Abstract, originally published in Seizure.

Background: People with epilepsy (PwE) were concerned about the safety of the novel 2019 Coronavirus Disease (COVID-19) vaccines.

Objective: This study aimed to assess the side effects experienced by PwE following vaccination with COVID-19 vaccines and to identify the causes of vaccine hesitation.

Methods: We administered a questionnaire to PwE, who visited the epilepsy clinic at Ibn Sina Hospital in Kuwait during the first two working weeks of April 2021. It included socio-demographic, epilepsy status, and vaccination data. In addition, we asked those who were not vaccinated yet about the reasons and their plan.

Results: A total of 111 PwE were surveyed, with 82 being vaccinated and 29 being unvaccinated. Out of the 82 vaccinated, 66 (80.5%) reported at least one side effect. Patients who received the Pfizer BioNTech mRNA vaccine (BNT162b2) (first, second dosage); and the Oxford-AstraZenecaa chimpanzee adenovirus-vectored vaccine (ChAdOx1nCoV-19) (first dose) had the following reactions: Pain at the injection site (40%, 67.6%), 43.8%, fatigue (47%, 32.4%), 46.9%, Headache (33.3%, 35.3%), 34.4% and Myalgia (40%, 35%), 50% respectively. Local site effects, including pain (67.6% vs. 40%, p = < 0.001) and redness (26.5% vs 6.7%, p = 0.019), were more statistically significantly after the second dose of BNT162b2 vaccine compared to the first dose of the same vaccine. While there was no significant difference in systemic side effects frequencies between the two doses of the BNT162b2 vaccine. The systemic side effects were more statistically significantly after the first dose of ChAdOx1nCoV-19 compared to the first dose of the BNT162b2 vaccine and those included fever (56.3% vs 13.3%, p = < 0.001), chills (37.5% vs 6.7%, p = < 0.001), myalgia (50% vs 40%, p = < 0.001) and arthralgia (25% vs 6.7%, p = 0.021). The local site reactions were not significantly different between the first doses of both vaccines. Among the subgroup who had vaccine-related side effects, 66.7% were females, 90.9% were 55 or younger, 63.6% were on polytherapy, 74% had side effects for one day or less, and 95% were symptoms free by the end of the first-week post-vaccination. Symptoms were mild in 68% of the patients and moderate in 29.3%. Most patients (93.9%) did not report seizure worsening after vaccination. The relative risk of seizure worsening after the first and second doses of BNT162b2 and the first dose of ChAdOx1nCoV-19 vaccines was 1.027 (95% CI 0.891-1.183), 1.019 (95% CI 0.928-1.119), and 1.026 (95% CI 0.929-1.134) respectively. After the first dose of BNT162b2, one patient reported the development of status epilepticus. Among the non-vaccinated group, 34.9% were still indecisive, while 37.9% rejected the vaccination. Fear of adverse effects (42.9%) and fear of epilepsy worsening (23.8%) were the main reasons for vaccine hesitation.

Conclusions: This study shows that the two vaccines under consideration (BNT162b2 [Pfizer] and ChAdOx1nCoV-19 [Oxford-AstraZeneca]) have a good safety profile and a low risk of epilepsy worsening among a cohort of people with epilkepsy in Kuwait.

Abstract, published in Epileptic Disorders

Restructuring of healthcare services during the COVID-19 pandemic has led to lockdown of epilepsy monitoring units (EMUs) in many hospitals. The ad-hoc taskforce of the International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) highlights the detrimental effect of postponing video-EEG monitoring of patients with epilepsy and other paroxysmal events. The taskforce calls for action for continued functioning of EMUs during emergency situations, such as the COVID-19 pandemic. Long-term video-EEG monitoring is an essential diagnostic service. Access to video-EEG monitoring of the patients in the EMUs must be given high priority. Patients should be screened for COVID-19, before admission, according to the local regulations. Local policies for COVID-19 infection control should be adhered to during the video-EEG monitoring. In cases of differential diagnosis in which reduction of anti-seizure medication is not required, home video-EEG monitoring should be considered as an alternative in selected patients.

Abstract, published in Epilepsy & Behavior

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 ketogenic diet therapy, as well as their caregivers, faced additional challenges during the COVID-19 pandemic, not only difficulties in accessing healthcare and ketogenic diet therapy maintenance but also on seizure control and mental health.

Abstract, published in Epilepsy & Behavior

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 people with epilepsy 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.

Abstract, published in Epilepsy Research

Objective: The objective of this study is to assess the role of prior experience with virtual care (through e-visits) in maintaining continuity in ambulatory epilepsy care during an unprecedented pandemic situation, comparing in person versus e-visit clinic uptake.

Methods: This is an observational study on virtual epilepsy care (through e-visits) over two years, during a pre-COVID period (14 months) continuing into the COVID-19 pandemic period (10 months). For a small initial section of patients seen during the study period a physician survey and a patient satisfaction survey were completed (n = 53). Outcomes of eVisits were analyzed using descriptive statistics.

Results: Median numbers of epilepsy clinic visits conducted during the COVID-19 period (27.5 new and 113 follow up) remained similar to the median uptake during the pre-COVID period (28 new and 116 follow up). Prior experience with e-visits for epilepsy yielded smooth transition into the pandemic period, with several other advantages. The majority of eVisits were successful despite technical difficulties and major components of history and management were still easily implemented. Results from patient surveys supported that a significant amount of time and money were saved, which was in keeping with our health-economic analysis.

Conclusion: Our study is one of the first few reports of fully integrated virtual care in a comprehensive epilepsy clinic starting much before start of the COVID-19 pandemic. The results of our study support the feasibility of using virtual care to deliver specialized outpatient care in a comprehensive epilepsy center.

Abstract, published in Epilepsy & Behavior

Introduction: Due to the high demand for information regarding COVID-19 vaccination in people with epilepsy (PWE), we assessed the symptoms and seizure control of PWE following their COVID-19 vaccination.

Methods: All adult patients who were treated at our center were asked to report on their vaccination status and, if vaccinated, about their experiences following their first COVID-19 vaccination with regard to adverse effects and seizure control.

Results: Fifty-four PWE have already received their first vaccination against COVID-19 (27 female, 20% seizure free, 96<% on anti-seizure medication) and were included in the study. Two-thirds tolerated the vaccines generally either very well or well. Thirty-three percent reported general vaccination adverse effects. The most frequently reported general adverse effects were, in descending order, headache, fatigue and fever, and shivering. With regard to epilepsy-related adverse effects, one patient reported increased seizure frequency one day after the first COVID-19 vaccination was administered, and one reported the occurrence of a new seizure type. None of the patients reported a status epilepticus or aggravation of preexisting adverse effects.

Conclusions: Our data suggest that vaccination against COVID-19 appears to be well tolerated in people with epilepsy, supporting the recommendation of vaccination to people with epilepsy.

Abstract, published in Epileptic Disorders

Objective. The objective of this brief report is to review an assessment paradigm for conducting virtual neuropsychological pre-surgical evaluations in the context of the COVID-19 pandemic.

Methods. A multidisciplinary epilepsy team at a Level 4 epilepsy center within a large children’s academic medical center convened to discuss the challenges and possible solutions for Phase II evaluations for pediatric patients with pharmacoresistant epilepsy during the COVID-19 pandemic. The neuropsychologists explored evidence-based methods of virtual evaluation and developed a systematic decision-making process for youth requiring a Phase II evaluation.

Results. We propose models of assessment which prioritize teleneuropsychology when possible to reduce the risk of infection: (1) evaluation with directly administered tests through a completely virtual format; (2) virtual/in-person hybrid evaluation; and (3) clinical observation/interview in a virtual format supplemented by survey data. These models are illustrated by three cases.

Significance. Using virtual assessment models, the team was able to meet the urgent patient care needs and collect useful data while minimizing the risk of virus spread. The paradigms presented may be useful examples for other multidisciplinary surgical teams interested in incorporating teleneuropsychology into their practices.

Abstract, published in Epilepsy Research

In regard to the global pandemic of COVID-19, it seems that persons with epilepsy (PWE) are not more vulnerable to get infected by SARS-CoV-2, nor are they more susceptible to a critical course of the disease. However, management of acute seizures in patients with COVID-19 as well as management of PWE and COVID-19 needs to consider potential drug-drug interactions between anti-seizure drugs and candidate drugs currently assessed as therapeutic options for COVID-19. Repurposing of several licensed and investigational drugs is discussed for therapeutic management of COVID-19. While for none of these approaches, efficacy and tolerability has been confirmed yet in sufficiently powered and controlled clinical studies, testing is ongoing with multiple clinical trials worldwide. Here, we have summarized the possible mechanisms of action of drugs currently considered as potential therapeutic options for COVID-19 management along with possible and confirmed drug-drug interactions that should be considered for a combination of anti-seizure drugs and COVID-19 candidate drugs. Our review suggests that potential drug-drug interactions should be taken into account with drugs such as chloroquine/hydroxychloroquine and lopinavir/ritonavir while remdesivir and tocilizumab may be less prone to clinically relevant interactions with ASMs.

Abstract, published in Epilepsy & Behavior

Objective: To perform a follow-up study of the quality of life in patients with epilepsy in the era of the COVID-19 crisis.

Methods: Two months before the first case of the COVID-19 in Serbia, we obtained the Serbian Version of Quality of Life Inventory for Epilepsy 31 (SVQOLIE-31) and Neurological Disorders Depression Inventory for Epilepsy scores (SVNDDI-E) for another study. We retested the same patients one year after in COVID-19 pandemic. In addition to SVQOLIE-31, and SVNDDI-E we used a generic questionnaire compiled from items related to the COVID-19.

Results: We retested 97 out of 118 patients (82.2%) for the follow-up analysis. The average age was 36.1 ± 12.2 (range: 18-69), and 49 were women (50.5%). The median duration of epilepsy was 13 years (range: 1.5-48). The structural etiology of epilepsy was noted in 41 (42.3%), unknown etiology in 41 (42.3%), and genetic etiology in 15 (15.4%) patients. Fewer patients (27.8%) experienced at least one seizure three months before follow-up testing when compared to patients who experienced at least one seizure three months in initial testing (36.0%) (p = 0.15). All patients reported full compliance with anti-seizure medication in the follow-up. The SVQOLIE-31 score during the COVID-19 pandemic visit (64.5 ± 14.6) was significantly lower than the SVQOLIE-31 score before the pandemic (p < 0.001). The SVNDDI-E score during the COVID-19 pandemic (10.5 ± 3.5) was significantly higher than the SVNDDI-E score before it (p < 0.001). Multiple linear regression analyses revealed fear of seizures, and fear of a reduction in household income, significantly associated with SVQOLIE-31 and SVNDDI-E overall score. These variables accounted for 66% and 27% of the variance of SVQOLIE-31 and SVNDDI-E overall score.

Significance: Lower quality of life, higher prevalence of depression, healthcare availability issues, and perceived fears during pandemic all suggest COVID-19 has negatively impacted lives of patients with epilepsy.

Abstract, originally published in Acta Neurologica Scandinavica

Objective: To analyze the medium-term impact of the COVID-19 pandemic on epilepsy patients, focusing on psychological effects and seizure control.

Methods: Prospective follow-up study to evaluate the medium-term effects of the COVID-19 pandemic on a cohort of epilepsy patients from a tertiary hospital previously surveyed during the first peak of the pandemic. Between July 1, 2020, and August 30, 2020, the patients answered an online 19-item questionnaire, HADS, and PSIQ scales. Short- and medium-term effects of the pandemic confinement and the perception of telemedicine were compared.

Results: 153 patients completed the questionnaire, mean ± SD age, 47.6 ± 19.3 years; 49.7% women. Depression was reported by 43 patients, significantly more prevalent than in the short-term analysis (29.2% vs. 19.7%; p = .038). Anxiety (38.1% vs. 36.1%; p = 0.749) and insomnia (28.9% vs. 30.9%, p = .761) remained highly prevalent. Seventeen patients reported an increase in seizure frequency (11.1% vs. 9.1%, p = .515). The three factors independently associated with an increase in seizure frequency in the medium term were drug-resistant epilepsy (odds ratio [OR] = 8.2, 95% CI 2.06-32.52), depression (OR = 6.46, 95% CI 1.80-23.11), and a reduction in income (OR = 5.47, 95% CI 1.51-19.88). A higher proportion of patients found telemedicine unsatisfactory (11.2% vs. 2.4%), and a lower percentage (44.8% vs. 56.8%) found it very satisfactory (p = .005).

Conclusions: Depression rates increased significantly after the first wave. Depression, drug-resistant epilepsy, and a reduction in family income were independent risk factors for an increased seizure frequency. Perception of telemedicine worsened, indicating need for re-adaptation.