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The podcast currently has 8 episodes available.
Join Dr. Bermeo in a conversation with Dr. Susan Arnold, and Dr. Fred Lado, as they discuss the article, "It’s Current: NAEC Provides Us With the Recipe to Build a Better Epilepsy Center".
Click here to read the article.
This podcast was sponsored by the National Association of Epilepsy Centers (NAEC).
2023 Guidelines for Specialized Epilepsy Centers
We’d also like to acknowledge Epilepsy Currents podcast editor Dr. Adriana Bermeo-Ovalle, and contributing editor Dr. Rohit Marawar, and the team at Sage.
In episode 7 of the Epilepsy Currents podcast, the discussion focuses on the 2023 Guidelines for Specialized Epilepsy Centers, published by the National Association of Epilepsy Centers (NAEC). Hosted by Dr. Adriana Bermeo, the episode features insights from Dr. Susan Arnold, the senior author of the executive summary of the report, and Dr. Fred Lado, president of the NAEC and the first author of the guidelines. The guidelines aim to set comprehensive standards for epilepsy care, particularly addressing the needs of patients with drug-resistant epilepsy.
Brief Summary
The 2023 NAEC guidelines for epilepsy care are designed to elevate the standards of care provided at specialized epilepsy centers. These guidelines distinguish between best practices for patient care and accreditation standards, the latter being what centers must meet to receive NAEC accreditation. Developed through an "evidence-informed consensus" process, these guidelines include contributions from a diverse panel, including neurologists, nurses, EEG technologists, social workers, neuropsychologists, patients, and caregivers. This inclusive approach ensures that the guidelines address comprehensive needs across the spectrum of epilepsy care.
Key Takeaways
Transcript
Adrianna Bermeo-Ovalle, MD (Host): The main purpose that brings our community together is our desire and resolve to offer people living with epilepsy the best alternatives of diagnosis and treatment; the ones that will empower them to live their best possible life. But what does that mean in practical terms? How do we put that intention into clinical practice? The National Association of Epilepsy Centers, NAEC, has taken a careful look at this question. We are delighted to have the opportunity to discuss together the 2023 Guidelines for Specialized Epilepsy Centers that will inform epilepsy care in the present and the future.
Welcome to Episode 7 of Epilepsy Currents Podcast. I am your host, Adriana Bermeo. I am the Senior Podcast Editor for Epilepsy Currents, the official journal of the American Epilepsy Society. Let me first welcome Dr. Susan Arnold. Dr. Arnold is Adjunct Professor of Pediatric Neurology at Yale University School of Medicine.
She's the Senior Author of the Executive Summary of the Report of the National Association of Epilepsy Centers, entitled Guidelines for Specialized Epilepsy Centers, which was published by the Green Journal Neurology in February of 2024. Dr. Arnold, thank you very much for joining us today.
Susan T Arnold, MD: I'm very happy to be here.
Host: It is also my pleasure to welcome Dr. Fred Lado. Dr. Lado is the president of the NAEC and professor of neurology at the Zucker School of Medicine in Hofstra University in Long Island, New York. Dr. Lado is the first author of the guidelines, which you can find linked to the Epilepsy Current site and at the NAEC home site. Dr. Lado, thank you for being with us today.
Fred A. Lado, MD, PhD: Thank you, Adriana, for the opportunity to speak with you.
Host: Great. For our listeners and our readers of Epilepsy Currents, you can also find an It's Currents commentary authored by Dr. Katherine Nichols and published in the May 2024 issue of Epilepsy Currents. So let's get this conversation started. Dr. Lado, I will start with you. Could you please explain to our listeners the role of the National Association of Epilepsy Centers in setting national standards for epilepsy care, especially for those dealing with drug resistant epilepsy?
Fred A. Lado, MD, PhD: So the NAEC was founded in 1987, and since almost the beginning, has published quality standards around the functioning and the care given in epilepsy centers. These standards have been updated approximately every 10 years. And these standards are different from the accreditation program that the NAEC runs. That accreditation program began in 2016. The guidelines have been the basis for developing accreditation standards, but for accreditation standards, centers have to provide evidence that they're meeting the guidelines. Guidelines are really focused on what is best practices. What is the best level of care that patients should be receiving?
Accreditation standards are focused on, are centers implementing these guidelines? Are they actually providing these services? Many of the recommendations that you'll find in these new guidelines are already present in prior versions of the NAEC guidelines and in the accreditation program, but many of the guidelines in the current version are new and sort of stretch the boundaries of areas that the NAEC is addressing as part of comprehensive epilepsy care.
We recognize that in sort of moving the goalpost somewhat, that in expanding the scope of guidelines, that epilepsy centers need to have adequate resources to implement. And so the process of incorporating these guidelines into accreditation is one that will unfold over the coming years, not all at once.
Host: Thank you very much for that answer. Can you just once more clarify what is the difference, how are the guidelines different from the accreditation process for the people in the epilepsy centers who may get a little bit nervous about all the new recommendations that come in the guidelines? What is the urgency for them to implement all of these recommendations into the care they provide for their patients?
Fred A. Lado, MD, PhD: Yes, this is a topic of great sensitivity in epilepsy centers. The guidelines, as we'll discuss are really the product of a consensus across sub specialists, patients, administrators, EEG techs, certainly epileptologists, about what makes a good epilepsy care, what makes a successful epilepsy center in taking care of patients.
But the guidelines are sort of a recommendation of best practices. They are not accreditation standards. Accreditation standards are what the NAEC uses to judge whether a program is meeting the requirements for NAEC accreditation, and that might involve showing reports, might involve doing a certain volume of particular cases or surgeries, it has different specific requirements.
The accreditation standards that the NAEC establishes and changes and updates from year to year, are informed by these guidelines. But the guidelines are a statement of what is considered best practice. The accreditation standards are a statement of what centers have to do to become accredited.
Host: Thank you very much for clarifying that for our listeners and our readers. Dr. Arnold, we understand that these guidelines were developed through a process that is called evidence informed consensus. Can you please elaborate on the methodology and how does it influence the recommendations provided? And if you could, how are they different from the prior guidelines published by the NAEC?
Susan T Arnold, MD: So, the idea when you're writing guidelines is really to have an evidence based process where you survey the literature, collect information, grade the evidence that you collect, and then write your recommendations based on that evidence with the level of the evidence supporting your guideline.
And that works very well for clinical treatment guidelines, where you can search the literature and find studies that compare, for example, one intervention to another. Unfortunately, for an operational guideline, such as the one we were writing for epilepsy centers, the literature doesn't have a lot of information.
And where we do have evidence, it's often not of very high quality and it has gaps. And so in that circumstance, you go to expert opinion. And so what we did is follow an evidence informed process; where we surveyed the literature, we gathered all the information, and then we went to our panel of experts. We educated them on what evidence was in the literature, discussed it as a group, and then created a consensus recommendation using the panel of experts.
What was really different, I think, this time around is that our panel of experts didn't just include the neurologists and neurosurgeons that we've included in the past, but a much broader panel of stakeholders. And so we had our neurology nurses, we had our EEG technologists, we had social workers, neuropsychologists, and most importantly, we had people with epilepsy and their caregivers, and all of that group together created the consensus recommendations for the guidelines.
Host: Thank you very much. It looks like everybody who will be affected or who has a stake in the matter was invited to participate. Dr. Lado, we will not have time in one podcast to discuss all the 52 recommendations, but, if you could walk us through the highlights of the recommendations, initially for the inpatient portion and the surgical programs, what are the items that you want our audience to remember from this podcast?
Fred A. Lado, MD, PhD: Yes, as you point out, Adriana, there are 52 recommendations in the current guidelines. Some of these are similar to our recommendations in the 2010 guidelines, but many have been updated.
With respect to inpatient services, we've always focused on resources. Do you have an EMU? Do you have the appropriate personnel?
In the current guidelines, we have a greater focus on the processes that take place. Are we providing a safe environment in the EMU? Do we have appropriate protocols for preventing escalation of seizures or acceleration of seizures in patients where medications have been reduced? And we have more emphasis on process in the multidisciplinary conferences. And this is an area that received a lot of attention in the current guidelines. We really make clear that the multidisciplinary conferences should be attended by a multidisciplinary group. And in those conferences, patients should really be considered with the full range of different surgeries that might benefit them or procedures, not just what a particular center might be best at doing, but really the full gamut.
And so, the patient can be confident when they go to an epilepsy center that they have received the most comprehensive evaluation and the recommendation of course of treatment most likely to render them seizure free. And then of course, we think that, as Dr. Arnold said, communication and informing patients throughout this process is important.
Host: Dr. Arnold, what about outpatient services? What encompasses comprehensive care for patients with epilepsy in these days and how do you see the future of epilepsy care in the outpatient setting?
Susan T Arnold, MD: Well, as Fred said, this is really the majority of epilepsy care is the outpatient care, not the inpatient areas we've focused on in the past. And so it was a very new thing for us to write guidelines addressing this very broad area. And it was really a struggle for the panel to figure out what was important and what to focus on, because of course everything is important when it addresses quality of care.
So we wrote some guidelines that address some of the American Academy of Neurology quality measures for outpatient care, and that was maybe our starting line and then we really listened to the panel, and in particular, we listened to our patients with epilepsy. We listened to, their caregivers, and we listened to the nurses and the EEG technologists who are often their advocates for us in the medical system.
And what we heard is that access to care is important, and as Fred mentioned, communication was important. And so we expanded our guidelines to those areas. We addressed centers needing to look at their access to outpatient clinic appointments and doing what they can to prioritize the sickest and the most urgent patients so that they're not waiting months for an appointment.
We addressed communication with patients, both using our electronic medical records and also using telehealth, which is something that was very new to all of us when COVID hit, but I think we've all learned a lot about managing telehealth services, since the COVID epidemic. Another thing that we looked at was screening for special needs and related complications for people with epilepsy; things like mental health needs, things like socioeconomic needs, barriers to obtaining their medication, for example. And finally, we looked at servicing special populations. Those that might have had additional needs such as neurodevelopmental difficulties, women with epilepsy and in particular patients with other mental health needs, and our patients with psychogenic non epileptic events.
Those are all patients that in the past have not really been included in the guidelines that we have written.
Host: Thank you, Dr. Arnold. It seems like between the inpatient and the outpatient updates, we will be able to see the patient in many more dimensions than we do currently, and that really makes me feel hopeful for the care that we provide. Dr. Arnold, what about pediatric epilepsy centers? Are there any specific considerations regarding pediatric epilepsy care?
Susan T Arnold, MD: Absolutely, and as a child neurologist, the pediatric population is close to my heart. And, throughout our guideline writing process, we tried to ask ourselves as we addressed each area, is there anything particular that we need to look at differently for children and for centers that treat children? And so you will see in these guidelines, really a greater emphasis, not just on adapting guidelines, emergency managment procedures to the needs of children, but also on the very specialized services that children require. Those include things such as Child Life Specialists, educational material that's focused on the needs of children and their parents. Pediatric anesthesiologists, so that when a child goes for an imaging study, they can be safely sedated, and we can have the highest quality image that we can obtain to make the best decisions for their care.
In addition, we discussed special services that are relevant for both adults and children with epilepsy, but often have a greater role in the management of children. And among those were dietary services. Dietary therapy has a very special role in certain pediatric epilepsies, in children with certain metabolic disorders, and also in children with certain very severe epilepsies.
And the guidelines anticipate that centers that serve children either will have a dietician or will be able to refer to a center that has a dietician to provide a full spectrum of therapy, including dietary therapy. Another area would be genetic services. In the last 15 or 20 years, the use of genetic testing has just exploded and has become critical in the evaluation and in the management of epilepsy, both for children and more and more recognized as being important in adults as well.
And the guidelines discussed the importance of having genetic testing available, understanding which patients will benefit most from it and how to direct the testing towards those populations that will have the most benefit. And then providing genetic counseling services and genetic specialists to manage patients with complex genetic problems.
We recognize that this is a big ask for a lot of centers. We also recognize there are a number of adult focused centers that do a very good job of offering services to older children and teenagers with epilepsy. But we really tried to put ourselves in the shoes of the parent of a child with epilepsy looking for a pediatric epilepsy center.
And for that parent and for that child, a center that advertises itself as a pediatric epilepsy center, the panel felt really had to offer a very broad range of services or have them available by referral, if not within the center.
Host: Yeah, thank you, Dr. Arnold. That really sounds like an amazing perspective of being able to include all of that in the offerings for our patients from the epilepsy centers. But as we know, managing comprehensive epilepsy care can be resource intensive. Dr. Lado, how do the guidelines address the challenges centers may face in implementing these standards, especially when you think about resource limited environments?
Fred A. Lado, MD, PhD: So we gave this lot of thought. And you're right. Some of these guidelines are resource intensive. I think it's important to recognize from the beginning that general neurologists, primary care doctors often play a role in the care of individuals with epilepsy and often offer important and excellent services to the patients with epilepsy.
So these standards are not meant to say that all care for patients with epilepsy must always check every box of these guidelines. Rather, these are to say that comprehensive epilepsy centers meet a higher level of care for patients with epilepsy, and doing so, need to have more resources.
Now, the transition from the current state to the future state, where we would like more and more of these resources to be available, can't be abrupt. There needs to be sort of an on ramp so programs can gradually develop resources where they're necessary. And so, the process of implementing the guidelines, rolling them out in the form of accreditation criteria, is a process that will unfold over several years.
It's not going to be from one year to the next. We hope that by outlining what these guidelines contain and where we're headed with accreditation standards, that epilepsy centers will have both the time as well as the facts to make the case for their hospital administration, for their administrators, to commit the resources necessary to keep the program going.
Host: Thank you very much for that answer. That would certainly be very welcome by epilepsy centers all around the country and even internationally because NAEC sets guidelines that can be used beyond our country for sure. Dr. Arnold, can you please walk us into the future? How do you see these guidelines influencing future development, future accreditation, and as you know very well the process, what areas or aspects need further refinement or further research?
Susan T Arnold, MD: As we've mentioned many times already, with the fact that the scope of these guidelines is so much broader than what we have done before, we recognize a couple of things. First of all, I'm very excited for people developing new centers, we've given them a much broader and more comprehensive list of criteria to work on to understand what an epilepsy center is and that it's more than just an epilepsy monitoring unit or a surgical program.
So I think that's key. Secondly, and we've also touched on this a little bit, the guidelines are so much broader that we can't just put all of them into the accreditation process. There's going to have to be a period of adapting our accreditation process to get its arms around the new guidelines, if you will.
As Fred mentioned, when we have guidelines, when we have something written down on paper, centers can take that to their institutions and try and get the resources they need. And our hope is that by publishing the guidelines, as we take time to phase them into the accreditation process; by the time we get there, our centers will be prepared.
They will have had the lead time to get the resources they need to meet some of these things. Looking toward the future, one of the things we learned is that 10 years is just too long to go between guideline processes. And NAEC is looking at a way to address guideline development that would be much more responsive to changes that are going on in the world of epilepsy treatment.
And so that we're not bringing a big slice of new information to the table every 10 years, but providing more real time, if you will, updates in our guideline process. And finally, there were a number of areas that we simply didn't address in the current guidelines, not because there was a lack of interest, but because either the evidence base wasn't there yet, or because we felt that we had simply gone as far as we could with one set of guideline revisions. And some of those things include looking more at outcomes because our goal for treating epilepsy is not just to have the best process within our epilepsy center, but also to have the best outcomes for epilepsy interventions. And I think that's an area that will take time to address, but eventually we'll need to look at how centers look critically at what they're doing and what their outcomes are and use that to continue to improve the care they provide to people with epilepsy.
Host: Well, it certainly feels like we are making steps into a brighter future for the care of our patients with epilepsy. I would like to invite our listeners to log in into the Epilepsy Currents website and click into the link to the National Associations of Epilepsy Centers guidelines into the original papers which are cited in our site as well.
I want to thank very much our guests and thank our listeners. I want to especially thank the National Associations of Epilepsy Centers, who is the sponsor of today's episode and came today to share these important guidelines with all of us.
I want to thank Dr. Rohit Marwar and the SAGE podcast production team. We look forward to having you join our next episode. Remember to subscribe to Epilepsy Currents podcast wherever you get your podcast and send us your feedback, suggestions, or questions through our website, EpilepsyCurrents.org, and don't forget to follow us on ex former Twitter, at AESCurrents.
Until next time, everybody.
Join Dr. Bermeo in a conversation with Dr. Jarrod E. Dalton, Dr. Bruce Hermann, and Dr. Samuel Terman, as they discuss the article, "Hiding in Plain Sight—Neighborhood Versus Individual Determinants of Psychological Outcomes in Patients With Epilepsy ".
Click here to read the article.
This podcast was sponsored by the American Epilepsy Society through a grant from the Centers for Disease Control (CDC).
These activities are supported by the Centers for Disease Control (CDC) and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,500,000 with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor are they an endorsement, by CDC/HHS, or the U.S. Government.
We’d also like to acknowledge contributing editor Dr. Rohit Marawar, and the team at Sage.
Summary
The podcast features a discussion on how environmental conditions, specifically neighborhood deprivation, affect cognitive outcomes and mood in individuals with pharmacoresistant temporal lobe epilepsy. Dr. Hermann & Dr. Dalton's study found that patients living in more deprived areas exhibited significantly lower cognitive performance and increased levels of anxiety and depression compared to those in less deprived areas. Dr. Terman's commentary critically assesses these findings, stressing the importance of considering environmental factors alongside biological ones in understanding and treating epilepsy.
Key Takeaways
[00:00:00] Adriana Bermeo (Host): It is well known that individuals living with epilepsy are at risk of experiencing cognitive decline and psychiatric comorbidities. But did you know that the individual's home address plays a significant role in the cognitive and psychiatric outcomes of people living with temporal lobe epilepsy?
[00:00:18] Welcome to episode number six of Epilepsy Currents podcast. Today, we will be talking about the role of environmental factors on cognition and mood of patients with temporal lobe epilepsy. I am your host, Adriana Bermeo. I am the Senior Podcast Editor for Epilepsy Currents, the official journal of the American Epilepsy Society.
[00:00:40] I want to first welcome contributing editor, Dr. Samuel Terman, who wrote the commentary, Hiding in Plain Sight--Neighborhood vs. Individual Determinants of Psychological Outcomes in Patients with Epilepsy. This commentary was published on the March 2024 issue of Epilepsy Currents. [00:01:00] Dr. Terman is an Assistant Professor at the University of Michigan. Dr. Terman, welcome to Epilepsy Currents Podcast.
[00:01:07] Samuel W. Terman, MD, MS: Thanks so much. Happy to be here.
[00:01:09] Host: It is also my pleasure to welcome Dr. Bruce Hermann, who is the Senior Author of the work that inspired this commentary, titled Association of Neighborhood Deprivation with Cognitive and Mood Outcomes in Adults with Pharmacoresistant Temporal Lobe Epilepsy. Their paper was published in Neurology in June 2023. Dr. Hermann is Emeritus professor of Neuropsychology at the University of Wisconsin School of Medicine and Public Health. Welcome, Dr. Hermann. Thank you for being with us.
[00:01:39] Bruce Hermann: Thank you, and good afternoon.
[00:01:41] Host: We are also joined by Dr. Jarrod Dalton, who is co-author on the original paper. Dr. Dalton is an Associate Professor and the Director of the Center for Population Health Research at the Cleveland Clinic's Lerner Research Institute. Dr. Dalton, thank you for being with us today.
[00:01:58] Jerrod Dalton, PhD: And thank you.
[00:01:59] Host: While [00:02:00] neurologists and epileptologists are familiar with the effects of the biological characteristics of the lesions causing epilepsy, the neurophysiological findings of the treatments we use in the clinic, we are much less likely to consider their patient's immediate living environment, their access to healthy foods, exposure to violence, or their access to transportation as potential modifiable variables directly affecting someone's epilepsy outcomes.
[00:02:28] Dr. Hermann. Would you mind sharing with us a snapshot of the findings from your study in a way our listeners can grasp?
[00:02:35] Bruce Hermann: Dr. Busch and I have been collaborators for quite some time, and she was able to compile an amazing cohort of 800 patients with pharmacoresistant temporal lobe epilepsy who underwent neuropsychological assessment as part of their inpatient evaluations at the Cleveland Clinic. And then, she and Dr. Dalton extracted home addresses from the EMR and binned the patients into ADI quintiles. [00:03:00] And from the neuropsychological battery that was quite extensive, as is commonly the case in preoperative evaluations, the data was reduced to seven mean cognitive domains, things such as intelligence, language, visual perception, verbal and visual memory, executive function, processing speed. And then, secondarily classified all the patients into four cognitive phenotypes that range from intact, essentially unaffected, to generalized cognitive impairment.
[00:03:32] So, the core finding and most important finding was that examination of the relationship of the Area Deprivation index was closely aligned with the cognitive scores. So as deprivation increased, cognitive scores went down. This was seen across seven of the six cognitive domain scores, and greater deprivation was associated with the more abnormal cognitive phenotype. And increasing neighborhood deprivation was also associated with [00:04:00] greater anxiety and depression. So, it really was quite a signal that we were able to observe. And as Dr. Terman pointed out in his commentary, you can just take a look at IQ. Quintile 1, the least deprived group, had a mean IQ score of 100, which is dead average. And the most deprived quintile, Quintile 5, their mean IQ was 86, which is a full standard deviation below average. So, very reliable and fairly strong signal throughout these results.
[00:04:28] Host: Yeah. Really striking findings, which seem to point out that the deprivation that patients are exposed is almost as important as the biology of the condition. And I'm sure we will discuss that in length later. Dr. Dalton, the concept of the Area Deprivation Index, or ADI, plays a central role in the study. Can you please help us understand what does this measure? How do these quintiles work? And how is this measurement different from other measurements of socioeconomic status?
[00:04:59] Jerrod Dalton, PhD: [00:05:00] Sure. Yeah, the Area Deprivation Index is a tool that we use in our research in a lot of settings. We work with clinical specialties across Cleveland Clinic and use this as one tool for understanding place-based health disparities. Essentially, the Area Deprivation Index, it's a latent variable model or a factor model that produces an index that captures correlation among 17 neighborhood-level characteristics. The ADI was established at the National Cancer Institute in 2003 by a demographer and sociologist named Gopal Singh. It was designed as scale of neighborhood socioeconomic position as opposed to socioeconomic status, which I can distinguish a little bit between the two. And it incorporates aspects of social organization, income, housing, economic inequality, and opportunity structure.
[00:05:56] So, the indicators that comprise the ADI [00:06:00] are varied, but they all speak to overall socioeconomic characteristics. So, it'll include measures of education, proportions by level of education. It includes measures of income, such as median family income, income disparities. It includes measures of housing and housing affordability, median home value, median rent, monthly mortgage amounts, and percent of households
[00:06:27] It also includes economic and employment measures such as labor force participation rates and poverty rates, family structure measures such as the percent of single-parent households among those with somebody less than 18 years of age, and a series of resources such as motor vehicle ownership, telephone ownership, and whether or not households have plumbing.
[00:06:50] Host: And those variables are related to the neighborhood where the patient is living rather than to the individual patient. Is that correct?
[00:06:57] Jerrod Dalton, PhD: That is absolutely correct. When we look [00:07:00] at these quintiles that you and Dr. Hermann were referring to, we have to be very careful not to stratify our patient populations based on observed socioeconomic position associated with their community, but rather stratify them according to the communities themselves.
[00:07:17] Host: Dr. Herrmann, it is certainly very intriguing to think that the environment can shape cognitive functions, potentially not only for patients with epilepsy, but particularly for patients with epilepsy. Can you elaborate on how factors like the person's neighborhood or community may influence their health, particularly their cognitive abilities and maybe if you can make a mechanistic idea of how does that work or what would be the factors that intervene in that relationship?
[00:07:47] Bruce Hermann: Yeah. Well from a neuropsychological standpoint, we don't have much of an understanding of how these neighborhood factors affect cognition. That, of course, was the point of the study. [00:08:00] And as you infer, in the field of neuropsychology of epilepsy, the lion's share of attention has been paid to the relationships between cognition and features of the epilepsy and its treatment.
[00:08:12] So, there are innumerable studies looking at aspects of cognition like intelligence, memory, language, and the epilepsy syndrome that the patient might have, or their age of onset, the duration, seizure frequency or severity, or the number of medications that they take. This is a classic heritage. And in addition, there's a large literature examining diverse neuroimaging correlates of cognition and psychiatric comorbidities, including depression and anxiety.
[00:08:41] But we have known for some time, just for example, through the CDC behavioral surveillance studies, that the economic, social, and lifestyle correlates of epilepsy can be punishing, and those have been documented. But how these factors relate to cognition and behavior have been less [00:09:00] well understood.
[00:09:01] Host: Dr. Terman, in your commentary, you highlight some strengths and also some limitations of the study. Would you like to share some of the specific issues that our readers may need to be aware when interpreting the findings?
[00:09:12] Samuel W. Terman, MD, MS: Yes. The study has many strengths, and like all studies, there are limitations and future directions. Some of the strengths have already been mentioned through Dr. Dalton and Hermann's discussion of the work, including a large sample size with an impressively long period of time in which patients were recruited with detailed expert cognitive assessments. Measuring the outcome well is important for any study. And while sometimes having many different domains and submeasures can raise concern for multiple comparisons when results are inconsistent, or you're not sure whether significant findings are true positives. In this case, I think it was a strength given convergence of results across multiple domains and subdomains of cognitive and neuropsychological [00:10:00] measures.
[00:10:00] But, that said, there are numerous limitations that I see. For example, as I read it, it was a cross-sectional study, which is good for hypothesis generation, but also that lack of temporal correlation, what happens over time. You can't distinguish causation from reverse causation. We can theorize what direction the relationship is going, but you can't be sure in a cross-sectional study. In other words, do neighborhoods affect people? Which is what we think from the study. Or do people non-randomly sort themselves into neighborhoods? That would be reverse causation, which is also plausible, but we can't tell.
[00:10:38] And there's some confusing relationships. For example, age was one factor in the multivariable models, and it actually was not associated with degree of cognitive impairment, which we know that aging is a very important feature of a person's cognitive health. So, future studies could address these things. For example, longitudinal data could surmount some of [00:11:00] these questions about causation versus reverse causation. There are even specialized statistical models that seek to isolate when in a person's life, what exposure matters most. For example, if a person's exposed to a neighborhood with a higher degree of deprivation earlier in life versus later in life, when does it matter most?
[00:11:21] It's also been mentioned that the mechanism by which some of the features of the ADI leads to outcome changes is unclear. And related to measurement of the ADI, a major strength is its ability to aggregate and summarize over the 17 different components that have been mentioned. But we're also left not knowing exactly quite which one is most critical when we lump rather than we split.
[00:11:45] And the ADI also, while it measures lots of things well, it also lacks potentially key measures: pollution, healthy food, social cohesion, the way a city is laid out. Also, if a high ADI neighborhood is juxtaposed next [00:12:00] to a low ADI neighborhood, there may be features that are complicated dynamics that we're not capturing here. So, we can't be sure which component of the ADI and also if there's a component in there that's just correlated with something that we haven't measured. We don't know exactly what's the driving force here.
[00:12:16] And then, two other thoughts in terms of perhaps limitations and/or future directions. The census block is an important grouping, which is how the ADI is categorized, but it's also not the only way that people are grouped. Neighborhoods in the world in which we live, we live in an online communities and a globalized society. So, just the sheer geographic location is likely important for healthy food and parks and pollution, but there's also so much more as we're connected to each other than just that specific census block.
[00:12:51] Host: Let me give you a follow up on that. Dr. Dalton, any thoughts on following these findings in a longitudinal way or including other measures of [00:13:00] deprivation or other social determinants of health.
[00:13:02] Jerrod Dalton, PhD: Yeah. I think, you know, Dr. Terman's comments are 100% right on the spot. You know, I think when I work with scientists, what I usually do is I will mention a lot of these limitations. And I will say that the ADI is just an analytic tool.
[00:13:18] A great first step in understanding social and place based health disparities in a particular, in a particular disease context, such as epilepsy. There are many issues with it. And the field of neighborhood measurement is very rapidly evolving. In terms of longitudinality, I think it's helpful for us to recall the social context under which we have place-based disparities in the United States, which was largely driven 80, 90 years ago by racial residential segregation and federal housing policy that discriminated against [00:14:00] racial and ethnic minority groups.
[00:14:01] So, in large part, we have this entrenched issue of economic deprivation in communities that disproportionately impacts those of minority race and ethnic status. And these things are very difficult to reverse. So as it relates to the question of the stability of overall measures of socioeconomic position over time, unfortunately, it's too stable. It's more stable than we would like it to be, that I personally would like it to be. And as a scientific rationale for a cross-sectional evaluation of area deprivation and relationship with outcomes, generally speaking, we have pretty stable results over time. Now, that said, there are of course issues of gentrification and neighborhood change over time that should be taken into account. And these available measures currently cross-sectionally defined. They don't accommodate in measurement [00:15:00] fashion neighborhood change.
[00:15:02] I might respond to a couple of the other good points that Dr. Terman made. Regarding the age, the age in this sample was relatively homogenous on the earlier side of the life course, around 20 to 50 years of age. So, mechanisms of cognitive decline in older adults may or may not had a large influence on the observed measures of cognition. And of course, the area deprivation and other place-based socioeconomic measures lack key mechanistic exposures like the ones that he mentioned. And like I said, it's a very active area of sociological research, and we frankly need enriched models that are more expressive than a single domain, and we've done a little bit of methodological work in our lab exploring just that.
[00:15:54] Host: Dr. Hermann, besides the cognitive outcomes, the study also highlights [00:16:00] worsening measurements of depression and anxiety in the patients with the most deprivation or the highest ADI quintile. How do you interpret these findings. And particularly, can you share with our listeners how did these findings vary when you took race into account, race and ethnicity?
[00:16:18] Bruce Hermann: Let me address this in the following way. First, we've been speaking in the abstract a little bit about deprivation and in the supplemental table of the neurology article, Drs. Busch and Dalton put together a very nice table that's informative about deprivation where people stand in these various quintiles.
[00:16:38] Let me just give you a few examples. For example, mean income. So, the mean income in the neighborhood and please correct my language if this is imprecise, Jarrod, but the mean income in the least disadvantaged quintile in that neighborhood is $118,000. The mean income in the most disadvantaged neighborhood, Quintile 5, was [00:17:00] $36,000. Huge difference. The percent of families below the poverty level in the least disadvantaged neighborhood, 1%; in the most disadvantaged neighborhood, 27%. Single parent households with youth under 18, 12% in the least disadvantaged, 68% in the most disadvantaged. And just one more, the percent of households without a vehicle, 1% in the least disadvantaged, 19% in the most disadvantaged.
[00:17:29] So in regards to the psychiatric comorbidities, there has been a long history of debate about what's important for a long time. The debate centered around where the seizure started from. So for those who had temporal lobe epilepsy, psychiatric comorbidity was driven by volumetric abnormalities in the depths of the temporal lobe and mesial regions, and/or the degree of spiking that might be shooting through limbic systems.
[00:17:58] And so, the [00:18:00] way role played by disadvantaged in social circumstances was relegated to have little role, actually. But if you think about these sorts of effects that I just mentioned, how can they not have an effect on somebody's emotional adjustment? And if you look at the general population and the relation of psychiatric comorbidities to these sorts of trends, they're quite apparent. So the most disadvantaged, and I'll start this sentence, but then ask Dr. Dalton to finish it, but in the most disadvantaged quintiles of our particular study minoritized groups were overrepresented as expected. And to address the issue of neighborhood disadvantage versus minority status, Jarrod carried out a number of analyses. And let me turn that over to you, Jarrod.
[00:18:49] Jerrod Dalton, PhD: When we look at race and ethnicity and its role in relationships with health disparities, it's important to consider the mechanisms by [00:19:00] which you would hypothesize there to be racial and ethnic differences and to study those mechanisms. And we did not hypothesize all such mechanisms associated with racial and ethnic minority status in this study. We evaluated one mechanism, which was the one I referred to earlier around racial residential segregation and the fact that in societal terms, not necessarily for a specific individual, but in societal terms, there are many barriers to economic mobility, and we have this prevalent problem of racial and ethnic minority populations residing in communities with low resources.
[00:19:42] So, there are a couple potential causal models that can be used to motivate analyses into these relationships. One would be a mediation analysis where you consider the extent to which selection into low-resource communities [00:20:00] is responsible for observed racial and ethnic disparities in your outcome. And that's exactly what we looked at here. So, we looked at models with and without adjustment for ADI and studied how the relationship between racial and ethnic minority status changed after accounting for what in technical terms would be the mediating effect of living in low-resource communities.
[00:20:28] So for our proportional odds logistic regression analysis looking at severity of cognitive phenotypes, what we found without adjustment was that minority race or ethnicity was associated with three times the risk of being in a higher or more severe cognition phenotype compared to non-minority patients. And then, after accounting for the neighborhood deprivation, that relationship was reduced to about 1.8. So in other words, [00:21:00] we do seem to have some signal of explanatory effect of ADI in terms of the racial and ethnic disparities in cognition in this patient population.
[00:21:13] Host: Thank you for that. It seems like there's so many layers to these. I would like to follow with Dr. Terman. When we study, and even from the clinic, when you see patients with medication-resistant epilepsy, how can we differentiate what is what
[00:21:27] Samuel W. Terman, MD, MS: well, it's a bit different from a research standpoint than a clinical standpoint, because there are things that you can do in one setting but can't do in another. From a research standpoint, it's a matter of measuring what matters when it matters, and we don't always have the luxury of having everything that we would like at exactly the right time points over a long period of time. But if you're trying to distinguish the effect of neighborhood deprivation versus the condition of epilepsy itself, you need to measure as many things about both of those things as accurately as you can. So, [00:22:00] variables like what anti-seizure medicines is the person on, at what doses, and what adherence, and what days did they have seizures, and were they convulsive, and how long were the seizures, and were they in status epilepticus? And you can very quickly see that, "Oh my goodness, there are so many." The world is so complicated and there's so many things that could influence the outcome. So, it's matter of what's feasible and being able capture those variables that you wish to distinguish and then you can decide, "Am I going to do a mediation or a structural equation model or some other type of model to try to tease out the effect of different potentially correlated covariates.
[00:22:40] From a clinical standpoint, sometimes if you're not sure, ultimately what you do is you manipulate what you can in the direction that you think it should be manipulated. For example, if you think a person could be having cognitive side effects due to their anti-seizure medicine and their seizures are not as problematic, then you go down. Or if you feel that their seizures are a [00:23:00] driver of their cognitive status, you go up and see if they can tolerate it better. But unfortunately, at this day and age, epilepsy care is a bit of a trial and error process.
[00:23:09] Maybe to take the next step in terms of another research avenue that people have done in socioeconomic disparities, people have even done some sorts of quasi experiments to exploit natural variation. There have been a limited number of actual randomized experiments where people were randomized to healthcare insurance versus not, or vouchers versus not, or even refugees coming out of dangerous neighborhoods or communities or countries. People were sorted new locations and people have studied these things. There're all kinds of variation, distance from a highway in terms of pollution and access to healthy food. So, there are lots of creative ways to measure the things that you would like to and the things that you think are important and would like to distinguish between. Sometimes if you can't, there are some other tricks up our sleeves using [00:24:00] clever quasi experiments or true experiments when it's ethically and practically feasible to do so.
[00:24:05] Host: Thank you very much. I will stay with that question and I would love to ask Dr. Hermann and Dr. Dalton, what's in the future? In the research arena when we consider the realm of environmental influences on neurologic conditions. In the discussion in your paper, you hint that maybe looking into how these variables affect the anatomical studies in patients with temporal lobe epilepsy may be in the works. Anything else, any future directions on where these type of studies are going or should go?
[00:24:36] Bruce Hermann: Yeah. I think an immediate applicability is with children with epilepsy, and even better, children who have new-onset epilepsies that addresses some of the points that have been raised in this discussion. So if you go and you start at the beginning with a cohort of children with epilepsy and controls in their homes of [00:25:00] origin developing over time, does epilepsy occur more often in high deprivation areas? Maybe, maybe not. What's the impact of deprivation on cognitive development going forward prospectively? What's the impact on brain development going forward? And if deprivation has an effect, how long does it last? Does it last one year, two years, three years? I mean, the literature on lifetime outcomes of youth with epilepsy generally, but not invariably, points to a somewhat difficult course in many regards as they age and grow older. And if these deprivation factors have an influence on cognition, cognitive development, brain development, then it becomes even more critical to get serious about this. And I think Dr. Terman had a very interesting point at the end of his commentary, you know, if you want to [00:26:00] intervene, do we intervene on or about? And we need to have sense, we don't have a relative ranking of the importance of deprivation versus type of epilepsy versus seizure control versus type of medication on memory, on intelligence, on depression. How much variance do these factors account for? And if you get a rank ordering, this is easy to say but hard to do, but if you can generate a rank ordering, the explanatory power correlation at the least gives you some ideas about where to go and what to do. And I think that's at least one important future for the direction, as well as getting a really good handle on exactly how is deprivation exerting its effect on a person. And one way is through imaging.
[00:26:52] Host: Thank you for that. I want to ask Dr. Terman to follow up on that, because you have some interesting [00:27:00] insight in your commentary about what can communities do besides the providers. You mentioned urban development and maybe food deserts come into mind. Any suggestions or any ideas of what can we do as providers or as a community to maybe mitigate some of these inequities.
[00:27:18] Samuel W. Terman, MD, MS: Yeah. Neighborhoods and cities are not randomly evolving entities. They are the product of planning. And so when we develop communities and neighborhoods, ideally we plan for success. Now, I'm far out of the realm of civil engineering and city planning and all this is very complicated, interfacing with politics and economics and political will. But, as Dr. Hermann mentioned, we need to understand which of these things are most critical. And after understanding which of these things are most critical, then deciding, well, if the problem is pollution, then that's a very different path than if the problem is lack of healthy food, or if the problem is crime and violence, [00:28:00] or if the problem is physical activity, or if it's truly a product of medical care. You know, these lead to very different types of solutions. Ultimately, it may be that as is often the case, that causes and effects are bidirectional and multifactorial, so it may be there is not one single solution, but a comprehensive suite of solutions to plan communities as well as we can.
[00:28:26] Host: Thank you all. I want to especially thank you for these very thought-provoking conversations. I'm sure as we go home to our own neighborhood and our own community and can imagine the communities and neighborhoods our patients are going back to after visiting us in the clinic. We may be planning in the future how to learn more about it and how can we make a difference over time.
[00:28:50] We are running out of time. I want to thank each of our guests. I want to thank our listeners. Special thanks also to the American [00:29:00] Epilepsy Society in partnership with the CDC and their initiative Disrupting Disparities: Documenting and Addressing Gaps in Epilepsy Care Through Healthcare Provider Education and Training. Their collaboration is the sponsor of today's episode.
[00:29:15] I want to thank Dr. Rohit Marawar and the SAGE podcast production team. We look forward to having all of you back on our next episode. Remember to subscribe to Epilepsy Currents podcast, wherever you get your podcast, and send us your feedback, suggestions, or questions through our website, epilepsycurrents.Org, and follow us on X, former Twitter, @aescurrents. Until next time, everybody.
Join Dr. Bermeo in a conversation with Dr. Ezequiel Gleichgerrcht, Dr. Erik Kaestner, and Dr. Peter Widdess Walsh, as they discuss the article, "More Than Meets the Eye: Human Versus Computer in the Neuroimaging of Temporal Lobe Epilepsy".
Click here to read the article.
This podcast was sponsored by the American Epilepsy Society.
We’d also like to acknowledge contributing editor Dr. Rohit Marawar, and the team at Sage Publishing.
Summary
This fantastic Epilepsy Currents podcast episode delves into a groundbreaking study on the application of artificial intelligence (AI) in differentiating temporal lobe epilepsy from Alzheimer's disease and healthy controls using MRI-based deep learning. The study, co-authored by Dr. Ezequiel Gleichgerrcht and Dr. Erik Kaestner, demonstrated AI's potential to significantly improve the accuracy of neuroimaging analysis in epilepsy. The commentary by Dr. Peter Widdess-Walsh provided a critical examination of these findings, highlighting the practical implications for clinical practice and the limitations of current methodologies. The discussion framed AI not only as a tool for enhancing diagnostic accuracy but also as a means to uncover subtle neurobiological differences between diseases, potentially leading to more personalized treatment approaches.
Key Takeaways
Transcript
Adriana Bermeo, MD (Host): Hello and welcome to episode five of Epilepsy Currents podcast. Today, we will be talking about the use of artificial intelligence and machine learning in the study of temporal lobe epilepsy. I am your host, Adriana Bermeo. I am the senior podcast editor for Epilepsy Currents, the official journal of the American Epilepsy Society.
Today, I am joined by a team of experts in this very exciting neurodiagnostic arena. I want to first welcome contributing editor, Dr. Peter Widdess-Walsh, who wrote the commentary "More Than Meets the Eye: Human vs. Computer Neuroimaging of Temporal Lobe Epilepsy." This commentary was published on December 2023 issue of Epilepsy Currents. Dr. Widdess-Walsh is a consultant neurologist and Clinical Associate Professor at Beaumont Hospital in Dublin, Ireland. Peter, welcome to Epilepsy Currents podcast. podcast.
Peter Widdess-Walsh, MD: Thank you very much, Adriana. I'm delighted to be here.
Host: Thank you for being here. It is also my pleasure to welcome Dr. Ezequiel Zeke Gleichgerrcht, who authored the work that inspired this commentary titled, "MRI Based Deep Learning Can Discriminate Between Temporal Lobe Epilepsy, Alzheimer's Disease, and Healthy Controls. Their paper was published in Nature Communications Medicine in 2023. Dr. Gleichgerrcht is an Assistant Professor of Neurology at Emory University. Zeke, welcome.
Ezequiel Gleichgerrcht, MD: Thank you. Thanks for having me.
Host: We are also joined by Dr. Erik Kaestner, co-author on the original paper and lead author on other related publications addressing the use of artificial intelligence in epilepsy. Dr. Kaestner is a postdoctoral scholar at University of California, San Diego. Erik, thanks for being with us today.
Erik Kaestner, PhD: Thank you. Excited for the conversation.
Host: Very good. I can tell you that artificial intelligence is one of the most requested topics when we ask our listeners and the epilepsy community. The challenges and opportunities presented by the use of AI in almost every aspect of our daily life, but particularly in healthcare, are intriguing, exciting, and potentially concerning to some. But before we start discussing AI, Peter, can you share with our listeners what is the added value of expanded neuroradiology in the care of patients with epilepsy?
Peter Widdess-Walsh, MD: Thanks, Adriana. And thank you for highlighting this very interesting and topical article for the podcast. And many thanks to Dr. Gleichgerrcht and Dr. Kaestner for being here with us. We know that MRI is a key tool in finding the underlying cause of focal epilepsy. However, up to 30% of MRIs are non-lesional. That is, there is no visible lesion responsible for the patient's epilepsy. We can sometimes lower this non-lesional percentage by using additional MRI techniques such as volumetry or various additional sequences or higher strength magnets. But these are not universally available or have limitations, so there's a gap there. We know that there is a focal epileptogenic network, but we cannot see it. And it is partly due to limitations of MRI technology, which are improving all the time, but it's partly due to limitations of what we can see visually with the human eye. There are also human error rates in analyzing MRI, even with skilled radiologists known as perceptual errors.
A shrunken, bright hippocampus is easier to see than subtle alterations in grey matter volumes. Particularly in surgically remediable epilepsies, finding a lesion or visualizing the epileptic network can make a huge difference in a better patient outcome after surgery. And even in non-surgical patients, it's very reassuring to have an imaging correlate of the epilepsy that you know is clinically present.
I'm not an AI expert and I wrote the commentary from the perspective of an epileptologist in clinical practice like many of our listeners. So, it was fascinating to learn more about AI and how it might fit into our daily practice in this area. The authors used the term computer vision in this article, and I'm excited to learn more about how computer vision can help us in the diagnosis of epilepsy.
Host: Thank you very much. We are certainly excited to see how we can advance our field further than what we are practicing at the moment. Zeke, could you paint the picture as for how is AI revolutionizing the field of radiology and particularly when it comes to neuroimaging analysis?
Ezequiel Gleichgerrcht, MD: Yeah, absolutely. And I think we start acknowledging that AI is becoming this true transformative force in medicine. Like you said, neuroimaging is by no means the exception. So for instance, if we think about AI and how it gives us frameworks to analyze huge amounts of imaging data, the pace and precision with which it can achieve it is unattainable by humans alone, right?
Humans not using this computer vision that Peter was mentioning. So, let's talk about neuroimaging specifically. AI algorithms can sift through MRI, CT scans, and, almost do a first pass at detecting abnormalities from brain tumors, there's applications for aneurysms, areas affected by stroke, you name it. Of course, our interest is in epilepsy, but we know how crucial early and accurate detection of some of these findings can be. So, you know, when trying to answer this question, how is it revolutionizing the field of radiology? I think it's really about how the accurate detection of these findings can be instrumental in patient care. So, AI applied to neuroimaging can help us mostly scale detection of brain diseases and have tremendous impact on outcomes.
But it's not just about detection of disease, right? AI now can support decisions about care tailoring or personalization of patient care, because if you can combine neuroimaging and health data, now you can offer insights that lead to more tailored strategies. For example, in other studies, we have shown that using AI, we can predict who becomes seizure free after epilepsy surgery based exclusively on preoperative imaging. And we found accuracies that are 30% points higher than what humans achieve just based on their combination of health data alone. You know, when I think about the revolution of AI, it's also paving the way for prediction or predictive analysis, things like forecasting disease progression or identifying when seizures will happen, for example, for a given patient. So, it's certainly a very exciting time for AI and neuroimaging and epilepsy.
Host: Wow, that's a lot of changes expected for the future in the way we practice. Erik, I want to bring it to you for those of us who are not tech wizards. Can you break down what this idea of convolutional neural network or CNN, what it is and how it could transform the way we interpret, particularly neuroimaging and MRI scans?
Erik Kaestner, PhD: So at its heart, a convolutional neural network is a way to learn patterns and data. And so for this particular project, we gave it a task. We said, "Can you differentiate patients with temporal lobe epilepsy from patients with Alzheimer's disease from healthy controls?" And we provided T1 images of the brain to do this. And so, In a lot of ways, it's very similar to what a neuroradiologist is doing. You present a neuroradiologist with an image of the brain and you ask for some sort of call on what they're seeing. So to understand what the neuroradiologist is doing, I'm going to have to defer to my colleagues in neuroscience. But it's a little more straightforward for the CNN.
So, a CNN is made up of a series of layers, and each layer basically performs a small set of computations. And so, the first layer, which is given access to the image of the brain, takes little pieces of the image, performs its calculations, passes that image on to the next layer, it performs its little calculations, passes that on to the next layer. And the number of layers is dependent on the person building it, so you decide how many layers there are. And eventually, all of this data arrives at the final layer, which makes a decision. It says, "I think this is a patient with TLE," "I think this is a patient with Alzheimer's," or "I think this is a healthy control." and so as for how this can transform how we interpret MRI scans, I've actually discovered over the last year, that this is an extremely robust debate that's kind of ongoing in the field. Because like I mentioned, there's a lot of similarities in the tasks that neuroradiologists are being asked to do and what we can ask a convolutional neural network to do.
And so, I was giving a talk recently and someone came up afterwards. A clinician came up afterwards and said, "Well, why would I trust this? You know, I have no idea what these numbers mean or where they're coming from or what the model's doing," which I think is a very fair question. Another person on the panel gave a good answer, which I'll crib from a little bit, which was, "Well, when you go to the doctor, can you really see what the doctor's brain is doing before they give you kind of their advice?" And so, I think this is a great way to think about what these networks, what these convolutional neural networks need to produce in order to gain the trust of the clinicians and of the patients. And so, in kind of a bedrock level, there's the behavior. You know, does the model get it right? Can we kind of trust it to give us the right answer over many patients? Then beyond that, we also need to think about how sure the model is. What information is it using? Is it using the proper information that we as clinicians and researchers have wanted to use? And also, we need to improve the outputs to a way that is interpretable by the human.
Host: Thank you very much. We will certainly discuss a little bit about how this difference is so remarkable and how can we trust it better. But I am curious to know why did your team decide to choose these particular control groups? What is similar or different between the Alzheimer's patients, and the relationship to healthy subjects? Dr. Gleichgerrcht, I'm curious, how did you decide to use these groups?
Ezequiel Gleichgerrcht, MD: Yeah. Thanks for the question because we thought about it a lot. And I'd say the rationale for having an Alzheimer's disease group they are competing against the TLE and the healthy controls for the machine to classify was at least twofold. On the one hand, we have literature, I would say, for the past two decades or so, showing that patients with temporal lobe epilepsy, at least at the group level, have patterns of atrophy that are widespread, right? So, it's not that we just see atrophy in the hippocampus or even in the temporal lobes. At the group level, the patterns of atrophy for TLE are sometimes extratemporal and even contralateral to the side of seizures. So, that was one side of the rationale.
On the other hand, you know, in a prior paper, I believe it was in 2021, we had already shown that AI could identify who had temporal lobe epilepsy solely from the clinical MRI. And we had that benchmark to ask ourselves this question, almost as the next natural step: Is the machine detecting TLE simply based on detecting hippocampal atrophy, or is it detecting widespread epilepsy-related patterns that the humans are not typically paying attention to? So, when we included Alzheimer's disease as a third group that offered this competing disorder with prominent hippocampal atrophy, right? That is the core of pathology in Alzheimer's disease, then we were trying to answer the question, is it, again, just the hippocampal atrophy driving the classification? And, again, hippocampal atrophy being pervasive in Alzheimer's disease, but also in so many TLE patients. And, I want to say that when we asked this question, the natural reaction was, "Well, we also have to make sure that the machine is not just detecting older versus younger brains." Because, of course, if it's detecting just age related patterns, of course, it's going to do a great job at distinguishing Alzheimer's disease from temporal lobe epilepsy, because the mean averages of those populations are so radically different.
So, a lot of our method, and I invite the audience to go and read about this, was about removing the effect of age on the brain images before we entered those images into the machine to have it classify disease. We put a lot of thought into it. And I think we had a model that can be replicated for other diseases where you're training a machine to try and detect the disease independently of all these other confounding factors like age and patterns of atrophy.
Host: So much to discern from all of these conditions that may have multiple targets in the brain. In order to go deeper a little bit into the technicalities of the study and in order to help our listeners read the paper and understand it, Erik, can you please unpack some of the jargon for our listeners? Could you explain terms like accuracy, precision, recall, the F1 score? What do they mean when someone reads the paper? How should they read these variables?
Erik Kaestner, PhD: Yeah. So, kind of in the analogy I was using earlier of how does the model gain our trust, these are kind of the bedrock elements where we're just asking, "Can you do the task? Can you get it right?" And so for something like accuracy, you're just saying, "All right, patient by patient, control by control, overall, are you able to get these accurate to some degree?" And then, we can go a little deeper and look at each individual condition, and that's where something like F1 score comes in where we can start to say, "How are you performing on patients with TLE?" How are you performing on patients with Alzheimer's?" And so, F1 score basically combines two of the other measures you mentioned, precision and recall. And precision says when the model claims that someone is a patient with TLE, is it right often? You know, is it kind of just saying this is a patient with TLE to everyone, and so we can't really trust it? Or is it being more conservative and kind of giving you a high level of accuracy within that specific patient group? And then, you have something like recall. Recall says of the patients with TLE in the cohort, Were you able to identify a large proportion of them or not? And so often these two measures, you can maximize one, but it hurts you in the other. So if you just guess patient with TLE for every single image you come across, then your recall will be quite high, because you will identify every single patient with TLE, but your precision will be quite low because, basically, every time you say it's a patient with TLE, you're going one for three. And so, F1 score is very useful because it combines these two. And so if a model is cheating in some way, it'll kind of reveal it by showing, "Okay, I don't think it's actually being quite truthful with us essentially. I don't think it's being fair." And so, like I said, once you've kind of interrogated the model's behavior in this way and said, "Okay, it seems to be doing the task quite well, then you can go on to the next step and start to interrogate it in other ways."
Host: I want to go to Peter. You know, in your commentary, you highlighted how the AI showed a success rate in detecting temporal lobe epilepsy of 90% compared to the human eyes, 47%, which is humbling. And I wonder what is your take on these AI outperforming the human eye. And how do you think AI assisted temporal lobe epilepsy detection will mean for our clinical practice?
Peter Widdess-Walsh, MB: Adriana, that's a great question. I would emphasize that we have to be careful with AI tools as to what exactly this particular AI tool used in the study, it was the carefully selected unilateral temporal lobe epilepsy and their T1 weighted MRI images. Patients with distorting structural lesions such as tumors or malformations were excluded.
Most of the scans visible to the human eye had mesial temporal sclerosis. So we see that the AI tool that the authors developed was quite a bit better at picking up these other cases that were not visible to the human eye. As I mentioned, there are limits to the human vision processing system, and we can only spontaneously analyze so many areas at once.
I gave the example in the commentary of the invisible gorilla study, an experiment where an image of an angry gorilla was placed over the lung area of a chest CT, and then radiologists looking for lung nodules missed the gorilla image 83 percent of the time due to attentive and perceptual error. So, I think AI imaging tools can help us see what we cannot see and also reduce this perceptual error.
Although I still think we'll need the radiologist or clinician to incorporate information from AI into the interpretation and clinical management of the patient. I wrote the title to be somewhat thought provoking, but perhaps a better title would have been not human versus computer, but human with computer.
AI is there to assist us in our decision making, not make the decision for us. AI tools will typically have a very specific purpose, such as in this study, to detect an MRI signature in unilateral temporal lobe epilepsy. And in its current form, it doesn't read the whole scan, or pick up unexpected findings, or incorporate the results into the whole clinical picture or with EEG or discuss it with the patient and their family.
So we're not out of a job yet, but it has the potential to enhance the delivery of care to our patients.
Adriana Bermeo, MD (Host): Thank you so much. I would love, Dr. Gleichick, to answer this question. Take on that, how do you see, the future of these, artificial intelligence, aid, in, identifying lesions in neuroimaging in patients with epilepsy? And how do you see the role of radiologists and neurologists, for the immediate future as it seems?
Ezequiel Gleichgerrcht, MD: Yeah, well, you know, as computer processing power increases, first our speed and capacity to process more data will also increase. And these advantages, or advanced computer, uh, set ups will get more affordable. In fact they are, and as they become more affordable, they also become more scalable. So we'll get almost an explosion, right, of applications across medicine.
Of course, that includes epilepsy, but I really love the way Peter described this, which is that, I really do not think of AI as a replacement for humans, but as this superpowered assistant, if you will, helping humans be more efficient and precise at their jobs. AI will direct our attention to possible subtle lesions that the human expert eyes may miss on the first pass.
We're busy clinically and our volumes are increasing across the country and so getting this super powered assistant certainly helps. And humans will be the ones vetting whether the AI detection is relevant and accurate. Like Peter said, they're integrating that into all the other elements of the clinical care the assessment.
So AI will help predict maybe clinical trajectories with greater accuracy. Clinicians are still going back and understanding what that trajectory means for their specific patient. They're having the discussions about that trajectory with the patient. And so I really want us to think about it as this super powered assistant.
Definitely not a replacement.
Adriana Bermeo, MD (Host): I like that perspective too. Peter, in your commentary, you highlight the fact that all the areas of the brain were found involved with temporal lobe epilepsy beyond temporal lobe structures. and your take on it of what it can mean for our understanding of the condition is quite, interesting and provoking. I would love it if you can elaborate on that.
Peter Widdess-Walsh, MB: Yeah, incredibly interesting to see what computer vision sees over what we see. Subtle patterns and volume and architecture probably reflect the epileptic network changes and its connections as well as the underlying epileptic substrate. We know from prior voxel based morphology studies and studies of cortical thickness, for example, from the Enigma study group, that both temporal and extratemporal structural network alterations are there in patients with temporal and extratemporal epilepsy.
This is supported by studies looking at functional connectivity, such as those from intracranial EEG. The authors have taken the next step to develop and train a model that we can plug MRI data into and get a meaningful and accurate output. Does this patient have a pattern consistent with temporal lobe epilepsy that is different from other limbic system pathologies such as Alzheimer's disease?
It would be really interesting to know if there were signature patterns within temporal lobe epilepsy such as which patients will be medication resistant, which will have more cognitive impairment, and who will have better outcomes after temporal lobectomy.
Adriana Bermeo, MD (Host): Wonderful. I have one more question for. All, which is, kind of stepping out a little bit of the paper in particular, and just thinking about the future and the use of AI in epilepsy care, even beyond radiology. Where do you think we're going? We have touched on it, a little bit briefly. Erik, we'd love to start with your take.
What is next for the use of artificial intelligence in epilepsy care?
Erik Kaestner, PhD: I mean, I think that for me personally, where my mind has been going lately is really on the question how do you get an interface between the human and the model? Because as both of the others pointed out, it really isn't that you receive kind of a definitive answer, put it in the chart and move on. You know, the clinician really has to be able to explain, not only in the chart, but also to the patient, why they think that, they're presenting with, this particular condition or another. And so having some sort of interface where the clinician can go back and forth with the model and say, Oh, really? You think this is a patient with TLE? I wasn't so sure. Like what is leading you in that direction and being able to kind of engage in that. And I think some of the large language models that we've probably all played with a little bit could be one avenue into that. But really kind of we're ending up in a, almost a, user interface set of questions.
Adriana Bermeo, MD (Host): Zeke, where are we going with AI in epilepsy?
Ezequiel Gleichgerrcht, MD: So before we move on, beyond the neuroimaging, let me just put in a plug for our group and definitely a lot of other groups that are creating a lot of applications from lateralizing side of epilepsy, detecting focal cortical dysplasia, but even cool stuff that I never even thought about. So, you know, 3TMRI is not available everywhere and there are these new portable scanners, I think they're 0.55 Tesla. So there's even AI applications now to augment those lower magnet power MRIs and try to bring them to the quality of a 3T. So there's still a lot to discover in the neuroradiology aspect. But beyond that, are a lot of algorithms trying to predict, for example, when the next seizure will happen.
Our team actually published last year, using paper seizure diaries to predict at the individual level when the next seizure will happen for a patient. And you can imagine the kinds of consequences that that would have as we get better. So, there are a lot of teams now working with wearables, chronic EEG, even chronic EGOG from systems like RNS and using those data to predict at the patient level. There are applications in development for tailored drugs and serum biomarkers, and they're all relying on AI algorithms to achieve in very short time frames things that would have taken years, just a few years ago.
So it's definitely a very exciting time for AI, well beyond neuroradiology and epilepsy.
Adriana Bermeo, MD (Host): Peter, how do you imagine your AI integrated epilepsy practice?
Peter Widdess-Walsh, MB: I think AI is here to stay. there are hurdles before it's available to the wider epilepsy community to use in clinical practice. So, for example, the AI tool used in this study was developed in house, which they typically are, and then these tools have to be validated on external data sets to ensure they generalizable.
And then there's hurdles around regulation and software development and maintenance and as they would be or can be classified as medical devices if used for clinical decision making, there is FDA or equivalent approval. So there are steps, before it's available, our desk, you know, for clinical practice, but I think AI is here to stay.
Adriana Bermeo, MD (Host): Thank you, everybody. It is certainly the picture of a hopeful future for our practice and most importantly for our patients. I want to sincerely thank our guests and thank our listeners. I want to give special thanks to the American Epilepsy Society, who's the sponsor of episode five of our podcast, and to Dr. Rohit Marawar and the SAGE production team for the podcast. We look forward to having you join our next episode, and I want to remind you as always to subscribe to Epilepsy Currents podcast wherever you get your podcast, and send us your feedback, suggestions, or questions through our website, EpilepsyCurrents.org, and don't forget to follow us, on X, formerly Twitter, @AESCurrents. See you next time, everybody.
Join Dr. Bermeo in a conversation with Dr. Page Pennell and Dr. Alison Pack as they discuss the article, "Dobbs Versus Jackson: Epilepsy, Reproductive Health, and Abortion".
Click here to read the article.
This podcast was sponsored by the American Epilepsy Society.
We’d also like to acknowledge contributing editor Dr. Rohit Marawar, and the team at Sage Publishing.
Summary: In this episode of the Epilepsy Currents podcast, Dr. Adriana Bermeo discusses the Supreme Court's decision on Dobbs v Jackson and its implications for people living with epilepsy. She is joined by Dr. Allison Pack, a professor of neurology at Columbia University, and Dr. Page Pennell, the chair of the Department of Neurology at the University of Pittsburgh School of Medicine. They discuss the key points and historical significance of the Roe v. Wade and Dobbs v Jackson rulings, the current state-by-state variation of abortion access in the United States, and the impact on women and people of childbearing age living with epilepsy. They also address the importance of contraception, the risks of anti-seizure medications during pregnancy, and the need for evidence-based care and advocacy for patients. Resources such as the Guttmacher Institute and the National Abortion Federation Hotline are mentioned for further information and support.
5 Key Takeaways:
1. The Supreme Court's decision on Dobbs v Jackson has significant consequences for persons living with epilepsy and their access to abortion.
2. The current state-by-state variation of abortion access in the United States is complex and can range from very restrictive to most protective.
3. Planned pregnancies are crucial for individuals with epilepsy to optimize outcomes for both the individual and the developing fetus.
4. Effective contraception is important for individuals with epilepsy, and options such as long-acting reversible contraception (IUDs) and birth control pills should be considered.
5. Neurologists and epilepsy specialists should advocate for their patients' rights and women's rights, ensuring that medical decisions are made by qualified practitioners based on evidence and with respect for the individual patient. Resources such as the Guttmacher Institute and the National Abortion Federation Hotline can provide information and support.
Transcript
Dr. Adriana Bermeo (00:05):
Hello and welcome to episode four of Epilepsy Currents podcast. I am your host, Adriana Bermeo. I am the senior podcast editor for Epilepsy Currents, the official journal of the American Epilepsy Society. It is my pleasure to welcome today's guest to talk about the Supreme Court's decision on Dobbs v Jackson and its consequences for persons living with epilepsy. We have two very special guests to help us understand the implications of this ruling on reproductive health and access to abortion for people living with epilepsy of childbearing potential. First, I want to welcome Dr. Pack, senior author of a commentary titled Dobbs versus Jackson Epilepsy Reproductive Health and Abortion, published online first in the May, 2023 issue of Epilepsy Currents. Dr. Pack is a professor of neurology at Columbia University. She's the Chief division of Epilepsy and sleep at New York Presbyterian, Columbia University Medical Center. I also want to especially welcome Dr. Page Pennell, who's the Henry B. Hickman Professor of Neurology and chair of the Department of Neurology at the University of Pittsburgh School of Medicine. Dr. Pennell is a global expert on the management of pregnancy-related issues in epilepsy, and she's also a past president of the American Epilepsy Society. Dr. Pack, let me start with you. Most of our listeners are familiar with Roe versus Wade and Dobbs versus Jackson Supreme Court rulings, but could you give us a quick refresher on the key points and historical significance of these two landmark cases?
Dr. Allison Pack (01:43):
Thank you very much, Adriana, and it's a pleasure to be here today and I want to thank the American Epilepsy Society for supporting this discussion as we go through our discussion today. Today we will be referring to persons with epilepsy of childbearing potential. Please recognize that we are aware that not all individuals who seek pregnancy or become pregnant identify as a woman. So I'm going to go through right now the court rulings ruling Roe v. Wade was enacted in 1973. In this ruling, the court ruled that the Constitution of the United States generally protected a right to abortion. This ruling was reaffirmed in 1992 in the ruling Planned Parenthood of Southeastern Pennsylvania versus Casey. Dobbs v Jackson was enacted on June 24th, 2022. With this ruling, the Constitution does not confer a right to abortion. Essentially, Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania versus Casey were overturned. The authority to regulate abortion went back to the state and the constitutional right to abortion was eliminated.
Dr. Adriana Bermeo (03:08):
Thanks, Dr. Pack, you were mentioning how things went back to the state, and as we know, the legal landscape of these rulings then are evolving. Acknowledging this is a moving target, could you please help us understand the current state-by-state variation of abortion access in the United States, and what does this mean for the physicians practicing in the different states?
Dr. Allison Pack (03:37):
Well, I have to say understanding the state-by-state variations is quite complex. I would draw all of your attention to the Guttmacher Institute, and there's a very good website whereby you can see the map of the United States and the outline of the various regulations or the various degrees of restriction. And these vary from most restrictive occurring in over 15 states whereby abortion is banned at 12 weeks and later. There are very restrictive, which bans abortion at 12 weeks and later. Some restrictions starting at the third trimester. Protective, it's banned at fetal viability between 24 and 26 weeks, and very protective whereby it's banned at fetal viability. And then there's some other regulations that give more protections than those states that are protective and then most protective whereby there is no restriction based on gestational age. As I mentioned earlier, the most restrictive; this includes, for example, Kentucky, Texas, very restrictive, North Carolina, Georgia, some restrictions, Virginia protective, Illinois, very protective New York, and then most protective, there's only one, and that is the state of Oregon. So it is important to understand that there are varying degrees of restrictions across the United States in these different categories. And as I mentioned earlier, I would draw your attention to the website from the Guttmacher Institute, which really is very helpful for you to understand what the restrictions are or not in the state that you live.
Dr. Adriana Bermeo (05:29):
Thank you very much, Dr. Pennell. Can I turn it to you? Can you please help us understand how these rulings affect particularly women and person of childbearing age or childbearing potential living with epilepsy?
Dr. Page Pennel (05:42):
Yes. Thank you also for inviting me for this very important podcast and to sit alongside Dr. Pack who is such an expert in this area. So unplanned pregnancies in the general population are known to have a higher complication rate, but especially in persons with epilepsy, it's incredibly important to have a Planned Pregnancy and for the woman to have the best seizure control possible for her with the medication regimen and vitamin regimen that will provide the opportunity for the safety of the developing fetus. Pregnancy also carries a risk to women directly and with persons with epilepsy there are reports of elevated maternal mortality. Studies in the UK have actually shown that the elevated rates of death in persons with epilepsy are due to SUDEP or sudden unexpected death in epilepsy. So if a woman with epilepsy goes into a pregnancy unplanned and also with a high seizure burden, the chances that pregnancy will be unsafe for her and her developing fetus are much higher. And if she doesn't have the opportunity to make a decision with her clinician about what to do after that time, it can be particularly devastating.
Dr. Adriana Bermeo (07:05):
Dr. Pack, your commentary in Epilepsy Currents really makes the point that neurologists ,epileptologists and the organizations who represent their interests should care and take action in protecting patients' rights and women's rights. Can you please expand on this idea? Why should neurologists and epilepsy specialists care?
Dr. Allison Pack (07:29):
Well as individuals or practitioners who take care of persons with epilepsy of childbearing potential, we want to provide the optimal environment both for seizure control and pregnancy outcomes for the individual as well as the developing fetus. It is as the American Epilepsy Society has stated, critically important that medical decisions are made by qualified practitioners and that this be done based on evidence with respect for the individual patient. Therefore, the decisions made for the outcome or the health of the individual should be up to the practitioner and patient themselves or the person with epilepsy. Many of our anti-seizure medications may increase the risk of unplanned pregnancy. This is important. It's important that the individual has an unplanned pregnancy and are in a state whereby there are extreme restrictions. Again, as I mentioned, the decision should be left up to the provider and the person with epilepsy. As well, many anti-seizure medications, notably valproic acid, can increase the risk of adverse or negative pregnancy outcomes. As practitioners, we need to be aware of and advocate for the patients that should this occur to these individuals, that they do have options available to them to optimize their health as well as the outcome of the developing fetus.
Dr. Adriana Bermeo (09:10):
Thank you so much for that. That definitely brings the point that we're all part of the caregiving team of our patient and their family. Dr. Pennell, these rulings also bring up attention to contraception. Could you please tell us about the most contraceptive options available for persons with epilepsy of childbearing potential and how widespread the use of these methods are and how effective they are and how are they different in people with epilepsy than in other individuals?
Dr. Page Pennel (09:44):
Yeah, certainly, as Dr. Pack pointed out it is very important that we discuss actually as the person caring for our patients with epilepsy, that we have these discussions with them about how important planned pregnancies are, which begins with effective contraception. Some studies found that up to 65% of women with epilepsy had reported at least one unplanned pregnancy. So this is certainly a very important and prevalent consideration. The most effective contraception we like to encourage is under the band of long-acting reversible contraception, which are the various IUDs. This could be a copper IUD or it could be an IUD that has progestin as part of its mechanism of action. But the progestin just works in the endometrial cavity and does not depend upon blood levels for its effectiveness. So therefore, even if a woman is on an enzyme-inducing anti-seizure medication, the IUD still has a very high effectiveness rate of over 99%.
(10:50):
However, thanks to the collaborations we've had over the years with our wonderful colleagues and contraceptive gynecology made me very much aware that there are so many factors that go into decision-making. And many women in the US in particular are not open to the idea of an IUD. So our message should not be that you need to use an IUD or else nothing that's definitely should not be our message. Combined oral contraceptive pills, birth control pills are still the most commonly used form of contraception and will be very commonly used in our patients as well. So we do need to know about the interactions, but if they're on an enzyme-inducing, anti-seizure medication, we need to make them aware of that, encourage backup barrier methods, et cetera. And when we think about the enzyme-inducing medications, we also need to be aware it's not just an old-generation versus new-generation story.
(11:48):
A lot of our newer medications also can lower the hormone levels from these hormonal contraceptives. Some of those medications, some people may be surprised to know include for instance, cenobamate, rufinamide, clobazam. So we need to have the discussion if they are going to use a hormonal form of contraception such as birth control pills or the vaginal ring to just let them know that they should also consider a backup barrier method, but also give them information about the more effective types of contraception. We also like to encourage, there's a progestin implant, the brand named Nexplanon, which has a very high effectiveness rate for contraception, but again, that can be affected if they're on a strong enzyme inducer. So again, we need to consider the medications they're on in their contraceptive choices.
Dr. Adriana Bermeo (12:46):
Great. Dr. Pennell, I'm going to stay with you because following the conversation on contraceptions, we also know a lot from collaborative groups and teams that you've been part of that anti-seizure medications can pose some risks for pregnancy of children of adults living with epilepsy. Can you briefly remind us of the potential risk of congenital malformations and neurodevelopmental issues related to exposure to medications and how these risks are related to our conversation of access to abortion?
Dr. Page Pennel (13:20):
Yeah, certainly. Thank you. I do like to remind us, we can get discouraged about all the things we don't know in this field, but how far we have come because the conversation used to be that all anti-seizure medications are very teratogenic and have a high risk to the developing fetus. But now we do have a lot of information to provide evidence-based counseling and care that we do have some medications that have very low rates of major congenital malformation, also known as birth defects. And these rates are really similar to the general population. The medications that really stand out with the most abundant information supporting this are lamotrigine, levetiracetam and oxcarbazepine. But we also know other medications have very, very high rates of these major congenital malformations. And the one that has the greatest risk is valproic acid. We also now have information on some medications about the neurodevelopmental outcomes, and so that some medications have very low neurodevelopmental risk.
(14:26):
And with that we have lamotrigine and levetiracetam in that safe category. But then again, we have higher risk medications such as valproate. We now have increasing information about the concern on fetal neurodevelopment for topiramate. We also know that topiramate can lower the fetal growth and result in small-for-gestational age and also has a sort of medium rate of the malformations. So topiramate is becoming another medication that is starting to have greater restriction on it just placed in Europe and maybe coming out in the United States as well for use and persons of even reproductive potential. So it's so important to be able to get on the best medication regimen for that person and also at the right dose that will help to control their seizures the best possible. It's also important that they're taking folic acid well prior to conception. If all of those things aren't lined up, we know that the risk for the developing fetus as well as the mother is higher. And that's where if they're not in an ideal situation and not having access to making decisions about continuing the pregnancy is more devastating. Out of all the malformations, the one that certainly has such a high morbidity is neural tube defects. And so that is one in particular of the malformations that often will garner a conversation about the possibility of termination if the person is in a state, that is an option.
Dr. Adriana Bermeo (16:12):
Thank you for that answer as well. Dr. Pack, can you help us understand other specific issues or risks for people with epilepsy that neurologists and epileptologists should be mindful of when giving perinatal counseling, particularly when we consider genetic causes of epilepsy? Is there anything that you discuss with your patients, especially considering these new abortion rulings?
Dr. Allison Pack (16:39):
I think there's several issues here, and one of the things that's very important is something that Dr. Pennell touched upon earlier is that planned pregnancies are associated with better outcomes, and for individuals with epilepsy, planned pregnancies are important to optimize outcomes not only for the individual but for the developing fetus. As such, just to highlight a point that Dr. Pennell made earlier, it's important in that setting for the individual to be using effective contraception and recognize a nationwide healthcare claims database, finding that 63% of individuals with epilepsy either use no contraception or used ineffective contraception. So part of your perinatal counseling should be on the importance of planned pregnancies. There are certainly some genetic epilepsies and individuals who may have children at risk for this. That would be important within genetic counseling to have that genetic counseling done prior to pregnancy. So important points here: planned pregnancy, genetic counseling, keep in mind that that does pertain to a few individuals, not the vast majority of individuals with epilepsy.
(18:02):
And then the other piece that's important is that some of the malformations that Dr. Pennell spoke about earlier may not become evident until much later in the pregnancy. So for example, we routinely counsel that individuals get an anatomic ultrasound, which typically occurs between 16 and 20 weeks. If the individual who were pregnant with epilepsy were pregnant, were to find out that there was a malformation, the very restricted states ban abortion at 12 weeks or later. So for many of these individuals, this would be, if there a malformation was found at that anatomic ultrasound screening, this would be too late in those states. So just to summarize and go over again, it's important to emphasize that planned pregnancies will optimize the outcome both for the individual with epilepsy as well as for the developing fetus. Effective contraception is an important component of this. There are some genetic conditions whereby it would be important to have that information or have that genetic counseling prior to getting pregnant and recognize some malformations may not become evident until later in the pregnancy where in many states, abortion is not an option. Importantly, though, please understand as we go through this topic, that with planned pregnancies, with focusing on choosing optimal anti-seizure medications, as discussed by Dr. Pennell, most individuals do have normal healthy pregnancies.
Dr. Adriana Bermeo (19:47):
Dr. Pennell, are there any specific concerns related to minorities or people of color in regards to access to care, pregnancy planning, and access to abortion?
Dr. Page Pennel (20:03):
Thank you for that very important question. We know that a lot of things we're talking about when it comes to any medical care, we have to consider also how it affects our underrepresented minorities because there are differences as access to care and higher complication rates, and many of these situations just such as this one. So when you look at just access to abortion services alone, that a much higher percentage of minorities do receive abortions than are in the general population. There's a lot of reasons that come into this, whether it's economic status and ability to provide for that child after birth or whether it's that they didn't have access to good contraception and good medical counseling before. So we know that this is going to affect this population even more to not have the access to termination of pregnancy. And then when you look at the flip side, continuing the pregnancy, just again in general that the pregnancy-related death rates are over three times higher in women of color than non-Hispanic Caucasian women. So their risk during pregnancy, regardless of all the other things we've talked about today, are higher just going into a pregnancy planned, and then as we know, unplanned are probably even greater.
Dr. Adriana Bermeo (21:31):
Dr. Pack, the last question for you. How can we as neurologists effectively champion evidence-based care and protect their professional judgment in the realm of reproductive decisions for their patients? And do you know of any resources we could share with our listeners if they want to further get informed or advocate for and with their patients?
Dr. Allison Pack (21:57):
Well, I think one of the key points of all of this is that access to care, access to different therapeutic options should be, I just want to emphasize this again, up to the clinician and the individual person with epilepsy not up to the state or national rulings. Therefore, it's important for all of us to advocate for the individuals that we treat. It's important for all of us to work together so that the individuals we treat have access to optimal healthcare so that we can increase the potential for planned pregnancies as well as allow that individual access to therapeutic options to optimize their health as well as the health of the developing fetus. As such, we should all be working with the various organizations that we're involved with, including the American Epilepsy Society, the American Academy of Neurology, to really advocate that the healthcare decisions are left up to the provider and the patient themselves. If an individual were to get pregnant and have a negative outcome or potential negative outcome and is considering an abortion but lives in a restricted state, there are resources for that individual. The National Abortion Federation Hotline is available and will help that individual. It's important for us to be informed about the legislation and rulings in our individual states, and as I mentioned several times before, I would draw your attention to the Guttmacher Institute, which will guide you very clearly what the potential restrictions are in the state that you live.
Dr. Adriana Bermeo (23:56):
Wonderful. This was a very informative overview of the current landscape of reproductive health and their impact on our patients, and also neurologists and epileptologists all around the country and in the very different scenarios that each of us is navigating. I want to thank you very much. Thanks a lot to our guests and our listeners, I want to specially thank the American Epilepsy Society, who's the sponsor for episode four of Epilepsy Currents, Dr. Rohit Marawar and the SAGE Podcast production team. We look forward to having you all join our next episode, and as always, I want to remind you to subscribe to Epilepsy Currents podcast wherever you get your podcast, and send us your feedback, suggestions, or questions through our website, epilepsy currents.org, and follow us on X formerly Twitter @aescurrents. Until next time.
Join Dr. Bermeo in a conversation with Dr. Mackenzie Cervenka and Dr. Manjari Tripathi as they discuss the article, " Keto is Not Just for Kids: A Randomized Trial of a Modified Atkins Diet for Adolescents and Adults With Anti-Seizure Medication Resistant Epilepsy ".
Click here to read the article.
This podcast was sponsored by the American Epilepsy Society.
We’d also like to acknowledge contributing editor Dr. Rohit Marawar, and the team at Sage Publishing.
Five Key Takeaways:
Dr. Adriana Bermeo (00:06):
Hello, and welcome to episode three of Epilepsy Currents podcast. I am your host, Adriana Bermeo. I am the senior podcast editor for Epilepsy Currents, the official journal of the American Epilepsy Society. It is my pleasure to welcome today's guest to talk about the use of ketogenic diets in the treatment of refractory epilepsy in adolescents and adults. First, I want to welcome our contributing editor for epilepsy current, Dr. Mackenzie Cervenka, who wrote a commentary titled "Keto Is Not Just For Kids: a randomized trial of a modified Atkins diets for adolescents and adults with anti-seizure medication resistant epilepsy". This was published online first in the March, 2023 issue of Epilepsy Currents. Dr. Cervenka is Professor of Neurology at John Hopkins School of Medicine. She's the medical director of the Adult Epilepsy Diet Center and the Adult Epilepsy Monitoring Unit. She developed the John Hopkins Adult Epilepsy Dietary Center in 2010 and has treated nearly 450 adults with epilepsy using ketogenic diet. Dr.Cervenka, welcome to Epilepsy Currents podcast.
Dr. Mackenzie Cervenka (01:16):
Thank you so much Dr. Bermeo for inviting me as a guest today at the Epilepsy Currents Podcast.
Dr. Adriana Bermeo (01:22):
It's a pleasure to have you. I also want to specially welcome Dr. Manjari Tripathi, who is the senior author of the publication that inspired this commentary titled "Safety, efficacy, and Tolerability of Modified Atkins Diet in Persons with Drug-Resistant Epilepsy." This was published in Neurology in March of 2023. Dr. Tripathi is a professor of neurology and epilepsy at the All India Institute of Medical Sciences, where she serves as director of the Epilepsy, Behavioral Neurology, and Sleep Medicine Programs. Dr. Tripathi, it's a pleasure to have you.
Dr. Manjari Tripathi (01:57):
Hi. Thank you. Great being here.
Dr. Adriana Bermeo (02:00):
Dr. Cervenka, I want to start with you. Our listeners may or may not be familiar with the concept of ketogenic diets for the treatment of epilepsy in adults particularly, but they may not know that there are different options for treatment. Can you please give us an overview of the principles of these dietary treatments and tell us what options can we can offer to our patients
Dr. Mackenzie Cervenka (02:21):
In our field? We refer to ketogenic diets for epilepsy actually as ketogenic diet therapies. And we do this to distinguish them from ketogenic diets that we typically hear about being used for weight loss or for other purposes, and that are not necessarily recommended or monitored by clinicians or treating teams. Technically, a ketogenic diet therapy is any dietary manipulation that can produce a state of nutritional ketosis, and that is a state where the body metabolizes fatty acids into ketone bodies. Those are beta hydroxybutyrate, acetoacetate, and acetone. There are a whole variety of ketogenic diet therapies, and these include what are called the classic or classical ketogenic diet. This was first described over one century ago. There are also modified versions of this classic ketogenic diet, specifically the Modified Atkins diet and a modified ketogenic diet. In addition to that, there is a low glycemic index diet or treatment, and that can also produce a state of ketosis, although it is not the primary goal of that particular diet, and any of these diets can be supplemented with medium chain triglyceride oil, and that is readily metabolized into ketone bodies. So that can be added to any of these other diets that I mentioned. Finally, these diets can also be combined with fasting, which also, encourages ketosis as well.
Dr. Adriana Bermeo (03:51):
Thank you so much, Dr. Tripathi. Do different options fit different demographics? Particularly I’m curious of why did your team choose to try specifically the modified Atkins diet in adults and adolescents with refractory epilepsy as opposed to other options as Dr. Cervenka was describing?
Dr. Manjari Tripathi (04:10):
So this is a very pertinent question. We need to give something which is acceptable, accessible, and affordable. Now, if you look at the traditional classic ketogenic diet, as Dr. Cervenka described it, it's a very restrictive diet, and it's rigid. It's rigid in terms that it restricts the calories and the fluids. It often requires weighing of food, at least in our center, the ketogenic diet requires the patient to be admitted for a washout and monitoring before the diet is started, whereas a modified Atkins diet does not restrict calories. However, it produces the same effect that is ketosis. So, it's more flexible, it's easier on the gut and the palate, and we know that adults and adolescence can be picky eaters and choosy. As you get older, you also get conditioned on the kind of foods that you eat. So in factoring all this, we decided that it'll be easier on our patients to have the modified Atkins diet, which is less rigid than the ketogenic diet. And hence we undertook the study with drug resistant epilepsy patients as compared to the classic ketogenic diet.
Dr. Adriana Bermeo (05:38):
Dr. Cervenka, how well accepted do you find these dietary treatments for among patients when you start them on, but also among neurologists and epileptologists? What, what do you think are the greatest barriers right now for them to be used more broadly in the clinic?
Dr. Mackenzie Cervenka (05:57):
I think it's interesting to look back at kind of the historical perspective of how the ketogenic diet evolved over time, because when it was initially introduced back in the 1920s, it was the only real treatment for epilepsy that was being looked at the time, and it was very popular then. It was being used for children, it was being used for adolescents and adults, and then anti-seizure medications became more readily available around the 1930s, and it really stopped being used for, for many decades, and it sort of reemerged in the late 1900s. However, when it reemerged, it was primarily in children. And so when you ask the question, how accepted is it as a treatment for epilepsy, I think it varies tremendously because I think now if you look in curricula for pediatric neurology residents, you'll see that ketogenic diet therapy is listed in that curriculum for pediatric neurology residents for a treatment of pediatric epilepsy.
Dr. Mackenzie Cervenka (07:01):
However, that may not necessarily be the case for adult epilepsy. And when I was in training and when I was learning about this I learned about ketogenic diet therapies from my pediatric epilepsy colleagues and wondered why it was not necessarily being used in adults and asked that question of my pediatric and adult colleagues and really did not have a good understanding of why that was the case. So I kind of delved into that a little bit deeper and discovered that there were plenty of epilepsy syndromes and seizure disorders that, that we knew the ketogenic diet was very effective for in children that adults also had. However, they were not necessarily being offered this therapy. And so really it has not been as well accepted in the adult population as it has been in children up until really the last couple of decades, to be honest.
Dr. Mackenzie Cervenka (08:01):
Now, something else happened that was very interesting, really around2017, and I refer to it as the keto craze, where the ketogenic diet suddenly became very popular for weight loss or different variations on the theme of the ketogenic diet. And I think this brought the concept of a ketogenic diet into the awareness of the general population such that there have even been individuals with epilepsy who started a diet for weight loss and then discovered that it helped with their seizures and began to investigate this and realized, oh, yes, it's been used to treat epilepsy for over a hundred years. So it's, it's a really interesting evolution. This has actually helped patients because those who have been treated with ketogenic diets have a lot more options with regards to foods that are available now because of the commercial availability of some of these foods being used for the purpose of weight loss. So I, do think that that has, has certainly helped with regards to barriers for the use more broadly in clinic the greatest barriers particularly for adults are the lack of familiarity of adults, neurologists, clinicians with diet therapies. So they have this discomfort just because they don't understand the diets or how to go about counseling patients for following these ketogenic diet therapies. Lack of nutritionist or dietician supports who work specifically with adults and also lack of reimbursement for these services. That is a very, very big barrier, particularly in the United States.
Dr. Adriana Bermeo (09:37):
Well, hopefully studies like the one we're discussing today will change some of those, you know, people getting more familiar and hopefully permeating all the way to finding more support and, different arenas. Dr. Tripathi, can you please give us an overview of the design and the results of this study you conducted among adolescents and adults with refractory epilepsy?
Dr. Manjari Tripathi (09:58):
Absolutely. So, when we are actually offering services of a drug-resistant epilepsy clinic, we are left with a large number of people with epilepsy who have been on many medications, typically two or more, and they still continue to have seizure and they cannot be offered epilepsy surgery because they have not been candidates for the same due to lack of a lesion or discordance of data. So we, in this study, prospectively enrolled patients who had been having seizures and they were having as many as 27 seizures per month. So when we enrolled these patients, when we analyzed the data, we found that they had at least 27 seizures per month. So that's a very high seizure frequency, and we followed up these patients for six months after initiating the diet. The patients were randomized into two groups, one group receiving the modified Atkins diet along with the conventional anti-seizure medication, which was not changed during the therapy.
Dr. Manjari Tripathi (11:12):
That means the patients were stabilized on anti-seizure medicines and they had a baseline seizure frequency before they were enrolled, and the other group continued to have their usual antiseizure medicines without the modified Atkins diet. Now, this diet is a medical diet, it needs monitoring, and our nutritionist and dietician was involved in monitoring these patients. But the assessment was done by a person other than us, and she was looking at the outcomes. We decided to take clinically meaningful outcomes, and in this case, of course, it'll be the reduction of seizures, which would be the primary outcome measure and secondary outcome measures would be change in behavior and quality of life. We also looked at their weight and their lipid profiles just to make sure that they weren't deranged by the end of the study. So basically it was a very well thought out and planned study and was undertaken after a lot of thinking to it as to what more can we offer our patients who are left without the option of surgery.
Dr. Manjari Tripathi (12:29):
So we had, as I told you, 160 people with epilepsy, which were drug resistant, having at least 27 seizures a month when we saw the results. And they had been having this resistant epilepsy for 10 years or more. So they were really, those, prolonged resistant epilepsy patients, and one doesn't know what to do with them when they're coming. And we've been taught ketogenic diet is for children. So we thought, you know, if we can't offer them something, they get enrolled into the study. What we found when we looked at the results at the end of the study was that 26% of the people who had taken both the drug therapy with modified Atkins diet had more than 50% reduction of seizures compared to only a minuscule 2.5% of people who had received drug therapy alone without the diet. And actually four people in the diet group became free of seizures.
Dr. Manjari Tripathi (13:32):
So you can imagine someone who's on four drugs or more having refractory epilepsy for 10 years or more, getting free of seizures. So four became seizure free. We found significant improvements in quality of life behavior. We did not find any per side effects. The diet was very well tolerated, and overall the patients felt a sense of improvement. However, a word of caution here, we were operating the trial during covid times, so we noted about a third of patients, 33% did not complete the study. However, we did an intention to treat analysis, which kind of overcomes the deficit of the dropouts, and most of them dropped out due to inability to follow up as a part of the COVID 19 pandemic. Some of them could not tolerate the diet, and some of them just dropped out because they felt it wasn't doing anything to them. So this was a limitation of the study, but I guess when we are doing studies which deal with something as a diet, this is bound to happen. So overall, it was a prospective randomized assessor blinded study, and it did pretty well for people who were refractory despite taking four or more medications.
Dr. Adriana Bermeo (14:54):
It's an, amazing design and study and really, really encouraging results. We noticed that the adult group in your study did better than the adolescents in regards to outcomes. Do you have any ideas of what, what would that have happened?
Dr. Manjari Tripathi (15:10):
Yeah, so at the end of six months in adolescence, about 36% of the patients who were on the diet had greater than 50% reduction, whereas in the adults it was 57%. Now, there could be several reasons for this, and I think the most important is that if anyone has dealt with this particular age bracket of adolescence, it's a difficult age. Generally, they're very picky about their food. They tend to like their carbs, they tend to binge on fast food, at least in India. The adolescents are typically into an American diet where they would want to have burgers and, you know, cola and, and chips. So, it's very difficult for us to consent them into the diet and any study cannot be done without consenting. So, one is of course that, and the second is, I guess though they were monitored for their compliance and their ketosis. There could be certain gut microbiome differences. We know that the diet works while acting at the neurotransmitters, whether it's promoting the inhibitory neurotransmitters, antioxidant mechanisms, anti-inflammatory mechanisms. It also works through there is a gut microbiome hypothesis for the mechanism of action of the diet. So there could be several other reasons, r this effect that we saw.
Dr. Adriana Bermeo (16:45):
I am convinced just to hear about the adherence in adolescence. I have a pre-teen at home. Dr. Cervenka. Can you talk to us a little bit about what considerations do we have for adults particularly following ketogenic diet therapies in regards to maybe long-term side effects or anything that they should be particularly wary of? Is there a specific time to them or liberalize the diet or discontinue them? And any practical points for, for our audience in regards adults in this therapy?
Dr. Mackenzie Cervenka (17:19):
I think it's really important to consider the differences between children and adults when you're considering how to manage the diet long-term. For instance, pediatric epilepsy syndromes may resolve in childhood, and many children are taken off of ketogenic diet therapies within a year or two of after starting them. Often they're taken off of their medicines, they're taken off of therapies, and we really don't have to think about these, what I call long, long side effects. I think particularly about individuals with glucose transporter type one deficiency syndrome, when I get concerned about long, long-term side effects because those are individuals that we believe are going to need to be on diet therapy long-term or perhaps lifelong. And some of those considerations include vitamin and mineral deficiencies. So, in particular zinc selenium, vitamin D carnitine deficiencies, we know that in children, even over the two years that they would typically be on a ketogenic diet therapy, you can see bone loss in those children.
Dr. Mackenzie Cervenka (18:28):
Typically, once the diet is stopped that reverses itself. However, if you're thinking about an adult who over time is at risk for progressive bone loss, you may be concerned that over time that can accelerate with the ketogenic diet therapy and there's mounting evidence that that could indeed be the case. We also know that nephrolithiasis is a risk with ketogenic diet therapies both in children and adults. And so of course for the longer that you're on a diet, the longer that you're at risk for having that occur. And then there's a body of literature looking at hyperlipidemia and potential risks for cardiovascular and cerebrovascular disease. One of the physicians here at Johns Hopkins investigator Dr. Tanya McDonald is looking into this at Johns Hopkins. And then there are researchers worldwide who are act actively investigating this topic as well, because certainly we're treating epilepsy, but we also don't want to be causing other long-term side effects over the course of a patient's lifetime that they're going to have to be dealing with later.
Dr. Mackenzie Cervenka (19:30):
So those are really the major ones that we are concerned about. Now with regards to weaning the diet in an adult, my particular approach is to think of it similarly to thinking of anti-seizure medications. So if there is an adult at an appropriate time for removing the anti-seizure medication, I would speak to them about removing the anti-seizure medicine, removing the diet, which of those things they would like to do first, we would look at the side effects and we would look at the overall burden of that therapy in deciding which of them we wanted to remove first if the patient was seizure free and if there was a good likelihood that they would remain seizure free after removal of that therapy. And then we would do that in a sequential fashion and we would wean rather than discontinuing it abruptly. And I think that's also very important because we have seen instances where if where a patient who abruptly stops the diet can suddenly begin to have a significant increase in their seizures, similarly to abruptly stopping an anti-seizure medication.
Dr. Adriana Bermeo (20:35):
Those are very, very really practical and, and useful considerations for us to manage patients in the clinic. Dr. Tripathi, we were particularly curious about the fact that you conducted this study in India, and we were wondering what particular challenges do you expect in different ethnic cultural populations? We imagine a good size of your, the population you deal with, maybe vegetarian. So what is your approach to handle this? Is it very prescriptive or do you give your patients freedom to find general rules of how to manage the diet?
Dr. Manjari Tripathi (21:12):
Well, it's not difficult at all. The key to success at least what we perceived in our study was a highly motivated caregiver team, and mostly it would be the mom. So many patients and their caregivers ask us, what can we give to eat to our child or to our patient with seizures? And previously, you know, when we weren't using diets, for reducing seizures, we would just brush the question aside and say, oh, the normal diet. But now when people or caregivers ask us that, is there any specific diet that's a good step where you then tell them about the possibility of manipulating the diet or modifying the diet in such a way that the proteins are more and the fats are more, and the carbs are really, really low, and that gets them interested. So rather than telling them straight away that it's a medical diet, we just give them a brief introduction and you'd be surprised how well they take it.
Dr. Manjari Tripathi (22:25):
For vegetarians, it's not a problem at all because majority of our people were vegetarian around 75%. And we do have very good protein options in you know, the vegetarian food particularly the soy protein, soy milk. And of course in India we have a lot of use of coconut oil too and other forms of healthy oils. So more and more, you know, mustard oil, olive oil, and we have particular form of fat, which we call the clarified butter, or ghee, which is made at home usually from the cream of the cow's milk. So many of our moms and caregivers are quite used to this kind of diet, even though they may be vegetarians. And if you look at the Indian scriptures, it's a little, you know, story I'm telling. We had one avatar, which was the Krishna avatar, and he thrived on stealing butter from and eating butter from the villagers' pots.
Dr. Manjari Tripathi (23:35):
So basically his diet was all ketogenic, it was high butter diet. So, when we tell them that the diet is going to be somewhat like what Krishna used to eat, they get even more thrilled. So, we did not find any kind of setback due to the vegetarian. The most important thing which we felt was to have a motivated caregiver, a motivated mom. And, you know, many of our people have heard of these diets reducing the weight, though we used to caution them that, you know, your weight may not reduce it may or may not, they would get all excited about it. And I think that was good too.
Dr. Adriana Bermeo (24:23):
Thank you so much for that perspective. Really interesting. Dr. Cervenka, we started with the history of these diets and definitely a rich history into them. But I would love to wrap up by asking you, what do you envision in our, in the future of these dietary therapies and how will they continue to be incorporated in our comprehensive epilepsy approach in the clinic? Do you see them becoming or be considered earlier, even before patients become refractory?
Dr. Mackenzie Cervenka (24:54):
So I've definitely envisioned several scenarios where that could be the case. I think the most obvious one that I had mentioned before would be glucose transporter type one deficiency syndrome. And I, I wouldn't say that that's really in the future. I think that that's happening now because we understand that ketogenic diet therapy is the gold standard for this condition. So as soon as patients are diagnosed, we place them on the diet. We understand that in fact, diet monotherapy in that case is going to be the most effective treatment. And so there are plenty of patients now with that particular syndrome that are on diet monotherapy and doing extremely well. So that's a very exciting example. There is also some evidence to suggest that certain generalized epilepsy, such as absence and juvenile myoclonic epilepsy that those patients respond very well to ketogenic diet therapies. So I can also envision scenarios where we might want to consider diet earlier in the management of those patients. In particular, whenever we're thinking about starting the diet in anti-seizure medication resistant patients with focal epilepsy, we do know that epilepsy surgery is more likely to produce seizure free then diet therapy. However, we don't have those options to offer patients with drug resistance generalized seizures. So I think we might want to consider diet therapy earlier in their management. That's one place that I can envision starting diet therapy earlier.
Dr. Adriana Bermeo (26:30):
Well, that's a wonderful place to end our conversation today. I want to really thank our guests for this fascinating conversation, and I want to thank our listeners for joining us today. We look forward to having you at our next episode. As always, please remember to subscribe to Epilepsy Currents podcast wherever you get your podcast, and send us your feedback, suggestions, or questions through our website, epilepsycurrents.org. And don't forget to follow us on Twitter at @AEScurrents. Until next time.
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