Depression, sleep quality, and social isolation among people with epilepsy in Bhutan: A cross-sectional study

PURPOSE

The aim of this study was to analyze the possible contributions of seizure burden, sleep quality, and social integration to depression among people with epilepsy (PWE) in Bhutan.

METHODS

Bhutan is a lower-middle-income country in Southeast Asia with a public healthcare system without neurologists. People with epilepsy were prospectively recruited from psychiatrist-run epilepsy clinics at the National Referral Hospital in the capital city of Thimphu. Adult participants with epilepsy were interviewed for clinical history, sleep quality using the Pittsburgh Sleep Quality Index, social networks using the Berkman-Syme Social Network Index, and depressive symptoms using the Patient Health Questionnaire - 9 (PHQ-9). A multivariable regression model was built to assess the relationship between depression as an outcome and the possible contributors of sleep quality, sex, and seizure in the prior month.

RESULTS

Out of 80 participants (39 women, mean age: 29.4 years old, range: 18-56 years, 58 [73%] with a seizure in the previous month), 33% had poor sleep quality, 68% were socially isolated, 30% had a mild depressive symptom burden or more, and 18% reported suicidal ideation at the time of their interview. Women had a higher average PHQ-9 score versus men, which showed a trend towards statistical significance (5.6 versus 3.3 PHQ-9 points, p = 0.07), and on average met criteria for mild depression. Social integration was not significantly associated with sleep quality and had no relationship with depressive burden. There was a small positive correlation between poorer sleep quality and depressive symptoms which showed a trend towards statistical significance (r = 0.21, p = 0.06). In a multivariable regression, poor sleep quality was associated with higher depressive symptom burden, adjusting for participant sex and having a seizure in the previous month (p = 0.01).

CONCLUSIONS

Our exploratory study disentangles the multilayered psychosocial burden of disease experienced by PWE in Bhutan, a lower-middle-income country with access to antiseizure medications and psychiatrists but not expert epilepsy services or human resources. Further investigation into the interrelationships among social isolation, poor sleep quality, depression, and seizure burden could identify preventable and remediable constituents of this burden.

The Changing Face of Osmotic Demyelination Syndrome: A Retrospective, Observational Cohort Study

Objective

To describe the long-term outcomes of osmotic demyelination syndrome (ODS) in an updated cohort.

Methods

We performed a retrospective medical records review of cases of ODS at the Massachusetts General and Brigham and Women's Hospitals using International Classification of Diseases-9th edition codes and a text-based search for central pontine myelinolysis, extrapontine myelinolysis, and osmotic demyelination syndrome (1999-2018). Cases were individually selected based on patients having neuroimaging and symptoms consistent with ODS and no other potentially explanatory etiology. Modified Rankin scale (mRS) scores were extracted at prehospitalization, hospital discharge, 6 months post discharge, and the most recently available clinical visit.

Results

We identified 45 cases of ODS (mean age 48.4 years, range 0.07-75 years; 58% female patients). Common comorbidities included liver disease (27%, n = 12), alcoholism (44%, n = 20), and kidney failure (20%, n = 9). Twenty-nine percent of patients had a rapid correction of hyponatremia. Twenty-nine percent had other electrolyte abnormalities. Only 59% (24/41) of patients with complete electrolyte data had abnormalities that could explain their ODS. At the 6-month follow-up, 16% of the patients were dead and 60% of patients had minimal-to-no disability (mRS 0-2).

Conclusions

ODS has a diverse range of clinical presentations. Not all patients have electrolyte abnormalities. The prognosis is generally favorable, although 1 in 6 patients had died at 6 months, likely because of underlying disease states.

Blood platelet RNA enables the detection of multiple sclerosis

Background

In multiple sclerosis (MS), clinical assessment, MRI and cerebrospinal fluid are important in the diagnostic process. However, no blood biomarker has been confirmed as a useful tool in the diagnostic work-up.

Objectives

Blood platelets contain a rich spliced mRNA repertoire that can alter during megakaryocyte development but also during platelet formation and platelet circulation. In this proof of concept study, we evaluate the diagnostic potential of spliced blood platelet RNA for the detection of MS.

Methods

We isolated and sequenced platelet RNA of blood samples obtained from 57 MS patients and 66 age- and gender-matched healthy controls (HCs). 60% was used to develop a particle swarm-optimized (PSO) support vector machine classification algorithm. The remaining 40% served as an independent validation series.

Results

In total, 1249 RNAs with differential spliced junction expression levels were identified between platelets of MS patients as compared to HCs, including EPSTI1, IFI6, and RPS6KA3, in line with reported inflammatory signatures in the blood of MS patients. The RNAs were subsequently used as input for a MS classifier, capable of detecting MS with 80% accuracy in the independent validation series.

Conclusions

Spliced platelet RNA may enable the blood-based diagnosis of MS, warranting large-scale validation.

Cancer in Syrian refugees in Jordan and Lebanon between 2015 and 2017

Protracted conflicts in the Middle East have led to successive waves of refugees crossing borders. Chronic, non-communicable diseases are now recognised as diseases that need to be addressed in such crises. Cancer, in particular, with its costly, multidisciplinary care, poses considerable financial and ethical challenges for policy makers. In 2014 and with funding from the United Nations High Commissioner for Refugees, we reported on cancer cases among Iraqi refugees in Jordan (2010-12) and Syria (2009-11). In this Policy Review, we provide data on 733 refugees referred to the United Nations High Commissioner for Refugees in Lebanon (2015-17) and Jordan (2016-17), analysed by cancer type, demographic risk factors, treatment coverage status, and cost. Results show the need for increased funding and evidence-based standard operating procedures across countries to ensure that patients have equitable access to care. We recommend a holistic response to humanitarian crises that includes education, screening, treatment, and palliative care for refugees and nationals and prioritises breast cancer and childhood cancers.

Neuromyelitis optica practice and prescribing changes in the setting of Covid19: A survey of neurologists

PURPOSE

This study reports and analyzes the findings from the responses of 192 neurologists in the United States and Canada to a new survey instrument distributed in April 2020 to assess NMO practice and prescribing changes during the Covid19 pandemic.

PRINCIPAL RESULTS

92% of responding neurologists considered their NMO patients to be at an elevated risk of acquiring Covid19. They also indicated sharp declines in visits, delays in treatment and related services, and several unmet needs deterring treatment.

MAJOR CONCLUSIONS

There is a need for evidence-based, comprehensive guidelines for treating NMO patients amid healthcare crises moving forward.

Impact of COVID-19 on U.S. and Canadian neurologists' therapeutic approach to multiple sclerosis: a survey of knowledge, attitudes, and practices

Objective

To report the understanding and decision-making of neuroimmunologists and their treatment of patients with multiple sclerosis (MS) during the early stages of the SARS-CoV-2 (COVID-19) outbreak.

Methods

A survey instrument was designed and distributed online to neurologists in April 2020.

Results

There were 250 respondents (response rate 21.8%). 243 saw >  = 10 MS patients in the prior 6 months (average 197 patients) and were analyzed further (92% USA, 8% Canada; average practice duration 16 years; 5% rural, 17% small city, 38% large city, 40% highly urbanized). Patient volume dropped an average of 79% (53–11 per month). 23% were aware of patients self-discontinuing a DMT due to fear of COVID-19 with 43% estimated to be doing so against medical advice. 65% of respondents reported deferring >  = 1 doses of a DMT (49%), changing the dosing interval (34%), changing to home infusions (20%), switching a DMT (9%), and discontinuing DMTs altogether (8%) as a result of COVID-19. Changes in DMTs were most common with the high-efficacy therapies alemtuzumab, cladribine, ocrelizumab, rituximab, and natalizumab. 35% made no changes to DMT prescribing. 98% expressed worry about their patients contracting COVID-19 and 78% expressed the same degree of worry about themselves.  > 50% believed high-efficacy DMTs prolong viral shedding of SARS-CoV-2 and that B-cell therapies might prevent protective vaccine effects. Accelerated pace of telemedicine and practice model changes were identified as major shifts in practice.

Conclusions

Reported prescribing changes and practice disruptions due to COVID-19 may be temporary but could have a lasting influence on MS care.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-10045-9) contains supplementary material, which is available to authorized users.

Tablet-based electroencephalography diagnostics for patients with epilepsy in the West African Republic of Guinea

BACKGROUND AND PURPOSE

Epilepsy is most common in lower-income settings where access to electroencephalography (EEG) is generally poor. A low-cost tablet-based EEG device may be valuable, but the quality and reproducibility of the EEG output are not established.

METHODS

Tablet-based EEG was deployed in a heterogeneous epilepsy cohort in the Republic of Guinea (2018-2019), consisting of a tablet wirelessly connected to a 14-electrode cap. Participants underwent EEG twice (EEG1 and EEG2), separated by a variable time interval. Recordings were scored remotely by experts in clinical neurophysiology as to data quality and clinical utility.

RESULTS

There were 149 participants (41% female; median age 17.9 years; 66.6% ≤21 years of age; mean seizures per month 5.7 ± SD 15.5). The mean duration of EEG1 was 53 ± 12.3 min and that of EEG2 was 29.6 ± 12.8 min. The mean quality scores of EEG1 and EEG2 were 6.4 [range, 1 (low) to 10 (high); both medians 7.0]. A total of 44 (29.5%) participants had epileptiform discharges (EDs) at EEG1 and 25 (16.8%) had EDs at EEG2. EDs were focal/multifocal (rather than generalized) in 70.1% of EEG1 and 72.5% of EEG2 interpretations. A total of 39 (26.2%) were recommended for neuroimaging after EEG1 and 22 (14.8%) after EEG2. Of participants without EDs at EEG1 (n = 53, 55.8%), seven (13.2%) had EDs at EEG2. Of participants with detectable EDs on EEG1 (n = 23, 24.2%), 12 (52.1%) did not have EDs at EEG2.

CONCLUSIONS

Tablet-based EEG had a reproducible quality level on repeat testing and was useful for the detection of EDs. The incremental yield of a second EEG in this setting was ~13%. The need for neuroimaging access was evident.

Socioeconomic associations of poorly controlled epilepsy in the Republic of Guinea: cross-sectional study

OBJECTIVE

To explore the socioeconomic factors associated with epilepsy in the Republic of Guinea.

METHODS

People living with epilepsy (PLWE) were prospectively recruited at Ignace Deen Hospital, Conakry, in 2018. An instrument exploring household assets as a measure of wealth was designed and administered. Multivariate logistic regression models with fixed effects were fitted to assess the associations of sociodemographic and microeconomic factors with self-reported frequency of seizures in the prior month and regular intake of antiseizure medications (ASMs). Participants were stratified by age group: children (<13 years), adolescents (13-21) and adults (>21).

RESULTS

A total of 285 participants (mean age 19.5 years; 129 females; 106 children, 72 adolescents, 107 adults, median household size 8) had an average of 4.2 seizures in the prior month. 64% were regularly taking ASMs. Direct costs of epilepsy were similar across income strata, averaging 60 USD/month in the lowest and 75 USD/month in the highest wealth quintiles (P = 0.42). The poorest PLWE were more likely to spend their money on traditional treatments (average 35USD/month) than on medical consultations (average 11 USD/month) (P = 0.01), whereas the wealthiest participants were not. Higher seizure frequency was associated with a lower household education level in adolescents and children (P = 0.028; P = 0.026) and with being male (P = 0.009) in children. Adolescents in higher-educated households were more likely to take ASMs (P = 0.004). Boys were more likely to regularly take ASMs than girls (P = 0.047).

CONCLUSIONS

Targeted programming for children and adolescents in the households with the lowest education and for girls would help improve epilepsy care in Guinea.

A drone delivery network for antiepileptic drugs: a framework and modelling case study in a low-income country

BACKGROUND

In urbanized, low-income cities with high rates of congestion, delivery of antiepileptic drugs (AEDs) by unmanned aerial vehicles (drones) to people with epilepsy for both emergency and non-urgent distribution may prove beneficial.

METHODS

Conakry is the capital of the Republic of Guinea, a low-income sub-Saharan African country (2018 per capita gross national income US$830). We computed the number of drones and delivery times to distribute AEDs from a main urban hospital to 27 pre-identified gas stations, mosques and pharmacies and compared these to the delivery times of a personal vehicle.

RESULTS

We predict that a single drone could serve all pre-identified delivery locations in Conakry within a 20.4-h period. In an emergency case of status epilepticus, 8, 20 and 24 of the 27 pre-identified destinations can be reached from the hub within 5, 10 and 15 min, respectively. Compared with the use of a personal vehicle, the response time for a drone is reduced by an average of 78.8% across all times of the day.

CONCLUSIONS

Drones can dramatically reduce the response time for both emergency and routine delivery of lifesaving medicines. We discuss the advantages and disadvantages of such a drone delivery model with relevance to epilepsy. However, the commissioning of a trial of drones for drug delivery in related diseases and geographies is justified.

MAMBO: Measuring ambulation, motor, and behavioral outcomes with post-stroke fluoxetine in Tanzania: Protocol of a phase II clinical trial

BACKGROUND

SSA has a high stroke incidence and post-stroke morbidity. An inexpensive pharmacological treatment for stroke recovery would be beneficial to patients in the region. Fluoxetine, currently on the World Health Organization Essential Medicines List, holds promise as a treatment for motor recovery after ischemic stroke, but its effectiveness is controversial and untested in this context in SSA.

AIM

To determine if fluoxetine 20 mg by mouth daily, given within 14 days of acute ischemic stroke, and taken for 90 days, is well-tolerated and safe with adequate adherence to justify a future randomized, controlled trial of fluoxetine in the United Republic of Tanzania.

METHODS

Open-label, phase II clinical trial enrolling up to 120 patients. Participants will be recruited from the Muhimbili National Hospital in Dar es Salaam, Tanzania, and followed for 90 days. The primary outcomes are: 1) safety, including serum sodium and hepatic enzyme levels; and 2) tolerability, as measured through study case report forms. The secondary outcomes are: 1) change in motor strength, as measured through the Fugl-Meyer Motor Scale; 2) adherence, as measured with electronic pill bottles; and 3) participant depressive symptom burden measured via standard questionnaires.

CONCLUSIONS

Expanding the evidence base for fluoxetine for Sub-Saharan African stroke survivors requires testing of its safety, tolerability, and adherence. Compared to prior studies in France and the United Kingdom, the patient characteristics, health infrastructure, and usual care for stroke recovery differ substantially in Tanzania. If fluoxetine reveals favorable endpoints, scale up of its use post-stroke is possible.

Multiple sclerosis in resource-limited settings: Research opportunities in an unequal world

This position piece is meant to extend the humanitarian argument for assisting people with multiple sclerosis (MS) in resource-limited settings, in this case, through research. It is also meant to highlight areas of strength of some low- and middle-income countries (LMICs), and therefore emphasize how the field of MS could best be served globally by more research with and for resource-limited populations. Possible areas of particular strength include (1) ethnicity, genetic diversity, and migration studies; (2) analysis of possibly emerging environmental and lifestyle-related risk factors; (3) understanding the immune system when exposed to novel pathogens and various infectious agents; (4) reverse innovation to promote better point-of-care diagnostic tests; (5) high participation rates in clinical registries and research; (6) appreciation of MS in special populations including a higher focus on pediatrics and pregnancy; (7) culturally adept means of treatment and rehabilitating disability; (8) models of care delivery for chronic, complex neurologic diseases; and (9) use of off-label, generic, and less commonly implemented disease-modifying therapy sequences. Strategies for strengthening the MS research landscape include (1) creation of centers of research excellence in LMICs and twinning of institutions between high- and low-income countries; (2) standardization of research procedures and reduction of bureaucracies; (3) consensus meetings and network building; (4) opening additional avenues for publications and expanding the types of available publications; (5) identifying and establishing dedicated funding mechanisms; (6) focus on local relevance; and (7) setting expectations to include patients from LMICs in international clinical trials. These underutilized opportunities build an argument that global partnerships for research and knowledge coordination could better reach across populations, geographies, economies, and expertise.

Missed opportunities for epilepsy surgery referrals in Bhutan: A cohort study

OBJECTIVE

To quantify the missed opportunities for epilepsy surgery referral and operationalize the Canadian Appropriateness of Epilepsy Surgery (CASES) tool for use in a lower income country without neurologists.

METHODS

People with epilepsy were recruited from the Jigme Dorji Wangchuck National Referral Hospital from 2014-2016. Each participant was clinically evaluated, underwent at least one standard EEG, and was invited to undergo a free 1.5 T brain MRI. Clinical variables required for CASES were operationalized for use in lower-income populations and entered into the free, anonymous website tool.

FINDINGS

There were 209 eligible participants (mean age 28.4 years, 56 % female, 179 with brain MRI data). Of the 179 participants with brain MRI, 43 (24.0 %) were appropriate for an epilepsy surgery referral, 21 (11.7 %) were uncertain, and 115 (64.3 %) were inappropriate for referral. Among the 43 appropriate referral cases, 36 (83.7 %) were "very high" and 7 (16.3 %) were "high" priorities for referral. For every unit increase in surgical appropriateness, quality of life (QoL) dropped by 2.3 points (p-value <0.001). Among the 68 patients who took >1 antiepileptic drug prior to enrollment, 42 (61.8 %) were appropriate referrals, 14 (20.6 %) were uncertain, and 12 (17.6 %) were inappropriate.

CONCLUSION

Approximately a quarter of Bhutanese epilepsy patients who completed evaluation in this national referral-based hospital should have been evaluated for epilepsy surgery, sometimes urgently. Surgical services for epilepsy are an emerging priority for improving global epilepsy care and should be scaled up through international partnerships and clinician support algorithms like CASES to avoid missed opportunities.

Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania

OBJECTIVE

Given the high post-stroke mortality and disability and paucity of data on the quality of stroke care in Sub-Saharan Africa, we sought to characterize the implementation of stroke-focused treatments and 90-day outcomes of neuroimaging-confirmed stroke patients at the largest referral hospital in Tanzania.

DESIGN

Prospective cohort study.

SETTING

Muhimbili National Hospital (MNH) in Dar es Salaam, July 2016-March 2017.

PARTICIPANTS

Adults with new-onset stroke (<14 days), confirmed by head CT, admitted to MNH.

MAIN OUTCOMES MEASURES

Modified Rankin scale (mRS) and vital status.

RESULTS

Of 149 subjects (mean age 57; 48% female; median NIH stroke scale (NIHSS) 19; 46% ischemic stroke; 54% hemorrhagic), implementation of treatments included: dysphagia screening (80%), deep venous thrombosis prophylaxis (0%), aspirin (83%), antihypertensives (89%) and statins (95%). There was limited ability to detect atrial fibrillation and carotid artery disease and no acute thrombolysis or thrombectomy. Of ischemic subjects, 19% died and 56% had severe disability (mRS 4-5) at discharge; 49% died by 90 days. Of hemorrhagic subjects, 33% died and 49% had severe disability at discharge; 50% died by 90 days. In a multivariable model, higher NIHSS score but not dysphagia, unconsciousness, or patient age was predictive of death by 90 days.

CONCLUSIONS

The 90-day mortality of stroke presenting at MNH is 50%, much higher than in higher income settings. Although severe stroke presentations are a major factor, efforts to improve the quality of care and prevent complications of stroke are urgently needed. Acute stroke interventions with low number needed to treat represent challenging long-term goals.

Progressive multifocal leukoencephalopathy: A 25-year retrospective cohort study

Objective

To characterize the risk factors, clinical course, and treatment of patients with progressive multifocal leukoencephalopathy (PML) diagnosed and followed over a 25-year epoch at 2 academic hospitals.

Methods

Patients with a definite diagnosis of PML were identified by positive CSF PCR for JC virus or histopathology between January 1, 1994, and January 1, 2019. Demographic and PML-specific variables were recorded on symptomatic presentation and at follow-up, including risk factors, clinical outcome, neuroimaging findings, and modified Rankin Scale (mRS) score at last follow-up.

Results

There were 91 patients with confirmed PML. HIV infection was the most common risk factor, identified in 49% (n = 45). Other frequent risk factors included lymphoma, leukemia, or myelodysplasia, identified in 31% of patients (n = 28); exposure to chemotherapeutic medications (30%, n = 27); and exposure to monoclonal antibody therapies (19%, n = 17). Thirty percent of the cohort was alive at the time of censoring, with a median mRS of 2 points, indicating slight disability at last follow-up. Median survival following PML diagnosis in HIV-infected patients was longer than in HIV-uninfected patients (1,992 vs 101 days, p = 0.024). Forty patients survived more than 1 year after PML symptom onset, of whom 24 were HIV infected (60%). Thirteen patients survived more than 10 years after PML symptom onset, all HIV infected, of the 59 patients diagnosed before June 1, 2009, and eligible for 10-year survivor status (22%).

Conclusions

We add to the limited literature on PML by reporting its epidemiology in a large observational cohort. These parameters may be useful for future clinical trials that measure survival and clinical outcomes.

Assessment of a neuro-developmental screening tool in children in Bhutan

Background: Developmental screening tools are designed to fit the cultural context in which they are utilized, yet often find a wider international audience. This study evaluates the efficacy of one such tool, the Parental Evaluation of Developmental Status: Developmental Milestones (PEDS:DM), developed in the United States and tested in the lower income Asian country of Bhutan. We aimed to test the PEDS:DM instrument to measure neurodevelopmental delay in children in Bhutan.

Methods: In total, 96 community-dwelling Bhutanese children (3-7 years old) without diagnosed neurocognitive conditions were recruited from ambulatory clinics in urban Bhutan in 2016 as part of a larger study on retinal imaging and cognitive and growth parameters. Scoring was based on neurocognitive domains (gross and fine motor, receptive and expressive speech, self-help, social-emotional). Rates of failure (meant to indicate delay) within domains were calculated.

Results: Modifications of some standard questions were deemed necessary by the study staff to suit the cultural context, such as replacing kickball with football in a question regarding games played with rules to maintain local relevance. In a modified PEDS:DM test with these improvised modifications, the mean percentage of age-appropriate domains failed was 58.8% and the mean percent delay was 12.3% (range 0-41.4%, available in n=83). The highest prevalence of failures was 59.4% for receptive language and 76.3% for expressive language, much higher than the lowest rate of failure seen in self-help (5.4%). 

Conclusions: The PEDS:DM requires further modifications and validation studies before it can be reliably implemented to assess developmental delay in children in Bhutan. In this pilot study, the rate of delay as reported by the PEDS:DM would be scored as markedly elevated, especially when compared to available epidemiologic studies in the region.

A cascade of care for people with epilepsy: learning from "HIV/AIDS 90-90-90"

Epilepsy is now more prevalent in many countries than HIV/AIDS. Building upon the advances of global policymaking for HIV/AIDS and creating a framework for countries and organizations to monitor progress in epilepsy care will help direct and justify much-needed novel programming. Given the clarity of the HIV/AIDS care continuum model and the UNAIDS 90-90-90 targets, I propose this same approach to the cascade of care could be used as a viable framework for people with epilepsy. In this model, the targets of success include (1) ensuring 90% of all people with epilepsy are aware of their diagnosis as a brain disorder, (2) starting 90% of people with epilepsy on quality controlled, appropriately chosen and well stocked antiepileptic drugs, and (3) achieving seizure freedom in 70% of those treated. At least 90% of all people with epilepsy must also be linked to and retained in appropriate care. Although the precise numbers may be debated, this cascade of care approach will assist in deconstructing the barriers to epilepsy care in populations better than the more familiar concept of the epilepsy treatment gap. These reflect concrete goals for health systems for epilepsy care that, if achieved, could lead to seizure freedom for the many people in lower income countries living with poorly controlled epilepsy.

School status and its associations among children with epilepsy in the Republic of Guinea

BACKGROUND

In low-income countries (LICs), there are multiple barriers for children with epilepsy (CWE) to attend school. We examined potentially modifiable associations with poor school performance in CWE in the West African Republic of Guinea.

METHODS

Children with epilepsy of school age were recruited using public announcements and a clinical register of people with epilepsy at the Ignace Deen Hospital in Conakry in 2018. A team of Guinean and U.S. neurologists and neurologists-in-training interviewed each CWE and parent for his/her epilepsy history, household finances, educational attainment level, and perceived stigma using the Stigma Scale of Epilepsy (SSE). Each child was also tested using the Wechsler Nonverbal Scale of Ability (WNV). Low school performance was defined as either not attending school or being held back a grade level at least once. Potential predictors of low school performance were analyzed.

FINDINGS

Of 128 CWE (mean age: 11.6 years, 48.4% female), 11.7% (n = 15) never attended school, 23.3% (n = 30) dropped out, and 64.8% (n = 83) were currently enrolled. Of CWE attending school, 46.9% (n = 39) were held back a grade level. Overall, 54 children were defined as low performers (LPs) (42%). ;Greater than 100 lifetime seizures (odds ratio (OR) = 8.81; 95% confidence interval (CI) = 2.51, 37.4; p = 0.001) and lower total WNV score (OR = 0.954; 95% CI = 0.926, 0.977; p < 0.001) were significantly associated with poor school performance in separate models, when controlling for potential confounders. Given the strong relationship between seizure freedom and school performance, we estimated that 38 additional CWE (33.6%) could become high performers (HPs) if all CWE were adequately treated to achieve the lifetime seizure category of <10 seizures and could be cognitively intact again. Models examining SSE and household wealth quintile were not significantly associated with school performance.

CONCLUSIONS

Higher lifetime seizures and lower WNV score were significantly associated with low school performance in CWE in Guinea. In spite of our conservative definition of high school performance (attending without failing) and risk of referral bias at an academic center where patients were allowed to self-refer, we demonstrate that seizure control in this setting could increase the number of CWE who could attend and stay in school.

Assessment of a neuro-developmental screening tool in children in Bhutan

Background: Developmental screening tools are designed to fit the cultural context in which they are utilized, yet often find a wider international audience. This study evaluates the efficacy of one such tool, the Parental Evaluation of Developmental Status: Developmental Milestones (PEDS:DM), developed in the United States and tested in the lower income Asian country of Bhutan. We aimed to test the PEDS:DM instrument to measure neurodevelopmental delay in children in Bhutan. Methods: In total, 96 community-dwelling Bhutanese children (3-7 years old) without diagnosed neurocognitive conditions were recruited from ambulatory clinics in urban Bhutan in 2016 as part of a larger study on retinal imaging and cognitive and growth parameters. Scoring was based on neurocognitive domains (gross and fine motor, receptive and expressive speech, self-help, social-emotional). Rates of failure (meant to indicate delay) within domains were calculated. Results: Modifications of some standard questions was deemed necessary by the study staff to suit the cultural context, such as replacing kickball with football in a question regarding games played with rules to maintain local relevance. In a modified PEDS:DM test with these improvised modifications, the mean percentage of age-appropriate domains failed was 58.8% and the mean percent delay was 12.3% (range 0-41.4%, available in n=83). The highest prevalence of failures was 59.4% for receptive language and 76.3% for expressive language, much higher than the lowest rate of failure seen in self-help (5.4%).  Conclusions: The PEDS:DM requires further modifications and validation studies before it can be reliably implemented to assess developmental delay in children in Bhutan. In this pilot study, the rate of delay as reported by the PEDS:DM would be scored as markedly elevated, especially when compared to available epidemiologic studies in the region.

Smartphone EEG and remote online interpretation for children with epilepsy in the Republic of Guinea: Quality, characteristics, and practice implications

PURPOSE

Children with epilepsy in low-income countries often go undiagnosed and untreated. We examine a portable, low-cost smartphone-based EEG technology in a heterogeneous pediatric epilepsy cohort in the West African Republic of Guinea.

METHODS

Children with epilepsy were recruited at the Ignace Deen Hospital in Conakry, 2017. Participants underwent sequential EEG recordings with an app-based EEG, the Smartphone Brain Scanner-2 (SBS2) and a standard Xltek EEG. Raw EEG data were transmitted via Bluetooth^™ connection to an Android^™ tablet and uploaded for remote EEG specialist review and reporting via a new, secure web-based reading platform, crowdEEG. The results were compared to same-visit Xltek 10-20 EEG recordings for identification of epileptiform and non-epileptiform abnormalities.

RESULTS

97 children meeting the International League Against Epilepsy's definition of epilepsy (49 male; mean age 10.3 years, 29 untreated with an antiepileptic drug; 0 with a prior EEG) were enrolled. Epileptiform discharges were detected on 21 (25.3%) SBS2 and 31 (37.3%) standard EEG recordings. The SBS2 had a sensitivity of 51.6% (95%CI 32.4%, 70.8%) and a specificity of 90.4% (95%CI 81.4%, 94.4%) for all types of epileptiform discharges, with positive and negative predictive values of 76.2% and 75.8% respectively. For generalized discharges, the SBS2 had a sensitivity of 43.5% with a specificity of 96.2%.

CONCLUSIONS

The SBS2 has a moderate sensitivity and high specificity for the detection of epileptiform abnormalities in children with epilepsy in this low-income setting. Use of the SBS2+crowdEEG platform permits specialist input for patients with previously poor access to clinical neurophysiology expertise.

Depressive Symptoms and Their Relation to Age and Chronic Diseases Among Middle-Aged and Older Adults in Rural South Africa

BACKGROUND

Understanding how depression is associated with chronic conditions and sociodemographic characteristics can inform the design and effective targeting of depression screening and care interventions. In this study, we present some of the first evidence from sub-Saharan Africa on the association between depressive symptoms and a range of chronic conditions (diabetes, HIV, hypertension, and obesity) as well as sociodemographic characteristics.

METHODS

A questionnaire was administered to a population-based simple random sample of 5,059 adults aged 40 years and older in Agincourt, South Africa. Depressive symptoms were measured using a modified version of the eight-item Center for Epidemiological Studies-Depression screening tool. Diabetes was assessed using a capillary blood glucose measurement and HIV using a dried blood spot.

RESULTS

17.0% (95% confidence interval: 15.9%-18.1%) of participants had at least three depressive symptoms. None of the chronic conditions were significantly associated with depressive symptoms in multivariable regressions. Older age was the strongest correlate of depressive symptoms with those aged 80 years and older having on average 0.63 (95% confidence interval: 0.40-0.86; p < .001) more depressive symptoms than those aged 40-49 years. Household wealth quintile and education were not significant correlates.

CONCLUSIONS

This study provides some evidence that the positive associations of depression with diabetes, HIV, hypertension, and obesity that are commonly reported in high-income settings might not exist in rural South Africa. Our finding that increasing age is strongly associated with depressive symptoms suggests that there is a particularly high need for depression screening and treatment among the elderly adults in rural South Africa.

Neuromyelitis optica after splenectomy: A secondary autoimmune phenomenon

We describe the case of a 53-year-old woman who undergoes total splenectomy and later presents with aquaporin-4 antibody positive neuromyelitis optica (NMO). The occurrence of NMO after acquired immunosuppression raises the possibility of NMO as a form of secondary autoimmunity.

Impairment in Activities of Daily Living, Care Receipt, and Unmet Needs in a Middle-Aged and Older Rural South African Population: Findings From the HAALSI Study

Objectives: The objective of this study is to analyze the degree to which care needs are met in an aging rural African population. Method: Using data from the Health and Aging in Africa: Longitudinal Study of an INDEPTH Community (HAALSI) baseline survey, which interviewed 5,059 adults aged older than 40 years in rural South Africa, we assessed the levels of limitations in activities of daily living (ADLs) and in unmet care for these ADLs, and evaluated their association with sociodemographic and health characteristics. Results: ADL impairment was reported by 12.2% of respondents, with the proportion increasing with age. Among those with ADL impairment, 23.9% reported an unmet need and 51.4% more a partially met need. Relatives provided help most often; formal care provision was rare. Unmet needs were more frequent among younger people and women, and were associated with physical and cognitive deficits, but not income or household size. Discussion: Unmet care needs in rural South Africa are often found among individuals less expected to require care.