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Kanner AM, Carrazana E, Munger Clary HM, Rabinowicz AL, Faught E. Anticipatory anxiety of seizures in epilepsy: A common, complex, and underrecognized phenomenon? Epileptic Disord 2024. [PMID: 38624139 DOI: 10.1002/epd2.20224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/01/2024] [Accepted: 03/30/2024] [Indexed: 04/17/2024]
Abstract
The diagnosis of epilepsy is associated with loss of predictability, which invariably results in the fear of when and if future seizures will occur. For a subset of patients with epilepsy (PWE), there may be a pathological persistent fear of seizure occurrence, resulting in limitations to daily activities through avoidant behaviors. Paradoxically, the research of anticipatory anxiety of seizures (AAS; also referred to as seizure phobia) has been practically nonexistent and, not surprisingly, this condition remains underrecognized by clinicians. The available data are derived from three small case series of patients followed in tertiary epilepsy centers. In this study, we review the available data on the reported clinical manifestations of AAS in PWE, and of the potential role of variables associated with it, such as personal and family psychosocial and psychiatric history and epilepsy-related variables. In addition, we review the need for the creation of screening tools to identify patients at risk of AAS and discuss potential treatment strategies, which could be considered as part of the comprehensive management for PWE.
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Affiliation(s)
- Andres M Kanner
- Comprehensive Epilepsy Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Enrique Carrazana
- Neurelis, Inc., San Diego, California, USA
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Heidi M Munger Clary
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Edward Faught
- Emory Epilepsy Program, Emory University School of Medicine, Atlanta, Georgia, USA
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Szaflarski JP, Besson H, D'Souza W, Faught E, Klein P, Reuber M, Rosenow F, Salas-Puig J, Soto Insuga V, Steinhoff BJ, Strzelczyk A, Bourikas D, Daniels T, Floricel F, Friesen D, Laloyaux C, Villanueva V. Effectiveness and tolerability of brivaracetam in patients with epilepsy stratified by comorbidities and etiology in the real world: 12-month subgroup data from the international EXPERIENCE pooled analysis. J Neurol 2024:10.1007/s00415-024-12253-z. [PMID: 38436680 DOI: 10.1007/s00415-024-12253-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/31/2024] [Accepted: 02/10/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To assess the effectiveness and tolerability of brivaracetam (BRV) in adults with epilepsy by specific comorbidities and epilepsy etiologies. METHODS EXPERIENCE/EPD332 was a pooled analysis of individual patient records from several non-interventional studies of patients with epilepsy initiating BRV in clinical practice. Outcomes included ≥ 50% reduction from baseline in seizure frequency, seizure freedom (no seizures within prior 3 months), continuous seizure freedom (no seizures since baseline), BRV discontinuation, and treatment-emergent adverse events (TEAEs) at 3, 6, and 12 months. Analyses were performed for all adult patients (≥ 16 years of age) and stratified by comorbidity and by etiology at baseline (patients with cognitive/learning disability [CLD], psychiatric comorbidity, post-stroke epilepsy, brain tumor-related epilepsy [BTRE], and traumatic brain injury-related epilepsy [TBIE]). RESULTS At 12 months, ≥ 50% seizure reduction was achieved in 35.6% (n = 264), 38.7% (n = 310), 41.7% (n = 24), 34.1% (n = 41), and 50.0% (n = 28) of patients with CLD, psychiatric comorbidity, post-stroke epilepsy, BTRE, and TBIE, respectively; and continuous seizure freedom was achieved in 5.7% (n = 318), 13.7% (n = 424), 29.4% (n = 34), 11.4% (n = 44), and 13.8% (n = 29), respectively. During the study follow-up, in patients with CLD, psychiatric comorbidity, post-stroke epilepsy, BTRE, and TBIE, 37.1% (n = 403), 30.7% (n = 605), 33.3% (n = 51), 39.7% (n = 68), and 27.1% (n = 49) of patients discontinued BRV, respectively; and TEAEs since prior visit at 12 months were reported in 11.3% (n = 283), 10.0% (n = 410), 16.7% (n = 36), 12.5% (n = 48), and 3.0% (n = 33), respectively. CONCLUSIONS BRV as prescribed in the real world is effective and well tolerated among patients with CLD, psychiatric comorbidity, post-stroke epilepsy, BTRE, and TBIE.
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Affiliation(s)
- Jerzy P Szaflarski
- University of Alabama at Birmingham (UAB) Heersink School of Medicine Department of Neurology and UAB Epilepsy Center, Birmingham, AL, USA.
| | | | - Wendyl D'Souza
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | | | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
| | | | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt, Germany
| | | | - Victor Soto Insuga
- Pediatric Neurology, Hospital Universitario Infantil Niño Jesús, Madrid, Spain
| | - Bernhard J Steinhoff
- Kork Epilepsy Center, Kehl-Kork and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt, Germany
| | | | | | | | | | | | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politécnico La Fe, EpiCARE member, Valencia, Spain
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Villanueva V, Laloyaux C, D'Souza W, Faught E, Klein P, Reuber M, Rosenow F, Salas-Puig J, Insuga VS, Strzelczyk A, Szaflarski JP, Chinn C, Daniels T, Floricel F, Friesen D, Sendersky V, Besson H, Steinhoff BJ. Effectiveness and Tolerability of 12-Month Brivaracetam in the Real World: EXPERIENCE, an International Pooled Analysis of Individual Patient Records. CNS Drugs 2023; 37:819-835. [PMID: 37684497 PMCID: PMC10501958 DOI: 10.1007/s40263-023-01033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Real-world evidence studies of brivaracetam (BRV) have been restricted in scope, location, and patient numbers. The objective of this pooled analysis was to assess effectiveness and tolerability of brivaracetam (BRV) in routine practice in a large international population. METHODS EXPERIENCE/EPD332 was a pooled analysis of individual patient records from multiple independent non-interventional studies of patients with epilepsy initiating BRV in Australia, Europe, and the United States. Eligible study cohorts were identified via a literature review and engagement with country lead investigators, clinical experts, and local UCB Pharma scientific/medical teams. Included patients initiated BRV no earlier than January 2016 and no later than December 2019, and had ≥ 6 months of follow-up data. The databases for each cohort were reformatted and standardised to ensure information collected was consistent. Outcomes included ≥ 50% reduction from baseline in seizure frequency, seizure freedom (no seizures within 3 months before timepoint), continuous seizure freedom (no seizures from baseline), BRV discontinuation, and treatment-emergent adverse events (TEAEs) at 3, 6, and 12 months. Patients with missing data after BRV discontinuation were considered non-responders/not seizure free. Analyses were performed for all adult patients (≥ 16 years), and for subgroups by seizure type recorded at baseline; by number of prior antiseizure medications (ASMs) at index; by use of BRV as monotherapy versus polytherapy at index; for patients who switched from levetiracetam to BRV versus patients who switched from other ASMs to BRV; and for patients with focal-onset seizures and a BRV dose of ≤ 200 mg/day used as add-on at index. Analysis populations included the full analysis set (FAS; all patients who received at least one BRV dose and had seizure type and age documented at baseline) and the modified FAS (all FAS patients who had at least one seizure recorded during baseline). The FAS was used for all outcomes other than ≥ 50% seizure reduction. All outcomes were summarised using descriptive statistics. RESULTS Analyses included 1644 adults. At baseline, 72.0% were 16-49 years of age and 92.2% had focal-onset seizures. Patients had a median (Q1, Q3) of 5.0 (2.0, 8.0) prior antiseizure medications at index. At 3, 6, and 12 months, respectively, ≥ 50% seizure reduction was achieved by 32.1% (n = 619), 36.7% (n = 867), and 36.9% (n = 822) of patients; seizure freedom rates were 22.4% (n = 923), 17.9% (n = 1165), and 14.9% (n = 1111); and continuous seizure freedom rates were 22.4% (n = 923), 15.7% (n = 1165), and 11.7% (n = 1111). During the whole study follow-up, 551/1639 (33.6%) patients discontinued BRV. TEAEs since prior visit were reported in 25.6% (n = 1542), 14.2% (n = 1376), and 9.3% (n = 1232) of patients at 3, 6, and 12 months, respectively. CONCLUSIONS This pooled analysis using data from a variety of real-world settings suggests BRV is effective and well tolerated in routine clinical practice in a highly drug-resistant patient population.
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Affiliation(s)
- Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politécnico La Fe, EpiCARE member, Avenida Fernando Abril Martorell 106, 46026, Valencia, Spain.
| | | | - Wendyl D'Souza
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Australia
| | | | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
| | | | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | | | - Victor Soto Insuga
- Pediatric Neurology, Hospital Universitario Infantil Niño Jesús, Madrid, Spain
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham (UAB) Heersink School of Medicine, Department of Neurology and UAB Epilepsy Center, Birmingham, AL, USA
| | | | | | | | | | | | | | - Bernhard J Steinhoff
- Kork Epilepsy Center, Kehl-Kork and Medical Faculty, University of Freiburg, Freiburg, Germany
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Kanner AM, Saporta AS, Kim DH, Barry JJ, Altalib H, Omotola H, Jette N, O'Brien TJ, Nadkarni S, Winawer MR, Sperling M, French JA, Abou-Khalil B, Alldredge B, Bebin M, Cascino GD, Cole AJ, Cook MJ, Detyniecki K, Devinsky O, Dlugos D, Faught E, Ficker D, Fields M, Gidal B, Gelfand M, Glynn S, Halford JJ, Haut S, Hegde M, Holmes MG, Kalviainen R, Kang J, Klein P, Knowlton RC, Krishnamurthy K, Kuzniecky R, Kwan P, Lowenstein DH, Marcuse L, Meador KJ, Mintzer S, Pardoe HR, Park K, Penovich P, Singh RK, Somerville E, Szabo CA, Szaflarski JP, Lin Thio KL, Trinka E, Burneo JG. Mood and Anxiety Disorders and Suicidality in Patients With Newly Diagnosed Focal Epilepsy: An Analysis of a Complex Comorbidity. Neurology 2023; 100:e1123-e1134. [PMID: 36539302 PMCID: PMC10074468 DOI: 10.1212/wnl.0000000000201671] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 10/25/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Mood, anxiety disorders, and suicidality are more frequent in people with epilepsy than in the general population. Yet, their prevalence and the types of mood and anxiety disorders associated with suicidality at the time of the epilepsy diagnosis are not established. We sought to answer these questions in patients with newly diagnosed focal epilepsy and to assess their association with suicidal ideation and attempts. METHODS The data were derived from the Human Epilepsy Project study. A total of 347 consecutive adults aged 18-60 years with newly diagnosed focal epilepsy were enrolled within 4 months of starting treatment. The types of mood and anxiety disorders were identified with the Mini International Neuropsychiatric Interview, whereas suicidal ideation (lifetime, current, active, and passive) and suicidal attempts (lifetime and current) were established with the Columbia Suicidality Severity Rating Scale (CSSRS). Statistical analyses included the t test, χ2 statistics, and logistic regression analyses. RESULTS A total of 151 (43.5%) patients had a psychiatric diagnosis; 134 (38.6%) met the criteria for a mood and/or anxiety disorder, and 75 (21.6%) reported suicidal ideation with or without attempts. Mood (23.6%) and anxiety (27.4%) disorders had comparable prevalence rates, whereas both disorders occurred together in 43 patients (12.4%). Major depressive disorders (MDDs) had a slightly higher prevalence than bipolar disorders (BPDs) (9.5% vs 6.9%, respectively). Explanatory variables of suicidality included MDD, BPD, panic disorders, and agoraphobia, with BPD and panic disorders being the strongest variables, particularly for active suicidal ideation and suicidal attempts. DISCUSSION In patients with newly diagnosed focal epilepsy, the prevalence of mood, anxiety disorders, and suicidality is higher than in the general population and comparable to those of patients with established epilepsy. Their recognition at the time of the initial epilepsy evaluation is of the essence.
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Affiliation(s)
- Andres M Kanner
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine.
| | - Anita S Saporta
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Dong H Kim
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - John J Barry
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Hamada Altalib
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Hope Omotola
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Nathalie Jette
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Terence J O'Brien
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Siddhartha Nadkarni
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Melodie R Winawer
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Michael Sperling
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Jacqueline A French
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Bassel Abou-Khalil
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Brian Alldredge
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Martina Bebin
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Gregory D Cascino
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Andrew J Cole
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Mark J Cook
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Kamil Detyniecki
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Orrin Devinsky
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Dennis Dlugos
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Edward Faught
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - David Ficker
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Madeline Fields
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Barry Gidal
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Michael Gelfand
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Simon Glynn
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Jonathan J Halford
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Sheryl Haut
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Manu Hegde
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Manisha G Holmes
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Reetta Kalviainen
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Joon Kang
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Pavel Klein
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Robert C Knowlton
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Kaarkuzhali Krishnamurthy
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Ruben Kuzniecky
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Patrick Kwan
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Daniel H Lowenstein
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Lara Marcuse
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Kimford J Meador
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Scott Mintzer
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Heath R Pardoe
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Kristen Park
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Patricia Penovich
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Rani K Singh
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Ernest Somerville
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Charles A Szabo
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Jerzy P Szaflarski
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - K Liu Lin Thio
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Eugen Trinka
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
| | - Jorge G Burneo
- From the University of Miami (A.M.K., A.S.S., D.H.K.), Miller School of Medicine; Stanford University (J.J.B., K.J.M.), School of Medicine; Yale University (H.A., K.D.), School of Medicine; University of Texas in Houston (H.O.), School of Medicine; Icahan School of Medicine at Mount Sinai (N.J., M.F., L.M.); Monash University School of Medicine (T.J.O.B., Patrick Kwan); New York University (S.N., J.A.F., O.D., M.G.H., Ruben Kuzniecky, H.R.P.), Grossman School of Medicine; Columbia University (M.R.W.), College of Physicians and Surgeons; Thomas Jefferson University (M.S., S.M.), Sidney Kimmel Medical College; Vanderbilt University (B.A.-K.), School of Medicine; University of California San Francisco (B.A., M.H., R.C.K., D.H.L.), School of Medicine; University of Alabama in Birmingham (M.B., J.P.S.), School of Medicine; Mayo Clinic (G.D.C.), School of Medicine; Harvard Medical School (A.J.C.); University of Melbourne (M.J.C.), School of Medicine; University of Pennsylvania (D.D., M.G.), Pearlman School of Medicine; Emory University (E.F.), School of Medicine; University of Cincinnati (D.F.), School of Medicine; University of Wisconsin (B.G.), School of Medicine; University of Michigan (S.G.), School of Medicine; Medical University of South Carolina (J.J.H.); Albert Einstein School of Medicine (S.H.); University of Eastern Finland (Reetta Kalviainen), School of Medicine; Johns Hopkins School of Medicine (J.K.); Mid-Atlantic Epilepsy and Sleep Center (Pavel Klein); University of Colorado (K.P.), School of Medicine; Minnesota Epilepsy Group (P.P.); Carolinas Pediatric Neurology Care (R.K.S.); New South Wales Hospital (E.S.); University of Texas in San Antonio (C.A.S.), School of Medicine; Washington University in Saint Louis (K.L.L.T.), School of Medicine; Paracelsus Medical University (E.T.); and University of Western Ontario (J.G.B.), School of Medicine
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Beghi E, Giussani G, Costa C, DiFrancesco JC, Dhakar M, Leppik I, Kwan P, Akamatsu N, Cretin B, O'Dwyer R, Kraemer G, Piccenna L, Faught E. The epidemiology of epilepsy in older adults: A narrative review by the ILAE Task Force on Epilepsy in the Elderly. Epilepsia 2023; 64:586-601. [PMID: 36625133 DOI: 10.1111/epi.17494] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023]
Abstract
In an aging world, it is important to know the burden of epilepsy affecting populations of older persons. We performed a selective review of epidemiological studies that we considered to be most informative, trying to include data from all parts of the world. We emphasized primary reports rather than review articles. We reviewed studies reporting the incidence and prevalence of epilepsy that focused on an older population as well as studies that included a wider age range if older persons were tabulated as a subgroup. There is strong evidence that persons older than approximately 60 years incur an increasing risk of both acute symptomatic seizures and epilepsy. In wealthier countries, the incidence of epilepsy increases sharply after age 60 or 65 years. This phenomenon was not always observed among reports from populations with lower socioeconomic status. This discrepancy may reflect differences in etiologies, methods of ascertainment, or distribution of ages; this is an area for more research. We identified other areas for which there are inadequate data. Incidence data are scarcer than prevalence data and are missing for large areas of the world. Prevalence is lower than would be expected from cumulative incidence, possibly because of remissions, excess mortality, or misdiagnosis of acute symptomatic seizures as epilepsy. Segmentation by age, frailty, and comorbidities is desirable, because "epilepsy in the elderly" is otherwise too broad a concept. Data are needed on rates of status epilepticus and drug-resistant epilepsy using the newer definitions. Many more data are needed from low-income populations and from developing countries. Greater awareness of the high rates of seizures among older adults should lead to more focused diagnostic efforts for individuals. Accurate data on epilepsy among older adults should drive proper allocation of treatments for individuals and resources for societies.
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Affiliation(s)
- Ettore Beghi
- Laboratory of Neurological Disorders, Department of Neuroscience, Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Giorgia Giussani
- Laboratory of Neurological Disorders, Department of Neuroscience, Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Cinzia Costa
- Section of Neurology, Santa Maria della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, Istituto di Ricovero e Cura a Caraterre Scientifico, San Gerardo Foundation, University of Milan-Bicocca, Monza, Italy
| | - Monica Dhakar
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Ilo Leppik
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Naoki Akamatsu
- Division of Neurology, Neuroscience Center, Fukuoka Samo Hospital, International University of Health and Welfare, Fukuoka, Japan
| | - Benjamin Cretin
- Neuropsychology Unit, Department of Neurology of the University Hospitals of Strasbourg, Strasbourg, France
| | - Rebecca O'Dwyer
- Department of Neurological Sciences, Rush Medical College, Chicago, Illinois, USA
| | | | - Loretta Piccenna
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia, USA
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Piccenna L, O'Dwyer R, Leppik I, Beghi E, Giussani G, Costa C, DiFrancesco JC, Dhakar MB, Akamatsu N, Cretin B, Krämer G, Faught E, Kwan P. Management of epilepsy in older adults: A critical review by the ILAE Task Force on Epilepsy in the elderly. Epilepsia 2023; 64:567-585. [PMID: 36266921 DOI: 10.1111/epi.17426] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/30/2022]
Abstract
Older adults represent a highly heterogeneous population, with multiple diverse subgroups. Therefore, an individualized approach to treatment is essential to meet the needs of each unique subgroup. Most comparative studies focusing on treatment of epilepsy in older adults have found that levetiracetam has the best chance of long-term seizure freedom. However, there is a lack of studies investigating other newer generation antiseizure medications (ASMs). Although a number of randomized clinical trials have been performed on older adults with epilepsy, the number of participants studied was generally small, and they only investigated short-term efficacy and tolerability. Quality of life as an outcome is often missing but is necessary to understand the effectiveness and possible side effects of treatment. Prognosis needs to move beyond the focus on seizure control to long-term patient-centered outcomes. Dosing studies with newer generation ASMs are needed to understand which treatments are the best in the older adults with different comorbidities. In particular, more high-level evidence is required for older adults with Alzheimer's disease with epilepsy and status epilepticus. Future treatment studies should use greater homogeneity in the inclusion criteria to allow for clearer findings that can be comparable with other studies to build the existing treatment evidence base.
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Affiliation(s)
- Loretta Piccenna
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Rebecca O'Dwyer
- Department of Neurological Sciences, Rush Medical College, Chicago, Illinois, USA
| | - Ilo Leppik
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ettore Beghi
- Department of Neuroscience, Mario Negri Institute for Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Giorgia Giussani
- Department of Neuroscience, Mario Negri Institute for Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Cinzia Costa
- Neuroscience Platform, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, Azienda Socio Sanitaria Territoriale (ASST) - San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Monica B Dhakar
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Naoki Akamatsu
- Department of Neurology, Fukuoka Sanno Hospital, International University of Health and Welfare School of Medicine, Fukuoka, Japan
| | - Benjamin Cretin
- Neuropsychology Unit, Department of Neurology, Strasbourg University Hospitals, Strasbourg, France
| | | | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Raspin C, Faught E, Armand J, Barion F, Pollit V, Murphy J, Danielson V. An economic evaluation of vagus nerve stimulation as an adjunctive treatment to anti-seizure medications for the treatment of drug resistant epilepsy in the United States. J Med Econ 2023; 26:189-199. [PMID: 36691763 DOI: 10.1080/13696998.2023.2171230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION People with recurrent epileptic seizures are typically treated with anti-seizure medications (ASMs). Around a third of epilepsy patients fail to achieve an adequate response to ASMs and may be eligible to receive vagus nerve stimulation (VNS) therapy for their drug-resistant epilepsy (DRE) if they are unsuited to surgery. VNS received approval from the United States (US) Food and Drug Administration agency. However, there has to date been no comprehensive cost effectiveness evaluation of VNS within the US setting. This study was designed, using a US Medicare perspective, to estimate costs and quality-adjusted life years (QALYs) associated with VNS as an adjunct to ongoing ASM therapy, compared to ASMs alone. METHODS We developed a cohort state transition model in Microsoft Excel, with four health states defined by different percentage reductions in seizure frequency, with a 3-month cycle and transition probabilities derived from published clinical trials and registry data. Sensitivity analyses were conducted to understand the impact of parameter uncertainty. Costs included the VNS device, placement, programming, battery changes, and removal; ASM therapy; adverse events associated with VNS (dyspnea, hoarseness, and cough); and costs associated with seizure burden (i.e. hospitalizations, emergency department visits, neurologist visits). RESULTS Under base case assumptions, treatment with VNS was associated with a 0.385 QALY gain and a $109,678 saving per patient, when compared with ASM therapy alone. The incremental net monetary benefit (iNMB) was $128,903 at a threshold of $50,000 per QALY, with the positive iNMB indicating that VNS is a highly cost effective treatment. This result is explained by the modeled reduction in relative seizure frequency and associated reduction in healthcare resource use that the VNS group experienced. Sensitivity analyses supported this conclusion. CONCLUSIONS VNS was evaluated as a cost effective addition to the current standard of care in the treatment of DRE in the US Medicare context.
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Affiliation(s)
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, GA, USA
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8
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Faught E. Economic aspects of treating seizure clusters. Epilepsia 2022; 63 Suppl 1:S45-S54. [PMID: 35999172 DOI: 10.1111/epi.17340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/29/2022]
Abstract
Seizure clusters may initiate a chain of events that have economic as well as clinical consequences. The potential economic consequences of seizure clusters must be weighed against the cost of medication to attenuate them. This is true both for individual patients and for society. Data needed for economic analyses include the chance that a cluster will progress to an adverse outcome, such as a need for emergency care, the costs of such an outcome, the cost of a rescue medication (RM), and the effectiveness of the RM. Indirect costs, such as lost employment for patients and caregivers, must also be considered. Several types of economic analyses can be used to determine costs and benefits of a medical intervention. There are studies comparing different RMs from an economic perspective, but there is little direct information on the costs of using an RM versus allowing clusters to run their course. However, the high expense of consequences of seizure clusters makes it likely that effective RMs will make economic as well as medical sense for many patients.
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Affiliation(s)
- Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia, USA
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Cramer JA, Faught E, Davis C, Misra SN, Carrazana E, Rabinowicz AL. Quality-of-life results in adults with epilepsy using diazepam nasal spray for seizure clusters from a long-term, open-label safety study. Epilepsy Behav 2022; 134:108811. [PMID: 35816831 DOI: 10.1016/j.yebeh.2022.108811] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/09/2022] [Accepted: 06/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The impact of seizure clusters and the use of intermittent rescue therapy for clusters on the quality of life (QoL) of patients with epilepsy has not been widely studied. The present analysis assessed QoL as a secondary endpoint among adult patients with seizure clusters enrolled in a long-term, phase 3, open-label safety study (NCT02721069) of diazepam nasal spray (Valtoco®). The QoL aspect of patients in this study has not been previously published. METHODS The 12-month safety study of diazepam nasal spray enrolled patients aged 6-65 years with seizure clusters. Adults aged ≥18 years completed the Quality of Life in Epilepsy (QOLIE)-31-P at baseline (day 0) and days 30, 150, 270, and 365. This instrument includes questions about patient health and daily activities with numeric values (1-100) assigned to responses; higher scores indicate better QoL. The QOLIE-31-P includes 7 subscales: Seizure Worry, Overall QoL, Emotional Well-Being, Energy/Fatigue, Cognitive Functioning, Medication Effects, and Social Functioning; an Overall Score is calculated as a weighted composite of the 7 subscales. Comparisons were made between subgroups of patients who had frequent (≥2) and infrequent (<2) monthly dosing of diazepam nasal spray and those whose doses were administered by the patient or a care partner. This safety study was not powered to assess efficacy endpoints; descriptive statistics were calculated across time points. In addition, safety measures, including treatment-emergent adverse events, are reported. RESULTS Seventy-two adults who responded to the QOLIE-31-P were included in the analyses. Mean QOLIE-31-P scores were stable or increased across time points. The mean total scores increased from day 0 to day 365 by 5.2 among patients providing data for ≥1 time point (follow-up group) and 2.2 among patients providing data at all time points (QOLIE all-assessments subgroup). Subscale means for Seizure Worry and Social Functioning showed the greatest numeric increase from baseline. Mean QOLIE-31-P scores were similar in all subgroups. The safety profile in the follow-up group was similar to that seen in all study adults. CONCLUSIONS Adults with refractory epilepsy who were treated with diazepam nasal spray for seizure clusters maintained or improved QOLIE subscale scores across the 12-month study period. Seizure Worry and Social Functioning subscale scores increased over time, suggesting improvement in these domains for this population with intractable epilepsy. Changes among subscale results suggest differences in sensitivity to the use of an intermittent treatment. The potential to improve patient function with treatment for seizure clusters warrants further study.
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Affiliation(s)
- Joyce A Cramer
- Consultant, Houston, TX, United States; Yale University School of Medicine, New Haven, CT, United States.
| | - Edward Faught
- Emory University School of Medicine, Atlanta, GA, United States
| | - Charles Davis
- CSD Biostatistics, Inc., Oro Valley, AZ, United States
| | | | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA, United States; University of Hawaii John A. Burns School of Medicine, Honolulu, HI, United States
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Rabinowicz AL, Faught E, Cook DF, Carrazana E. Implications of Seizure-Cluster Treatment on Healthcare Utilization: Use of Approved Rescue Medications. Neuropsychiatr Dis Treat 2022; 18:2431-2441. [PMID: 36325434 PMCID: PMC9619205 DOI: 10.2147/ndt.s376104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open
Abstract
PURPOSE People with epilepsy may experience seizure clusters despite a stable regimen of antiseizure medications. Such clusters have the potential to last ≥24 hours, typically occur in the community setting, and may progress to medical emergencies, such as status epilepticus, if untreated. Thus, long-acting rescue therapy for seizure clusters is needed that can be administered by nonmedical individuals outside a hospital. Benzodiazepines are the foundation of rescue therapy for seizure clusters. The approved outpatient treatments (ie, diazepam, midazolam) have differing profiles that may affect multiple aspects of health-care utilization. The current labeling of these medications allows for a second dose if needed to control the cluster. Although no head-to-head studies directly comparing rescue treatments have been conducted, differences between studies with generally similar designs may provide context for the potential importance of second doses of rescue therapy on health-care utilization. METHODS For this analysis, large, long-term, open-label studies of approved seizure-cluster treatments designed for use by nonmedical caregivers were reviewed, and the percentage of seizure clusters for which a second dose was used or that were not controlled at 6, 12, and 24 hours was examined. Available data on hospitalizations were also collected. RESULTS The 3 identified studies meeting the inclusion criteria were for use of diazepam rectal gel, intranasal midazolam, and diazepam nasal spray. Across these studies, the use of a second dose ranged from <40% at 6 hours to <13% at 24 hours. Hospitalizations and serious treatment-emergent adverse events were reported variably across these studies. CONCLUSION These results demonstrate the importance of second doses of rescue therapy for seizure clusters for optimizing health-care utilization. Need for second doses should be included as one component. In turn, when second doses are needed, they have the potential to curtail emergency department use and hospitalization and to prevent further seizure clusters.
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Affiliation(s)
| | - Edward Faught
- Emory Epilepsy Program, Emory University School of Medicine, Atlanta, GA, USA
| | - David F Cook
- Clinical Development & Medical Affairs, Neurelis, Inc., San Diego, CA, USA
| | - Enrique Carrazana
- Clinical Development & Medical Affairs, Neurelis, Inc., San Diego, CA, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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11
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Drane DL, Willie JT, Pedersen NP, Qiu D, Voets NL, Millis SR, Soares BP, Saindane AM, Hu R, Kim MS, Hewitt KC, Hakimian S, Grabowski T, Ojemann JG, Loring DW, Meador KJ, Faught E, Miller JW, Gross RE. Superior Verbal Memory Outcome After Stereotactic Laser Amygdalohippocampotomy. Front Neurol 2021; 12:779495. [PMID: 34956059 PMCID: PMC8695842 DOI: 10.3389/fneur.2021.779495] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/05/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: To evaluate declarative memory outcomes in medically refractory epilepsy patients who underwent either a highly selective laser ablation of the amygdalohippocampal complex or a conventional open temporal lobe resection. Methods: Post-operative change scores were examined for verbal memory outcome in epilepsy patients who underwent stereotactic laser amygdalohippocampotomy (SLAH: n = 40) or open resection procedures (n = 40) using both reliable change index (RCI) scores and a 1-SD change metric. Results: Using RCI scores, patients undergoing open resection (12/40, 30.0%) were more likely to decline on verbal memory than those undergoing SLAH (2/40 [5.0%], p = 0.0064, Fisher's exact test). Patients with language dominant procedures were much more likely to experience a significant verbal memory decline following open resection (9/19 [47.4%]) compared to laser ablation (2/19 [10.5%], p = 0.0293, Fisher's exact test). 1 SD verbal memory decline frequently occurred in the open resection sample of language dominant temporal lobe patients with mesial temporal sclerosis (8/10 [80.0%]), although it rarely occurred in such patients after SLAH (2/14, 14.3%) (p = 0.0027, Fisher's exact test). Memory improvement occurred significantly more frequently following SLAH than after open resection. Interpretation: These findings suggest that while verbal memory function can decline after laser ablation of the amygdalohippocampal complex, it is better preserved when compared to open temporal lobe resection. Our findings also highlight that the dominant hippocampus is not uniquely responsible for verbal memory. While this is at odds with our simple and common heuristic of the hippocampus in memory, it supports the findings of non-human primate studies showing that memory depends on broader medial and lateral TL regions.
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Affiliation(s)
- Daniel L. Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | - Jon T. Willie
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Nigel P. Pedersen
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
- Coulter Department of Biomedical Engineering, Emory University, Atlanta, GA, United States
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Natalie L. Voets
- Nuffield Department of Clinical Neurosciences, Oxford Centre for Functional MRI of the Brain, University of Oxford, Oxford, United Kingdom
| | - Scott R. Millis
- Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine, Detroit, MI, United States
| | - Bruno P. Soares
- Department of Radiology, University of Vermont Medical Center, Burlington, VT, United States
| | - Amit M. Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Ranliang Hu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States
| | - Michelle S. Kim
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | - Kelsey C. Hewitt
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Shahin Hakimian
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | - Thomas Grabowski
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | - Jeffrey G. Ojemann
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, United States
| | - David W. Loring
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Kimford J. Meador
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, United States
| | - Edward Faught
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - John W. Miller
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, United States
| | - Robert E. Gross
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
- Coulter Department of Biomedical Engineering, Emory University, Atlanta, GA, United States
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
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Faught E. Restoring EEG to its Rightful Place in Alzheimer Disease Care. Epilepsy Curr 2021; 21:175-176. [PMID: 34867098 PMCID: PMC8609586 DOI: 10.1177/1535759721998656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Association of Epileptiform Abnormalities and Seizures in Alzheimer Disease Lam AD, Sarkis RA, Pellerin KR, et al. Neurology. 2020;95(16):e2259-e2270. doi:10.1212/WNL.0000000000010612 Objective: To examine the relationship between scalp electroencephalography (EEG) biomarkers of hyperexcitability in Alzheimer disease (AD) and to determine how these electric biomarkers relate to the clinical expression of seizures in AD. Methods: In this cross-sectional study, we performed 24-hour ambulatory scalp EEGs on 43 cognitively normal elderly healthy controls (HC), 41 participants with early-stage AD with no history or risk factors for epilepsy (AD-NoEp), and 15 participants with early-stage AD with late-onset epilepsy related to AD (AD-Ep). Two epileptologists blinded to diagnosis visually reviewed all EEGs and annotated all potential epileptiform abnormalities. A panel of 9 epileptologists blinded to diagnosis was then surveyed to generate a consensus interpretation of epileptiform abnormalities in each EEG. Results: Epileptiform abnormalities were seen in 53% of AD-Ep, 22% of AD-NoEp, and 4.7% of HC. Specific features of epileptiform discharges, including high frequency, robust morphology, right temporal location, and occurrence during wakefulness and rapid eye movement (REM), were associated with clinical seizures in AD. Multiple EEG biomarkers concordantly demonstrated a pattern of left temporal lobe hyperexcitability in early stages of AD, whereas clinical seizures in AD were often associated with bitemporal hyperexcitability. Frequent small sharp spikes were specifically associated with epileptiform EEGs and thus identified as a potential biomarker of hyperexcitability in AD. Conclusion: Epileptiform abnormalities are common in AD but not all equivalent. Specific features of epileptiform discharges are associated with clinical seizures in AD. Given the difficulty recognizing clinical seizures in AD, these EEG features could provide guidance on which patients with AD are at high risk of clinical seizures.
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French JA, Cole AJ, Faught E, Theodore WH, Vezzani A, Liow K, Halford JJ, Armstrong R, Szaflarski JP, Hubbard S, Patel J, Chen K, Feng W, Rizzo M, Elkins J, Knafler G, Parkerson KA. Safety and Efficacy of Natalizumab as Adjunctive Therapy for People With Drug-Resistant Epilepsy: A Phase 2 Study. Neurology 2021; 97:e1757-e1767. [PMID: 34521687 DOI: 10.1212/wnl.0000000000012766] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To explore efficacy/safety of natalizumab, a humanized monoclonal anti-α4-integrin antibody, as adjunctive therapy in adults with drug-resistant focal epilepsy. METHODS Participants with ≥6 seizures during the 6-week baseline period were randomized 1:1 to receive natalizumab 300 mg IV or placebo every 4 weeks for 24 weeks. Primary efficacy outcome was change from baseline in log-transformed seizure frequency, with a predefined threshold for therapeutic success of 31% relative reduction in seizure frequency over the placebo group. Countable seizure types were focal aware with motor signs, focal impaired awareness, and focal to bilateral tonic-clonic. Secondary efficacy endpoints/safety were also assessed. RESULTS Of 32 and 34 participants dosed in the natalizumab 300 mg and placebo groups, 30 (94%) and 31 (91%) completed the placebo-controlled treatment period, respectively (one participant was randomized to receive natalizumab but not dosed due to IV complications). Estimated relative change in seizure frequency of natalizumab over placebo was -14.4% (95% confidence interval [CI] -46.1%-36.1%; p = 0.51). The proportion of participants with ≥50% reduction from baseline in seizure frequency was 31.3% for natalizumab and 17.6% for placebo (odds ratio 2.09, 95% CI 0.64-6.85; p = 0.22). Adverse events were reported in 24 (75%) and 22 (65%) participants receiving natalizumab vs placebo. DISCUSSION Although the threshold to demonstrate efficacy was not met, there were no unexpected safety findings and further exploration of possible anti-inflammatory therapies for drug-resistant epilepsy is warranted. TRIAL REGISTRATION INFORMATION The ClinicalTrials.gov registration number is NCT03283371. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that IV natalizumab every 4 weeks, compared to placebo, did not significantly change seizure frequency in adults with drug-resistant epilepsy. The study lacked the precision to exclude an important effect of natalizumab.
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Affiliation(s)
- Jacqueline A French
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Andrew J Cole
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Edward Faught
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - William H Theodore
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Annamaria Vezzani
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Kore Liow
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Jonathan J Halford
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Robert Armstrong
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Jerzy P Szaflarski
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Sarah Hubbard
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Jagdish Patel
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Kun Chen
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Wei Feng
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Marco Rizzo
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study.
| | - Jacob Elkins
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Gabrielle Knafler
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
| | - Kimberly A Parkerson
- From the NYU Grossman School of Medicine (J.A.F.), New York, NY; Massachusetts General Hospital (A.J.C.), Boston; Emory University School of Medicine (E.F.), Atlanta, GA; National Institutes of Health (W.H.T.), Bethesda, MD; IRCCS-Istituto di Ricerche Farmacologiche Mario Negri (A.V.), Milan, Italy; Hawaii Pacific Neuroscience (K.L.), Honolulu; Medical University of South Carolina (J.J.H.), Charleston; Asheville Neurology Specialists (R.A.), NC; University of Alabama at Birmingham (J.P.S.); Biogen (S.H., J.P., W.F., M.R.), Cambridge; Alexion (K.C.), Boston; Sarepta (J.E.), Cambridge; Envision Pharma Group (G.K.), Fairfield, CT; and Stoke Therapeutics (K.A.P.), Bedford, MA. K.C., J.E., and K.A.P. were affiliated with Biogen, Cambridge, MA, at the time of the study
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Faught E, Li X, Choi J, Malhotra M, Knoth RL. Real-world analysis of hospitalizations in patients with epilepsy and treated with perampanel. Epilepsia Open 2021; 6:645-652. [PMID: 34170633 PMCID: PMC8633480 DOI: 10.1002/epi4.12515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES (1) To evaluate risk of hospitalization following initiation of perampanel (pre- and post-analysis) and (2) to compare hospitalization rates following initiation of perampanel vs lacosamide. METHODS Patients were identified from Symphony Health's Patient Integrated Database if they had a prescription for perampanel (July 1, 2014-June 30, 2016). Patients 4-11 years of age with any partial-onset seizure (POS) or ≥12 years of age with any POS or primary generalized tonic-clonic seizure (GTCS) (pre-post); or ≥12 years of age (perampanel vs lacosamide). The first fill of perampanel ("index date") marked the start of the analysis period. Patients had ≥1 additional fill for perampanel and ≥2 diagnoses for epilepsy or nonfebrile convulsion diagnosis during pre-index (based on ICD-9/ICD-10 codes). Patients were matched using a 1:1 propensity scoring method for the perampanel vs lacosamide analysis. Primary outcome was hospitalization during the one year following medication initiation. RESULTS Pre- and post-perampanel: N = 1771 (mean age 34 years, 55% female). One-year all-cause hospitalization risk ratio was 0.76 (P < .05) and 36.2% with hospitalization during the pre-period vs 29.5% in the follow-up. One-year epilepsy-related inpatient hospitalization risk ratio was 0.72 (P < .05) and 30.8% with hospitalization during the pre-period vs 23.9% during follow-up. In the perampanel and lacosamide cohorts, N = 1717 per cohort after matching, most baseline demographics were balanced. A higher percentage of subjects were prescribed ≥3 anti-seizure medications for perampanel vs lacosamide (60.5% vs 57.7%, P < .001). The perampanel cohort had a 9.6% reduction in all-cause hospitalizations vs 5.8% for the lacosamide cohort (P < .05). Epilepsy-related hospitalizations decreased from the pre-index rate by 9.9% for perampanel and 8.3% for lacosamide (P < .05). Among those with baseline hospitalizations, perampanel was associated with a 59.9% reduction in all-cause hospitalizations vs 48.6% for lacosamide (P < .05), and for epilepsy-related hospitalizations, a reduction of 65.0% vs 58.9%, respectively (P < .05). SIGNIFICANCE Perampanel was associated with a significant reduction in one-year hospitalization risk.
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Affiliation(s)
- Edward Faught
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - Xuan Li
- Eisai Inc., Woodcliff Lake, NJ, USA
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Faught E. Reoperations for Epilepsy: How Many Times Should We Bat? Epilepsy Curr 2021; 20:367-368. [PMID: 34025257 PMCID: PMC7818212 DOI: 10.1177/1535759720961059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Long-Term Outcomes of Reoperations in Epilepsy Surgery Yardi R, Morita-Sherman ME, Fitzgerald Z, et al. Epilepsia.
2020;61(3):465-470. https://pubmed.ncbi.nlm.nih.gov/32108946/ Objective: To analyze longitudinal seizure outcomes following epilepsy surgery, including
reoperations, in patients with intractable focal epilepsy. Methods: Clinicoradiological characteristics of patients who underwent epilepsy surgery from
1995 to 2016 with follow-up of ≥1 year were reviewed. In patients undergoing
reoperations, the latest resection was considered the index surgery. The primary
outcome was complete seizure freedom (Engel I) at last follow-up. Potentially
significant outcome variables were first identified using univariate analyses and
then fit in multivariate Cox proportional hazards models. Results: Of 898 patients fulfilling study criteria, 110 had reoperations: 92 had one
resection prior to the index surgery and 18 patients had 2 or more prior resective
surgeries. Two years after the index surgery, 69% of patients with no prior
surgeries had an Engel score of I, as opposed to only 42% of those with one prior
surgery, and 33% of those with 2 or more prior resections (P <
.001). Among surgical outcome predictors, the number of prior epilepsy surgeries,
female sex, lesional initial magnetic resonance imaging, no prior history of
generalization, and pathology correlated with better seizure outcomes on univariate
analysis. However, only sex (P = .011), history of generalization
(P = .016), and number of prior surgeries (P =
.002) remained statistically significant in the multivariate model. Significance: Although long-term seizure control is possible in patients with failed prior
epilepsy surgery, the chances of success diminish with every subsequent resection.
Outcome is additionally determined by inherent biological markers (sex and secondary
generalization tendency), rather than traditional outcome predictors, supporting a
hypothesis of “surgical refractoriness.”
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Gupta K, Dickey AS, Hu R, Faught E, Willie JT. Robot Assisted MRI-Guided LITT of the Anterior, Lateral, and Medial Temporal Lobe for Temporal Lobe Epilepsy. Front Neurol 2020; 11:572334. [PMID: 33329314 PMCID: PMC7729070 DOI: 10.3389/fneur.2020.572334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/12/2020] [Indexed: 11/18/2022] Open
Abstract
Robotic systems have fundamentally altered the landscape of functional neurosurgery. These allow automated stereotaxy with high accuracy and reliability, and are rapidly becoming a mainstay in stereotactic surgeries such as deep brain stimulation (DBS), stereoelectroencephalography (SEEG), and stereotactic laser ablation/MRI guided laser interstitial thermal therapy (MRgLITT). Robotic systems have been effectively applied to create a minimally invasive approach for diagnostics and therapeutics in the treatment of epilepsy, utilizing robots for expeditious and accurate stereotaxy for SEEG and MRgLITT. MRgLITT has been shown to approach open surgical techniques in efficacy of seizure control while minimizing collateral injury. We describe the use of robot assisted MRgLITT for a minimally invasive laser anterior temporal lobotomy, describing the approach and potential pitfalls. Goals of MRgLITT are complete ablation of the epileptogenic zone and avoiding injury to uninvolved structures. In the middle fossa these include structures such as cranial nerves in the skull base and cavernous sinus and the thalamus. These can be mitigated with careful trajectory planning and control of laser ablation intensity.
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Affiliation(s)
- Kunal Gupta
- Department of Neurosurgery, Emory University Hospital, Atlanta, GA, United States.,Department of Neurosurgery, Indiana University Health, Indianapolis, IN, United States
| | - Adam S Dickey
- Department of Neurology, Emory University Hospital, Atlanta, GA, United States
| | - Ranliang Hu
- Department of Radiology, Emory University Hospital, Atlanta, GA, United States
| | - Edward Faught
- Department of Neurology, Emory University Hospital, Atlanta, GA, United States
| | - Jon T Willie
- Department of Neurosurgery, Emory University Hospital, Atlanta, GA, United States.,Department of Neurological Surgery, Washington University School of Medicine, Washington, DC, United States
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Vossler DG, Bainbridge JL, Boggs JG, Novotny EJ, Loddenkemper T, Faught E, Amengual-Gual M, Fischer SN, Gloss DS, Olson DM, Towne AR, Naritoku D, Welty TE. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee. Epilepsy Curr 2020; 20:245-264. [PMID: 32822230 PMCID: PMC7576920 DOI: 10.1177/1535759720928269] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose: Established tonic–clonic status epilepticus (SE) does not stop in one-third
of patients when treated with an intravenous (IV) benzodiazepine bolus
followed by a loading dose of a second antiseizure medication (ASM). These
patients have refractory status epilepticus (RSE) and a high risk of
morbidity and death. For patients with convulsive refractory status
epilepticus (CRSE), we sought to determine the strength of evidence for 8
parenteral ASMs used as third-line treatment in stopping clinical CRSE. Methods: A structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) was
performed to identify original studies on the treatment of CRSE in children
and adults using IV brivaracetam, ketamine, lacosamide, levetiracetam (LEV),
midazolam (MDZ), pentobarbital (PTB; and thiopental), propofol (PRO), and
valproic acid (VPA). Adrenocorticotropic hormone (ACTH), corticosteroids,
intravenous immunoglobulin (IVIg), magnesium sulfate, and pyridoxine were
added to determine the effectiveness in treating hard-to-control seizures in
special circumstances. Studies were evaluated by predefined criteria and
were classified by strength of evidence in stopping clinical CRSE (either as
the last ASM added or compared to another ASM) according to the 2017
American Academy of Neurology process. Results: No studies exist on the use of ACTH, corticosteroids, or IVIg for the
treatment of CRSE. Small series and case reports exist on the use of these
agents in the treatment of RSE of suspected immune etiology, severe
epileptic encephalopathies, and rare epilepsy syndromes. For adults with
CRSE, insufficient evidence exists on the effectiveness of brivaracetam
(level U; 4 class IV studies). For children and adults with CRSE,
insufficient evidence exists on the effectiveness of ketamine (level U; 25
class IV studies). For children and adults with CRSE, it is possible that
lacosamide is effective at stopping RSE (level C; 2 class III, 14 class IV
studies). For children with CRSE, insufficient evidence exists that LEV and
VPA are equally effective (level U, 1 class III study). For adults with
CRSE, insufficient evidence exists to support the effectiveness of LEV
(level U; 2 class IV studies). Magnesium sulfate may be effective in the
treatment of eclampsia, but there are only case reports of its use for CRSE.
For children with CRSE, insufficient evidence exists to support either that
MDZ and diazepam infusions are equally effective (level U; 1 class III
study) or that MDZ infusion and PTB are equally effective (level U; 1 class
III study). For adults with CRSE, insufficient evidence exists to support
either that MDZ infusion and PRO are equally effective (level U; 1 class III
study) or that low-dose and high-dose MDZ infusions are equally effective
(level U; 1 class III study). For children and adults with CRSE,
insufficient evidence exists to support that MDZ is effective as the last
drug added (level U; 29 class IV studies). For adults with CRSE,
insufficient evidence exists to support that PTB and PRO are equally
effective (level U; 1 class III study). For adults and children with CRSE,
insufficient evidence exists to support that PTB is effective as the last
ASM added (level U; 42 class IV studies). For CRSE, insufficient evidence
exists to support that PRO is effective as the last ASM used (level U; 26
class IV studies). No pediatric-only studies exist on the use of PRO for
CRSE, and many guidelines do not recommend its use in children aged <16
years. Pyridoxine-dependent and pyridoxine-responsive epilepsies should be
considered in children presenting between birth and age 3 years with
refractory seizures and no imaging lesion or other acquired cause of
seizures. For children with CRSE, insufficient evidence exists that VPA and
diazepam infusion are equally effective (level U, 1 class III study). No
class I to III studies have been reported in adults treated with VPA for
CRSE. In comparison, for children and adults with established convulsive SE
(ie, not RSE), after an initial benzodiazepine, it is likely that loading
doses of LEV 60 mg/kg, VPA 40 mg/kg, and fosphenytoin 20 mg PE/kg are
equally effective at stopping SE (level B, 1 class I study). Conclusions: Mostly insufficient evidence exists on the efficacy of stopping clinical CRSE
using brivaracetam, lacosamide, LEV, valproate, ketamine, MDZ, PTB, and PRO
either as the last ASM or compared to others of these drugs.
Adrenocorticotropic hormone, IVIg, corticosteroids, magnesium sulfate, and
pyridoxine have been used in special situations but have not been studied
for CRSE. For the treatment of established convulsive SE (ie, not RSE), LEV,
VPA, and fosphenytoin are likely equally effective, but whether this is also
true for CRSE is unknown. Triple-masked, randomized controlled trials are
needed to compare the effectiveness of parenteral anesthetizing and
nonanesthetizing ASMs in the treatment of CRSE.
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Affiliation(s)
| | - Jacquelyn L Bainbridge
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | - Edward J Novotny
- 384632University of Washington, Seattle, WA, USA.,Seattle Children's Center for Integrative Brain Research, Seattle, WA, USA
| | | | | | | | - Sarah N Fischer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - David S Gloss
- Charleston Area Medical Center, Charleston, West Virginia, VA, USA
| | | | - Alan R Towne
- 6889Virginia Commonwealth University, Richmond, VA, USA
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Abstract
Importance Limited population-based data are available on antiepileptic drug (AED) treatment patterns in women of childbearing age with epilepsy; the current population risk is not clear. Objectives To examine the AED treatment patterns and identify differences in use of valproate sodium and topiramate by comorbidities among women of childbearing age with epilepsy. Design, Setting, and Participants A retrospective cohort study used a nationwide commercial database and supplemental Medicare as well as Medicaid insurance claims data to identify 46 767 women with epilepsy aged 15 to 44 years. The eligible study cohort was enrolled between January 1, 2009, and December 31, 2013. Data analysis was conducted from January 1, 2017, to February 22, 2018. Exposures Cases required an International Classification of Diseases, Ninth Revision, Clinical Modification-coded epilepsy diagnosis with continuous medical and pharmacy enrollment. Incident cases required a baseline of 2 or more years without an epilepsy diagnosis or AED prescription before the index date. For both incident and prevalent cases, focal and generalized epilepsy cohorts were matched by age, payer type, and enrollment period and then compared. Main Outcomes and Measures Antiepileptic drug treatment pattern according to seizure type and comorbidities. Results Of the 46 767 patients identified, there were 8003 incident cases (mean [SD] age, 27.3 [9.4] years) and 38 764 prevalent cases (mean [SD] age, 29.7 [9.0] years). Among 3219 women in the incident epilepsy group who received AEDs for 90 days or more, 3173 (98.6%) received monotherapy as first-line treatment; among 28 239 treated prevalent cases, 18 987 (67.2%) received monotherapy. In 3544 (44.3%) incident cases and 9480 (24.5%) prevalent cases, AED treatment was not documented during 180 days or more of follow-up after diagnosis. Valproate (incident: 35 [5.81%]; prevalent: 514 [13.1%]) and phenytoin (incident: 33 [5.48%]; prevalent: 178 [4.53%]) were more commonly used for generalized epilepsy and oxcarbazepine (incident: 53 [8.03%]; prevalent: 386 [9.89%]) was more often used for focal epilepsy. Levetiracetam (incident: focal, 267 [40.5%]; generalized, 271 [45.0%]; prevalent: focal, 794 [20.3%]; generalized, 871 [22.2%]), lamotrigine (incident: focal, 123 [18.6%]; generalized, 106 [17.6%]; prevalent: focal, 968 [24.8%]; generalized, 871 [22.2%]), and topiramate (incident: focal, 102 [15.5%]; generalized, 64 [10.6%]; prevalent: focal, 499 [12.8%]; generalized, 470 [12.0%]) were leading AEDs prescribed for both focal and generalized epilepsy. Valproate was more commonly prescribed for women with comorbid headache or migraine (incident: 53 of 1251 [4.2%]; prevalent: 839 of 8046 [10.4%]), mood disorder (incident: 63 of 860 [7.3%]; prevalent: 1110 of 6995 [15.9%]), and anxiety and dissociative disorders (incident: 57 of 881 [6.5%]; prevalent: 798 of 5912 [13.5%]). Topiramate was more likely prescribed for those with comorbid headache or migraine (incident: 335 of 1251 [26.8%]; prevalent: 2322 of 8046 [28.9%]). Conclusions and Relevance Many women appear to be treated with valproate and topiramate despite known teratogenicity risks. Comorbidities may affect selecting certain AEDs despite their teratogenicity risks.
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Affiliation(s)
- Hyunmi Kim
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California
| | - Edward Faught
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - David J Thurman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
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Faught E. Measure for Measure: Measuring the Usefulness of Measuring Antiseizure Medication Levels. Epilepsy Curr 2020; 20:132-133. [PMID: 32550829 PMCID: PMC7281894 DOI: 10.1177/1535759720915845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Therapeutic Drug Monitoring of Newer Antiepileptic Drugs: A Randomized Trial for
Dosage Adjustment Aícua-Rapún I, André P, Rossetti AO, et al. Ann Neurol.
2020;87(1):22-29. doi:10.1002/ana.25641. Objective: Therapeutic drug monitoring (TDM) of antiepileptic drugs (AEDs) is widely
established for older generation AEDs, whereas there is limited evidence about newer
AEDs. Our aim is to assess the benefit of TDM of newer generation AEDs in epilepsy.
Methods: We performed a randomized, controlled trial comparing systematic with
rescue TDM of lamotrigine, levetiracetam, oxcarbazepine, topiramate, brivaracetam,
zonisamide, or pregabalin. Participants were adults with epilepsy, in whom treatment
with newer generation AEDs was initiated or needed adjustment. In the systematic TDM
arm, AED plasma levels were available at each appointment, whereas in the rescue TDM
arm, levels were known only if a study end point was reached (inefficacy or adverse
events). The primary outcome was the proportion of participants who followed 1 year
without reaching one of the predefined end points. Results: A total of 151
participants were enrolled; global retention in the study was similar in both arms
(56% overall, 58% in the systematic, and 53% in the rescue TDM arm,
P = .6, Cox regression). There was no difference in terms of
outcome regarding treatment efficacy or tolerability. Partial adherence of
clinicians to TDM (adjusting or not AED dosage based on blood levels) did not
explain this lack of benefit. Interpretation: This study provides class A evidence
that systematic drug-level monitoring of newer generation AEDs does not bring
tangible benefits in the management of patients with epilepsy. Poor correlation
between clinical effects and drug levels likely accounts for this finding. However,
TDM is useful in several situations, such as pregnancy, as well as when there are
compliance issues.
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Kalilani L, Faught E, Thurman D, Kim H. Author response: Assessment and effect of a gap between new-onset epilepsy diagnosis and treatment in the US. Neurology 2020; 94:503. [DOI: 10.1212/wnl.0000000000009104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/15/2020] [Indexed: 11/15/2022] Open
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Thurman DJ, Faught E, Helmers S, Kim H, Kalilani L. New-onset lesional and nonlesional epilepsy in the US population: Patient characteristics and patterns of antiepileptic drug use. Epilepsy Res 2019; 157:106210. [PMID: 31605878 DOI: 10.1016/j.eplepsyres.2019.106210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 09/02/2019] [Accepted: 09/24/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Describe treatment patterns in patients from the United States with new-onset epilepsy, comparing those with and without lesional epilepsy. METHODS In this observational study we used Truven Health MarketScan databases derived from commercial health insurance, Medicare and Medicaid claims covering at least 5 years, commencing in 2008. We identified incident epilepsy cases based on International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating epilepsy or recurrent seizures, taking into account antiepileptic drug (AED) claims, consistent with International League Against Epilepsy Commission on Epidemiology recommendations. We identified patients with lesional epilepsy when associated diagnoses indicated central nervous system infection, neoplasm, traumatic brain injury, stroke, senile dementia and static encephalopathy. Lesional and nonlesional cohorts were matched 1:1 on baseline characteristics of age, sex and insurance type for group comparisons. RESULTS In unmatched cohorts lesional epilepsy patients (N = 15,302) were more commonly older (mean age 48.7 years) compared with nonlesional epilepsy patients (N = 15,970; mean age 18.5 years). Among lesional patients <20 years of age, the leading putative etiology was static encephalopathy, while among ages ≥20 years and older, the leading putative etiology was stroke or cerebrovascular disease. In matched cohorts (7063 patients each), those with lesional epilepsy were significantly less likely to be untreated at 1 year versus those with nonlesional epilepsy (37.2% vs 56.1%). In children and adults among matched cohorts, levetiracetam was the most common AED prescribed for initial AED therapy for the lesional (39.5%) and nonlesional (32.1%) groups. Lesional epilepsy patients on monotherapy were only slightly less likely than nonlesional epilepsy patients to be on the same AED 1 year after treatment initiation (55.6% vs 59.7%). SIGNIFICANCE Compared with patients with lesional epilepsy, a higher proportion of patients with nonlesional epilepsy remain untreated 1 year after diagnosis. There were differences in AED selection by epilepsy etiology; levetiracetam is the most commonly prescribed drug for both cohorts.
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Affiliation(s)
- David J Thurman
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA 30329, USA.
| | - Edward Faught
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA 30329, USA.
| | - Sandra Helmers
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA 30329, USA
| | - Hyunmi Kim
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30322, USA.
| | - Linda Kalilani
- UCB Pharma, 8010 Arco Corporate Drive, Raleigh NC 27617, USA.
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22
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Faught E. The Winner by a Nose: Intranasal Midazolam. Epilepsy Curr 2019; 19:310-312. [PMID: 31456435 PMCID: PMC6864572 DOI: 10.1177/1535759719870508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Safety and Efficacy of Midazolam Nasal Spray in the Outpatient Treatment of Patients With Seizure Clusters—A Randomized, Double-Blind, Placebo-Controlled Trial. Detyniecki K, Van Ess PJ, Sequeira DJ, Wheless JW, Meng TC, Pullmnaan WE. Epilepsia. 2019. doi:10.1111/epi.15159. Epub ahead of print. Objective: To evaluate the safety and efficacy of a novel formulation of midazolam administered as a single-dose nasal spray (MDZ-NS) in the outpatient treatment of patients experiencing seizure clusters (SCs). Methods: This was a phase III, randomized, double-blind, placebo-controlled trial (ClinicalTrials.gov NCT01390220) with patients aged ≥12 years on a stable regimen of antiepileptic drugs. Following an in-clinic test dose phase (TDP), patients entered an outpatient comparative phase (CP) and were randomized (2:1) to receive double-blind MDZ-NS 5 mg or placebo nasal spray, administered by caregivers when they experienced an SC. The primary efficacy end point was treatment success (seizure termination within 10 minutes and no recurrence 10 minutes to 6 hours after trial drug administration). Secondary efficacy end points were proportion of patients with seizure recurrence 10 minutes to 4 hours and time to next seizure >10 minutes after double-blind drug administration. Safety was monitored throughout. Results: Of 292 patients administered a test dose, 262 patients were randomized and 201 received double-blind treatment for an SC (n = 134 MDZ-NS, n = 67 placebo, modified intent-to-treat population). A significantly greater proportion of MDZ-NS than placebo-treated patients achieved treatment success (53.7% vs 34.4%; P = .0109). Significantly, fewer MDZ-NS- than placebo-treated patients experienced seizure recurrence (38.1% vs 59.7%; P = .0043). Time-to-next seizure analysis showed early separation (within 30 minutes) between MDZ-NS and placebo that was maintained throughout the 24-hour observation period (21% difference at 24 hours; P = .0124). Sixteen (5.5%) patients discontinued because of a treatment-emergent adverse event (TEAE) during the TDP and none during the CP. During the CP, 27.6% and 22.4% of patients in the MDZ-NS and placebo groups, respectively, experienced ≥1 TEAE. Significance: The MDZ-NS was superior to placebo in providing rapid, sustained seizure control when administered to patients experiencing an SC in the outpatient setting and was associated with a favorable safety profile.
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Pisu M, Richman J, Szaflarski JP, Funkhouser E, Dai C, Juarez L, Faught E, Martin RC. High health care costs in minority groups of older US Medicare beneficiaries with epilepsy. Epilepsia 2019; 60:1462-1471. [PMID: 31169918 DOI: 10.1111/epi.16051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine health care costs in diverse older Medicare beneficiaries with epilepsy. METHODS Using 2008-2010 claims data, we conducted a longitudinal cohort study of a random sample of Medicare beneficiaries augmented for minority representation. Epilepsy cases (n = 36 912) had ≥1 International Classification of Diseases, Ninth Edition (ICD-9) 345.x or ≥2 ICD-9 780.3x claims, and ≥1 antiepileptic drug (AED) in 2009; new cases (n = 3706) had no seizure/epilepsy claims nor AEDs in the previous 365 days. Costs were measured by reimbursements for all care received. High cost was defined as follow-up 1-year cost ≥ 75th percentile. Logistic regressions examined association of high cost with race/ethnicity, adjusting for demographic, clinical, economic, and treatment quality factors. In cases with continuous 2-year data, we obtained costs in two 6-month periods before and two after the index event. RESULTS Cohort was ~62% African Americans (AAs), 11% Hispanics, 5% Asians, and 2% American Indian/Alaska Natives. Mean costs in the follow-up were ~$30 000 (median = $11 547; new cases, mean = $44 642; median = $25 008). About 19% white compared to 27% AA cases had high cost. AA had higher odds of high cost in adjusted analyses (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.11-1.29), although this was only marginally significant when adjusting for AED adherence (OR = 1.09, 95% CI = 1.01-1.18, P = 0.03). Factors associated with high cost included ≥1 comorbidity, neurological care, and low AED adherence. Costs were highest at ~$17 000 in the 6 months immediately before and after the index event (>$29 000 for new cases). SIGNIFICANCE The financial sequelae of epilepsy among older Americans disproportionally affect minorities. Studies should examine contributors to high costs.
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Affiliation(s)
- Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chen Dai
- Center for Health Service Research, University of Kentucky, Lexington, Kentucky
| | - Lucia Juarez
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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Kalilani L, Faught E, Kim H, Burudpakdee C, Seetasith A, Laranjo S, Friesen D, Haeffs K, Kiri V, Thurman DJ. Assessment and effect of a gap between new-onset epilepsy diagnosis and treatment in the US. Neurology 2019; 92:e2197-e2208. [PMID: 30971487 PMCID: PMC6537131 DOI: 10.1212/wnl.0000000000007448] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/11/2019] [Indexed: 01/06/2023] Open
Abstract
Objective To estimate the treatment gap between a new epilepsy diagnosis and antiepileptic drug (AED) initiation in the United States. Methods Retrospective claims-based cohort study using Truven Health MarketScan databases (commercial and supplemental Medicare, calendar years 2010–2015; Medicaid, 2010–2014) and a validation study using PharMetrics Plus Database linked to LRx claims database (2009–2014). Persons met epilepsy diagnostic criteria, had an index date (first epilepsy diagnosis) with a preceding 2-year baseline (1 year for persons aged 1 to <2 years; none for persons <1 year), and continuous medical and pharmacy enrollment without epilepsy/seizure diagnosis or AED prescription during baseline. Outcomes included percentage of untreated persons (no AED prescription) up to 3 years' follow-up and comparative outcomes (incidence rate ratio: untreated persons/treated persons), including medical events and health care resource utilization. Results In the primary study, 59,970 persons met selection (or inclusion) criteria; 36.7% of persons with newly diagnosed epilepsy remained untreated up to 3 years after diagnosis. In the validation study (N = 30,890), 31.8% of persons remained untreated up to 3 years after diagnosis. Lack of AED treatment was associated with an adjusted incidence rate ratio (95% confidence interval) of 1.2 (1.2–1.3) for medical events, 2.3 (2.2–2.3) for hospitalizations, and 2.8 (2.7–2.9) for emergency department visits. Conclusions One-third of newly diagnosed persons remain untreated up to 3 years after epilepsy diagnosis. The increased risk of medical events and health care utilization highlights the consequences of delayed treatment after epilepsy diagnosis, which might be preventable.
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Affiliation(s)
- Linda Kalilani
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC.
| | - Edward Faught
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - Hyunmi Kim
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - Chakkarin Burudpakdee
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - Arpamas Seetasith
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - Scott Laranjo
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - David Friesen
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - Kathrin Haeffs
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - Victor Kiri
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
| | - David J Thurman
- From UCB Pharma (L.K.), Raleigh, NC; Department of Neurology (E.F., D.J.T.), Emory University School of Medicine, Atlanta, GA; Department of Neurology (H.K.), Stanford University School of Medicine, Palo Alto, CA; IQVIA (C.B., A.S.), Fairfax, VA; UCB Pharma (S.L.), Smyrna, GA; UCB Pharma (D.F.), Ascot, Berkshire, UK; UCB Pharma (K.H.), Monheim am Rhein, Germany; and FV & JK Consulting Ltd. (V.K.), Guildford, Surrey, UK. S.L. is currently employed by Aerie Pharmaceuticals, Durham, NC
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Faught E. The Cost of the Second Seizure: Rethinking the Treatment Decision. Epilepsy Curr 2019; 19:88-90. [PMID: 30955429 PMCID: PMC6610411 DOI: 10.1177/1535759719835367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Antiepileptic Drug Treatment After an Unprovoked First Seizure: A Decision Analysis Bao EL, Chao LY, Ni P, et al. Neurology. 2018;91(15):e1429-e1439. doi:10.1212/WNL.0000000000006319 Objective: To compare the expected quality-adjusted life-years (QALYs) in adult patients undergoing immediate versus deferred antiepileptic drug (AED) treatment after a first unprovoked seizure. Methods: We constructed a simulated clinical trial (Markov decision model) to compare immediate versus deferred AED treatment after a first unprovoked seizure in adults. Three base cases were considered, representing patients with varying degrees of seizure recurrence risk and effect of seizures on quality of life (QOL). Cohort simulation was performed to determine which treatment strategy would maximize the patient’s expected QALYs. Sensitivity analyses were guided by clinical data to define decision thresholds across plausible measurement ranges, including seizure recurrence rate, effect of seizure recurrence on QOL, and efficacy of AEDs. Results: For patients with a moderate risk of recurrent seizures (52.0% over 10 years after first seizure), immediate AED treatment maximized QALYs compared to deferred treatment. Sensitivity analyses showed that for the preferred choice to change to deferred AED treatment, key clinical measures needed to reach implausible values were 10-year seizure recurrence rate ≤38.0%, QOL reduction with recurrent seizures ≤0.06, and efficacy of AEDs on lowering seizure recurrence rate ≤16.3%. Conclusion: Our model determined that immediate AED treatment is preferable to deferred treatment in adult first-seizure patients over a wide and clinically relevant range of variables. Furthermore, our analysis suggests that the 10-year seizure recurrence rate that justifies AED treatment (38.0%) is substantially lower than the 60% threshold used in the current definition of epilepsy.
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Faught E. Balancing reality with hope in epilepsy therapy. Neurology 2018; 91:989-990. [DOI: 10.1212/wnl.0000000000006561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
PURPOSE OF REVIEW Our purpose is to review evidence relating to the concept that interictal epileptiform discharges (IEDs) impair brain performance. RECENT FINDINGS Sophisticated measures of motor and cognitive performance have clarified older observations, confirming that in both animals and humans, IEDs affect aspects of performance, IED morphology, frequency, anatomical distribution, and duration matter. However, we now know that it is difficult to draw a line between IEDs and seizures, not only by electrical criteria but even by metabolic and molecular measures. IEDs impair performance acutely and probably chronically. Thus, there are good theoretical reasons for suppressing them, but no consensus has been reached on how much effort this deserves. Many antiepileptic medications effective for control of clinical seizures have little effect on IEDs. Better methods of measuring outcomes may allow selection of individual patients for whom treatment aimed at IEDs is worthwhile.
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Affiliation(s)
- Edward Faught
- Emory University, Brain Health Center 292, 12 Executive Park Drive NE, Atlanta, GA, 30306, USA.
| | - Ioannis Karakis
- Emory University, Brain Health Center 292, 12 Executive Park Drive NE, Atlanta, GA, 30306, USA
| | - Daniel L Drane
- Emory University, Brain Health Center 292, 12 Executive Park Drive NE, Atlanta, GA, 30306, USA.,University of Washington, Seattle, WA, USA
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Faught E, Helmers S, Thurman D, Kim H, Kalilani L. Patient characteristics and treatment patterns in patients with newly diagnosed epilepsy: A US database analysis. Epilepsy Behav 2018; 85:37-44. [PMID: 29906700 DOI: 10.1016/j.yebeh.2018.05.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/10/2018] [Accepted: 05/10/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The objective of this study was to determine patient characteristics and antiepileptic drug (AED) treatment patterns in patients with newly diagnosed epilepsy in a United States (US) population followed for ≥180 days. METHODS In this retrospective cohort study, Commercial, Supplemental Medicare, and Medicaid insurance claims from US-based Truven Health MarketScan® claims database were analyzed for incident epilepsy cases (index date: January 2010-June 2013; prior baseline of 2 years [1 year for ages 1 to <2 years; none for those <1 year]). Cases met epilepsy criteria consistent with the International League Against Epilepsy diagnostic guidelines, with continuous medical and pharmacy enrollment without an epilepsy or seizure diagnosis or AED prescription during baseline. Treatment was classified as monotherapy (one AED for ≥90 continuous days), polytherapy (at least two AEDs for ≥90 days), or untreated (no AED claims but other pharmacy or healthcare claims). Treatment pattern comparisons used matched cohorts across seizure types. RESULTS Of 58,757 incident cases, 50,838 had a follow-up of ≥180 days. The median (range) follow-up duration was 529 (180-1096) days. Patient characteristics were similar across seizure types (matched focal vs. generalized epilepsy, N = 9949 each). At 6 and 12 months post-index, 46.8% and 52.2% of patients, respectively, had received AED treatment. Of 29,226 patients receiving treatment, 74.7% and 1.6% received monotherapy and polytherapy for ≥90 days, respectively, as first-line treatment; remaining patients received AED for <90 days and were excluded. The probability of remaining on initial treatment after 1 year was 61.0% for monotherapy and 36.5% for polytherapy. The most common first-line AEDs were levetiracetam (44.4%), phenytoin (6.5%), valproic acid (6.4%), lamotrigine (6.3%), oxcarbazepine (5.7%), topiramate (5.5%), and gabapentin (5.3%). CONCLUSION Although the majority of treated patients received AED monotherapy consistent with guidelines, suboptimal rates of AED treatment and persistence of first-line treatment after initial epilepsy diagnosis suggest that efforts are needed to improve patient care.
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Affiliation(s)
- Edward Faught
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA 30329, USA.
| | - Sandra Helmers
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA 30329, USA
| | - David Thurman
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA 30329, USA
| | - Hyunmi Kim
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Dr NE, Atlanta, GA 30322, USA.
| | - Linda Kalilani
- UCB Pharma, 8010 Arco Corporate Drive, Raleigh, NC 27617, USA.
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Kanner AM, Ashman E, Gloss D, Harden C, Bourgeois B, Bautista JF, Abou-Khalil B, Burakgazi-Dalkilic E, Park EL, Stern J, Hirtz D, Nespeca M, Gidal B, Faught E, French J. Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new-onset epilepsy: Report of the American Epilepsy Society and the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Epilepsy Curr 2018; 18:260-268. [PMID: 30254527 PMCID: PMC6145382 DOI: 10.5698/1535-7597.18.4.260] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective: To update the 2004 American Academy of Neurology (AAN) guideline for treating new-onset focal or generalized epilepsy (GE) with second- and third-generation antiepileptic drugs (AEDs). Methods: The 2004 AAN criteria was used to systematically review literature (January 2003 to November 2015), classify pertinent studies according to the therapeutic rating scheme, and link recommendations to evidence strength. Results: Several second-generation AEDs are effective for new-onset focal epilepsy. Data are lacking on efficacy in new-onset generalized tonic-clonic seizures, juvenile myoclonic epilepsy, or juvenile absence epilepsy, and on efficacy of third-generation AEDs in new-onset epilepsy. Recommendations: Lamotrigine (LTG) should (Level B) and levetiracetam (LEV) and zonisamide (ZNS) may (Level C) be considered in decreasing seizure frequency in adults with new-onset focal epilepsy. LTG should (Level B) and gabapentin (GBP) may (Level C) be considered in decreasing seizure frequency in patients ≥60 years with new-onset focal epilepsy. Unless there are compelling adverse-effect-related concerns, ethosuximide (ETS) or valproic acid (VPA) should be considered before LTG to decrease seizure frequency in treating absence seizures in childhood absence epilepsy (Level B). No high-quality studies suggest clobazam, eslicarbazepine, ezogabine, felbamate, GBP, lacosamide, LEV, LTG, oxcarbazepine, perampanel, pregabalin, rufinamide, tiagabine, topiramate, vigabatrin, or ZNS is effective in treating new-onset epilepsy because no high-quality studies exist in adults of various ages. A recent FDA strategy allows extrapolation of efficacy across populations; therefore, for focal epilepsy, eslicarbazepine and lacosamide (oral only for pediatric use) as add-on or monotherapy in persons ≥4 years old and perampanel as monotherapy received FDA approval.
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Affiliation(s)
| | - Eric Ashman
- 2Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI
| | - David Gloss
- 3Department of Neurology, Charleston Area Medical Center, Charleston, WV
| | - Cynthia Harden
- 4Department of Neurology, Mount Sinai Beth Israel, New York, NY
| | | | | | | | | | | | - John Stern
- 10School of Medicine, University of California, Los Angeles
| | - Deborah Hirtz
- 11School of Medicine, University of Vermont, Burlington
| | - Mark Nespeca
- 12Children's Hospital, University of California San Diego School of Medicine
| | - Barry Gidal
- 13School of Pharmacy, University of Wisconsin, Madison
| | | | - Jacqueline French
- 15Department of Neurology, New York University Langone Comprehensive Epilepsy Center, New York
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Kanner AM, Ashman E, Gloss D, Harden C, Bourgeois B, Bautista JF, Abou-Khalil B, Burakgazi-Dalkilic E, Park EL, Stern J, Hirtz D, Nespeca M, Gidal B, Faught E, French J. Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs II: Treatment-resistant epilepsy: Report of the American Epilepsy Society and the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Epilepsy Curr 2018; 18:269-278. [PMID: 30254528 PMCID: PMC6145395 DOI: 10.5698/1535-7597.18.4.269] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objective: To update the 2004 American Academy of Neurology (AAN) guideline for managing treatment-resistant (TR) epilepsy with second- and third-generation antiepileptic drugs (AEDs). Methods: 2004 criteria were used to systematically review literature (January 2003 to November 2015), classify pertinent studies according to the therapeutic rating scheme, and link recommendations to evidence strength. Results: Forty-two articles were included. Recommendations: The following are established as effective to reduce seizure frequency (Level A): immediate-release pregabalin and perampanel for TR adult focal epilepsy (TRAFE); vigabatrin for TRAFE (not first-line treatment; rufinamide for Lennox-Gastuat syndrome (LGS) (add-on therapy). The following should be considered to decrease seizure frequency (Level B): lacosamide, eslicarbazepine, and extended-release topiramate for TRAFE (ezogabine production discontinued); immediate- and extended-release lamotrigine for generalized epilepsy with TR generalized tonic-clonic (GTC) seizures in adults; levetiracetam (add-on therapy) for TR childhood focal epilepsy (TRCFE) (1 month to 16 years), TR GTC seizures, and TR juvenile myoclonic epilepsy; clobazam for LGS (add-on therapy); zonisamide for TRCFE (6-17 years); oxcarbazepine for TRCFE (1 month to 4 years). The text presents Level C recommendations. AED selection depends on seizure/syndrome type, patient age, concomitant medications, and AED tolerability, safety, and efficacy. This evidence-based assessment informs AED prescription guidelines for TR epilepsy and indicates seizure types and syndromes needing more evidence. A recent FDA strategy allows extrapolation of efficacy across populations; therefore, for focal epilepsy, eslicarbazepine and lacosamide (oral only for pediatric use) as add-on or monotherapy in persons ≥4 years of age and perampanel as monotherapy received FDA approval.
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Affiliation(s)
| | | | - David Gloss
- 3Charleston Area Medical Center, Charleston, WV
| | | | | | | | | | | | | | - John Stern
- 10University of California in Los Angeles, School of Medicine, Los Angeles, CA
| | - Deborah Hirtz
- 11University of Vermont Medical Center, Burlington, VT
| | - Mark Nespeca
- 12Children's Hospital, University of California San Diego School of Medicine, CA
| | - Barry Gidal
- 13University of Wisconsin, School of Pharmacy, Madison, WI
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Kanner AM, Ashman E, Gloss D, Harden C, Bourgeois B, Bautista JF, Abou-Khalil B, Burakgazi-Dalkilic E, Llanas Park E, Stern J, Hirtz D, Nespeca M, Gidal B, Faught E, French J. Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs II: Treatment-resistant epilepsy. Neurology 2018; 91:82-90. [DOI: 10.1212/wnl.0000000000005756] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/29/2018] [Indexed: 02/07/2023] Open
Abstract
ObjectiveTo update the 2004 American Academy of Neurology guideline for managing treatment-resistant (TR) epilepsy with second- and third-generation antiepileptic drugs (AEDs).Methods2004 criteria were used to systemically review literature (January 2003 to November 2015), classify pertinent studies according to the therapeutic rating scheme, and link recommendations to evidence strength.ResultsForty-two articles were included.RecommendationsThe following are established as effective to reduce seizure frequency (Level A): immediate-release pregabalin and perampanel for TR adult focal epilepsy (TRAFE); vigabatrin for TRAFE (not first-line treatment); rufinamide for Lennox-Gastaut syndrome (LGS) (add-on therapy). The following should be considered to decrease seizure frequency (Level B): lacosamide, eslicarbazepine, and extended-release topiramate for TRAFE (ezogabine production discontinued); immediate- and extended-release lamotrigine for generalized epilepsy with TR generalized tonic-clonic (GTC) seizures in adults; levetiracetam (add-on therapy) for TR childhood focal epilepsy (TRCFE) (1 month–16 years), TR GTC seizures, and TR juvenile myoclonic epilepsy; clobazam for LGS (add-on therapy); zonisamide for TRCFE (6–17 years); oxcarbazepine for TRCFE (1 month–4 years). The text presents Level C recommendations. AED selection depends on seizure/syndrome type, patient age, concomitant medications, and AED tolerability, safety, and efficacy. This evidence-based assessment informs AED prescription guidelines for TR epilepsy and indicates seizure types and syndromes needing more evidence. A recent Food and Drug Administration (FDA) strategy allows extrapolation of efficacy across populations; therefore, for focal epilepsy, eslicarbazepine and lacosamide (oral only for pediatric use) as add-on or monotherapy in persons ≥4 years of age and perampanel as monotherapy received FDA approval.
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Kanner AM, Ashman E, Gloss D, Harden C, Bourgeois B, Bautista JF, Abou-Khalil B, Burakgazi-Dalkilic E, Llanas Park E, Stern J, Hirtz D, Nespeca M, Gidal B, Faught E, French J. Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new-onset epilepsy. Neurology 2018; 91:74-81. [DOI: 10.1212/wnl.0000000000005755] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/03/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo update the 2004 American Academy of Neurology (AAN) guideline for treating new-onset focal or generalized epilepsy with second- and third-generation antiepileptic drugs (AEDs).MethodsThe 2004 AAN criteria were used to systematically review literature (January 2003–November 2015), classify pertinent studies according to the therapeutic rating scheme, and link recommendations to evidence strength.ResultsSeveral second-generation AEDs are effective for new-onset focal epilepsy. Data are lacking on efficacy in new-onset generalized tonic-clonic seizures, juvenile myoclonic epilepsy, or juvenile absence epilepsy, and on efficacy of third-generation AEDs in new-onset epilepsy.RecommendationsLamotrigine (LTG) should (Level B) and levetiracetam (LEV) and zonisamide (ZNS) may (Level C) be considered in decreasing seizure frequency in adults with new-onset focal epilepsy. LTG should (Level B) and gabapentin (GBP) may (Level C) be considered in decreasing seizure frequency in patients ≥60 years of age with new-onset focal epilepsy. Unless there are compelling adverse effect–related concerns, ethosuximide or valproic acid should be considered before LTG to decrease seizure frequency in treating absence seizures in childhood absence epilepsy (level B). No high-quality studies suggest clobazam, eslicarbazepine, ezogabine, felbamate, GBP, lacosamide, LEV, LTG, oxcarbazepine, perampanel, pregabalin, rufinamide, tiagabine, topiramate, vigabatrin, or ZNS is effective in treating new-onset epilepsy because no high-quality studies exist in adults of various ages. A recent Food and Drug Administration (FDA) strategy allows extrapolation of efficacy across populations; therefore, for focal epilepsy, eslicarbazepine and lacosamide (oral only for pediatric use) as add-on or monotherapy in persons ≥4 years old and perampanel as monotherapy received FDA approval.
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Faught E, Szaflarski JP, Richman J, Funkhouser E, Martin RC, Piper K, Dai C, Juarez L, Pisu M. Risk of pharmacokinetic interactions between antiepileptic and other drugs in older persons and factors associated with risk. Epilepsia 2018; 59:715-723. [PMID: 29411348 DOI: 10.1111/epi.14010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine the frequency of older Americans with epilepsy receiving concomitant prescriptions for antiepileptic drugs (AEDs) and non-epilepsy drugs (NEDs) which could result in significant pharmacokinetic (PK) interaction, and to assess the contributions of racial/ethnic, socioeconomic, and demographic factors. METHODS Retrospective analyses of 2008-2010 Medicare claims for a 5% random sample of beneficiaries ≥67 years old in 2009 augmented for minority representation. Prevalent cases had ≥1 ICD-9 345.x or ≥2 ICD-9 780.3x, and ≥1 AED. Among them, incident cases had no seizure/epilepsy claim codes nor AEDs in preceding 365 days. Drug claims for AEDs, and for the 50 most common NEDs within +/- 60 days of the index epilepsy date were tabulated. Interacting pairs of AEDs/NEDs were identified by literature review. Logistic regression models were used to examine factors affecting the likelihood of interaction risk. RESULTS Interacting drug pairs affecting NED efficacy were found in 24.5% of incident, 39% of prevalent cases. Combinations affecting AED efficacy were found in 20.4% of incident, 29.3% of prevalent cases. Factors predicting higher interaction risk included having ≥ 1 comorbidity, being eligible for Part D low Income Subsidy, and not living in the northeastern US. Protective factors were Asian race/ethnicity, and treatment by a neurologist. SIGNIFICANCE A substantial portion of older epilepsy patients received NED-AED combinations that could cause important PK interactions. The lower frequency among incident vs. prevalent cases may reflect changes in prescribing practices. Avoidance of interacting AEDs is feasible for most persons because of the availability of newer drugs.
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Affiliation(s)
- Edward Faught
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kendra Piper
- Department of Gynecology and Obstetrics, Emory University, Atlanta, GA, USA
| | - Chen Dai
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lucia Juarez
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Halford JJ, Sperling MR, Nair DR, Dlugos DJ, Tatum WO, Harvey J, French JA, Pollard JR, Faught E, Noe KH, Henry TR, Jetter GM, Lie OV, Morgan LC, Girouard MR, Cardenas DP, Whitmire LE, Cavazos JE. Detection of generalized tonic-clonic seizures using surface electromyographic monitoring. Epilepsia 2017; 58:1861-1869. [PMID: 28980702 PMCID: PMC5698770 DOI: 10.1111/epi.13897] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2017] [Indexed: 11/27/2022]
Abstract
Objective A prospective multicenter phase III trial was undertaken to evaluate the performance and tolerability in the epilepsy monitoring unit (EMU) of an investigational wearable surface electromyographic (sEMG) monitoring system for the detection of generalized tonic–clonic seizures (GTCSs). Methods One hundred ninety‐nine patients with a history of GTCSs who were admitted to the EMU in 11 level IV epilepsy centers for clinically indicated video‐electroencephalographic monitoring also received sEMG monitoring with a wearable device that was worn on the arm over the biceps muscle. All recorded sEMG data were processed at a central site using a previously developed detection algorithm. Detected GTCSs were compared to events verified by a majority of three expert reviewers. Results For all subjects, the detection algorithm detected 35 of 46 (76%, 95% confidence interval [CI] = 0.61–0.87) of the GTCSs, with a positive predictive value (PPV) of 0.03 and a mean false alarm rate (FAR) of 2.52 per 24 h. For data recorded while the device was placed over the midline of the biceps muscle, the system detected 29 of 29 GTCSs (100%, 95% CI = 0.88–1.00), with a detection delay averaging 7.70 s, a PPV of 6.2%, and a mean FAR of 1.44 per 24 h. Mild to moderate adverse events were reported in 28% (55 of 199) of subjects and led to study withdrawal in 9% (17 of 199). These adverse events consisted mostly of skin irritation caused by the electrode patch that resolved without treatment. No serious adverse events were reported. Significance Detection of GTCSs using an sEMG monitoring device on the biceps is feasible. Proper positioning of this device is important for accuracy, and for some patients, minimizing the number of false positives may be challenging.
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Affiliation(s)
- Jonathan J Halford
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Michael R Sperling
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Dileep R Nair
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Dennis J Dlugos
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Jay Harvey
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, Texas, U.S.A
| | - Jacqueline A French
- Department of Neurology, New York University Comprehensive Epilepsy Center, New York, New York, U.S.A
| | - John R Pollard
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia, U.S.A
| | - Katherine H Noe
- Department of Neurology, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - Thomas R Henry
- Department of Neurology, University of Minnesota Medical Center, Minneapolis, Minnesota, U.S.A
| | - Gina M Jetter
- Northeast Texas Neurology Associates, Tyler, Texas, U.S.A
| | - Octavian V Lie
- Department of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A
| | - Lola C Morgan
- Department of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A
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Bainbridge J, De Backer M, Eckhardt K, Tennigkeit F, Bongardt S, Sen D, Werhahn KJ, Shaibani A, Faught E. Safety and tolerability of lacosamide monotherapy in the elderly: A subgroup analysis from lacosamide trials in diabetic neuropathic pain. Epilepsia Open 2017; 2:415-423. [PMID: 29588972 PMCID: PMC5862116 DOI: 10.1002/epi4.12079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2017] [Indexed: 01/22/2023] Open
Abstract
Objective To assess the safety profile of lacosamide monotherapy in elderly (≥65 years) subjects with diabetic neuropathic pain (DNP). Methods Of 1,863 DNP subjects in double‐blind, randomized, placebo‐controlled trials of lacosamide monotherapy (NCT00861445, NCT00235469, NCT00238524, NCT00135109, NCT00350103), 502 were elderly. Safety data from elderly subjects were compared with that of younger subjects (<65 years) within these DNP trials. It should be noted that lacosamide is approved for the treatment of focal (partial‐onset) seizures; it is not approved/recommended for the treatment of DNP. Results Overall, cardiovascular diseases were prevalent in the DNP population, as was the use of cardiac, blood pressure, diabetes, and cholesterol‐lowering medications among both young and elderly subjects. The most frequently reported adverse events (AEs) for lacosamide monotherapy (200, 400, and 600 mg/day combined) in elderly versus younger subjects were dizziness (16.2% vs. 13.2%), nausea (10.0% vs. 9.4%), and headache (8.0% vs. 8.7%). Incidences of cardiac disorder AEs were higher in elderly versus younger subjects receiving placebo (6.2% vs. 3.9%), lacosamide 200 (4.8% vs. 3.3%), lacosamide 400 (7.0% vs. 4.1%), and lacosamide 600 mg/day (7.7% vs. 4.0%). Discontinuation rates because of any AE in the elderly versus younger subjects were similar for placebo (8.8% vs. 7.0%) and lacosamide 200 mg/day (9.6% vs. 11.9%) and higher for lacosamide 400 (25.1% vs. 10.8%) and lacosamide 600 mg/day (52.7% vs. 28.3%). Significance Lacosamide monotherapy was well tolerated in elderly subjects with DNP, with an overall AE profile consistent with that reported in epilepsy trials.
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Affiliation(s)
- Jacquelyn Bainbridge
- University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora Colorado U.S.A
| | | | | | | | | | - David Sen
- UCB Pharma Raleigh North Carolina U.S.A
| | | | - Aziz Shaibani
- Nerve and Muscle Center of Texas Houston Texas U.S.A
| | - Edward Faught
- Emory University School of Medicine Atlanta Georgia U.S.A
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Faught E, Laliberté F, Wang Z, Barghout V, Haider B, Lejeune D, Germain G, Choi J, Wagh A, Duh MS. Health care resource utilization before and after perampanel initiation among patients with epilepsy in the United States. Epilepsia 2017; 58:1742-1748. [DOI: 10.1111/epi.13857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Edward Faught
- Emory University School of Medicine; Atlanta Georgia U.S.A
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Szaflarski JP, Martin RC, Faught E, Funkhouser E, Richman J, Piper K, Juarez L, Dai C, Pisu M. Quality Indicator for Epilepsy Treatment 15 (QUIET-15): Intervening after recurrent seizures in the elderly. Epilepsy Behav 2017; 70:253-258. [PMID: 28412154 PMCID: PMC5438892 DOI: 10.1016/j.yebeh.2017.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/03/2017] [Accepted: 03/04/2017] [Indexed: 11/24/2022]
Abstract
In this study, we examined the provision of care to older adults with epilepsy and compliance with the "Quality Indicator for Epilepsy Treatment 15" (QUIET-15) measure. We analyzed 2008-2010, 5% random sample of Medicare beneficiaries augmented with data from all beneficiaries who identified as a minority with claims related to seizures (780.3x) or epilepsy (345.xx). Of 36,912 identified epilepsy cases, 12.6% had ≥1 emergency room (ER) visit for seizure(s). For those who presented to ER, among those taking anti-epileptic drugs (AEDs), AED was changed in 15.4%, dose adjusted in 19.7%, and stopped in 14.9%; among those not taking AED, therapy was initiated in 68.5%. In adjusted logistic regressions, African-Americans were more likely to have recurrent seizures than Whites (OR 1.41, 95%CI 1.27-1.56), while Asians were less likely to have recurrent seizures (OR 0.71, 95%CI 0.57-0.89). There were no significant racial/ethnic differences in the likelihood of a post-seizure intervention. The chance of seizure recurrence leading to ER visit decreased with age and increased with the number of comorbidities. Patients with seizure recurrence were more likely to be taking an enzyme-inducing AED (OR 1.69, 95%CI 1.57-1.82) and receiving Part D Low Income Subsidy (OR 1.36, 95%CI 1.22-1.51). The probability of AED change after a seizure was higher for patients with ≥4 comorbidities (OR 1.69, 95%CI 1.25-2.27), patients who saw a neurologist (OR 1.49, 95%CI 1.30-1.70), and patients who were taking an enzyme-inducing AED (OR 1.47, 95%CI 1.27-1.71). Overall, a minority of Medicare beneficiaries experienced seizure recurrence that resulted in an ER visit. However, only half of them received treatment concordant with QUIET-15. Though racial differences were observed in occurrence of seizures, none were noted in the provision of care.
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Affiliation(s)
| | - Roy C. Martin
- Department of Neurology, University of Alabama at Birmingham
| | | | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham
| | - Kendra Piper
- Department of Gynecology and Obstetrics, Emory University
| | - Lucia Juarez
- Department of Surgery, University of Alabama at Birmingham
| | - Chen Dai
- Department of Surgery, University of Alabama at Birmingham
| | - Maria Pisu
- Department of Surgery, University of Alabama at Birmingham
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Gupta S, Ryvlin P, Faught E, Tsong W, Kwan P. Understanding the burden of focal epilepsy as a function of seizure frequency in the United States, Europe, and Brazil. Epilepsia Open 2017; 2:199-213. [PMID: 29588949 PMCID: PMC5719850 DOI: 10.1002/epi4.12050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 11/12/2022] Open
Abstract
Objective To understand the current burden of focal epilepsy (FE) as a function of seizure frequency. Methods Patients were identified from the United States (2011, 2012, and 2013), five European countries (EU; France, Germany, Italy, Spain, United Kingdom) (2011 and 2013), and Brazil (2011 and 2012) National Health and Wellness Survey (NHWS), a nationally representative, Internet‐based survey of adults (18+ years). The NHWS collected data on respondents’ quality of life (QoL), health utilities, productivity loss, and healthcare resource utilization. Indirect and direct costs were calculated from the literature. Altogether, 345 of 176,093 (U.S.A.), 73 of 30,000 (United Kingdom), 53 of 30,001 (Germany), 53 of 30,000 (France), 41 of 12,011 (Spain), 37 of 17,500 (Italy), and 71 of 24,000 (Brazil) respondents self‐reported a diagnosis of FE. Results Many respondents (U.S.A.: 56.2%; 5EU: 41.6%; Brazil + 5EU: 40.5%) reported persistent seizures (≥1 per year). Over 60% to just over 71% of respondents with FE were treated with antiepileptic drugs (AEDs). In the United States, seizure frequency was associated with hospitalizations, indirect costs (ages 18–60), and total direct costs. For the 5EU and Brazil + 5EU, seizure frequency was associated with physical QoL, health utilities, activity impairment, and emergency room (ER) visits. Additional associations were observed for the 5EU on hospitalizations, indirect costs (ages 18–60), ER visit costs, and total direct costs and for Brazil + 5EU on absenteeism, overall work impairment, and provider visits. Costing was not performed for Brazil + 5EU. Significance Around half of the patients had persistent seizures despite most taking an AED in this 2011–2013 dataset. The results support the hypothesis that reducing seizures can improve productivity and reduce resource utilization and associated costs. Regional differences may reflect differences in healthcare systems and selected patient populations. Overall, the results suggest that additional treatment options are needed to improve seizure control and reduce related costs.
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Affiliation(s)
| | - Philippe Ryvlin
- Département des Neurosciences Cliniques Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - Edward Faught
- Emory Epilepsy Program Emory University School of Medicine Atlanta Georgia U.S.A
| | - Wan Tsong
- Global Value & Access Eisai Inc. Woodcliff Lake New Jersey U.S.A
| | - Patrick Kwan
- The University of Melbourne and Royal Melbourne Hospital Parkville Victoria Australia
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Martin RC, Faught E, Szaflarski JP, Richman J, Funkhouser E, Piper K, Juarez L, Dai C, Pisu M. What does the U.S. Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy? Epilepsia 2017; 58:548-557. [PMID: 28176298 DOI: 10.1111/epi.13675] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Disparities in epilepsy treatment are not uncommon; therefore, we examined population-based estimates of initial antiepileptic drugs (AEDs) in new-onset epilepsy among racial/ethnic minority groups of older US Medicare beneficiaries. METHODS We conducted retrospective analyses of 2008-2010 Medicare administrative claims for a 5% random sample of beneficiaries augmented for minority representation. New-onset epilepsy cases in 2009 had ≥1 International Classification of Diseases, Ninth Revision (ICD-9) 345.x or ≥2 ICD-9 780.3x, and ≥1 AED, AND no seizure/epilepsy claim codes or AEDs in preceding 365 days. We examined AED use and concordance with Quality Indicators of Epilepsy Treatment (QUIET) 6 (monotherapy as initial treatment = ≥30 day first prescription with no other concomitant AEDs), and prompt AED treatment (first AED within 30 days of diagnosis). Logistic regression examined likelihood of prompt treatment by demographic (race/ethnicity, gender, age), clinical (number of comorbid conditions, neurology care, index event occurring in the emergency room (ER)), and economic (Part D coverage phase, eligibility for Part D Low Income Subsidy [LIS], and ZIP code level poverty) factors. RESULTS Over 1 year of follow-up, 79.6% of 3,706 new epilepsy cases had one AED only (77.89% of whites vs. 89% of American Indian/Alaska Native [AI/AN]). Levetiracetam was the most commonly prescribed AED (45.5%: from 24.6% AI/AN to 55.0% whites). The second most common was phenytoin (30.6%: from 18.8% Asians to 43.1% AI/AN). QUIET 6 concordance was 94.7% (93.9% for whites to 97.3% of AI/AN). Only 50% received prompt AED therapy (49.6% whites to 53.9% AI/AN). Race/ethnicity was not significantly associated with AED patterns, monotherapy use, or prompt treatment. SIGNIFICANCE Monotherapy is common across all racial/ethnic groups of older adults with new-onset epilepsy, older AEDs are commonly prescribed, and treatment is frequently delayed. Further studies on reasons for treatment delays are warranted. Interventions should be developed and tested to develop paradigms that lead to better care.
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Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia, U.S.A
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Kendra Piper
- Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia, U.S.A
| | - Lucia Juarez
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Chen Dai
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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Faught E. Epilepsy and nonadherence. Neurology 2016; 87:452-3. [DOI: 10.1212/wnl.0000000000002797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Pellock JM, Faught E, Foroozan R, Sergott RC, Shields WD, Ziemann A, Lee D, Dribinsky Y, Torri S, Othman F, Isojarvi J. Which children receive vigabatrin? Characteristics of pediatric patients enrolled in the mandatory FDA registry. Epilepsy Behav 2016; 60:174-180. [PMID: 27208827 DOI: 10.1016/j.yebeh.2016.03.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
Vigabatrin (Sabril®) is an antiepileptic drug (AED) currently indicated in the US as a monotherapy for patients 1month to 2years of age with infantile spasms (IS) and as adjunctive therapy for patients ≥10years of age with refractory complex partial seizures (rCPS) whose seizures have inadequately responded to several alternative treatments and for whom the potential benefits outweigh the risk of vision loss. The approval required an FDA mandated registry. This article describes 5years of demographic and treatment exposure data from US pediatric patients (<17years). Participation is mandatory for all US Sabril® prescribers and patients. A benefit-risk assessment must be documented for patient progression to maintenance therapy. This includes demographic diagnosis and reports of ophthalmologic assessments (where available). Patient data were grouped by age as proxies for indication (IS: <3years, rCPS: ≥3 to <17years). As of August 26, 2014, 5546/6823 enrolled patients were pediatric/total; 4472 (81%) were vigabatrin-naïve. Seventy-one percent of patients were <3years of age; 29% were ≥3 to <17years of age. Etiologies of IS were identified as cryptogenic (21%), symptomatic tuberous sclerosis (17%), and symptomatic other (42%). The majority of patients with IS (56%) attempted no prior treatments; 16% received adrenocorticotropic hormone prior to vigabatrin. A third of patients with IS were receiving 1 concomitant treatment with vigabatrin. For patients with rCPS, 39% attempted 1-3 prior treatments; 27% were receiving 2 concomitant treatments at enrollment. A total of 1852 (41%) patients did not undergo baseline ophthalmological assessment; 25% of patients with IS and 42% of patients with rCPS were exempted for neurologic disabilities. Kaplan-Meier estimates predict that 71% and 65% of vigabatrin-naïve patients with IS and rCPS, respectively, would remain in the registry at 6months. Most pediatric vigabatrin patients have IS as an underlying diagnosis, especially those <3years of age. A proportion of those with rCPS remain on long-term vigabatrin despite the risk of adverse events.
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Affiliation(s)
| | | | | | - Robert C Sergott
- Wills Eye Institute and Thomas Jefferson University Medical College, Philadelphia, PA, USA
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Faught E. Reflections on monotherapy trials for epilepsy. Lancet Neurol 2016; 15:657. [DOI: 10.1016/s1474-4422(16)00123-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 03/08/2016] [Indexed: 12/01/2022]
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Kim H, Thurman DJ, Durgin T, Faught E, Helmers S. Estimating Epilepsy Incidence and Prevalence in the US Pediatric Population Using Nationwide Health Insurance Claims Data. J Child Neurol 2016; 31:743-9. [PMID: 26719495 DOI: 10.1177/0883073815620676] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/28/2015] [Indexed: 11/17/2022]
Abstract
This study aims to determine prevalence and incidence of epilepsy in the US pediatric population. We analyzed commercial claims and Medicaid insurance claims data between 2008 and 2012. Over 8 million continuously enrolled lives aged 0 to 19 years were included. Our definition of a prevalent case of epilepsy was based on International Classification of Diseases-coded diagnoses of epilepsy or seizures and evidence of prescribed antiepileptic drugs. Incident cases were identified in subjects continuously enrolled for ≥2 years of which the first 2 years had no indication of epilepsy or seizures. The overall prevalence estimate for 2012 was 6.8 per 1,000 children. The overall incidence estimate for 2012 was 104 per 100,000 pediatric population. This study provides estimates of the prevalence and incidence of epilepsy in the US pediatric population, using large claims datasets from multiple US population sectors. The findings appear reasonably representative of the US-insured pediatric population.
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Affiliation(s)
- Hyunmi Kim
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Edward Faught
- Emory University School of Medicine, Atlanta, GA, USA
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Krauss G, Faught E, Foroozan R, Pellock JM, Sergott RC, Shields WD, Ziemann A, Dribinsky Y, Lee D, Torri S, Othman F, Isojarvi J. Sabril® registry 5-year results: Characteristics of adult patients treated with vigabatrin. Epilepsy Behav 2016; 56:15-9. [PMID: 26807550 DOI: 10.1016/j.yebeh.2015.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/30/2015] [Accepted: 12/02/2015] [Indexed: 11/16/2022]
Abstract
Vigabatrin (Sabril®), approved in the US in 2009, is currently indicated as adjunctive therapy for refractory complex partial seizures (rCPS) in patients ≥ 10 years old who have responded inadequately to several alternative treatments and as monotherapy for infantile spasms (IS) in patients 1 month to 2 years of age. Because of reports of vision loss following vigabatrin exposure, FDA approval required a risk evaluation mitigation strategy (REMS) program. Vigabatrin is only available in the US through Support, Help, And Resources for Epilepsy (SHARE), which includes a mandated registry. This article describes 5 years of demographic and treatment exposure data from adult patients (≥ 17 years old) in the US treated with vigabatrin and monitored in the ongoing Sabril® registry. Registry participation is mandatory for all US Sabril® prescribers and patients. A benefit-risk assessment must be documented by the physician for a patient to progress to maintenance therapy, defined as 1 month of vigabatrin treatment for patients with IS and 3 months for patients with rCPS. Ophthalmologic assessments must be documented during and after completion of therapy. As of August 26, 2014, a total of 6823 patients were enrolled in the registry, of which 1200 were adults at enrollment. Of these patients, 1031 (86%) were naïve to vigabatrin. The majority of adult patients (n=783, 65%) had previously been prescribed ≥ 4 AEDs, and 719 (60%) were receiving ≥ 3 concomitant AEDs at vigabatrin initiation. Prescribers submitted an initial ophthalmological assessment form for 863 patients; an ophthalmologic exam was not completed for 300 (35%) patients and thus, were considered exempted from vision testing. Of these patients, 128 (43%) were exempted for neurologic disabilities. Clinicians discontinued treatment in 8 patients because of visual field deficits (VFD) (5 patients naïve to vigabatrin and 3 patients previously exposed). Based on Kaplan-Meier survival estimates, it is estimated that approximately 71%, 55%, and 40% of adult patients naïve to vigabatrin would remain in the registry at 3, 6, and 12 months, respectively. These demographic data suggest that a proportion of adult patients remain on vigabatrin long-term despite the risks of adverse events and significant underlying AED resistance and neurologic disease.
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Affiliation(s)
| | | | | | | | - Robert C Sergott
- Wills Eye Institute and Thomas Jefferson University Medical College, Philadelphia, PA, USA
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Gupta S, Kwan P, Faught E, Tsong W, Forsythe A, Ryvlin P. Understanding the burden of idiopathic generalized epilepsy in the United States, Europe, and Brazil: An analysis from the National Health and Wellness Survey. Epilepsy Behav 2016; 55:146-56. [PMID: 26773686 DOI: 10.1016/j.yebeh.2015.12.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/01/2015] [Accepted: 12/10/2015] [Indexed: 09/30/2022]
Abstract
The aim of this study was to understand the current burden of primary generalized tonic-clonic seizures (PGTCS) associated with idiopathic generalized epilepsy (IGE) as a function of seizure frequency. We analyzed data for (IGE) as a proxy measure of PGTCS. Little is known about the quality of life (QoL), health utility, productivity, healthcare resource utilization (HRU), and cost burden of PGTCS or IGE. Patients were identified from the US (2011, 2012, & 2013), 5EU (2011 & 2013), and Brazil (2011 & 2012) National Health and Wellness Survey, a nationally representative, internet-based survey of adults (18+ years). Patients that self-reported a diagnosis of IGE were categorized into seizure frequencies of: ≥1 seizure per week, 1-3 seizures per month, 1-4 seizures per year, or <1 seizure per year. QoL was measured using the SF-36v2 Mental (MCS) and Physical Component Summary (PCS) scores, health utilities with the SF-6D, productivity with the Work Productivity and Activity Impairment (WPAI) questionnaire, and HRU as reported in the past six months. Unit costs were estimated from the literature and multiplied against HRU values to calculate direct costs and WPAI values to calculate indirect costs. Generalized linear regression was utilized to examine the relationship between seizure frequency and each measure of burden with adjustment for covariates. Out of the general population surveyed, IGE was self-reported in 782 of 176,093 (US), 172 of 30,000 (UK), 106 of 30,001 (Germany), 87 of 30,000 (France), 31 of 12,011 (Spain), 22 of 17,500 (Italy), and 34 of 24,000 (Brazil). Persistent seizures (≥1 per year) were reported in over 40% of patients with IGE (10-15% with ≥1 seizure per week, 10-15% with 1-3 seizures per month, 20-25% with 1-4 seizures per year). Over 75% were treated with antiepileptic drugs (AEDs). Compared with those having <1 seizure per year (reference group), patients in the two most frequent seizure categories reported worse MCS and PCS scores. Patients in the three highest seizure frequency groups consistently reported worse health utility scores, and greater presenteeism (attending work while not physically or mentally capable of working), overall work impairment, activity impairment, HRU, indirect costs, and direct costs than the reference group. Despite the availability of AEDs during the year surveyed, a substantial number of patients experienced persistent seizures. Increasing seizure frequency was clearly associated with worse outcomes. The burden of PGTCS and IGE may be proportionally reduced by newer AEDs which may increase the proportion of seizure-free patients or shift more patients into lower seizure frequency categories.
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Affiliation(s)
- Shaloo Gupta
- Kantar Health, 1 Independence Way, Suite 220, Princeton, NJ 08540, USA.
| | - Patrick Kwan
- The University of Melbourne and Royal Melbourne Hospital, Parkville, VIC 3050, Australia.
| | - Edward Faught
- Emory University School of Medicine, Emory Epilepsy Program, 12 Executive Park Drive NE, Atlanta, GA 30329, USA.
| | - Wan Tsong
- Eisai Inc., Global Value & Access, 155 Tice Blvd., Woodcliff Lake, NJ 07677, USA.
| | - Anna Forsythe
- Eisai Inc., Global Value & Access, 155 Tice Blvd., Woodcliff Lake, NJ 07677, USA.
| | - Phillipe Ryvlin
- Centre Hospitalier Universitaire Vaudois, Département des Neurosciences Cliniques, BH/10/137 Rue du Bugnon 46, CH-1011 Lausanne, Switzerland.
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Helmers SL, Thurman DJ, Durgin TL, Pai AK, Faught E. Descriptive epidemiology of epilepsy in the U.S. population: A different approach. Epilepsia 2015; 56:942-8. [PMID: 25921003 DOI: 10.1111/epi.13001] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine prevalence and incidence of epilepsy within two health insurance claims databases representing large sectors of the U.S. METHODS A retrospective observational analysis using Commercial Claims and Medicare (CC&M) Supplemental and Medicaid insurance claims data between January 1, 2007 and December 31, 2011. Over 20 million continuously enrolled lives of all ages were included. Our definition of a prevalent case of epilepsy was based on International Classification of Diseases, Ninth Revision, Clinical Modification-coded diagnoses of epilepsy or seizures and evidence of prescribed antiepileptic drugs. Incident cases were identified among prevalent cases continuously enrolled for ≥ 2 years before the year of incidence determination with no epilepsy, seizure diagnoses, or antiepileptic drug prescriptions recorded. RESULTS During 2010 and 2011, overall age-adjusted prevalence estimate, combining weighted estimates from all datasets, was 8.5 cases of epilepsy/1,000 population. With evaluation of CC&M and Medicaid data separately, age-adjusted prevalence estimates were 5.0 and 34.3/1,000 population, respectively, for the same period. The overall age-adjusted incidence estimate for 2011, combining weighted estimates from all datasets, was 79.1/100,000 population. Age-adjusted incidence estimates from CC&M and Medicaid data were 64.5 and 182.7/100,000 enrollees, respectively. Incidence data should be interpreted with caution due to possible misclassification of some prevalent cases. SIGNIFICANCE The large number of patients identified as having epilepsy is statistically robust and provides a credible estimate of the prevalence of epilepsy. Our study draws from multiple U.S. population sectors, making it reasonably representative of the U.S.-insured population.
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Affiliation(s)
- Sandra L Helmers
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - David J Thurman
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | | | - Akshatha Kalsanka Pai
- Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Edward Faught
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
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Faught E, Helmers SL, Begley CE, Thurman DJ, Dilley C, Clark C, Fritz P. Newer antiepileptic drug use and other factors decreasing hospital encounters. Epilepsy Behav 2015; 45:169-75. [PMID: 25819943 DOI: 10.1016/j.yebeh.2015.01.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/16/2015] [Accepted: 01/28/2015] [Indexed: 11/15/2022]
Abstract
A retrospective analysis was conducted in one claims database and was confirmed in a second independent database (covering both commercial and government insurance plans between 11/2009 and 9/2011) for the understanding of factors influencing antiepileptic drug (AED) use and the role of AEDs and other health-care factors in hospital encounters. In both datasets, epilepsy cases were identified by AED use and epilepsy diagnosis coding. Variables analyzed for effect on hospitalization rates were as follows: (1) use of first-generation AEDs or second-generation AEDs, (2) treatment changes, and (3) factors that may affect AED choice. Lower rates of epilepsy-related hospital encounters (encounters with an epilepsy diagnosis code) were associated with use of second-generation AEDs, deliberate treatment changes, and treatment by a neurologist. Epilepsy-related hospital encounters were more frequent for patients not receiving an AED and for those with greater comorbidities. On average, patients taking ≥1 first-generation AED experienced epilepsy-related hospitalizations every 684days, while those taking ≥1second-generation AED were hospitalized every 1001days (relative risk reduction of 31%, p<0.01). Prescriptions for second-generation AEDs were more common among neurologists and among physicians near an epilepsy center. Use of second-generation AEDs, access to specialty care, and deliberate efforts to change medications following epilepsy-related hospital encounters improved outcomes of epilepsy treatment based on average time between epilepsy-related hospital encounters. These factors may be enhanced by public health policies, private insurance reimbursement policies, and education of patients and physicians.
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Affiliation(s)
- Edward Faught
- Department of Neurology, Emory University School of Medicine, 101 Woodruff Circle NE, Atlanta, GA 30322, USA.
| | - Sandra L Helmers
- Department of Neurology, Emory University School of Medicine, 101 Woodruff Circle NE, Atlanta, GA 30322, USA.
| | - Charles E Begley
- Division of Management, Policy, and Community Health, The University of Texas - Houston School of Public Health, 1200 Hermann Pressler Street, E317, Houston, TX 77030, USA.
| | - David J Thurman
- Department of Neurology, Emory University School of Medicine, 101 Woodruff Circle NE, Atlanta, GA 30322, USA.
| | - Cynthia Dilley
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Chris Clark
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
| | - Patty Fritz
- UCB Pharma, 1950 Lake Park Dr SE, Smyrna, GA 30080, USA.
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Martin RC, Faught E, Richman J, Funkhouser E, Pisu M. In response: Research using archival health care data: Let the buyer beware. Epilepsia 2015; 56:322-3. [PMID: 25708478 DOI: 10.1111/epi.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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Sperling MR, Rosenow F, Faught E, Hebert D, Doty P, Isojärvi J. Efficacy of lacosamide by focal seizure subtype. Epilepsy Res 2014; 108:1392-8. [DOI: 10.1016/j.eplepsyres.2014.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 05/30/2014] [Accepted: 06/17/2014] [Indexed: 12/22/2022]
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Martin RC, Faught E, Richman J, Funkhouser E, Kim Y, Clements K, Pisu M. Psychiatric and neurologic risk factors for incident cases of new-onset epilepsy in older adults: Data from U.S. Medicare beneficiaries. Epilepsia 2014; 55:1120-7. [DOI: 10.1111/epi.12649] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Roy C. Martin
- Department of Neurology; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Edward Faught
- Department of Neurology; Emory University; Atlanta Georgia U.S.A
| | - Joshua Richman
- Department of Surgery; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Ellen Funkhouser
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Yongin Kim
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Kay Clements
- Department of Health Services Administration; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Maria Pisu
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama U.S.A
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