Efficacy and safety of VNS therapy or continued medication management for treatment of adults with drug-resistant epilepsy: systematic review and meta-analysis

Vagus nerve stimulation (VNS) Therapy® is an adjunctive neurostimulation treatment for people with drug-resistant epilepsy (DRE) who are unwilling to undergo resective surgery, have had unsuccessful surgery or are unsuitable for surgery. A systematic review and meta-analysis were conducted to determine the treatment effects of VNS Therapy as an adjunct to anti-seizure medications (ASMs) for the management of adults with DRE. A literature search was performed in August 2020 of the Medline®, Medline® Epub Ahead of Print, Embase, and the Cochrane library databases. Outcomes examined included reduction in seizure frequency, seizure freedom, ASM load, discontinuations, and serious adverse events (SAEs). Comparators included best medical practice, ASMs, low-stimulation or sham VNS Therapy. Four RCTs and six comparative observational studies were identified for inclusion. Against comparators, individuals treated with VNS had a significantly better odds of experiencing a ≥ 50% reduction in seizure frequency (OR: 2.27 [95% CI 1.47, 3.51]; p = 0.0002), a ≥ 75% reduction in seizure frequency (OR: 3.56 [95% CI 1.59, 7.98]; p = 0.002) and a reduced risk for increased ASM load (risk ratio: 0.36 [95% CI 0.21, 0.62]; p = 0.0002). There was no difference in the odds of discontinuation or the rate of SAEs between VNS versus comparators. This meta-analysis demonstrated the benefits of VNS Therapy in people with DRE, which included improvement in seizure frequency without an increase in the rate of SAEs or discontinuations, thereby supporting the consideration of VNS Therapy for people who are not responding to ASMs and those unsuitable or unwilling to undergo surgery.

A Qualitative Analysis to Understand Perception about Medication-Related Problems among Older Minority Adults in a Historically Black Community

Older adults taking multiple chronic medications experience an increased risk of adverse drug events and other medication-related problems (MRP). Most current literature on medication management involves researcher-driven intervention, yet few studies investigate patients’ understanding of MRP in a diverse community setting. This report investigates patients’ perception of MRP and patient-centered strategies among a cohort of the older adult group in a historically Black urban community. The study design is qualitative using structured open-ended questions in a multidisciplinary patient-centered focus group. Patients (age 65 years or older) taking seven or more medications were recruited. The group comprises patients, caregivers, pharmacists, health educators, a physician, and a nurse. Recordings of the group discussion are transcribed verbatim and analyzed using thematic content analysis and categorized by codes developed from the social-ecological model. The group reports patient-provider relationships, previous experience, fear of side effects played important roles in medication adherence. There is an unmet need for medication management education and tools to organize complex medication lists from multiple providers. This study provides important insights into MRP experienced by minority older adults and provided researchers with potential strategies for future interventions.

Efficacy and Safety of VNS Therapy or Continued Medication Management for Treatment of Adults with Drug-Resistant Epilepsy: Systematic Review and Meta-Analysis

Vagus nerve stimulation (VNS) Therapy® is an adjunctive neurostimulation treatment for people withdrug-resistant epilepsy (DRE) who are unwilling to undergo resective surgery, have had unsuccessfulsurgery or are unsuitable for surgery. A systematic review and meta-analysis were conducted todetermine the treatment effects of VNS Therapy as an adjunct to anti-seizure medications (ASMs) forthe management of adults with DRE.A literature search was performed in August 2020 of the Medline®, Medline® Epub Ahead of Print,Embase, and the Cochrane library databases. Outcomes examined included reduction in seizurefrequency, seizure freedom, ASM load, discontinuations, and serious adverse events (SAEs).Comparators included best medical practice, ASMs, low-stimulation or sham VNS Therapy.Four RCTs and six comparative observational studies were identified for inclusion. Against comparators,individuals treated with VNS had a significantly better odds of experiencing a ≥50% reduction in seizurefrequency (OR: 2.27 [95% CI: 1.47, 3.51]; p=0.0002), a ≥75% reduction in seizure frequency (OR: 3.56[95% CI: 1.59, 7.98]; p=0.002) and a reduced risk for increased ASM load (risk ratio: 0.36 [95% CI: 0.21,0.62]; p=0.0002). There was no difference in the odds of discontinuation or the rate of SAEs betweenVNS versus comparators.This meta-analysis demonstrated the benefits of VNS Therapy in people with DRE, which includedimprovement in seizure frequency without an increase in the rate of SAEs or discontinuations, therebysupporting the consideration of VNS Therapy for people who are not responding to ASMs and thoseunsuitable or unwilling to undergo surgery.

Knowledge Requirements and Unmet Needs of Informal Caregivers of Patients with End-Stage Kidney Disease (ESKD) Receiving Haemodialysis: A Narrative Review

Background: Patients with end-stage kidney disease receiving haemodialysis rely heavily on informal caregivers to support them living at home. Informal caregiving may exact a toll on caregivers’ physical, emotional, and social well-being, impacting negatively on their overall quality of life. The aim of this narrative review is to report knowledge requirements and needs of informal caregivers of patients with end stage kidney disease (ESKD) receiving haemodialysis. Methods: The review followed the Preferred Reporting Items for Reporting Systematic Reviews and Meta-analyses (PRISMA). Five electronic databases were searched: Web of Science, PsycINFO, Embase, Medline, and CINAHL to identify the experiences and unmet needs of informal caregivers of patients with end stage kidney disease (ESKD) receiving haemodialysis. Results: Eighteen papers were included in the review and incorporated a range of methodological approaches. There are several gaps in the current literature around knowledge and informational needs and skills required by informal caregivers, such as signs and symptoms of potential complications, dietary requirements, and medication management. Although most research studies in this review illustrate the difficulties and challenges faced by informal caregivers, there is a paucity of information as to which support mechanisms would benefit caregivers. Conclusion: Informal caregivers provide invaluable assistance in supporting people with ESKD undergoing haemodialysis. These informal caregivers however experience multiple unmet needs which has a detrimental effect on their health and negatively influences the extent to which they can adequately care for patients. The development of supportive interventions is essential to ensure that informal caregivers have the requisite knowledge and skills to allow them to carry out their vital role.

Levamisole-Induced Leukoencephalopathy in Russia: Analysis of 30 Cases

Aims: To raise medical specialists’ awareness regarding the severity of possible complications of levamisole administration and demonstrate the role of accurate medical history collection in differential diagnosis. Background: Levamisole, an anthelmintic drug with immunomodulatory effects, has long been used worldwide till early 2000s, when its association with demyelinating leukoencephalopathy was established. However, in the developing countries it is still widely used for prevention and treatment of helminthic invasion in humans. Actual prevalence of levamisole-induced multiple inflammatory leukoencephalopathy (LEV-induced MIL) in Russia remains unknown, and therefore, the study of its frequency and characteristics is indisputably important. Objectives: To determine the clinical features and MRI findings of levamisole-induced MIL in the Russian population and to analyse the frequency of diagnostic errors at the initial assessment. Methods: A single-center retrospective analysis of total 30 patients who were diagnosed with LEV-induced MIL and attended Research Center of Neurology was conducted. Inclusion criteria were 1) clinically: acute or subacute polysymptomatic onset of neurological disturbances, 2) MRI: multifocal demyelinating lesion with no evidence of dissemination in time, 3) anamnestic data: levamisole exposure from 2 to 8 weeks before symptoms onset as well as monophasic disease course (absence of relapses according to follow up assessments up to 3 years). Results: Clinically, presentation with constitutional symptoms, including headache, fever, fatigue and myalgia, focal motor disturbances and dysarthria prevailed in our cohort. On the brain MRI, multiple foci of demyelination with simultaneous gadolinium enhancement were observed. The link between neurological symptoms and levamisole intake has often been detected only during follow-up assessments. Patients were most often misdiagnosed with acute disseminated encephalomyelitis, stroke and multiple sclerosis. In most cases LEV-induced MIL was successfully treated with intravenous corticosteroids and/or plasma exchange (PLEX), however, residual neurologic symptoms preserved in some patients. Additionally, two detailed clinical cases of patients being initially misdiagnosed are presented in the article. Conclusion: The differential diagnosis remains difficult for suspected cases of LEV-induced MIL that could lead to delayed therapy initiation, and consequently incomplete recovery. Growing evidence suggests that a single administration of levamisole even in low doses might potentially lead to severe neurological deficit or death. Therefore, changes in medication management policies are required in order to prevent uncontrolled use of levamisole.