- ), were generated to investigate the role of Depdc5 in SUDEP and cardiac activity during seizures. RESULTS Holter, echocardiographic, and electrocardiographic (ECG) examinations provided no evidence for altered clinical cardiac function in the patient cohort, of whom 3 DEPDC5 patients succumbed to SUDEP and 6 had a family history of SUDEP. There was no cardiac injury at autopsy in a postmortem DEPDC5 SUDEP case. The HA-tagged Depdc5 mouse revealed expression of Depdc5 in the brain, heart, and lungs. Simultaneous electroencephalographic-ECG records on Depdc5c/- mice showed that spontaneous epileptic seizures resulting in a SUDEP-like event are not preceded by cardiac arrhythmia. INTERPRETATION Mouse and human data show neither structural nor functional cardiac damage that might underlie a primary contribution to SUDEP in the spectrum of DEPDC5-related epilepsies. ANN NEUROL 2022;91:101-116.
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Affiliation(s)
- Alexandre Bacq
- Sorbonne University, Paris Brain Institute (ICM), Inserm, CNRS, AP‐HP, Pitié‐Salpêtrière HospitalParisFrance
| | - Delphine Roussel
- Sorbonne University, Paris Brain Institute (ICM), Inserm, CNRS, AP‐HP, Pitié‐Salpêtrière HospitalParisFrance
| | - Thomas Bonduelle
- Sorbonne University, Paris Brain Institute (ICM), Inserm, CNRS, AP‐HP, Pitié‐Salpêtrière HospitalParisFrance
- Epilepsy and Neurology Department, Bordeaux University Hospital CenterBordeauxFrance
| | - Sara Zagaglia
- Department of Clinical and Experimental EpilepsyUniversity College London Queen Square Institute of NeurologyLondonUK
- Chalfont Centre for EpilepsyBucksUK
| | - Marina Maletic
- Sorbonne University, Paris Brain Institute (ICM), Inserm, CNRS, AP‐HP, Pitié‐Salpêtrière HospitalParisFrance
| | - Théo Ribierre
- Sorbonne University, Paris Brain Institute (ICM), Inserm, CNRS, AP‐HP, Pitié‐Salpêtrière HospitalParisFrance
| | - Homa Adle‐Biassette
- Pathological Anatomy Department, University of Paris, AP‐HP, Lariboisière Hospital, DMU, DREAM, UMR 1141, INSERMParisFrance
| | - Cécile Marchal
- Epilepsy and Neurology Department, Bordeaux University Hospital CenterBordeauxFrance
| | - Mélanie Jennesson
- Department of PediatricsAmerican Memorial Hospital, Reims University Hospital CenterReimsFrance
| | - Isabelle An
- Epileptology Unit and Reference Center of Rare Epilepsies, Pitié‐Salpêtrière Hospital, AP‐HPParisFrance
| | - Fabienne Picard
- EEG and Epilepsy Unit, Department of Clinical NeurosciencesUniversity Hospitals and Faculty of Medicine of GenevaGenevaSwitzerland
| | - Vincent Navarro
- Sorbonne University, Paris Brain Institute (ICM), Inserm, CNRS, AP‐HP, Pitié‐Salpêtrière HospitalParisFrance
- Epileptology Unit and Reference Center of Rare Epilepsies, Pitié‐Salpêtrière Hospital, AP‐HPParisFrance
| | - Sanjay M. Sisodiya
- Department of Clinical and Experimental EpilepsyUniversity College London Queen Square Institute of NeurologyLondonUK
- Chalfont Centre for EpilepsyBucksUK
| | - Stéphanie Baulac
- Sorbonne University, Paris Brain Institute (ICM), Inserm, CNRS, AP‐HP, Pitié‐Salpêtrière HospitalParisFrance
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Abstract
INTRODUCTION Patients with severe epilepsy are at increased risk of cardiovascular disease and arrhythmias. Although antiseizure medications (ASMs) may have indirect protective effects against cardiovascular events by reducing seizure frequency and hence sudden death in epilepsy, some of them exert cardiotoxic effects. AREAS COVERED Patients with epilepsy, mainly those with severe forms, are at higher risk of cardiac disease because their heart can have structural alterations and electrical instability as a consequence of repeated seizures. Some ASMs have direct protective effects through anti-inflammatory, antioxidant, hypotensive, and lipid-reducing properties. Antiseizure medications can also have toxic cardiac effects including both long-term consequences, such as the increased risk of atherogenesis and subsequent cardiovascular disease due to the influence on lipid profile and pro-inflammatory milieu, and immediate effects as the increased risk of potentially fatal arrhythmias due to the influence on ion channels. Sodium channel blocking ASMs may also affect cardiac sodium channels and this effect is particularly observed in subjects with genetic mutations in cardiac ion channels. Fenfluramine cause valvulopathies in obese subjects and this effect need to be evaluated in epilepsy patients. EXPERT OPINION For the selection of treatment, cardiotoxic effects of ASMs should be considered; cardiac monitoring of treatment is advisable.
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Affiliation(s)
- Gaetano Zaccara
- Department of Eidemiology, Regional Health Agency of Tuscany, Firenze, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (Sabes-asdaa), Merano-Meran, Italy
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Kobau R, Zack MM, Sapkota S, Sajatovic M, Kiriakopoulos E. When and why US primary care providers do and do not refer their patients with new-onset seizures or existing epilepsy or seizure disorders to neurologists-2018 DocStyles. Epilepsy Behav 2021; 125:108385. [PMID: 34740091 PMCID: PMC11034734 DOI: 10.1016/j.yebeh.2021.108385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/03/2021] [Accepted: 10/16/2021] [Indexed: 11/27/2022]
Abstract
Monitoring primary care providers' (PCP) attitudes and experiences with referrals of their patients with new-onset seizures or existing epilepsy/seizure disorders may help evaluate whether interventions to coordinate PCP and neurology care reduce treatment gaps and improve patient outcomes. To examine PCPs' attitudes toward, and experiences with, referral to specialty care of their patients with new-onset seizures or existing epilepsy/seizure disorders, we used cross-sectional 2018 DocStyles data to examine study outcomes. We selected a subsample of respondents who had a practice with at least 1% of patients with an epilepsy/seizure disorder and who answered questions about this disorder. We stratified provider actions, referral behavior, and referral enabling factors and barriers by epilepsy/seizure disorder caseload and provider type. We examined different patterns of responses by referral behavior and provider type. The final sample (n = 1284) included 422 family practitioners, 432 internists, 233 pediatricians, and 197 nurse practitioners. Most PCPs refer their patients with new-onset seizures to a neurologist, particularly to determine or confirm the diagnosis and appropriate treatment. Strikingly, about 40% of PCPs did not indicate a referral if their epilepsy/seizure disorder patient was unresponsive to treatment. Internists less likely referred their patients than pediatricians, nurse practitioners, or family practitioners. Less than one-third of all practitioners consulted seizure treatment guidelines. Prompt appointments, communication with the PCP, the patient's insurance, and referral back to primary care may facilitate referrals. Interventions that enhance enabling factors for guidelines-based care and that can increase opportunities for PCPs to consult with neurologists and/or refer their patients with uncontrolled seizures to specialty care are warranted.
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Affiliation(s)
- Rosemarie Kobau
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 4770 Buford Highway NE, MS 107-6, Atlanta, GA 30341, USA.
| | - Matthew M Zack
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 4770 Buford Highway NE, MS 107-6, Atlanta, GA 30341, USA
| | - Sanjeeb Sapkota
- ASRT Inc., Epilepsy Program, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Mail Stop 107-6, 4770 Buford Hwy, 30341 GA, USA
| | - Martha Sajatovic
- University Hospital Cleveland Medical Center, 10524 Euclid Ave, Cleveland, OH 44106, USA
| | - Elaine Kiriakopoulos
- Dartmouth Geisel School of Medicine, 1 Rope Ferry Road, Hanover, NH 03755-1404, USA
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Guo J, Min D, Feng HJ. Genistein, a Natural Isoflavone, Alleviates Seizure-Induced Respiratory Arrest in DBA/1 Mice. Front Neurol 2021; 12:761912. [PMID: 34803895 PMCID: PMC8599950 DOI: 10.3389/fneur.2021.761912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/13/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: Sudden unexpected death in epilepsy (SUDEP) is a fatal event that ranks second in years of potential life lost among neurological disorders. Seizure-induced respiratory arrest (S-IRA) is the primary instigator leading to death in many SUDEP cases. However, there are currently no effective preventive strategies against S-IRA other than the seizure control. Therefore, it is critical to develop new avenues to prevent SUDEP by investigating the pharmacological interventions of S-IRA. In the present study, we examined the effect of genistein, an isoflavone found in various dietary vegetables, on the incidence of S-IRA in DBA/1 mice. Methods: DBA/1 mice exhibited generalized seizures and S-IRA when subjected to acoustic stimulation. Genistein was intraperitoneally administered alone or in combination with an adrenoceptor antagonist and a serotonin (5-HT) receptor antagonist, respectively. The effects of drug treatments on S-IRA incidence and seizure behaviors were examined. Results: The incidence of S-IRA in DBA/1 mice was significantly reduced 2 h after injection of genistein at 1–90 mg/kg as compared with that in the vehicle control. Genistein could block S-IRA without interfering with any component of seizures, especially at relatively lower dosages. The S-IRA-suppressing effect of genistein was reversed by an α2 adrenoceptor antagonist but was not altered by an α1 antagonist. The inhibitory effect of genistein on S-IRA was not affected by a 5-HT3 or 5-HT2A receptor antagonist. Significance: Our data show that genistein reduces S-IRA incidence and can specifically block S-IRA in DBA/1 mice. Its suppressing effect on S-IRA is dependent on activating α2 adrenoceptors. Our study suggests that genistein, a dietary supplement, is potentially useful to prevent SUDEP in at-risk patients.
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Affiliation(s)
- Jialing Guo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States.,Department of Anesthesia, Harvard Medical School, Boston, MA, United States
| | - Daniel Min
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Hua-Jun Feng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States.,Department of Anesthesia, Harvard Medical School, Boston, MA, United States
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Shlobin NA, Sander JW. Reducing Sudden Unexpected Death in Epilepsy: Considering Risk Factors, Pathophysiology and Strategies. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00691-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
Sudden Unexpected Death in Epilepsy (SUDEP) is the commonest cause of epilepsy-related premature mortality in people with chronic epilepsy. It is the most devastating epilepsy outcome. We describe and discuss risk factors and possible pathophysiological mechanisms to elucidate possible preventative strategies to avert SUDEP.
Recent Findings
Sudden death accounts for a significant proportion of premature mortality in people with epilepsy compared to the general population. Unmodifiable risk factors include a history of neurologic insult, younger age of seizure-onset, longer epilepsy duration, a history of convulsions, symptomatic epilepsy, intellectual disability, and non-ambulatory status. Modifiable risk factors include the presence of convulsive seizures, increased seizure frequency, timely and appropriate use of antiseizure medications, polytherapy, alcoholism, and supervision while sleeping. Pathophysiology is unclear, but several possible mechanisms such as direct alteration of cardiorespiratory function, pulmonary impairment, electrocerebral shutdown, adenosine dysfunction, and genetic susceptibility suggested.
Summary
Methods to prevent SUDEP include increasing awareness of SUDEP, augmenting knowledge of unmodifiable risk factors, obtaining full seizure remission, addressing lifestyle factors such as supervision and prone positioning, and enacting protocols to increase the detection of and intervention for SUDEP. Further studies are required to characterize precisely and comprehensively SUDEP risk factors and pathophysiological drivers and develop evidence-based algorithms to minimize SUDEP in people with epilepsy.
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Bonanni P, Gambardella A, Tinuper P, Acone B, Perucca E, Coppola G. Perampanel as first add-on antiseizure medication: Italian consensus clinical practice statements. BMC Neurol 2021; 21:410. [PMID: 34702211 PMCID: PMC8549193 DOI: 10.1186/s12883-021-02450-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/14/2021] [Indexed: 01/21/2023] Open
Abstract
Background When use of a single antiseizure medication (ASM) fails to induce seizure remission, add-on therapy is justified. Perampanel (PER) is approved in Europe as adjunctive therapy for focal, focal to bilateral tonic-clonic seizures and generalized tonic-clonic seizures. Aim of the study was to establish whether PER is suitable for first add-on use. Methods A Delphi methodology was adopted to assess consensus on a list of 39 statements produced by an Expert Board of 5 epileptologists. Using an iterative process, statements were finalized by a Delphi Panel of 84 Italian pediatric and adult neurologists. Each statement was rated anonymously to determine level of agreement on a 9-point Likert scale. Consensus was established as agreement by at least 80% of the panelists. The relevance of each statement was also assessed on a 3-point scale. Results Consensus was achieved for 37 statements. Characteristics of PER considered to justify its use as first add-on include evidence of a positive impact on quality of life based on long term retention data, efficacy, tolerability, and ease of use; no worsening of cognitive functions and sleep quality; a low potential for drug interactions; a unique mechanism of action. Potential unfavorable factors are the need for a relatively slow dose titration; the potential occurrence of behavioral adverse effects; lack of information on safety when used in pregnancy; limited access to plasma PER levels. Conclusion Perampanel has many features which justify its use as a first add-on. Choice of an ASM as first add-on should be tailored to individual characteristics. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02450-y.
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Affiliation(s)
- Paolo Bonanni
- IRCCS Eugenio Medea Scientific Institute, Epilepsy Unit, Conegliano, Via Costa Alta 37, 31015, Conegliano, TV, Italy.
| | | | - Paolo Tinuper
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | | | - Emilio Perucca
- Division of Clinical and Experimental Pharmacology, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy.,Department of Neuroscience, Monash University, Melbourne, Australia
| | - Giangennaro Coppola
- Department of Medicine, Surgery, Odontoiatry, Medical School of Salerno, University of Salerno, Salerno, Italy
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Wang H, Chen D, He J, He Y, Liu L, Zhou D. Trend of Sudden Unexpected Death in Epilepsy Incidence Rate in Rural West China. Front Neurol 2021; 12:735201. [PMID: 34630306 PMCID: PMC8498108 DOI: 10.3389/fneur.2021.735201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/23/2021] [Indexed: 02/05/2023] Open
Abstract
Objectives: To explore the trend of sudden unexpected death in epilepsy (SUDEP) incidence rate over time in rural west China. Methods: We scanned probable SUDEP patients from the epilepsy program between 2010 and 2019 in rural West China and performed a verbal autopsy for each eligible patient. We calculated the crude and sex-adjusted incidence rate of SUDEP per person-year over a calendar year and the year of follow-up. We calculated the incidence rate ratio with the Poisson model in STATA 12.0 and calculated the annual percentage change (APC) and average annual percentage change in Joinpoint Trend Analysis Software 4.8.0.1 to analyze the trend of SUDEP incidence rate. Results: In 2010–2019, 44 probable SUDEPs were identified from 10,128 patients with a total person-year of 31,347. The crude and sex-adjusted incidence rates of SUDEP were 1.40 and 1.45%0. Twenty-five (56.8%) of the 44 probable SUDEPs had no generalized tonic-clonic seizure 3 months before their death. The incidence of probable SUDEP decreased significantly in the calendar year [APC = −11.7, 95% confidence interval (CI): −21.7 to −0.3] and in time of follow-up (average annual percentage change = −21.2, 95% CI: −34.3 to −5.4). Comparing the first 5 years in follow-up with the subsequent 3 years, the incidence rate of SUDEP decreased significantly (estimated incidence rate ratio = 0.4, 95% CI: 0.2 to 0.8). Significance: SUDEP happened to 1.4 cases per thousand patient-years in convulsive epilepsy in rural west China between 2010 and 2019. The incidence rate of SUDEP presented a downward trend over the time of follow-up.
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Affiliation(s)
- Haijiao Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jun He
- Sichuan Center of Disease Control and Prevention, Chengdu, China
| | - Yujin He
- Sichuan Center of Disease Control and Prevention, Chengdu, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Layer N, Brandes J, Lührs PJ, Wuttke TV, Koch H. The effect of lamotrigine and other antiepileptic drugs on respiratory rhythm generation in the pre-Bötzinger complex. Epilepsia 2021; 62:2790-2803. [PMID: 34553376 DOI: 10.1111/epi.17066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Lamotrigine and other sodium-channel blocking agents are among the most commonly used antiepileptic drugs (AEDs). Because other sodium channel blockers, such as riluzole, can severely alter respiratory rhythm generation during hypoxia, we wanted to investigate if AEDs can have similar effects. This is especially important in the context of sudden unexpected death in epilepsy (SUDEP), the major cause of death in patients suffering from therapy-resistant epilepsy. Although the mechanism of action is not entirely understood, respiratory dysfunction after generalized tonic-clonic seizures seems to play a major role. METHODS We used transverse brainstem slice preparations from neonatal and juvenile mice containing the pre-Bötzinger complex (PreBötC) and measured population as well as intracellular activity of the rhythm-generating network under normoxia and hypoxia in the presence or absence of AEDs. RESULTS We found a substantial inhibition of the gasping response induced by the application of sodium channel blockers (lamotrigine and carbamazepine). In contrast, levetiracetam, an AED-modulating synaptic function, had a much smaller effect. The inhibition of gasping by lamotrigine was accompanied by a significant reduction of the persistent sodium current (INap) in PreBötC neurons. Surprisingly, the suppression of persistent sodium currents by lamotrigine did not affect the voltage-dependent bursting activity in PreBötC pacemaker neurons, but led to a hypoxia-dependent shift of the action potential rheobase in all measured PreBötC neurons. SIGNIFICANCE Our results contribute to the understanding of the effects of AEDs on the vital respiratory functions of the central nervous system. Moreover, our study adds further insight into sodium-dependent changes occurring during hypoxia and the contribution of cellular properties to the respiratory rhythm generation in the pre-Bötzinger complex. It raises the question of whether sodium channel blocking AEDs could, in conditions of extreme hypoxia, contribute to SUDEP, an important issue that warrants further studies.
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Affiliation(s)
- Nikolas Layer
- Department of Neurology and Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Janine Brandes
- Department of Neurology and Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Philipp Justus Lührs
- Department of Neurology and Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Thomas V Wuttke
- Department of Neurology and Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Henner Koch
- Department of Neurology and Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,Department of Epileptology, Neurology, RWTH University of Aachen, Aachen, Germany
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40
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Tomaszewski M, Zolkowska D, Plewa Z, Czuczwar SJ, Łuszczki JJ. Effect of acute and chronic exposure to lovastatin on the anticonvulsant action of classical antiepileptic drugs in the mouse maximal electroshock-induced seizure model. Eur J Pharmacol 2021; 907:174290. [PMID: 34217711 DOI: 10.1016/j.ejphar.2021.174290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/02/2021] [Accepted: 06/25/2021] [Indexed: 10/21/2022]
Abstract
Numerous studies indicate neuroprotective activity of statins, commonly used cholesterol lowering drugs in epilepsy and several other neurological diseases. Promising anti-convulsant and neuroprotective effects of statins, attributed to their anti-excitotoxic and anti-inflammatory action were reported in several animals' seizure models. To determine the effects of acute (single) and chronic (once daily for 7 consecutive days) administration of lovastatin on the protective activity of four classical antiepileptic drugs such as carbamazepine, phenobarbital, phenytoin and valproate in the mouse maximal electroshock seizure model. Seizure activity (maximal electroconvulsions) in mice were generated by alternating current delivered via ear-clip electrodes. Adverse-effect profile of lovastatin combinations with the tested antiepileptic drugs was assessed in the chimney test (motor performance). Total brain concentrations of antiepileptic drugs were evaluated with the fluorescence polarization immunoassay technique as a measure of the pharmacokinetic interaction between drugs. Lovastatin administered acutely or chronically (5-20 mg/kg) did not significantly affect the threshold for electroconvulsions in mice. Acute lovastatin (10 mg/kg) significantly enhanced the anticonvulsant effect of valproate, which was accompanied with a 34% significant increase in total brain concentration of valproate. Acute lovastatin in combination with phenytoin impaired motor performance by notably decreasing the TD50 value of phenytoin. Chronic lovastatin (10 mg/kg) markedly enhanced the anticonvulsant potential of phenytoin. Acute lovastatin increased anticonvulsant action of valproate but also significantly raised level of valproate in brain after combined administration suggesting pharmacokinetic nature of interaction. The combinations of chronic lovastatin combined with phenytoin can potentially enhance the anticonvulsant potency of phenytoin.
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Affiliation(s)
- Michał Tomaszewski
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090, Lublin, Poland; Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, 20-090, Lublin, Poland
| | - Dorota Zolkowska
- Department of Neurology, UC Davis School of Medicine, 4635 2nd Avenue, Sacramento, CA, 95817, USA
| | - Zbigniew Plewa
- Department of General, Oncological and Minimally Invasive Surgery, 1st Military Clinical Hospital, Lublin, Poland
| | - Stanisław J Czuczwar
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090, Lublin, Poland
| | - Jarogniew J Łuszczki
- Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL 20-090, Lublin, Poland.
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Josephson CB, Engbers JDT, Sajobi TT, Wiebe S. Adult onset epilepsy is defined by phenotypic clusters with unique comorbidities and risks of death. Epilepsia 2021; 62:2036-2047. [PMID: 34453326 DOI: 10.1111/epi.16996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This study was undertaken to identify clusters of adult onset epilepsy with distinct comorbidities and risks of early and late death. METHODS This was a retrospective open cohort study that included all adults meeting a case definition for epilepsy after the Acceptable Mortality Recording date in the Health Improvement Network database for the years 2000-2012 inclusive. Unsupervised agglomerative hierarchical clustering was performed to identify unique clusters of patients based on their predicted risk of early (<4 years of epilepsy diagnosis) and late (≥4 years from diagnosis) mortality and patient-level clinical characteristics. RESULTS We identified 10 499 presumed incident cases of epilepsy from 11 194 182 patients. Four phenotypic clusters were identified in the early and late risk periods. Early clusters include older adults with cardiovascular disease and a high risk of death (median predicted risk = 20%, interquartile range [IQR] = 9%-31%), a group with moderate risk of death and cancer (median predicted risk = 6%, IQR = 2%-15%), a group with psychiatric disease/substance use and few somatic comorbidities (median predicted risk = 5%, IQR = 2%-9%), and one with a younger age at onset and few comorbidities (median predicted risk = 4%, IQR = 1%-11%). There was minimal movement of individuals between clusters for those surviving the early risk period. Age- and sex-standardized 3-year mortality ratios were more than sixfold higher than the general population for every cluster, even those primarily comprised of healthy younger adults. SIGNIFICANCE Adult onset epilepsy is marked by unique clusters of comorbid conditions and elevated risks of death that form discrete populations for targeted therapeutic interventions. These clusters remain relatively stable between the early and late mortality risk periods. Of particular interest are the clusters marked by young and otherwise healthy adults whose standardized mortality ratio is sixfold higher than general population despite few conventional risk factors for premature death.
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Affiliation(s)
- Colin B Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Centre for Health Informatics, University of Calgary, Calgary, AB, Canada
| | | | - Tolulope T Sajobi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Samuel Wiebe
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Leitner DF, Faustin A, Verducci C, Friedman D, William C, Devore S, Wisniewski T, Devinsky O. Neuropathology in the North American sudden unexpected death in epilepsy registry. Brain Commun 2021; 3:fcab192. [PMID: 34514397 PMCID: PMC8417454 DOI: 10.1093/braincomms/fcab192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 11/12/2022] Open
Abstract
Sudden unexpected death in epilepsy is the leading category of epilepsy-related death and the underlying mechanisms are incompletely understood. Risk factors can include a recent history and high frequency of generalized tonic-clonic seizures, which can depress brain activity postictally, impairing respiration, arousal and protective reflexes. Neuropathological findings in sudden unexpected death in epilepsy cases parallel those in other epilepsy patients, with no implication of novel structures or mechanisms in seizure-related deaths. Few large studies have comprehensively reviewed whole brain examination of such patients. We evaluated 92 North American Sudden unexpected death in epilepsy Registry cases with whole brain neuropathological examination by board-certified neuropathologists blinded to the adjudicated cause of death, with an average of 16 brain regions examined per case. The 92 cases included 61 sudden unexpected death in epilepsy (40 definite, 9 definite plus, 6 probable, 6 possible) and 31 people with epilepsy controls who died from other causes. The mean age at death was 34.4 years and 65.2% (60/92) were male. The average age of death was younger for sudden unexpected death in epilepsy cases than for epilepsy controls (30.0 versus 39.6 years; P = 0.006), and there was no difference in sex distribution respectively (67.3% male versus 64.5%, P = 0.8). Among sudden unexpected death in epilepsy cases, earlier age of epilepsy onset positively correlated with a younger age at death (P = 0.0005) and negatively correlated with epilepsy duration (P = 0.001). Neuropathological findings were identified in 83.7% of the cases in our cohort. The most common findings were dentate gyrus dysgenesis (sudden unexpected death in epilepsy 50.9%, epilepsy controls 54.8%) and focal cortical dysplasia (FCD) (sudden unexpected death in epilepsy 41.8%, epilepsy controls 29.0%). The neuropathological findings in sudden unexpected death in epilepsy paralleled those in epilepsy controls, including the frequency of total neuropathological findings as well as the specific findings in the dentate gyrus, findings pertaining to neurodevelopment (e.g. FCD, heterotopias) and findings in the brainstem (e.g. medullary arcuate or olivary dysgenesis). Thus, like prior studies, we found no neuropathological findings that were more common in sudden unexpected death in epilepsy cases. Future neuropathological studies evaluating larger sudden unexpected death in epilepsy and control cohorts would benefit from inclusion of different epilepsy syndromes with detailed phenotypic information, consensus among pathologists particularly for more subjective findings where observations can be inconsistent, and molecular approaches to identify markers of sudden unexpected death in epilepsy risk or pathogenesis.
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Affiliation(s)
- Dominique F Leitner
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Arline Faustin
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Chloe Verducci
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Christopher William
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Pathology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Sasha Devore
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Thomas Wisniewski
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Pathology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Psychiatry, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
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Surges R, Conrad S, Hamer HM, Schulze-Bonhage A, Staack AM, Steinhoff BJ, Strzelczyk A, Trinka E. [SUDEP in brief - knowledge and practice recommendations on sudden unexpected death in epilepsy]. DER NERVENARZT 2021; 92:809-815. [PMID: 33591415 PMCID: PMC8342364 DOI: 10.1007/s00115-021-01075-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 11/29/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the sudden and unexpected death of an epilepsy patient, which occurs under benign circumstances without evidence of typical causes of death. SUDEP concerns all epilepsy patients. The individual risk depends on the characteristics of the epilepsy and seizures as well as on living conditions. Focal to bilateral and generalized tonic-clonic seizures (TCS), nocturnal seizures and lack of nocturnal supervision increase the risk. Most SUDEP cases are due to a fatal cascade of apnea, hypoxemia and asystole in the aftermath of a TCS. Two thirds of SUDEP cases in unsupervised epilepsy patients with TCS could probably be prevented. Wearables can detect TCS and alert caregivers. SUDEP information is desired by most patients and relatives, has a favorable impact on treatment adherence and behavior and has no negative effects on mood and quality of life.Recommendations of the committee on patient safety of the German Society of Epileptology: the ultimate treatment goal is seizure freedom. If this cannot be achieved, control of TCS should be sought. All epilepsy patients and their relatives should be informed about SUDEP and risk factors. Patients and relatives should be informed about measures to counteract the elevated risk and imminent SUDEP. The counselling should be performed during a face-to-face discussion, at the time of first diagnosis or during follow-up visits. The counselling should be documented. Wearables for TCS detection can be recommended. If TCS persist, therapeutic efforts should be continued. The bereaved should be contacted after a SUDEP.
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Affiliation(s)
- Rainer Surges
- Klinik und Poliklinik für Epileptologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | | | - Hajo M Hamer
- Epilepsiezentrum, Klinik für Neurologie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | | | | | - Bernhard J Steinhoff
- Epilepsiezentrum Kork, Kehl-Kork, Deutschland
- Universitätsklinik Freiburg, Freiburg, Deutschland
| | - Adam Strzelczyk
- Epilepsiezentrum Frankfurt Rhein-Main, Zentrum der Neurologie und Neurochirurgie, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University and Centre for Cognitive Neuroscience, Salzburg, Österreich
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Österreich
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Hakami T, Hakami M. Sudden unexpected death in epilepsy: Experience of neurologists in Saudi Arabia. Epilepsy Behav 2021; 121:108025. [PMID: 34022620 DOI: 10.1016/j.yebeh.2021.108025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/17/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
IMPORTANCE Sudden unexpected death in epilepsy (SUDEP) may account for up to 17% of all deaths in epilepsy. However, it is unknown if neurologists discuss this risk with patients. OBJECTIVE This study aimed to examine the understanding and practices of SUDEP by neurologists in Saudi Arabia. METHODS An electronic web-based survey was sent to 125 neurologists using the mailing list of the Saudi Neurology Society. The survey questions included respondents' demographics, frequency of SUDEP discussion, reasons for discussing/not discussing SUDEP, and perceived patient reactions. Respondents' knowledge of the SUDEP risk factors was examined using 12 items from the currently available literature. Logistic regression analyses were applied to examine the factors that influence the frequency of SUDEP discussions and perceived patient reactions. PARTICIPANTS The participants were neurologists who had completed postgraduate training, devoted >5% of their time to clinical care, and had at least one patient with epilepsy in their independent neurology clinic. RESULTS A total of 60 respondents met the eligibility criteria and completed the surveys. Of them, 25% discussed SUDEP most of the time, 65% sometimes or rarely, and 10% never discussed it. Of those who discussed SUDEP with their patients, 63.3% did it if the patient was at high risk. Poor compliance with antiepileptic drugs (AEDs) was the most common patient factor highlighted (81.7%). The perceived patients' reactions were variable, with positive reactions (motivation to comply and appreciation) being the most frequent. The majority of respondents (78.3%) had incomplete understanding of the published SUDEP risk factors, with SUDEP knowledge scores ≤2.5 (≤50% of the possible total score). The most identified risk factors were frequent generalized tonic-clonic seizures (83.3%), long duration of epilepsy (53.3%), lack of use or sub-therapeutic levels of AEDs (50%), and AED polytherapy (50%). No association was found between how often SUDEP was discussed and other factors, including training in epilepsy, ≥10 years in practice, seeing ≥100 patients, and having SUDEP cases in the past two years. It was found that patients positively reacted to discussion on SUDEP if neurologists had a good understanding of the SUDEP risk factors (χ2 = 5.773, p = 0.016). CONCLUSIONS Neurologists in Saudi Arabia do not often discuss SUDEP with patients that have epilepsy. Moreover, when they do, they stress a more individualized approach despite having only a limited understanding of the SUDEP risk factors. Our findings suggest that more guidance should be provided to practitioners on how best to counsel their patients about SUDEP.
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Affiliation(s)
- Tahir Hakami
- The Faculty of Medicine, Jazan University, Jazan, Saudi Arabia.
| | - Mohammed Hakami
- Division of Neurology, King Fahd Central Hospital, Jazan, Saudi Arabia
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45
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Nascimento FA, Laze J, Friedman D, Lam A, Devinsky O. SUDEP education among U.S. and international neurology trainees. Epilepsy Behav 2021; 121:108098. [PMID: 34111766 DOI: 10.1016/j.yebeh.2021.108098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Abstract
We evaluated baseline sudden unexpected death in epilepsy (SUDEP) knowledge and counseling practices among national and international adult neurology trainees with a 12-question online survey. The survey was emailed to all 169 U.S. neurology residency program directors and select international neurology/epilepsy program leaders. Program leaders were asked to distribute the survey link to adult neurology trainees. There were 161 respondents in the U.S. and 171 respondents outside the U.S. The latter were from 25 Latin American, European, Asian, and African countries. More than 90% of all trainees reported familiarity with SUDEP definition. Familiarity with SUDEP risk factors and mitigation measures ranged from 56% to 67% across these groups, with international trainees slightly more familiar with risk factors (67% vs. 61% in U.S.) but less familiar with mitigation measures (56% vs. 63% in U.S.). Approximately half of national (49%) and international (54%) trainees rarely or never counseled patients on SUDEP. Less than half of national (44%) and international (41%) trainees were educated about SUDEP. Many U.S. and adult neurology trainees remain unfamiliar with SUDEP risk factors and mitigation measures. Sudden unexpected death in epilepsy counseling falls below recommended standards. We suggest that worldwide neurology training programs' leaderships consider improving SUDEP education targeted at adult neurology trainees.
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Affiliation(s)
- Fábio A Nascimento
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | - Juliana Laze
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Alice Lam
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Orrin Devinsky
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
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Nei M, Pickard A. The role of convulsive seizures in SUDEP. Auton Neurosci 2021; 235:102856. [PMID: 34343824 DOI: 10.1016/j.autneu.2021.102856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/01/2021] [Accepted: 07/19/2021] [Indexed: 11/19/2022]
Abstract
Convulsive seizures are the most consistently reported risk factor for SUDEP. However, the precise mechanisms by which convulsive seizures trigger fatal cardiopulmonary changes are still unclear. Additionally, it is not clear why some seizures cause death when most do not. This article reviews the physiologic changes that occur during and after convulsive seizures and how these may contribute to SUDEP. Seizures activate specific cortical and subcortical regions that can cause potentially lethal cardiorespiratory changes. Clinical factors, including sleep state, medication treatment and withdrawal, positioning and posturing during seizures, and underlying structural or genetic conditions may also affect specific aspects of seizures that may contribute to SUDEP. While seizure control, either through medication or surgical treatment, is the primary intervention that reduces SUDEP risk, unfortunately, seizures cannot be fully controlled despite maximal treatment in a significant proportion of people with epilepsy. Thus specific interventions to prevent adverse seizure-related cardiopulmonary consequences are needed. The potential roles of repositioning/stimulation after seizures, oxygen supplementation, cardiopulmonary resuscitation and clinical treatment options in reducing SUDEP risk are explored. Ultimately, understanding of these factors may lead to interventions that could reduce or prevent SUDEP.
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Affiliation(s)
- Maromi Nei
- Sidney Kimmel Medical College at Thomas Jefferson University, Jefferson Comprehensive Epilepsy Center, Department of Neurology, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, United States of America.
| | - Allyson Pickard
- Sidney Kimmel Medical College at Thomas Jefferson University, Jefferson Comprehensive Epilepsy Center, Department of Neurology, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, United States of America
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Szurhaj W, Leclancher A, Nica A, Périn B, Derambure P, Convers P, Mazzola L, Godet B, Faucanie M, Picot MC, De Jonckheere J. Cardiac Autonomic Dysfunction and Risk of Sudden Unexpected Death in Epilepsy. Neurology 2021; 96:e2619-e2626. [PMID: 33837114 DOI: 10.1212/wnl.0000000000011998] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/26/2021] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE We aimed to test whether patients who died of sudden unexpected death in epilepsy (SUDEP) had an abnormal cardiac autonomic response to sympathetic stimulation by hyperventilation. METHODS We conducted a retrospective, observational, case-control study of a group of patients who died of SUDEP and controls who were matched to the patients for epilepsy type, drug resistance, sex, age at EEG recording, age at onset of epilepsy, and duration of epilepsy. We analyzed the heart rate (HR) and HR variability (HRV) at rest and during and after hyperventilation performed during the patient's last EEG recording before SUDEP. In each group, changes over time in HRV indexes were analyzed with linear mixed models. RESULTS Twenty patients were included in each group. In the control group, the HR increased and the root mean square of successive RR-interval differences (RMSSD) decreased during the hyperventilation and then returned to the baseline values. In the SUDEP group, however, the HR and RMSSD did not change significantly during or after hyperventilation. A difference in HR between the end of the hyperventilation and 4 minutes after its end discriminated well between patients with SUDEP and control patients (area under the receiver operating characteristic curve 0.870, sensitivity 85%, specificity 75%). CONCLUSION Most of patients with subsequent SUDEP have an abnormal cardiac autonomic response to sympathetic stimulation through hyperventilation. An index reflecting the change in HR on hyperventilation might be predictive of the risk of SUDEP and could be used to select patients at risk of SUDEP for inclusion in trials assessing protective measures.
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Affiliation(s)
- William Szurhaj
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France.
| | - Alexandre Leclancher
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Anca Nica
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Bertille Périn
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Philippe Derambure
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Philippe Convers
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Laure Mazzola
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Bertrand Godet
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Marie Faucanie
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Marie-Christine Picot
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Julien De Jonckheere
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
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Lee JW. Sometimes, More Is More: Antiseizure Medication polytherapy Is Associated With Decreased SUDEP Risk. Epilepsy Curr 2021; 21:90-92. [PMID: 34025282 PMCID: PMC8010867 DOI: 10.1177/1535759720988546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pharmacologic Treatment and SUDEP risk: A Nationwide, Population-Based, Case-Control Study Sveinsson O, Andersson T, Mattsson P, et al. Neurology. 2020;95(18):e2509-e2518. doi:10.1212/WNL.0000000000010874 Objective: We conducted a nationwide case–control study in Sweden to test the hypothesis that antiepileptic drugs (AEDs) mono- or polytherapy, adherence, antidepressants, neuroleptics, β-blockers, and statins are associated with sudden unexpected death in epilepsy (SUDEP) risk. Methods: Included were 255 SUDEP cases and 1148 matched controls. Information on clinical factors and medications came from medical records and the National Patient and Prescription Registers. The association between SUDEP and medications was assessed by odds ratios (ORs) with 95% CIs adjusted for potential risk factors including type of epilepsy, living conditions, comorbidity, and frequency of generalized tonic–clonic seizures (GTCS). Results: Polytherapy, especially taking 3 or more AEDs, was associated with a substantially reduced risk of SUDEP (OR: 0.31, 95% CI: 0.14-0.67). Combinations including lamotrigine (OR: 0.55, 95% CI: 0.31-0.97), valproic acid (OR: 0.53, 95% CI: 0.29-0.98), and levetiracetam (OR: 0.49, 95% CI: 0.27-0.90) were associated with reduced risk. No specific AED was associated with increased risk. Regarding monotherapy, although numbers were limited, the lowest SUDEP risk was seen in users of levetiracetam (0.10, 95% CI: 0.02-0.61). Having nonadherence mentioned in the medical record was associated with an OR of 2.75 (95% CI: 1.58-4.78). Statin use was associated with a reduced SUDEP risk (OR: 0.34, 95% CI: 0.11-0.99) but selective serotonin reuptake inhibitor use was not. Conclusion: These results provide support for the importance of medication adherence and intensified AED treatment for patients with poorly controlled GTCS in the effort to reduce SUDEP risk and suggest that comedication with statins may reduce risk.
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Nashef L, Rugg-Gunn F. Reducing the risk of SUDEP. Neurology 2020; 95:807-808. [DOI: 10.1212/wnl.0000000000010916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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