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Watson GDR, Afra P, Bartolini L, Graf DA, Kothare SV, McGoldrick P, Thomas BJ, Saxena AR, Tomycz LD, Wolf SM, Yan PZ, Hagen EC. A journey into the unknown: An ethnographic examination of drug-resistant epilepsy treatment and management in the United States. Epilepsy Behav 2021; 124:108319. [PMID: 34563807 DOI: 10.1016/j.yebeh.2021.108319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 12/14/2022]
Abstract
Patients often recognize unmet needs that can improve patient-provider experiences in disease treatment management. These needs are rarely captured and may be hard to quantify in difficult-to-treat disease states such as drug-resistant epilepsy (DRE). To further understand challenges living with and managing DRE, a team of medical anthropologists conducted ethnographic field assessments with patients to qualitatively understand their experience with DRE across the United States. In addition, healthcare provider assessments were conducted in community clinics and Comprehensive Epilepsy Centers to further uncover patient-provider treatment gaps. We identified four distinct stages of the treatment and management journey defined by patients' perceived control over their epilepsy: Gripped in the Panic Zone, Diligently Tracking to Plan, Riding a Rollercoaster in the Dark, and Reframing Priorities to Redefine Treatment Success. We found that patients sought resources to streamline communication with their care team, enhanced education on treatment options beyond medications, and long-term resources to protect against a decline in control over managing their epilepsy once drug-resistant. Likewise, treatment management optimization strategies are provided to improve current DRE standard of care with respect to identified patient-provider gaps. These include the use of digital disease management tools, standardizing neuropsychiatrists into patients' initial care team, and introducing surgical and non-pharmacological treatment options upon epilepsy and DRE diagnoses, respectively. This ethnographic study uncovers numerous patient-provider gaps, thereby presenting a conceptual framework to advance DRE treatment. Further Incentivization from professional societies and healthcare systems to support standardization of the treatment optimization strategies provided herein into clinical practice is needed.
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Affiliation(s)
| | - Pegah Afra
- Department of Neurology, Weill-Cornell Medicine, New York, NY 10065, USA
| | - Luca Bartolini
- Division of Pediatric Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Daniel A Graf
- Department of Neurology, Geisinger Health System, Danville, PA 17822, USA
| | - Sanjeev V Kothare
- Department of Pediatric Neurology, Northwell Health, New York, NY 10011, USA
| | - Patricia McGoldrick
- Boston Children's Health Physicians and Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY 10595, USA
| | - Bethany J Thomas
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Aneeta R Saxena
- Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, MA, USA
| | | | - Steven M Wolf
- Boston Children's Health Physicians and Maria Fareri Children's Hospital, New York Medical College, Valhalla, NY 10595, USA
| | - Peter Z Yan
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Eliza C Hagen
- LivaNova, Neuromodulation Unit, Houston, TX 77058, USA; Department of Neurology, Alameda County Medical Center, Oakland, CA 94602, USA
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Perven G, Podkorytova I, Ding K, Agostini M, Alick S, Das R, Dave H, Dieppa M, Doyle A, Harvey J, Lega B, Zepeda R, Hays R. Non-lesional mesial temporal lobe epilepsy requires bilateral invasive evaluation. Epilepsy Behav Rep 2021; 15:100441. [PMID: 33898964 PMCID: PMC8058515 DOI: 10.1016/j.ebr.2021.100441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 03/06/2021] [Accepted: 03/09/2021] [Indexed: 01/04/2023] Open
Abstract
Bilateral ictal onsets may lead to surgery failure in mesial temporal lobe epilepsy. Bitemporal SEEG seizures were recorded despite of unilateral non-invasive tests. Patients with non-lesional MTLE need bitemporal invasive evaluation before resection.
Purpose Mesial temporal lobe epilepsy (MTLE) usually responds well to surgical treatment, although in non-lesional cases up to 50% of patients experience seizure relapse. The possibility of bilateral independent seizure onset should be considered as a reason for epilepsy surgery failure. Methods In a cohort of 177 patients who underwent invasive presurgical evaluation with stereo-tactically placed electrodes in two level four epilepsy centers, 29 had non-lesional MTLE. Invasive evaluation results are described. Results Among 29 patients with non-lesional MRI and mesial temporal lobe seizure onset recorded during stereo-EEG (SEEG) evaluation, four patients with unilateral preimplantation hypothesis had independent bilateral mesial temporal seizures on SEEG despite of unilateral non-invasive evaluation data. Three of these patients were treated with bitemporal responsive neurostimulator system (RNS). Independent bilateral mesial temporal seizures have been confirmed on RNS ECoG (electrocorticography). The fourth patient underwent right anterior temporal lobectomy. Conclusion We propose that patients with non-lesional mesial temporal lobe epilepsy would benefit from bilateral invasive evaluation of mesial temporal structures to predict those patients who would be at most risk for surgical failure. Neurostimulaiton could be an initial treatment option for patients with independent bitemporal seizure onset.
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Affiliation(s)
- Ghazala Perven
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Irina Podkorytova
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Kan Ding
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Mark Agostini
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Sasha Alick
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Rohit Das
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Hina Dave
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Marisara Dieppa
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Alexander Doyle
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Jay Harvey
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Bradley Lega
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA.,Department of Neurosurgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8855, USA
| | - Rodrigo Zepeda
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
| | - Ryan Hays
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8508, USA
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Hoffman CE, Parker WE, Rapoport BI, Zhao M, Ma H, Schwartz TH. Innovations in the Neurosurgical Management of Epilepsy. World Neurosurg 2020; 139:775-788. [PMID: 32689698 DOI: 10.1016/j.wneu.2020.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/02/2020] [Indexed: 10/23/2022]
Abstract
Technical limitations and clinical challenges have historically limited the diagnostic tools and treatment methods available for surgical approaches to the management of epilepsy. By contrast, recent technological innovations in several areas hold significant promise in improving outcomes and decreasing morbidity. We review innovations in the neurosurgical management of epilepsy in several areas, including wireless recording and stimulation systems (particularly responsive neurostimulation [NeuroPace]), conformal electrodes for high-resolution electrocorticography, robot-assisted stereotactic surgery, optogenetics and optical imaging methods, novel positron emission tomography ligands, and new applications of focused ultrasonography. Investigation into genetic causes of and susceptibilities to epilepsy has introduced a new era of precision medicine, enabling the understanding of cell signaling mechanisms underlying epileptic activity as well as patient-specific molecularly targeted treatment options. We discuss the emerging path to individualized treatment plans, predicted outcomes, and improved selection of effective interventions, on the basis of these developments.
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Affiliation(s)
- Caitlin E Hoffman
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA.
| | - Whitney E Parker
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Benjamin I Rapoport
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Mingrui Zhao
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Hongtao Ma
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
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