Epilepsy in India I: Epidemiology and public health

The Influence of Epilepsy on Oral Health Outcomes: A Retrospective Study in South Indian Adults

Introduction Epilepsy, a chronic neurological disorder marked by recurrent seizures, affects approximately 50 million people worldwide with a higher prevalence in developing countries. This condition challenges motor skills and coordination, leading to poor oral health maintenance. The study aimed to evaluate the effect of epilepsy on oral health outcomes in adults by contrasting South Indian epileptics with healthy controls. The primary objective was to assess the prevalence of oral health issues in patients with epilepsy compared to healthy individuals and to analyze the types and frequency of dental procedures required in epileptic patients compared to healthy controls in the South Indian population. Materials and methods A retrospective study was conducted in the Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Chennai, India. Approved by the Institutional Human Ethical Committee (Registration ID: IHEC/SDC/OMED-2202/23/106), the study involved 105 epileptic patients and 105 healthy controls from records between January 2021 and December 2023. Both male and female patients within the age limit of 18-55 years were included. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 29.0 (Released 2022; IBM Corp., Armonk, New York, United States). Results The study involved 210 participants with an equal gender distribution. Valproate was the most common medication used by 39% of epileptic patients. Gingival hyperplasia was significantly more prevalent in the epileptic group (24%). The epileptic group also required more dental procedures, with 32% of teeth needing restoration, 20% root canal treatment, and 20% extraction, compared to 12%, 11%, and 5%, respectively, in the control group. Conclusion Epileptic patients exhibit poorer oral health outcomes, including higher rates of gingival hyperplasia and a greater need for dental procedures compared to healthy controls. These findings highlight the necessity for targeted dental care and regular monitoring for individuals with epilepsy to improve their oral health and overall quality of life.

Fisetin-loaded chitosan nanoparticles ameliorate pilocarpine-induced temporal lobe epilepsy and associated neurobehavioral alterations in mice: Role of ROS/TNF-α-NLRP3 inflammasomes pathway

Fisetin has displayed potential as an anticonvulsant in preclinical studies yet lacks clinical validation. Challenges like low solubility and rapid metabolism may limit its efficacy. This study explores fisetin-loaded chitosan nanoparticles (NP) to address these issues. Using a murine model of pilocarpine-induced temporal lobe epilepsy, we evaluated the anticonvulsant and neuroprotective effects of fisetin NP. Pilocarpine-induced seizures and associated neurobehavioral deficits were assessed after administering subtherapeutic doses of free fisetin and fisetin NP. Changes in ROS, inflammatory cytokines, and NLRP3/IL-18 expression in different brain regions were estimated. The results demonstrate that the fisetin NP exerts protection against seizures and associated depression-like behavior and memory impairment. Furthermore, biochemical, and histological examinations supported behavioral findings suggesting attenuation of ROS/TNF-α-NLRP3 inflammasome pathway as a neuroprotective mechanism of fisetin NP. These findings highlight the improved pharmacodynamics of fisetin using fisetin NP against epilepsy, suggesting a promising therapeutic approach against epilepsy and associated behavioral deficits.

Knowledge, attitudes and practices of psychiatrists in India regarding sudden unexpected death in epilepsy (SUDEP) and seizure-related harm

Sudden unexpected death in Epilepsy (SUDEP) is one of the leading causes of death in people with epilepsy (PWE). Awareness and taking adequate preventive measures are pivotal to reducing SUDEP. Nearly 80% of PWE live in lower-middle-income countries (LMICs) such as India where for many, epilepsy management is by psychiatrists. To evaluate the knowledge, attitude and practices of Indian psychiatrists on SUDEP and seizure risk. A cross-sectional online survey of 12 Likert response questions using validated themes, was circulated among Indian Psychiatric Society members. Non-discriminatory exponential snowballing technique leading to convenience non-probability sampling was used. The inquiry involved SUDEP-related topics including the need for and importance of counselling. Descriptive statistics and the chi-square test were used for analysis. The psychiatrists responding (n = 134) were likely to be males (72.4 %), urban (94 %) and affiliated to academic institutions (76.1 %). Nearly all saw PWE monthly with over half (54 %) seeing more than 10. Nearly two-third (64.17 %) did not counsel PWE regarding SUDEP, due to fear of raising concerns in caregivers/family (33.3 %), patients (38.9 %) or lack of time (35.6 %), though 37 % had lost patients due to SUDEP. Over two-third (66.7 %) agreed risk counselling was important. Barriers included fear of raising concerns, limited time, and training. A strong need for national SUDEP guidelines (89 %) and suitable training (75.4 %) was expressed. Though epilepsy care is provided by a considerable number of psychiatrists, there is a poor understanding of SUDEP. Enhancing the awareness and understanding of SUDEP is likely to enhance epilepsy care.

Determinants of Outcomes in Convulsive Status Epilepticus: An Observational Study at a Tertiary Care Center in North India

Objective Status epilepticus (SE) presents a critical neurological emergency associated with high morbidity and mortality rates worldwide. However, the determinants influencing outcomes in SE within specific regional contexts remain less explored, especially within North India. Understanding the factors influencing the prognosis of SE in this region is crucial for tailored therapeutic approaches and improved patient outcomes.  Materials and methods This observational study was conducted at Jawaharlal Nehru Medical College, Aligarh, India, from December 1, 2020, to November 31, 2022. Patients who presented with convulsive SE lasting more than five minutes or repetitive and discrete seizures with impaired consciousness between the interictal period for at least 30 minutes were included in the study. Their clinical and biochemical variables at presentation were assessed and correlated with the outcome. Results Out of the 110 patients included in the study, males represented 59.1% (n=65), outnumbering females, who comprised 40.9% (n=45). Favourable outcome was observed in 66.36% (n=73) of patients, and unfavourable outcome was observed in 33.63% (n=37). The mean time interval between seizure onset to the patient's arrival at the hospital was 5.30 ± 4.96 hours, and the mean time interval between seizure onset to the point of seizure control was 7.10 ± 6.38 hours. On analysing the factors associated with unfavourable outcome, the type of seizure at onset (p=0.021), Glasgow Coma Scale (GCS) of <=12 at presentation (p<0.001), presence of refractory seizure (p<0.001), presence of abnormal epileptiform discharges on electroencephalography (p=0.001), Status Epilepticus Severity Score (STESS) of >2 (p<0.001), serum lactate levels (p<0.001), duration of hospital stay (p=0.004), time interval between seizure onset to hospital arrival (p<0.001) and time interval between seizure onset to the point of seizure control (p<0.001) showed significant association. However, on analysing the independent risk factors of unfavourable outcome using multivariate logistic regression, only duration of hospital stay (p<0.001, odds ratio (OR): 1.205, 95% confidence interval (CI): 1.046-1.389), and GCS of less than or equal to 12 at presentation (p<0.001, OR: 12.354, 95% CI: 2.974-51.319) showed significant association. Conclusions Our study highlighted key clinical and time-related parameters influencing the outcome of convulsive SE. Understanding these factors is crucial for better treatment and improved patient outcomes. Further research is essential for refining interventions in this complex condition.

Nonadherence to antiepileptic medication and associated factors among persons with epilepsy in India: A systematic review and meta-analysis

BACKGROUND

Nonadherence to antiepileptic drugs (AEDs) is a prevalent issue in India, contributing to suboptimal seizure control, higher morbidity and mortality, increased hospitalization rates, and a substantial effect on the overall quality of life for individuals with epilepsy.

OBJECTIVES

This study aimed to measure the prevalence of medication adherence among individuals with epilepsy in India and to identify factors associated with nonadherence.

METHODS

Following PRISMA guidelines, we searched PubMed, Scopus, Embase, and Google Scholar for studies on AED adherence in India. Quality assessment employed Newcastle Ottawa Scale adapted for cross-sectional studies. Pooled prevalence was ascertained using a random-effects model in R software (version 4.2.2), with a 95% confidence interval. Heterogeneity was estimated with the I2 statistic, and publication bias was appraised via a funnel plot. Subgroup analyses, based on study region and adherence measurement tool, were done to investigate heterogeneity.

RESULTS

Nine cross-sectional studies with 1772 participants were analyzed. The pooled prevalence of adherence to AEDs in India stood at 49.9% (95% CI: 39.8%-60.1%). Subgroup analyses showed comparable adherence rates in the South (50.9%) and North (46.5%) regions of India. However, adherence rates varied substantially based on the measurement tool: Morisky Medication Adherence Scale-4 (MMAS-4) reported 71.3%, MMAS-8 indicated 45.9%, and Morisky Green Levine (MGL) adherence scale exhibited 42.0%. Factors contributing to non-adherence to antiepileptic therapies involved poor socioeconomic status, lower education levels, polytherapy, drug-related side effects, and substance abuse.

CONCLUSIONS

Almost half of persons with epilepsy in India were non-adherent to their AEDs. This underscores the importance for healthcare professionals to pay greater attention to improving the adherence rate to AEDs within the healthcare service.

Neuropsychological Rehabilitation for Epilepsy in India: Looking Beyond the Basics

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Variations in the Neurosurgical Management of Depressed Skull Fractures in Adults: An International Cross-Sectional Survey

BACKGROUND

 Depressed skull fractures have been well described since antiquity, yet its management remains controversial. Contentious issues include the use of prophylactic antibiotics and antiepileptics, the role of nonoperative management, and the replacement/removal of bone fragments. Our objective was to explore the management patterns of closed and open depressed skull fractures across the world.

METHODS

 A 23-item, web-based survey was distributed electronically to the members of national neurosurgical associations, and on social media platforms. The survey was open for data collection from December 2020 to April 2021.

RESULTS

 A total of 218 respondents completed the survey, representing 56 countries.With regard to open fractures, most respondents (85.8%) treated less than 50 cases annually. Most respondents (79.4%) offered prophylactic antibiotics to all patients with open fractures, with significant geographical variation (p < 0.001). Less than half of the respondents (48.2%) offered prophylactic antiepileptics. Almost all respondents (>90%) reported the following indications as important for surgical management: (1) grossly contaminated wound, (2) dural penetration, (3) depth of depression, and (4) underlying contusion/hematoma with mass effect. Most respondents treated less than 50 cases of closed depressed skull fractures annually. Most European respondents (81.7%) did not offer prophylactic antiepileptics in comparison to most Asian respondents (52.7%; p < 0.001). Depth of depression, an underlying hematoma/contusion with mass effect, and dural penetration were the most important surgical indications.

CONCLUSIONS

 There remains a great degree of uncertainty in the management strategies employed across the world in treating depressed fractures, and future work should involve multinational randomized trials.

Impact of ABCB1 genetic polymorphism on carbamazepine dose requirement among Southern Indian persons with epilepsy

OBJECTIVES

Carbamazepine (CBZ) is one of the oldest, yet first line drugs for treating epilepsy. However, there is a large inter-individual difference in requirement of maintenance dose and one third of persons treated with antiepileptic drugs (AEDs) exhibit drug resistance to therapy. One of the proposed mechanisms for the drug resistance was increased expression of efflux transporter P-glycoprotein. The pharmacogenetic studies of drug transporters (ABCB1) done in combination therapies of AEDs were inconclusive. Hence, we have attempted to study the impact of ABCB1 3435C>T genetic polymorphism and CBZ monotherapy in persons with epilepsy (PWE) from South India, which is a genetically distinct population. With this background, this study was aimed to determine the dose of CBZ in ABCB1 3435C>T genotypes and to determine the distribution of ABCB1 3435C>T genotypes (which codes P-glycoprotein) between responders and non-responders to CBZ therapy.

METHODS

A cross sectional study was conducted in 200 persons with epilepsy, who were categorised as responders and non-responders according to ILAE (international league against epilepsy) criteria. Eligible participants were enrolled from the epilepsy clinic of the neurology department and five ml of blood was collected. DNA extraction and genotyping were done by phenol-chloroform method and real time polymerase chain reaction (RT-PCR), respectively.

RESULTS

The mean maintenance dose of carbamazepine was statistically significant among different genotypes (p<0.05) of ABCB1 3435C>T (526 vs. 637 mg/day in CC vs. TT genotype). There was no significant association between ABCB1 3435C>T polymorphism (p=0.827) and CBZ resistance in PWE. Duration of disease and age of onset were found to be significant in predicting the response to CBZ therapy.

CONCLUSIONS

We report that ABCB1 3435C>T polymorphism is significantly associated with an increase in dose requirement of CBZ in persons with epilepsy from South India.

Schiff Bases: A Captivating Scaffold with Potential Anticonvulsant Activity

One of the most important organic compounds, also known as a Schiff base, imine, or azomethine, has been associated with several biological processes. The group is a component of both natural or synthetic chemicals and functions as both a precursor and an intermediary in the synthesis of therapeutically active substances. The review highlights the various non-metal Schiff bases' structure-activity relationship (SAR) studies, general model, docking, and design approach for anticonvulsant actions. Schiff bases serve as linkers in numerous synthetic compounds with a variety of activities, according to the findings of several investigations. As a result, the current review will give readers a thorough understanding of the key ideas put forth by different researchers regarding the anticonvulsant properties of Schiff bases. It will serve as a valuable information source for those planning to synthesize new anticonvulsant molecules that contain Schiff bases as pharmacophores or biologically active moieties.

Magnitude and Determinant Factors of Pediatrics Seizures in Pediatrics Emergency Unit at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2020: A Retrospective and Descriptive Study

Background

One of the most prevalent medical problems affecting kids is epilepsy, which is the most prevalent chronic neurological condition in kids in both developed and developing nations. The spectrum of diseases that make up childhood epilepsy syndromes ranges from mild to potentially fatal. Children may experience seizures due to a variety of illnesses, such as infection, severe brain injury, and anatomical deformity. It is the foremost visit calculates in neurological and cognitive impedance in children in low-income countries as well as the foremost common reason for pediatric clinic confirmations in children from destitute countries. All things considered, constrained things have been conducted in Ethiopia. Hence, this ponder points to survey the size and related variables of pediatric seizures among children conceded to Tikur Anbessa pediatric emergency.

Methods

By looking through 256 patient charts, an institution-based retrospective cross-sectional analysis was done. Data collection utilized a systematic checklist that had been evaluated beforehand. The EpiData version 4.4.2.2 was used to enter the data, which was then exported for analysis to the SPSS version 25. Binary logistic regression and descriptive statistics were employed. Variables from the bivariate analysis that had a p-value of less than 0.25 were carried over to multivariate analysis. The strength and existence of the link were assessed using adjusted odds ratios with a 95% confidence interval and a p-value of 0.05, respectively.

Result

Patients' ages ranged from 3.7 to 2.8 years on average. 4.5% of patients had seizures, and 155 of them (60.5%) were men, with a male-to-female ratio of (1.5 : 1). Males and females experienced seizures on average at 1.3 (95% CI: 1.1, 1.5) and 2 (95% CI: 1.6, 2.5) years old, respectively. AOR: 2.68 (95% CI: 1.192, 6.68, p = 0.02) and AOR: 2.8 (95% CI: 2.576, 5.302, p = 0.04) both demonstrated statistically significant correlations with pediatric seizure.

Conclusion

A vast number of children experienced convulsions, with generalized seizures being the most prevalent form. The chances of a child having a seizure were linked to their family history and where they were born. Therefore, health workers and other people who are involved in healthcare need to work harder on the factors that they have already identified.

The Application of Deep Learning to Electroencephalograms, Magnetic Resonance Imaging, and Implants for the Detection of Epileptic Seizures: A Narrative Review

Epilepsy is a neurological disorder characterized by recurrent seizures affecting millions worldwide. Medically intractable seizures in epilepsy patients are not only detrimental to the quality of life but also pose a significant threat to their safety. Outcomes of epilepsy therapy can be improved by early detection and intervention during the interictal window period. Electroencephalography is the primary diagnostic tool for epilepsy, but accurate interpretation of seizure activity is challenging and highly time-consuming. Machine learning (ML) and deep learning (DL) algorithms enable us to analyze complex EEG data, which can not only help us diagnose but also locate epileptogenic zones and predict medical and surgical treatment outcomes. DL models such as convolutional neural networks (CNNs), inspired by visual processing, can be used to classify EEG activity. By applying preprocessing techniques, signal quality can be enhanced by denoising and artifact removal. DL can also be incorporated into the analysis of magnetic resonance imaging (MRI) data, which can help in the localization of epileptogenic zones in the brain. Proper detection of these zones can help in good neurosurgical outcomes. Recent advancements in DL have facilitated the implementation of these systems in neural implants and wearable devices, allowing for real-time seizure detection. This has the potential to transform the management of drug-refractory epilepsy. This review explores the application of ML and DL techniques to Electroencephalograms (EEGs), MRI, and wearable devices for epileptic seizure detection. This review briefly explains the fundamentals of both artificial intelligence (AI) and DL, highlighting these systems' potential advantages and undeniable limitations.

Clinical and Liver Biochemistry Phenotypes, and Outcome in 133 Patients with Anti-seizure Drug-Induced Liver Injury

AIMS AND OBJECTIVE

Anti-seizure drugs that cause idiosyncratic drug-induced liver injury (DILI) are an important cause of morbidity and mortality in individuals exposed to these drugs. The clinical and demographic characteristics, the liver injury pattern, the outcome, and the agents responsible for hepatotoxicity have not been thoroughly studied. We investigated the aforementioned characteristics in a large cohort of DILI registry patients.

METHODS

Patients with anti-seizure DILI were studied from a large single-center DILI registry between 1998 and 2021. DILI was defined by international working group criteria with at least a probable relation with RUCAM. Immunoallergic features and organ-specific contribution to outcome were investigated.

RESULTS

Anti-seizure drugs accounted for 133 patients (12.5%) among 1067 patients with idiosyncratic DILI. Compared to other agents, patients with anti-seizure DILI were younger (31 vs 41 years; p = 0.31), were more often females (52% vs 46%; p = 0.19) and had a lower frequency of jaundice (41% vs 59%, p = 0.001), MELD score (14.5 vs 16.5; p = 0.02) and mortality (9.8% vs 15.7%, p = 0.03). Anti-seizure DILI exhibited a greater frequency of hypersensitivity skin rashes (75% vs 22%, p < 0.001), including DRESS (51% vs 13%, p < 0.001) and SJS/TEN (19% vs1%, p < 0.001). A total of 18 different anti-seizure agents were responsible for DILI, largely contributed by carbamazepine (n = 36), phenytoin (n = 71), phenobarbitone (n = 8) and valproate (n = 14) which accounted for 89% of cases and 85% of 13 deaths.

CONCLUSIONS

Anti-seizure DILI are caused predominantly by first generation drugs. Newer agents account for < 10% of cases. Hypersensitivity reaction is the most common phenotypic presentation. Both severity and mortality are lower with anti-seizure DILI.

Evaluation of efficacy and safety of clobazam as an add-on drug in the treatment of generalized tonic-clonic seizure not controlled with valproic acid monotherapy

BACKGROUND

Epilepsy is one of the major neuron-damaging neurological disorders. Generalized tonic-clonic seizure (GTCS) is the commonest one. Refractory patterns cannot be controlled by simple monotherapy with antiepileptic drugs (AEDs). Valproic acid (VPA) is one of the widely prescribed AEDs but it may not control many cases up to its maximum tolerable doses. In this study, we have seen the safety and efficacy of clobazam to control seizure in the adult population as an add-on drug over valproate, in cases of valproate uncontrolled seizures.

MATERIALS AND METHODS

Patients on VPA monotherapy but not responding to it were recruited after applying inclusion and exclusion criteria and clobazam was added. There were two follow-ups at the interval of 6 months each. Seizure frequency and quality of life inventory in epilepsy-31 items (QOLIE-31) score were recorded to denote efficacy, and the occurrence of any adverse effect was also noted to elicit safety.

RESULTS

Out of 101 patients, 78 were male and 23 were female. The most common age group was 18-30 y. Seizure frequency from 2.99 ± 0.95 decreased significantly on the third visit to 0.25 ± 0.43. QOLIE-31 scores of seizure worry, overall quality, emotional well-being, and cognition improved in the second follow-up. Fatigue, somnolence, and weight gain were the major side effects.

CONCLUSION

Clobazam could be a good choice as an add-on in GTCS not controlled with VPA monotherapy. Clobazam definitely reduces seizure frequency and seizure worry and improves cognitive function and overall quality of life.

Neuroscience Engagement and Outreach on Neurodevelopmental Disorders: A Report from India

The current project was funded by the Global Engagement Seed Grant from the International Brain Research Organisation (IBRO) as part of the IBRO-led Global Engagement Initiative. The project was focused on public awareness about neurodevelopmental disorders (NDDs) as well as neuroscience engagement. Thus, the project had two specific aims: (a) public awareness about epidemiology, diagnosis, risk factors, prevention of NDDs and relevant government guidelines and available policies (b) public engagement in neuroscience. Therefore, the current project report with an emphasis on the requirement of neuroscience engagement and outreach at the societal level, highlights several activities such as population-based workshops and webinars, carried out as part of the project in both rural and urban areas to enhance the public engagement in neuroscience and awareness on several NDDs.

Key message

India is an extremely diverse country with significant variations in cultural, educational, financial, socioeconomic status and linguistic aspects. With about 27% of its population living below the poverty line, India accounts for about 23 million children suffering from a disability, most of whom do not seek medical help. These data highlight the gravity of the situation which calls for urgent actions from governments, healthcare professionals, researchers and policymakers to design adequate public awareness programs regarding several prevalent NDDs. Therefore, the current project was an effort to bring public awareness about brain health and the epidemiology, diagnosis and prevention of NDDs and relevant government guidelines and available policies.

Prevalence of headache disorders in patients living with epilepsy in rural region in western part of India

BACKGROUND AND AIMS

Headache disorders cause significant distress in patients living with epilepsy (PWE) and are underreported. This study aimed to evaluate the prevalence of various forms of headache in PWE.

METHODOLOGY

Two hundred and three PWE were evaluated for the presence and type of headache as per the International Classification of Headache Disorders (ICHD)-3 classification criteria. The severity was graded using the Headache Under Response to Treatment (HURT)-3. A subgroup analysis of headache and epilepsy was done. The World Health Organization-5 (WHO-5) questionnaire was used to assess mental well-being. The Mini International Neuropsychiatric Interview (MINI) questionnaire was used to study the psychiatric comorbidities, which were classified according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV classification.

RESULTS

The prevalence of headaches in PWE was 45% [60% females]. Female gender and younger age were significantly associated with migraine (p values of 0.03 and 0.05, respectively). Migraine was the most common type of headache (71%), followed by tension-type headache (TTH) (23%) in PWE. The headache was inter-ictal in 80% of PWE. In PWE with migraine, both juvenile myoclonic epilepsy (JME) and frontal lobe epilepsy (FLE) had a 28% prevalence. In PWE with TTH, FLE was more common (43%). The prevalence of migralepsy in PWE was 4% [n = 4; 2 each of occipital lobe epilepsy (OLE) and idiopathic generalized epilepsy (IGE)]. A psychiatric illness was more than two times more likely in PWE with headache (n = 34; 37%) as compared to PWE without headache (n = 19; 17%). Patients living with epilepsy with headaches and psychiatric comorbidities had significantly lower mental well-being (p = 0.001). Forty five percent of PWE with headaches required acute management, and 35% required prophylactic management for their headache.

CONCLUSION

Headache is frequently ignored in PWE. It can affect their mental health and quality of life. Evaluation and management of headache in PWE is very important.

A Comparison of the Quality of Life of People With Epilepsy Receiving Home-Based and Clinic-Based Epilepsy Care Using the European Quality of Life Five-Dimension Three-Level (EQ-5D-3L) Scale

Background and objective Epilepsy is a chronic neurological condition that, both physically and psychologically, puts a person at risk for poor quality of life (QOL). People with epilepsy (PWE) may experience shame, fear, and rejection and feel discriminated against, hence avoiding social interactions. To avoid being labeled as having epilepsy, patients may conceal their disease and refuse medical attention, which can lead to treatment discontinuation and significantly impact the quality of life. Epilepsy care in India has fallen back on primary care physicians because there are not enough neurologists available to treat the condition. Home-based care (HBC) may overcome many barriers by providing free antiepileptic drugs (AEDs), eliminating the "distance to a health facility," and providing correct information that may improve QOL. This study is therefore conducted to compare the QOL between people with epilepsy receiving home-based care (HBC) and routine clinic-based care (CBC). Methodology The people with epilepsy enrolled in this study were already part of a community-based randomized controlled trial conducted to compare the effect of regular home-based epilepsy care with routine clinic-based epilepsy care on antiepileptic adherence among urban and peri-urban areas of Ludhiana, Punjab, India (explained further in the study). The present study is a cohort study where the two cohorts, one receiving home-based epilepsy care (n = 97) and the other receiving routine clinic-based epilepsy care (n = 76), were compared for QOL at two points in time, i.e., at baseline (at enrolment) and after 24 months of receiving epilepsy care, using the European Quality of Life Five-Dimension Three-Level (EQ-5D-3L) scale. Results The mean EQ-5D-3L index scores for the HBC group at baseline were 0.88 ± 0.15, and after 24 months, the scores increased to 0.94 ± 0.17. The baseline mean index scores for the CBC group were 0.89 ± 0.21, and after 24 months, the value increased to 0.90 ± 0.19. The mean difference in QOL in the HBC group showed a higher difference than in the CBC group (0.06 ± 0.1 versus 0.01 ± 0.1), but the difference was found to be statistically not significant (p = 0.067). As per the five dimensions of the EQ-5D-3L scale, i.e., mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, there was a decrease in the number of PWE reporting problems among both groups after 24 months of epilepsy care. Sociodemographic and clinical variables such as level of education, working status, age at the onset of seizures, frequency of seizures, treatment regimen, presence of comorbidities, and adverse drug reactions significantly affect the QOL of people with epilepsy at p < 0.05. Conclusion The results of the study emphasize that epilepsy has a negative impact on QOL. The results showed a higher QOL among the people in the HBC group as compared to the CBC group, but the difference was not statistically significant. There was an improvement in QOL from baseline after dedicated care in both groups. The problems related to mobility, self-care, usual activities, pain/discomfort, and anxiety/depression have been significantly reduced in the HBC group. Having low levels of education, not having a job, starting to have seizures at a young age, having seizures more often, receiving more than one type of treatment, and the presence of other health problems and side effects are factors associated with poor QOL among people with epilepsy.

Evaluation of Metabolic Parameters on Use of Newer Antiepileptics Versus Conventional Antiepileptics in Patients of Generalised Tonic-Clonic Seizure: An Observational Study

Background and objective Epilepsy is the commonest serious neurological condition and around 50 million people live with epilepsy (PWE). Primary and secondary generalised tonic-clonic seizures (GTCS) together constitute up to 50% of adult and adolescent epilepsy. GTCS respond well to broad-spectrum AEDs like valproate, phenytoin, levetiracetam, lamotrigine, and topiramate. Carbamazepine and oxcarbazepine are considered alternatives. Metabolic derangements with the conventional AEDs (phenytoin causes loss of bone mass in women, phenytoin and carbamazepine produce increases in serum lipid and C-reactive protein, weight gain with valproate) are well documented. But, there is limited data regarding the effect of the newer AEDs on metabolic parameters. Thus, this study was undertaken to assess the effects of the newer AEDs on the metabolic profile of patients with epilepsy. Material and methods A prospective observational study was conducted in the Department of Pharmacology, in collaboration with the Department of Neurology at S.C.B. Medical College and Hospital, Cuttack. 100 diagnosed patients with GTCS receiving monotherapy of either conventional or newer anti-epileptics were included in the study. Their metabolic parameters like total cholesterol, serum sodium, serum TSH and fasting blood glucose were collected at baseline, three months, and six months. ADRs were collected during the entire study period and causality assessment was done using WHO-UMC Causality Assessment Scale. All the data were analysed using SPSS 20.0 after applying appropriate statistical tests. Results There was a significant increase in total cholesterol in all four groups (p=0.002) but a pathological increase in the phenytoin and oxcarbazepine groups. There was a significant rise in the serum TSH levels in all groups except levetiracetam, but a pathological increase was seen with phenytoin and valproate, i.e., the conventional ones. Statistically significant hyponatremia was seen with valproate and oxcarbazepine. A rise in the FBS was seen with both phenytoin and valproate (p=0.002) but a pathological rise was seen with phenytoin. Out of the total reported ADRs, 53.5% were seen with conventional AEDs, and the rest 46.5% were seen with newer ones. Conclusion The advent of newer anti-epileptic drugs has unfolded wider horizons to the treatment of epilepsy. Each of these drugs has a unique mechanism of action, making it less prone to resistance. Metabolic derangements are a key determinant in the compliance of these drugs as they can predispose to other co-morbidities. Periodic monitoring of the various metabolic parameters is useful and together with patient counselling can improve the effectiveness of the anti-epileptic drugs.

UGT2B7 gene polymorphism and linkage disequilibrium in pediatric epileptic patients and their influence on sodium valproate monotherapy: A cohort study

Background: Uridine 5′-diphospho glucuronosyl transferase (UGT) is the main enzyme responsible for the glucuronide conjugation, the principal metabolic pathway of sodium valproate. The objective of the study was to explore if there was an association between the UGT2B7 genetic polymorphism and clinical efficacy and safety in paediatric epileptic patients on sodium valproate monotherapy.

Methods and materials: The cohort study included 100 pediatric epileptic patients aged 2–18 years who had been on sodium valproate monotherapy for at least 1 month. PCR-RFLP was carried out to assess the genetic polymorphism patterns of UGT2B7 (C161T, A268G, G211T). Based on the extent of seizure control throughout the 1-year follow-up, clinical outcome was assessed in terms of responders and non-responders. Hepatic, renal, and other lab parameters were assayed to determine safety. The SNPstat web software was used to calculate linkage disequilibrium.

Results: Out of 100 patients, CC (38%), CT (43%), TT (19%) pattern was observed in UGT2B7 (C161T) gene, AA (15%), AG (39%), GG (46%) in (A268G) gene and GG (80%), GT (18%), TT (02%) in (G211T) gene. There was no statistical difference in clinical outcome with distinct UGT2B7 genetic polymorphism patterns, according to the findings. With low D′ and R2 values, linkage disequilibrium between alleles was statistically insignificant. However, the associations of C161T and G211T with treatment response were significant (p = 0.014) in determining treatment response.

Conclusion: Our findings show that the genetic variation of UGT2B7 had no bearing on the clinical outcome of epilepsy. Gene interactions, on the other hand, had an impact on treatment response.

Knowledge, Attitude, and Practice of epilepsy in Wayanad, Kerala

OBJECTIVE

Epilepsy is a common neurological condition characterized by recurrent seizures. The aim of the study was to assess the level of Knowledge, Attitude, and Practices (KAP) in epilepsy in the district of Wayanad.

METHODS

This study was conducted among adults residing in Wayanad. This was a community-based door-to-door survey conducted among adults residing in Wayanad District between August 2021 and November 2021. A semi-structured questionnaire was used for data collection. The questionnaire included 23 items that could define the information on the level of knowledge and attitude toward epilepsy.

RESULT

A total of 394 subjects without epilepsy were included in this study. According to the results of this study, 68.8% of respondents were female and 85.3% of them had completed at least primary school education. 93.1% of participants had heard about epilepsy and 64.5% of participants were aware that epilepsy was a brain disorder. 30.5% of participants believed that a person with epilepsy could not get married. 73.9% of participants recommended allopathic treatment for epilepsy and only 9.9% of participants knew about surgical treatment option for epilepsy.

CONCLUSION

Despite having a good understanding of the disease, there is a general tendency in the population to consider patients with epilepsy as incapable of leading a normal life. The choice of modern treatment methods over traditional is also a positive aspect.

Understanding the Role of Stigma and Misconceptions in the Experience of Epilepsy in India: Findings From a Mixed-Methods Study

It is surprising that although 12 million people in India suffer from epilepsy this remains a thoroughly under-researched area in the sociology of health and practice. We address this intellectual and policy neglect by reviewing the social, psychological and legal challenges governing the lives of people living with epilepsy (PWE) by paying particular attention to negotiations in arranged marriages and employment. Drawing on the analytical frameworks of the sociological study of stigma, critical race theory and paying attention to the cultural models of health and suffering, this study utilized a combination of (online) survey data (N = 100) and in-depth qualitative interviews (N = 10) with PWE and their families. The online survey was administered to map the level of awareness about epilepsy and its clinical management among the general population, whereas the in-depth interviews were conducted to understand the experience, self-perception and everyday struggles of those diagnosed with the condition. Findings from the survey on non-PWE suggest a general lack of awareness and fearful misconceptions around epilepsy related seizures. In-depth interviews with PWEs revealed concealment (of the illness) as a dominant coping strategy to attenuate the social alienation and rejection associated with epilepsy. Further, PWE participants reported persistent discrimination, harassment and prejudiced understanding of diminished cognitive capacities at workplaces as a result of cultural myths and popular representations of epilepsy-related seizures. The study also demonstrated the significance of institutional support groups in assisting PWE to cope with symbolic violence and forge solidarities. We conclude with reflections on the ethical dilemmas faced by medical practitioners while dealing with social-medical interventions of epilepsy treatment. Overall, results from this study undergird the significance to revisit the social-moral as well as legal frameworks that persistently restrict opportunities for PWE in India. In an attempt to reimagine inclusive futures regardless of disease, disability and affliction, we attempt to move beyond the biomedical gaze and instead privilege stories of individual personhood, struggles and aspirations.

Demographic Profile and Prescribing Patterns of Anti-epileptic Drugs in Indian Epilepsy Patients: Electronic Medical Record-Based Nation-Wide Retrospective Cohort Study

The aim of this study was to provide real-world data on clinical characteristics, risk factors, and treatment patterns in Indian patients with epilepsy. Electronic medical record (EMR) data of patients diagnosed with epilepsy between January 2001 and December 2019, which included demographics, diagnosis, anti-epileptic drug usage, and underlying risk factors were evaluated. The majority of patients were between the age group of 18 and 55 years (n=3,186), with males accounting for 62% and the remaining 38% being females. Further, the most common comorbidity was hypertension (23.3%, n=1,470), followed by diabetes mellitus (10.8%, n=683) and depression (9.4%, n=597). The most prevalent form of epilepsy was focal epilepsy (n=5,141 81.4%), followed by generalized epilepsy (n=601). Focal epilepsy was most prevalent in males (62%, n=3,167) and most common in the age group of 18-55 years (50.3%, n=2588). Anti-epileptic drug (AED) usage data from 6,318 patients showed that the most commonly prescribed AED alone or in combination for both focal and generalized epilepsy was levetiracetam (41.8%, n= 2645). Data collected from this study are aligned but do not completely agree with the Guidelines for the Management of Epilepsy in India (GEMIND). This affirms treatment initiation with AED monotherapy; however, the treatment choices do not necessarily follow the recommended guidelines to select conventional AEDs, at low strengths, at initiation.

Psychopathological Aspects in Children with Epilepsy and Its Contributing Factors: A Cross-Sectional Study from India

Background  Children with epilepsy (CWE) are at high risk of psychopathological problems because of neurobiological, social, and treatment factors.

Objectives  This study was conducted to estimate the prevalence of psychopathological problems in CWE and their contributing factors.

Methods  This cross-sectional study was done in pediatric neurology clinic and outpatient department of a government medical college in Northern India. Children between the ages of 4 and 14 years with intelligence quotient > 70 were enrolled; for CWE, the criteria were antiepileptic drugs therapy for more than 6 months and for controls it was being free from any chronic illness. Childhood Psychopathology Measurement Schedule (CPMS) was used for assessing psychopathological problems.

Results  A total of 135 CWE and 70 controls were enrolled, groups were similar in respect of age, gender, socioeconomic status, and family history. CWE group had significantly high mean  ±  standard deviation CPMS scores (13.68  ±  10.57) as compared with controls (9.75  ±  7.97) ( p  < 0.0001). These scores were particularly high in sectors of low intelligence, conduct disorder, psychotic symptoms, and depression. Academic performance was significantly poor in CWE (39%) versus controls (6%) ( p 0.042). Age of onset, duration, type, and etiology of epilepsy had no significant relation with CPMS scores. Polytherapy and treatment with valproate were associated with high CPMS scores ( p 0.005 and 0.045).

Conclusion  Psychopathological problems are frequently associated with epilepsy in children and antiepileptic drug therapy might contribute to it.

Knowledge gap exists among caregivers of adults compared to caregivers of children with epilepsy: a comparative analysis from a low resource setting

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We compared knowledge, attitude, behavior, belief and seizure recognition among CG-A and CG-C.

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Overall performance of caregivers of adults and children in tested domains was good.

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Knowledge-behavior, knowledge-faith and knowledge-seizure recognition gaps existed in CG-A.

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Lack of formal education in CG-A lead to inadequate factual knowledge and the knowledge gaps.

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CG-A need focused education to improve seizure recognition and response and dispel epilepsy myths.

Caregivers of adults (CG-A) and caregivers of children (CG-C) may differ in their knowledge, attitude and behavior and hence their education requirements during epilepsy counseling could vary. This study compares the current knowledge, attitudes, behavior during a seizure, presence of myths surrounding epilepsy and ability to recognize seizures among a sample of CG-A and CG-C. Caregivers of children and adult patients with minimum 6 months history of epilepsy were enrolled. Information was collected using a questionnaire about clinical and demographic details and five domains (KAP-plus); knowledge, attitude, behavior, presence of myths and a video data for identification of focal impaired awareness seizures (FIAS) and generalized tonic-clonic seizures (GTCS). There were 132 CG-A and 127 CG-C. CG-C were younger and better educated compared to CG-A (formal education of 64.6% vs 44.7% p = 0.001). CG-A and CG-C were comparable in the knowledge and attitude domains. CG-A scored less than CG-C in the domains of behavior (15.5 vs 16.8 p = <0.001), myths (15.4 vs 16.2 p = 0.002), video recognition of FIAS and GTCS (0.7 vs 0.94 p = 0.001) and KAP-plus score (22.9 vs 24.6 p = 0.017). The knowledge-behavior or knowing-doing gap, knowledge-faith gap and knowledge-recognition gaps existed more among CG-A compared to CG-C. Focused education strategies are required to bridge the gap among CG-A.

Cell-based Therapy Approach for Drug-resistant Epilepsy

Drug-resistant epilepsy (DRE) is a global public health problem. This category includes patients who continue to experience seizures despite long-term anti-epileptic medications. DRE can lead to severe disability and morbidity in older children and adults and is associated with increased risk of mortality than the general population. This report describes the case of a 15-year-old male patient with DRE successfully managed with autologous cell-based and hyperbaric oxygen therapy. The patient underwent two sessions of cell-based therapy consisting of cells derived from the bone marrow, adipose tissue, and peripheral blood followed by neuro-physiotherapy and oxygen therapy. Post-treatment, the patient experienced decrease in the frequency of seizures and reduction in the dosage of anti-epileptic medications. Electroencephalogram taken one year after the therapy revealed improvement in seizure activity. The outcomes in this case may be considered a preliminary finding in formulating more robust treatment strategies using cell-based therapy for DRE.

Response to sertraline and antiepileptic drugs in pentylenetetrazole kindling in rats

Anti-epileptic drugs (AEDs) are the mainstay of epilepsy treatment but these may be a potential risk factor for behavioral disturbances particularly depression which requires treatment. In this study, the effect of antidepressant sertraline (SRT) in combination with AEDs sodium valproate (SV) and levetiracetam (LEV) on seizures, cognitive impairment and oxidative stress in rats was evaluated. After administration of 24th injection of pentylenetetrazole (PTZ), 77.8% rats were kindled. Administration of SRT showed no protective effect on kindling development while SV was 100% protective. With LEV 42.9% were kindled. On combining SRT with SV or LEV 25% and 20% rats were kindled. A significant increase in latency to reach platform zone in Morris water maze(MWM), and increased transfer latencies in Elevated plus maze(EPM) was observed in PTZ kindled rats as compared to normal control on day 49 and when LEV was combined with SRT. In EPM test, however none of the drug treatments had any effect on transfer latencies except LEV pretreated kindled group. In Passive avoidance (PA) test, kindling was associated with a significant decrease in retention time(p = 0.018) while LEV and SV had no effect. The PTZ kindled rats showed significantly higher malondialdehyde(MDA) levels in brain hippocampus(p = 0.0286) while both SRT and SV were associated with significantly lower MDA levels as compared to kindled control group. In case of glutathione (GSH), kindling had no significant effect. The use of sertraline for depression in persons with epilepsy on AEDs needs to be carefully evaluated and monitored due to likelihood of individual variation.

Prevalence of depression and suicidal ideation in persons with epilepsy during the COVID-19 pandemic: A longitudinal study from India

OBJECTIVES

COVID-19 pandemic has disrupted healthcare services for chronic disorders such as epilepsy. In this study, the impact of COVID-19 pandemic on persons with epilepsy (PWE) with regard to their seizure control, depression status, and medication adherence was assessed.

METHODS

After ethical clearance, 449 PWE who had been previously evaluated for depression at All India Institute of Medical Sciences (AIIMS), New Delhi, India, were telephonically revaluated using Mini International Neuropsychiatric Interview and surveyed for source of medication and medication adherence over past 6 months. The prevalence and the association of depression, suicidality, and seizures during pandemic with different PWE variables were determined.

RESULTS

Out of 449 PWE, 70.6% responded. 19.9% were diagnosed positive for depression as per MINI while suicidal ideation was observed in 5.4%. Seventy six (23.9%) PWE reported seizures during pandemic. The incidence was greater in females, unemployed, previously uncontrolled epilepsy, polytherapy, altered use of medications, and depressed PWE. Seizure during pandemic, increased seizure frequency, previous history of depression, and altered use of medications were all significantly associated with depression during COVID-19 pandemic (2.6-95%CI, 1.45-4.73; 1.9-95%CI, 1.01-3.57; 8.8-95%CI, 4.54-17.21; 2.9-95%CI, 1.19-7.24), and polytherapy (2.9-95%CI, 0.92-9.04), seizures during pandemic (3.9-95%CI, 1.45-10.53) and previous history of depression and suicidality, were related with suicidal ideation.

CONCLUSION

COVID-19 pandemic-induced disruptions can be detrimental for PWE, and restoring services to the precovid levels as well as putting appropriate continuity plans in place for care of PWE should be a priority.

Sexual Dysfunction in Male Patients with Idiopathic Generalized Tonic Clonic Seizures

BACKGROUND

Epilepsy is the second most common neurological disorder, and it may have a significant effect on sexual functions in epileptic patients.

MATERIALS AND METHODS

Sexual dysfunctions were assessed in 146 male patients suffering from generalized tonic-clonic seizure (GTCS) with a seizure-free interval of at least 1 year. Out of 146 patients enrolled, 46 patients had a psychiatric impairment and were excluded from the study, after applying the General Health questionnaire12 (GHQ12) scale and detailed psychiatric evaluation. The remaining patients were evaluated for the presence of sexual dysfunction by applying Arizona Sexual Experience scale (ASEX). Sixty-six patients scoring more than 19 as a cutoff score on the ASEX scale were further interviewed by a psychiatrist, and a diagnosis of sexual dysfunction was made as per ICD 10 Diagnostic criteria.

RESULTS

Sexual dysfunction was diagnosed in 66% (n = 66) of the patients. Erectile dysfunction was the most common sexual disorder diagnosed in 36% of the patients (n = 36) followed by premature ejaculation in 26% (n = 26) and decreased libido (hypoactive sexual desire) seen in 4% (n = 4) of the patients. In patients with sexual dysfunction, a significant association was observed with the duration of epilepsy and type of therapy (mono/polytherapy) (P value < 0.05). Erectile dysfunction and hypoactive desire were more common in patients taking polytherapy, whereas premature ejaculation was more common in patients on monotherapy.

CONCLUSION

Significant impairment of sexual functions was observed in male epileptics with GTCS. A high index of suspicion should be kept in mind by the practicing clinician on diagnosing and treating sexual dysfunction in them.

UGT1A6 and UGT2B7 Gene Polymorphism and its Effect in Pediatric Epileptic Patients on Sodium Valproate Monotherapy

OBJECTIVES

To evaluate the pattern of UGT1A6 and UGT2B7 gene polymorphism in pediatric epileptic patients and to compare the sodium valproate concentration in different patterns of UGT gene polymorphism.

METHODS

In this cross-sectional study, 99 pediatric epileptic patients aged 2-18 y receiving Sodium valproate monotherapy for the past one month were included from JusticeK S Hegde Charitable hospital, Mangalore after obtaining informed consent. Genetic polymorphism patterns were evaluated by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Trough level serum valproate concentration was estimated by high-performance liquid chromatography (HPLC). Sodium valproate concentration in different UGT genotypes was compared by Analysis of Variance (ANOVA). P value <0.05 was considered significant.

RESULTS

In the present study population, the predominant mutant allele pattern was observed in UGT1A6 (T19G, A541G, A552C) gene. In UGT2B7 (A268G, C161T) showed predominant mutant allele pattern while (G211T) showed predominant wild type. Mean steady-state sodium valproate concentration was 105.40 ± 49.9 μg/ml and adjusted sodium valproate concentration was 5.5 ± 3.2 mg/kg/L. It was found that there was no statistical difference in sodium valproate concentration in different UGT1A6 and UGT2B7 gene polymorphism.

CONCLUSION

The present study concluded that though there was a difference in pattern of gene polymorphism with concerning UGT1A6 and UGT2B7, however, it has not contributed to variation in serum concentration of sodium valproate in the present study population.

Significant treatment gap and co-morbidities identified in an epidemiological survey of pediatric epilepsy in rural suburbs of India

PURPOSE

A cross-sectional epidemiological survey of children was conducted in two rural clusters to estimate the point prevalence and study various aspects of childhood epilepsy.

MATERIAL AND METHODS

In the first stage, a house-to-house survey was conducted by health workers using a screening questionnaire, which was pre-validated in a pilot study. All screen positive houses were visited by pediatric neurologist for detailed evaluation. Children with a clinical diagnosis of epilepsy underwent EEG and were evaluated for type of seizure, epilepsy syndrome, etiology, co-morbidities and treatment gap. Knowledge, attitude and practice regarding epilepsy was assessed amongst caregivers of the affected children.

RESULTS

A total population of 75,455 population was screened, 19,181 children aged 2 months to 18 years were identified. Out of 355 screen positive children, 66 were diagnosed with epilepsy. The point prevalence of pediatric epilepsy was 3.44 per 1000 children. 53% had focal epilepsy, 31.8% had an identifiable epilepsy syndrome, 44% had at least one comorbidity. The etiology was identified in 68%, the commonest being perinatal brain insult. The magnitude of treatment gap was 45.45%, with significant deficits in knowledge.

CONCLUSION

There are significant deficits in diagnosis and treatment of pediatric epilepsy among the rural population of India. The existing rural health care facilities need to be augmented to facilitate the timely diagnosis and optimum care of these children, including care of associated co-morbidities.

Diagnostic added value of interictal magnetic source imaging in presurgical evaluation of persons with epilepsy: A prospective blinded study

BACKGROUND AND PURPOSE

In presurgical evaluation for epilepsy surgery, information is sourced from various imaging modalities to accurately localize the epileptogenic zone. Magnetoencephalography (MEG) is a newer noninvasive technique for localization. However, there is limited literature to evaluate if MEG provides additional advantage over the conventional imaging modalities in clinical decision making. The objective of this study was to assess the diagnostic added value of MEG in decision making before epilepsy surgery.

METHOD

This was a prospective observational study. Patients underwent 3 h of recording in a MEG scanner, and the resulting localizations were compared with other complimentary investigations. Added value of MEG (considered separately from high-density electroencephalography) was defined as the frequency of cases in which (i) the information provided by magnetic source imaging (MSI) avoided implantation of intracranial electrodes and the patient was directly cleared for surgery, and (ii) MSI indicated additional substrates for implantation of intracranial electrodes. Postoperative seizure freedom was used as the diagnostic reference by which to measure the localizing accuracy of MSI.

RESULTS

A total of 102 patients underwent epilepsy surgery. MEG provided nonredundant information, which contributed to deciding the course of surgery in 33% of the patients, and prevented intracranial recordings in 19%. A total of 76% of the patients underwent surgical resection in sublobes concordant with MSI localization, and the diagnostic odds ratio for good (Engel I) outcome in these patients was 2.3 (95% confidence interval 0.68, 7.86; p = 0.183) after long-term follow-up of 36 months.

CONCLUSION

Magnetic source imaging yields additional useful information which can significantly alter as well as improve the surgical strategy for persons with epilepsy.

Association of UGT1A6 gene polymorphism with clinical outcome in pediatric epileptic patients on sodium valproate monotherapy

Pediatric epilepsy comprises chronic neurological disorders characterized by recurrent seizures. Sodium valproate is one of the common antiseizure medications used for treatment. Glucuronide conjugation is the major metabolic pathway of sodium valproate, carried out by the enzyme uridine 5'-diphosphate (UDP) glucuronosyl transferase (UGT) whose gene polymorphisms may alter the clinical outcome. The objective of this study was to assess the association between UGT1A6 genetic polymorphism and clinical outcome in terms of efficacy and tolerability in pediatric epileptic patients on sodium valproate monotherapy. Pediatric epileptic patients (n=65) aged 2-18 years receiving sodium valproate monotherapy for the past one month were included. Genetic polymorphism patterns of UGT1A6 (T19G, A541G, A552C) were evaluated by PCR-RFLP. Clinical outcome was seizure control during the 6 months observation period. Tolerability was measured by estimating the hepatic, renal, and other lab parameters. Out of 65 patients, TT (40%), TG (57%), and GG (3%) patterns were observed in UGT1A6 (T19G) gene, AA (51%), AG (40%), and GG (9%) in (A541G) gene, and AA (43%), AC (43%), and CC (14%) in (A552C) gene. No statistical difference in clinical outcome was found for different UGT1A6 genetic polymorphism patterns. We concluded that different patterns of UGT1A6 genetic polymorphism were not associated with the clinical outcome of sodium valproate in terms of efficacy and tolerability. Sodium valproate was well-tolerated among pediatric patients with epilepsy and can be used as an effective antiseizure medication.

Quality of Life among Middle and Secondary School Children with Epilepsy

Objectives  Epilepsy is a leading cause of disability in school-going children. The objectives of this study were to estimate the prevalence of epilepsy in middle and secondary school children and to assess their quality of life (QOL).

Materials and Methods  This was a cross-sectional study done in schools under the municipal corporation area of Latur Taluka, Maharashtra. At school, children were screened for epilepsy and the positive children were visited at home. Children with confirmed epilepsy were used to calculate prevalence. The QOL of children diagnosed to have epilepsy was assessed using Quality of Life in Childhood Epilepsy Questionnaire (QOLCE-55) version 1.0.

Statistical Analysis  Mean scores in scales and subscales of QOLCE-55 were calculated. Association between variables was analyzed using unpaired/independent t -test and analysis of variance. Statistically significance was fixed for a p -value less than 0.05.

Results  Prevalence of epilepsy in middle and secondary school children was found to be 3.20 per 1000. In QOLCE-55, physical functioning was the most compromised, with the lowest mean QOL score (mean = 58.3, standard deviation = 20.66). Present age of the child, age at the first seizure episode, and time interval since last seizure had a statistically significant relation with QOL. The treatment gap was found to be 70.4%.

Conclusions  Assessment of QOL in children with epilepsy is important for effective and comprehensive management of epilepsy.

The development and efficacy of a mobile phone application to improve medication adherence for persons with epilepsy in limited resource settings: A preliminary study

OBJECTIVE

Persons with epilepsy (PWE), especially those with limited education backgrounds from developing countries, are challenged by complicated medication regimens, debilitating seizures, and stigmatization in their daily life. Consequently, it is difficult for physicians to ensure medication adherence. This study validates a novel mobile application which was hypothesized to increase medication adherence and self-management skills in PWE. Created by medical professionals, the application included behavioral and educational components and was built to be easy-to-understand for those of socio-economically disadvantaged backgrounds.

METHODS

This was a parallel, two-armed randomized controlled trial in which a total of 96 participants were enrolled from a Neurology Outpatient Department into a control standard care group and a mobile application group that used the smartphone application (app) in addition to the standard medical treatment. The app was intuitive and easy to understand for those coming from a socio-economically disadvantaged background. Medication adherence and self-efficacy were assessed with the Morisky Green and Levine Scale (MGLS) and the Epilepsy Self Efficacy Scale (ESES). Patients were reassessed 12 weeks later. Change in seizure frequency following administration of the application was a secondary outcome.

RESULTS

In an intent-to-treat analysis, the mobile application interventional group showed over a 60% increase in the proportion of medication adherence (P < 0.0001). The mean self-efficacy score for the mobile application group was increased from 269.5 to 289.75 (P < 0.0001). The control group showed no statistically significant increases in either the proportion adherent or mean self-efficacy scores.

SIGNIFICANCE

This study demonstrated the statistically significant performance of a mobile application in improving medication adherence and self-management skills in Indian persons with epilepsy.

Efficacy and safety of adjunctive perampanel in patients with focal seizures or generalized tonic-clonic seizures: Post hoc analysis of Phase II and Phase III double-blind and open-label extension studies in India

Objective

This post hoc analysis assessed the efficacy and safety of adjunctive perampanel in patients (aged ≥ 12 years) with focal seizures (FS), with/without focal to bilateral tonic-clonic seizures (FBTCS), or generalized tonic-clonic seizures (GTCS) in India.

Methods

Centers in India were identified from six double-blind, randomized, Phase II and Phase III studies of adjunctive perampanel (2-12 mg/day) and their open-label extensions (OLEx). Efficacy assessments included median percent change in seizure frequency per 28 days, 50% and 75% responder and seizure-freedom rates. Treatment-emergent adverse events (TEAEs) were monitored.

Results

Overall, 128 patients (placebo, n = 39; perampanel, n = 89) were included in the double-blind Safety Analysis Set and 126 (FS, n = 113 [placebo, n = 32; perampanel, n = 81]; FBTCS, n = 35 [placebo, n = 14; perampanel, n = 21]; GTCS, n = 13 [placebo, n = 6; perampanel, n = 7]) comprised the Full Analysis Set. Median percent reductions in seizure frequency per 28 days for placebo vs perampanel for Indian patients were as follows: 34.8% vs 49.8% (FS; not significant [NS]) and 43.1% vs 60.5% (FBTCS; NS) at 4-12 mg/day, respectively, and -22.4% vs 8.2% (GTCS; NS) at 8 mg/day, respectively. Fifty-percent responder rates were 37.5% vs 55.1% (FS; NS), 42.9% vs 60.0% (FBTCS; NS), and 16.7% vs 42.9% (GTCS; NS), respectively; seizure-freedom rates were 0.0% vs 5.8%, 7.1% vs 10.0%, and 0.0% vs 14.3%, respectively (all NS). Overall, 110 patients entered OLEx studies (FS, n = 99; GTCS, n = 11). Perampanel was efficacious for up to four years for FS and FBTCS and two years for GTCS. Across double-blind and OLEx studies, TEAEs occurred in 58.4% and 83.6% of Indian perampanel-treated patients, respectively; dizziness was most common. Efficacy and safety outcomes were generally similar overall between Indian and non-Indian patients.

Significance

These data suggest adjunctive perampanel (up to 12 mg/day) may be a suitable anti-seizure medication for patients (aged ≥ 12 years) with FS, with/without FBTCS, or GTCS in India.

A review of caregiver distress in epilepsy in India: Current issues and future directions for research

India is home to a large number of individuals with epilepsy, with many of these patients having high care needs. Owing to limited infrastructural support and prevalent cultural attitudes, most of these individuals are cared for by their families. Such informal caregiving is often associated with poor physical and psychological outcomes, but the state of caregivers of people with epilepsy in India remains largely ignored. This review summarizes currently available research on distress among caregivers for people with epilepsy in India. A review of 20 studies published till July 2020 revealed significant burden in this population. Caregiving was reported to negatively impact one's physical and mental health, overall family functioning, and financial status. A range of seizure-related variables were found to be associated with greater perceived burden, with the impact of patient characteristics and psychosocial factors on burden being relatively unexplored. Much of the research identified was characterized by methodological limitations such as small sample sizes, exclusion of patients with comorbidities, and a failure to distinguish between carers of adult and pediatric populations, thus overshadowing the specific needs of each group. There is a need for larger, well-designed studies that focus on culture-specific psychological and social factors in the Indian context of caregiving for people with epilepsy.

The study of ischemia modified albumin as an early biomarker of epilepsy in adolescent population: a cross-sectional study

OBJECTIVES

Epilepsy is one of the most common neurological disorders, diagnosis of which is challenging as many unrelated conditions may mimic seizure. Epilepsy impairs the quality of life of patients due to associated physical and psychological trauma. Epileptic patients are also at increased risk of premature death due to autonomic disturbance and fatal accidents. The aim of the present research work was to study ischemia modified albumin (IMA) as an early biomarker of epilepsy in the adolescent population.

METHODS

Twenty-five diagnosed cases of epilepsy and 25 healthy volunteers as control of adolescent group were recruited as study subjects. The study subjects were age and sex matched. Clinical evaluation, routine biochemical parameters and IMA estimation were carried out. Serum IMA was measured by spectrophotometric method.

RESULTS

The mean serum IMA levels were significantly raised in epileptic patients (0.69 ± 0.1 absorbance units [ABSU]) as compared to the healthy control group (0.52 ± 0.24 ABSU) (p=0.004). ROC curve of IMA predicted that at cut off of 0.59 ABSU, the IMA has 96% sensitivity and 52% specificity for diagnosing epilepsy.

CONCLUSIONS

IMA may be used as a biomarker for early diagnosis of epilepsy as well as to differentiate epileptic seizure from various non epileptic disorders in the adolescent population.

Antiepileptic Drug Prices, Availability and Affordability in a Resource-Limited Setting

Background:

The availability and affordability of antiepileptic drugs (AEDs) are critical to the success of public health initiatives enabling care for people with epilepsy in the community.

Objective:

To pilot survey the availability and affordability of AEDs in the community.

Methods:

Field workers used standard WHO–Health Action International approaches and collected data on the availability of, and maximum retail prices of originator brands and least price generics of AEDs in 46 randomly selected public (n = 29), private (n = 8), and charitable (n = 9) pharmacy outlets. Median price ratios were computed apropos international reference prices of corresponding medications and affordability gauged with reference to daily wage of lowest paid worker.

Results:

Only 10 outlets (7 – private, 3 – public, and none – charitable) stocked at least one essential AED. Median price ratios varied between 1.1 and 1.5 essentially reflecting the difference between the least price generics and originator brands. Of note, carbamazepine-retard, 200 mg put up the slightest difference in prices of originator and least price generic brands and also was the most affordable AED.

Conclusions:

The availability and affordability of most AEDs were poor and hence, this needs to be studied on a wider scale and thereafter efforts to improve both the availability and affordability are desirable in order to address the huge treatment gap for epilepsy in India.

Affordability, availability and tolerability of anti-seizure medications are better predictors of adherence than beliefs: Changing paradigms from a low resource setting

OBJECTIVES

Anti-seizure medication (ASM) non-adherence contributes to treatment gap and increases mortality and morbidity associated with epilepsy. Beliefs about medications are considered better predictors of ASM non-adherence than clinico-demographic factors. We aimed to look into ASM non-adherence rates among adults with epilepsy (AWE), identify the contributing barriers and determine whether medication beliefs were more powerful predictors than clinico-demographic factors.

METHODS

This was a cross-sectional study of AWE receiving ASMs. Participants (n = 304) were assessed by validated questionnaires, for non-adherence (8-item Morisky Medication Adherence Scale) and perceptions of ASMs (Beliefs about Medicines Questionnaire) along with clinico-demographic details.

RESULTS

Our group with high literacy and low-income had a high non-adherence rate (55 %) despite having positive beliefs (Mean necessity-concern differential [NCD] = 2.86). Among the beliefs, ASM non-adherence was significantly associated with ASM-concern (t = 4.23, p < 0.001) and NCD (t = -4.11, p < 0.001). Stepwise multiple linear regression analysis showed that non-adherence was significantly associated with per-capita income (β -0.215, p < 0.001), ASM side effects (β 0.177, p = 0.001), high seizure frequency (β 0.167, p = 0.002), ASM availability (β -0.151, p = 0.004), ASM costs (β -0.134, p = 0.013 and NCD (β -0.184, p = 0.001). NCD accounted for 2.9 % of the variance in non-adherence whereas the other clinico-demographic variables together accounted for 14.6 %.

CONCLUSION

We describe a paradigm shift in AWE with high non-adherence to ASMs, wherein clinico-demographic variables emerge as better predictors of non-adherence than beliefs. High literacy facilitates the perception of need for ASMs whereas costs and side effects hamper adherence.

Lamotrigine Nanoparticle Laden Polymer Composite Oral Dissolving Films for Improving Therapeutic Potential of the Hydrophobic Antiepileptic Molecule

Lamotrigine is used for neurological disorders and antiepileptic therapy at frequent dosing due to its poor solubility. The present work aims to study the influence of combining the Lamotrigine nanoparticles and polymer composite oral dissolving film to improve the solubility and dissolution kinetics of the drug. The Lamotrigine-Eudragit E100 nanoparticles were synthesized through solvent evaporation followed by precipitation process, which were laden in oral dissolving films through solvent casting technique. The optimized nanoparticles were assessed for particle size, colloidal stability, drug entrapment efficiency, in vitro release profile, physicochemical characteristics, and cytotoxicity. The optimized polymeric nanoparticles of Lamotrigine: Eudragit E100 (1:0.5) exhibited monodispersed particles with 103 nm average size, +7.96 mV zeta potential, and 82.96% ± 1.2% entrapment efficiency. The composite oral matrix films blended with polyvinyl alcohol and polyvinyl pyrrolidone (0.5:0.5 ratio) incorporated with the polymeric nanoparticles demonstrated >64% drug release within 2 h. The nanoparticles and its composite films exhibited 9- and 11-fold higher drug release than pure drug, respectively. The analytical characterization studies proved the formation of nanoparticles with mild drug-polymer interactions and optimum stability, which resulted in enhanced solubility and dissolution of drug. The nanoparticles displayed lesser cytotoxicity to the normal (Vero) cells at concentration of 10-50 μg/mL compared to pure drug. The optimized polymeric nanoparticle loaded oral films could be suitable for in vivo administration of Lamotrigine at low doses to improve bioavailability and therapeutic efficiency with reduced side effects.

Efficacy, safety, and tolerability of adjunctive perampanel in patients from China with focal seizures or generalized tonic-clonic seizures: Post hoc analysis of phase III double-blind and open-label extension studies

Aims

This post hoc analysis assessed the efficacy and safety/tolerability of adjunctive perampanel in patients from China (aged ≥12 years) with focal seizures (FS), with/without focal to bilateral tonic‐clonic seizures (FBTCS), or generalized tonic‐clonic seizures (GTCS).

Methods

Study centers in China were identified using data from five double‐blind, randomized, phase III studies of adjunctive perampanel (2‐12 mg/day) and their open‐label extensions (OLEx). Efficacy assessments included median percent reduction in seizure frequency per 28 days, and 50% and 75% responder and seizure‐freedom rates. Safety/tolerability assessments included monitoring of treatment‐emergent adverse events (TEAEs).

Results

Overall, 277 patients (placebo, n = 79; perampanel, n = 198) were included in the double‐blind safety analysis set. The full analysis set comprised 274 patients (FS, n = 238 [placebo, n = 60; perampanel, n = 178]; FBTCS, n = 120 [placebo, n = 31; perampanel, n = 89]; GTCS, n = 36 [placebo, n = 18; perampanel, n = 18]). Median percent reductions in seizure frequency for placebo vs perampanel were as follows: 16.6% vs 32.4% (FS; P < 0.05) and 39.1% vs 48.2% (FBTCS; not significant [NS]) at 4‐12 mg/day, and 37.9% vs 82.6% (GTCS; NS) at 8 mg/day; 50% responder rates were 31.7% vs 37.4% (FS; NS), 48.4% vs 51.9% (FBTCS; NS), and 33.3% vs 61.1% (GTCS; NS), respectively. Seizure‐freedom rates were 1.7% vs 9.2%, 16.1% vs 25.3%, and 16.7% vs 44.4%, respectively (all NS). Overall, 262 patients entered the OLEx (FS, n = 228; GTCS, n = 34). Perampanel was efficacious for up to four years for FS and FBTCS and up to two years for GTCS. Across the double‐blind and OLEx studies, TEAEs were reported in 65.7% and 81.3% of perampanel‐treated patients, respectively; the most common was dizziness. Efficacy and safety/tolerability outcomes were generally similar between Chinese and non‐Chinese patients.

Conclusion

Adjunctive perampanel (up to 12 mg/day) may be a suitable treatment for Chinese patients with FS, with/without FBTCS, or GTCS, with similar efficacy and safety/tolerability compared to non‐Chinese patients.

Need for pharmacoeconomic consideration of antiepileptic drugs monotherapy treatment in persons with epilepsy

Objective

Newer antiepileptic drugs (AEDs) are expected to have less adverse effects (AEs) and drug interactions as compared to conventional AEDs but the high cost is the major limitation for their use. This study evaluated variation in the cost of treatment with newer and conventional AEDs through its correlation with treatment efficacy and AEs in persons with epilepsy (PWE).

Methods

This cross-sectional study included PWE (28.9 ± 9.9 years) having focal and generalized seizures on conventional [valproate, carbamazepine, phenytoin] or newer AEDs [levetiracetam, oxcarbazepine] for >6 months. Seizure frequency during the study (6 months) was compared to that within 6 months before the study. Other parameters assessed were Quality of life in epilepsy, Pittsburgh Sleep Quality Index, Gastrointestinal Quality of life Index, and Liverpool AEs Profile. The cost of treatment was determined as direct, indirect, and intangible costs. The incremental cost-effectiveness ratio (ICER) analysis was also performed.

Results

Out of 214 PWE, 51.4% were on newer AEDs. Newer and conventional AEDs did not differ significantly in seizure frequency reduction (60.29 vs. 53.09%), quality of life parameters, though these were improved significantly during the study period. The direct medical cost and total cost of treatment were lesser with conventional AEDs (p < 0.001 in both) than newer AEDs, but the intangible cost did not differ. The total cost of treatment was significantly influenced by factors (as per regression analysis) including the type of AEDs (significant difference between valproate, carbamazepine, and levetiracetam), frequency of seizures, cost of medicine (70.34% of total cost), hospital admission, and treatment of AEs. As per ICER, newer AEDs need an additional USD 8.39 per unit reduction in seizure frequency.

Conclusion

Newer AEDs have comparatively better efficacy, though not significant than conventional AEDs. However, the additional cost per unit improvement is quite high with newer AEDs, necessitating pharmacoeconomic consideration in epilepsy treatment.

Acteoside Isolated from Colebrookea oppositifolia Smith Attenuates Epilepsy in Mice Via Modulation of Gamma-Aminobutyric Acid Pathways

The present study was aimed to evaluate the anticonvulsant activity of acteoside and explore its mechanism of action. Initially, the acteoside was evaluated in maximal electroshock (MES) and pentylenetetrazole (PTZ)-induced convulsions, and later it was evaluated against N-methyl-D-aspartic acid (NMDA)-induced mortality in Swiss albino mice. Based on the response in these models, further evaluations were performed to explore the mechanism of action. In the results, the acteoside (10, 25, and 50 mg/kg) has shown significant anticonvulsant activity in the PTZ model (p < 0.01 for all doses); however, there was no protection observed in MES and NMDA models. Therefore, further mechanism-based studies were performed on the PTZ model, and the outcomes have revealed that there was a significant reduction in GABA (p < 0.01 for both regions) and elevation of glutamate (p < 0.01 for both regions) in the cortex and hippocampus regions of PTZ-treated animals. Further, the antioxidant levels (SOD, catalase, GPx, GR, GSH, LPO) were altered significantly (p < 0.01 for all parameters), with reduced GABA_A mRNA levels (p < 0.01) in the PTZ control compared with the normal control. Interestingly, co-administration of acteoside (25 mg/kg) (p < 0.01 for all parameters) has restored all the PTZ-induced alterations compared to PTZ-control. Moreover, the anti-PTZ action of acteoside was completely blocked in the presence of flumazenil, and thus confirmed the GABAergic mechanism behind the anticonvulsant activity of acteoside. Besides, actophotometer and rotarod tests have confirmed that the acteoside is free from central side effects like motor incoordination and locomotor deficits.