The 62nd Annual Meeting of the American Epilepsy Society

The American Epilepsy Society (AES) held its annual meeting, “the premiere conference for epilepsy and other seizure disorders,” in Seattle in December 2008. Neurologists and other healthcare professionals who treat patients with epilepsy disorders came from all over the world to share findings from ongoing research, presented in the form of symposia, lectures, scientific exhibitions, and poster and platform sessions. Following are highlights from the conference. For more information, visit www.aesnet.org.

The symposium “Expert Consensus Process on Patient Safety in the Epilepsy Monitoring Unit” featured a discussion on the results of a survey that evaluated patient care and safety issues in epilepsy monitoring units (EMUs). Analysis of the data demonstrated that there is “a need for the creation of standards in patient care and safety measures in EMUs across the United States.”

The lead researchers created four workgroups, and tasked them with creating recommendations on how to improve patient safety within the EMU.

Seizure Provocation Group

This group reviewed the types of seizure provocations, AED withdrawal, and behavioral and psychiatric issues. No available research exists, but it recommended developing evidence-based information for practice.

Acute Seizure Management Group

This group focused on communication and education, patient admission history, and postictal safety. The issue of communication errors leading to medical errors was once again emphasized during the discussion. This group recommended improving written and/or electronic forms, creating a model for structured communication, and setting up teamwork training. It also stressed the importance of properly educating the epilepsy team.

Seizure Observation Group

The presenters admitted that they had some difficulty in making recommendations, because there is a dearth of literature on seizure observation. However, the group was able to come up with the following suggestions:

• All adverse events and falls cannot be controlled, so EMUs must implement observation plans and develop better treatment plans.

• Expert observers are not always available, so EMUs need to figure out a way to set up acceptable plans.

• EMUs need to put measures in place to compensate for the fact that late-night staff might not be as capable as the daytime staff.

Activity and Environment Group

This group evaluated safety concerns related to the physical environment of the EMU, and discussed whether EMUs should create a daily checklist focused on patient safety. It stressed the importance of providing appropriate admission and discharge education to patients and families.

Regarding the design of EMUs, the group made several recommendations for improving patient safety in the bathrooms, especially since patients want to maintain some independence and do not want to ask for assistance when using the bathroom. Suggested solutions included using soft toilet seats and safer flooring, and, if absolutely needed, enabling nurses to lock the bathroom door from the outside. “In the continuum of patient care, EMUs are critically important and can significantly drive outcomes,” said EMU Study Group member Gregory L. Barkley, MD, Clinical Vice Chair, Department of Neurology, Henry Ford Hospital. “This is why the AES has made it a priority to examine EMUs and formulate best practices and guidelines that will establish a standard, increase efficiency and, most importantly, improve patient outcomes.”

First Public Results of the SANTE Trial Announced at AES

Robert Fisher, MD, professor of neurology and director of the Stanford Epilepsy Center, presented the first public results of the Stimulation of the Anterior Nucleus of the Thalamus in Epilepsy (SANTE) study of 110 patients aged 18-65 years. Researchers saw a significant improvement in seizure control with use of deep brain stimulation during double-blind, open-label, and long-term follow-up phases. During the double-blind phase, one patient became seizure free, with two patients in open-label and nine in long-term follow-up also becoming seizure free. A significant decrease in the number of seizures was seen in 19% of participants. Fisher also said that researchers reported significant seizure control improvements in patients with severe seizure types. These results will enable Medtronic to seek FDA approval to sell the device.

Key highlights from the study include:

• 53 patients using the device in conjunction with epilepsy medications saw a 38% median reduction in seizure frequency at three months.

• 60% of study participants for whom researchers had long-term data reported a 50% or greater reduction in seizure rate at the end of the study period.

The study’s objective of a 30% median improvement was surpassed, with a 63% median reduction of seizures seen (one in five patients had a 90% seizure reduction). Additionally, Fisher stressed that this is the first completed large enrollment trial to test deep brain stimulation for epilepsy.

Now, said Fisher, since the device has proven to work, “we need to figure out how it can be made better.”

Monotherapy Failure and New AEDs on the Horizon

Monotherapy is effective in approximately 50% of patients with epilepsy when delivered in modest doses, according to Kathryn Hollad, MD, PhD, who added that the reason people fail is due to side effects and lack of efficacy.

Tracy Glauser, MD, discussed the options available to patients and physicians when monotherapy fails—neurologists should consider polytherapy; many patients with epilepsy and seizure disorders take multiple AEDs, but the goal, said Glauser, is to find combinations that improve efficacy and decrease toxicity and adverse events. Neurologists need to be vigilant against drug—drug interactions. Glauser said adverse drug reactions lead to approximately 100,000 deaths each year and two million serious reactions, based on global numbers and not specific to epilepsy and other seizure disorders. In a recent ADR report, two AEDs were listed among the 27 most dangerous drugs available, making patients who keep up to date on epilepsy research concerned that their AED treatment will find its way on to the list as well. Glauser recommended that neurologists should consider using computer software with automatic drug alerts when making treatment decisions.

Meir Bialer, PhD, MBA, gave a presentation covering the AED pipeline. According to Bialer, only 30% of epilepsy patients are seizure free. What makes this especially discouraging is that only 10% of AED treatments that reach the IND stage are approved. Bialer explained that one way to alleviate industry concerns is by creating second-generation drugs. Of the 19 recently approved drugs in Bialer’s presentation, the majority were second-generation, as the approval process for second-generation agents is much faster than the process for brand new drugs.

Technology and Neurosurgery

This symposium featured “Ultra High Field MRI: Insights for the Normal and Epileptic Brain,” presented by Hoby Hetherington, PhD; “Optogenetics: Development and Application,” by Karl Deisseorth, MD, PhD; “Single neuron Recordings in the Human Brain: Cognitive and Epileptogenic Networks,” by Itzhak Fried, MD, PhD; and “Brain Modeling and Navigation,” by David Roberts, MD. The common message shared by these neurosurgeons was that technology is necessary to deliver the best and most appropriate care to patients with epilepsy and other seizure disorders. Although the symposium focused on neurosurgery-specific content, it is still important that all neurologists be aware of the latest technological advancements in imaging, electrophysiology, and brain modeling.

Discussion with Samuel Wiebe, MD, director of the University of Calgary Epilepsy Program and chair of the North American Commission of International League Against Epilepsy During the AES meeting, MDNG had the opportunity to speak with Samuel Wiebe, MD, director of the University of Calgary Epilepsy Program and chair of the North American Commission of International League Against Epilepsy, about the relationship between neuro-infections and epilepsy. In this podcast, Wiebe explains that neuro-infection is the second most common cause of epilepsy worldwide, which can be prevented through education and basic hygiene. He also discusses the major campaign being launched by the WHO to decrease or eradicate neuroinfections worldwide by 2015, among many other topics.

www.hcplive.com/mdnglive/podcasts/2008AES_Wiebe