Patients with epilepsy during the COVID-19 pandemic: Depressive symptoms and their association with healthcare access.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak impacted the lives of worldwide people with epilepsy (PWE) in various aspects, particularly in those countries most significantly affected by this pandemic, such as Brazil. We aimed to investigate the prevalence of depressive symptoms in PWE and their correlation with epilepsy features and access to treatment. METHODS: PWE were invited to answer a cross-sectional online-based survey to assess and rate depressive symptoms using the NDDI-E during the first year of the COVID-19 pandemic and its relation to multiple lifestyles epilepsy clinical aspects. RESULTS: A total of 490 PWE were recruited. The prevalence of depressive symptoms during the COVID-19 pandemic was 35.3% (cutoff score > 15 on NDDI-E). The factors associated with higher NDDI-E scores were: female sex, increased seizure frequency, barriers to access to their treating physician and antiseizure medication, and unemployment. Regarding the pandemic impact on PWE healthcare, 29.2% reported restricted access to their medication, 46.1% barriers to access their physicians, 94.2% had their consultations canceled due to the pandemic, and 28.4% had seizure worsening in this period. CONCLUSION: The COVID-19 pandemic affected PWE access to the healthcare system. Depressive symptoms were more severe in patients with higher seizure frequency who had difficulties obtaining proper medical care. The COVID-19 pandemic may impact the healthcare and mental wellbeing of patients with chronic diseases such as epilepsy. Nevertheless, prospective studies on epilepsy and COVID-19 are still lacking.

Challenges faced by people with epilepsy on ketogenic diet therapy and their caregivers during the COVID-19 pandemic in Brazil.

BACKGROUND: Although ketogenic diet therapy (KDT) is a well-established, nonpharmacologic therapeutic option for patients with pharmacoresistant epilepsy, its availability is still not widespread. The COVID-19 pandemic may have further restricted the access of people with pharmacoresistant epilepsy (PWE) to KDT. Thus, we evaluated the experiences of Brazilian PWE and their caregivers during the first year of the pandemic. METHODS: An online self-assessed survey containing 25 questions was distributed via social media to be answered by PWE treated with KDT or their caregivers through Google Forms from June 2020 to January 2021. Mental health was assessed using the DASS and NDDI-E scales. RESULTS: Fifty adults (>18 yo), of whom 68% were caregivers, answered the survey. During the pandemic, 40% faced adversities in accessing their usual healthcare professionals and 38% in obtaining anti-seizure medication (ASM). Despite these issues, 66% of those on KDT could comply with their treatment. Those struggling to maintain KDT (34%) named these obstacles mainly: diet costs, social isolation, food availability, and carbohydrate craving due to anxiety or stress. An increase in seizure frequency was observed in 26% of participants, positively associated with difficulties in obtaining ASM [X2 (1, N = 48) = 6.55; p = 0.01], but not with KDT compliance issues. CONCLUSIONS: People with pharmacoresistant epilepsy and undergoing KDT, as well as their caregivers, faced additional challenges during the COVID-19 pandemic, not only difficulties in accessing healthcare and KDT maintenance but also on seizure control and mental health.

Perceptions of Modulatory Factors in Migraine and Epilepsy: A Multicenter Study.

Background: Migraine and epilepsy are both common episodic disorders, typically precipitated or inhibited by some modulatory factors (MFs). Objective: To assess the self-perception of MFs in patients with migraine (PWM) compared to patients with epilepsy (PWE) with a standardized protocol in different countries. Methods: Transcultural multicenter comparative cross-sectional study. All consecutive patients who fulfilled the ICHD-3 criteria for migraine and ILAE's criteria for epilepsy, with at least 1 year of follow-up were interviewed with a semi-structured questionnaire on clinical and epidemiological data and were asked to identify all experienced MFs from a provided list. Results: A total of 608 individuals were surveyed at five university referral centers in Brazil, Guatemala, Lithuania and Turkey. Two hundred and nineteen (91.6%) PWM and 305 (82.7%) PWE identified attack precipitating factors (PFs; p < 0.001). The most frequent three PFs reported by epilepsy patients were: "lack of sleep" (56.6%), "emotional stress" (55.3%), "negative feelings" (53.9%), while among migraine patients "emotional stress" (81.6%), "lack of sleep" (77.8%), "negative feelings" (75.7%) were cited. Inhibitory factors (IFs) for the episodes were reported by 68 (28.5%) PWM and 116 (31.4%) PWE. "Darkness" was the most common one, described by 35.6% of PWM whereas "positive feelings" reported by 10.6% of PWE. Most MFs are concordant across the countries but some transcultural differences were noted. Conclusion: The MFs of migraine and epilepsy attacks and their varying frequencies according to different countries were investigated with the same standardized questionnaire, for the first time. MFs were recognized very often in both migraine and epilepsy cohorts, but in distinct disease-specific prevalence, being more frequent in migraine. Recognition of self-perceived MFs may be helpful for the management of both illnesses.

Challenges in telemedicine for adult patients with drug-resistant epilepsy undergoing ketogenic diet treatment during the COVID-19 pandemic in the public healthcare system in Brazil.

Hygienic and sanitary measures and social distancing policies implemented during the new coronavirus disease - COVID-19 - pandemic have altered the care and follow-up provided by healthcare professionals for patients with chronic diseases, including patients with epilepsy (PWEs). Telemedicine has become a solution for the healthcare of PWEs in many developed countries. In this short communication, we trace a particular perspective for the application of telemedicine for PWEs undergoing ketogenic diet (KD) treatment, considering the social and economic difficulties faced by healthcare teams in resource-poor countries, such as Brazil. During the pandemic, financial strain was the main impediment to following KD. The pandemic increased socioeconomic insecurity and access to KD-related products, as well as increasing anxiety in 71% of PWE, impacting their KD treatment follow-up. The challenges of telemedicine in Brazil include not only social and economic issues but also access to food, healthcare services, and education for the population, in addition to digital inclusion.

Cardiometabolic risk and effectiveness of the modified Atkins Ketogenic Diet for adult patients with pharmacoresistant epilepsies in a middle-income country.

A ketogenic diet may be a therapeutic option for approximately one third of patients with epilepsy. These patients continue to have seizures despite suitable pharmacological treatment. Regardless of the diet's therapeutic potential regarding seizure control, adverse events may coexist. This requires constant monitoring of the patient as comorbidities may emerge. A prospective, nonrandomized and uncontrolled study was conducted to evaluate the effect of a ketogenic diet on cardiometabolic parameters (lipid profile, glycemic profile and body composition variables) and seizure control in adult patients with pharmacoresistant epilepsies. Patients followed the Modified Atkin's Diet (MAD), with a restriction of 20 g of carbohydrates per day, adequate protein amounts and fats ad libitum for 24 weeks. Fourteen eligible patients were enrolled in the study, however, only eight completed the treatment (four women with an average age of 33.5 ± 9.9 years and four men with an average age of 27.5 ± 9.0 years; p = 0.386). The median of focal impaired awareness seizures decreased from 9.0 (interquartile range [IQR] 4.0-28.0) seizures per month pre-diet to 4.0 (IQR 0.5-11.2) seizures per month in 12 weeks (p = 0.028), i.e. a 55.5% reduction. Total cholesterol (19,711 ± 1373 mg/dL to 28,427 ± 2545 mg/dL; p = 0.016), LDL (131.47 ± 1319 mg/dL to 194.85 ± 20.41 mg/dL; p = 0.037), and non-HDL (140.20 ± 13.04 mg/dL to 219.75 ± 28.53 mg/dL; p = 0.028) levels increased progressively over the intervention period, being significant at 24 weeks (n = 6). A significant reduction in blood glucose (89.70 ± 2.20 mg/dL to 82.62 ± 1.45 mg/dL at week 24, p < 0.001, n = 6), insulin (11.02 ± 1.78 µUI/mL to 6.20 ± 0.71 µUI/mL at week 12, p < 0.001, n = 6) and HOMA-IR index was observed (1.46 ± 0.29 to 0.91 ± 0.23 at week 24, p < 0.001, n = 5). The estimated cardiovascular risk after treatment was low for all patients (less than 10 %). A significant reduction in body weight (76.28 ± 6.62 kg to 69.14 ± 5.63 kg; p < 0.001), body mass index (26.41 ± 1.79 kg/m² to 24.05 ± 1.58 kg/m²; p = 0.001), and waist (87.40 ± 4.98 cm to 78.61 ± 3.94 cm; p < 0.001) and arm circumferences (32.12 ± 1.97 cm to 28.98 ± 1.30 cm; p < 0.001) was observed (n = 8), as well as reduction in fat mass (26.85 ± 3.15 g to 21.54 ± 2.64 g; p < 0.001) and fat free mass (48.01 ± 2.75 g to 46.60 ± 2.29 g; p < 0.001), n = 7. Adverse events were generally mild and treatable, with the following being the most common: headache (50 %), weakness (50 %), and gastrointestinal symptoms (37.5 %). Potentially atherogenic lipid profile changes were observed; however, improved glycemic control and reduced body weight and waist circumference demonstrated an improvement in cardiometabolic parameters. Framingham score and the QRISK3 showed lower cardiovascular disease risk for some of the patients. Our data suggests MAD could be an appropriate therapeutic choice for adults with pharmacoresistant epilepsies.