The treatment gap in epilepsy: the current situation and ways forward

Mortality implications and factors associated with nonengagement in a public epilepsy care initiative in a transient population

BACKGROUND

Community-based, public care programs are a requisite to close the epilepsy treatment gap in disadvantaged communities in low- and middle-income countries (LMICs). Potential beneficiaries may, however, choose not to engage in these programs.

AIMS

The aim of the study was to describe factors associated with and mortality consequences of nonacceptance of a public epilepsy care initiative.

METHODS

In this cross-sectional study, we contacted 207 (36%) people out of 575 who screened positive for epilepsy during a population-based survey of 59,509 people. They were invited for neurological evaluation and care provision (including antiseizure medications (ASMs)) but chose not to engage. Structured questionnaires and qualitative interviews were conducted to determine reason for their nonengagement. Factors associated with nonengagement were evaluated by univariate and multivariate analysis. We conducted verbal autopsies for those who had died.

RESULTS

Ten (5%) of the 207 individuals died since the initial screening; six with epilepsy-related causes. Of those who could be contacted (n = 48), 40 (19%) were confirmed to have epilepsy. Nonengaging individuals were likely to be older (odds ratio (OR): 1.02; 95% confidence interval (CI), 1.01, 1.11), locals (OR: 4.32; 95% CI, 1.55, 12.03), and earn less than US$ 78/month (OR: 3.6; 95% CI, 1.62, 8.06). Reasons for not engaging included a belief that epilepsy is inconsequential, loss of daily wages owing to healthcare facility visit and physical infirmity.

CONCLUSIONS

Nonacceptance of a community-based public epilepsy care initiative is associated with high premature mortality, mostly attributed to epilepsy-related causes. Older age, ethnic status, and economic deprivation are factors associated with nonacceptance, though the underlying reasons may be varied.

Knowledge of Pharmacists about Anti-epileptic Drugs in a Developing Country

BACKGROUND

Pharmacists play an essential role in educating the epileptic patients about their disease and their medications. Improving the patient's awareness may lead to improve their compliance and decrease drug-drug interaction and ultimately improve their quality of life.

OBJECTIVE

This study aimed to assess the pharmacist's knowledge about anti-epileptic drugs in Khartoum State, Sudan.

METHODS

We conducted a descriptive cross-sectional study in Khartoum State, Sudan. Proportionate stratified sampling was used to determine the targeted Pharmacies, and all pharmacists who were present in the selected pharmacy at the time of data collection and fulfilled our selection criteria were included in the study. A structure closed-ended questionnaire was used to collect quantitative data from candidates.

RESULTS

Majority of participants were female (66.9%), less than 30 years old (66.7%) and have less than 5 years of experience (62.1%). Unfortunately, the majority of the participants (85.3%) had poor knowledge, and only (14.7%) of them had good knowledge. Furthermore, the study revealed that age (p =.030), years of experience (p =.026) and the degree in pharmacy (p = .003) were significantly associated with knowledge level.

CONCLUSION

Majority of the pharmacists in Khartoum State have poor knowledge about anti-epileptic drugs. Further research is needed to investigate the actual factors behind this knowledge gap and to propose interventions to improve the pharmacist's knowledge and practice aiming to improve the quality of health care provided to the patients.

Community-based management of epilepsy in Southeast Asia: Two intervention strategies in Lao PDR and Cambodia

Background

Epilepsy affects more than 50 million people worldwide, 80% of whom live in low- and middle-income countries (LMICs). In Southeast Asia, the prevalence is moderate (6‰), and the main public health challenge is reducing the treatment gap, which reaches more than 90% in rural areas.

Methods

This 12-month comparative study (intervention vs. control areas) assessed the community effectiveness of two different strategies for the identification and home follow-up of people with epilepsy by Domestic Health Visitors for epilepsy (DHVes). In Lao PDR, DHVes were health center staff covering several villages via monthly visits; in Cambodia, DHVes were health volunteers living in the villages.

Findings

At baseline, the treatment gap was >95% in Lao PDR and 100% in Cambodia. After 12 months, the treatment gap in Lao PDR decreased by 5·5% (range: 4·0–12·2) in the intervention area and 0·5% (range: 0·4–0·8) in the control area (p<0·0001). In Cambodia, the treatment gap decreased by 34·9% (range: 29·0–44·1) in the intervention area and 8·1% (range: 6·7–10·2) in the control area (p<0·0001). Among the PWEs followed at home by the DHVes, the proportion adhering to drug treatment was 85·2% in Lao PDR and 78·1% in Cambodia. The cost associated with strategy implemented in Cambodia, compared with the control area, was lower than the cost associated with strategy implemented in Lao PDR.”

Interpretation

The treatment gap was significantly reduced with both intervention strategies, but the effect was larger in Cambodia. The results of this cost analysis pave the way for scaling-up in rural areas of Lao PDR and Cambodia, and experimental adaptation in other LMICs.

Funding

The study was funded by the Global Health Department of Sanofi and Grand Challenges Canada (grant number 0325–04).

Evaluation of epilepsy and burn patterns in a tertiary hospital in southwestern Iran

PURPOSE

Based on the high rates of burn injuries in patients with epilepsy, it is crucial to evaluate the epidemiological factors, etiology, types of burns, and outcome of these certain individuals and to enhance knowledge about the possible risks of epilepsy-related burns by preventive actions and programs.

METHOD

Our retrospective study was carried out from September 2013 to February 2017 in Amir-al Momenin Hospital, a tertiary referral burns and plastic surgery healthcare center. Because of the fact that a number of patients with burns had experienced their trauma at the time of convulsion or in postconvulsion phase, it is necessary to evaluate the outcome, burn patterns, etiology of injury, and related epidemiological factors in order to develop a greater understanding of possible risks of epilepsy-related burns by preventive actions and programs.

RESULT

In our study, 2715 patients who referred to burn centers and hospitalized with a mean age of 26.838 (standard deviation (SD) = 21.186) were enrolled, in which 29 patients were involved in burn accidents due to epilepsy and seizure, resulting in a 1.1% epilepsy incidence in these individuals. In patients with seizure disorder, there was a mean rate of 5.8 (SD = 1.923) cases per year. Eighteen (62.1%) were male, and 11 (37.9%) were female. There were no cases of seizure-induced burn injury in pediatrics (<15 years) in our study. Among the patients with seizure-induced burns, 11 (out of 1101; 37.9%) were from rural areas, while 18 (out of 1570; 62.1%) were from urban locations. The occurrence of accidents due to seizure was also categorized based on the season, with the highest occurrence during winter (12 out of 683; 41.4%) and lowest during spring (3 out of 659; 10.3%). The mechanism of burn in patients with seizures was also documented, in which 12 (41.4%) were due to liquid, 12 (41.4%) due to fire, 1 (3.4%) due to explosion, and 1 (3.4%) due to other objects. Out of patients with seizure-induced burns, 21 (72.4%) were discharged, 2 released with their own will, 1 was transferred, and 5 (17.2%) died in the course of hospitalization.

CONCLUSION

This study demonstrates that burn injuries by epilepsy are a public health concern in low- and middle-income countries. Therefore, we suggest the execution of a strong national epilepsy preventive actions and programs, as well as proper education for both medical practitioners and patients of the possible dangers as part of an injury control program.

Ethical, Social, and Economic Challenges in Managing a Child with Dravet Syndrome in a Developing Country

Epilepsy is a chronic neurological disorder with a significant impact on sociocultural and economic aspects. The management of epilepsy in low-middle income countries (LMICs) is influenced by many factors such as disease burden, poverty, educational status, the reflection of the disease as a social stigma, diverse religious beliefs, and treatment expense. Despite the improvement in educational and social parameters, the stigmatization of the disease is still evident in many LMICs. The associated comorbidities and neurodevelopmental disorders further add to the cost and stigmatization. The pediatric neurologists/epileptologists in LMICs are encountered by distinctive ethical, social, and economic dilemmas during the patient care and management of epilepsy. This article discusses the various ethical dilemmas in a child with Dravet syndrome in a developing country.

Epilepsy treatment gap in Sub-Saharan Africa: Meta-analysis of community-based studies

OBJECTIVE

To evaluate the prevalence, highlight the variation and determine the trend over time, of epilepsy treatment gap (ETG) in Sub-Saharan Africa (SSA).

METHODS

We systematically searched PubMed, MEDLINE, Embase, ISI databases, and African Journal Online (AJOL). We determined the pooled prevalence estimate of ETG and the degree of heterogeneity in the region. Further subgroup analysis by sub-region, settlement setting, and cutoff adopted for active epilepsy in the studies was carried out. Meta-regression technique was also used to determine the trend of the ETG magnitude over time.

RESULTS

Twenty-three studies from SSA met the inclusion criteria. We found a high level of discordance among the studies that were included. Collectively, the estimated ETG was 68.5% (95% CI: 59.5%-77.5%). On subgroup analysis, the prevalence of the ETG was 67% (95% CI: 52%, 83%) in the Western, 68% (95% CI: 56%, 80%) in the Eastern, and 63% (95% CI: 53%, 73%) in the Southern Africa sub-regions. On stratified analysis based on 1-year, 5-year, and 2-year cutoffs for definition of active epilepsy, the prevalence figures for the ETG were 71% (95% CI: 56%, 85%), 55% (95% CI: 33%, 77%), and 57% (95% CI: 43%, 71%), respectively. Meta-regression result suggested that the prevalence of the ETG decreases by approximately by 0.006 per year.

CONCLUSION

The study showed a high prevalence of ETG, higher than the average for resource poor countries, and twice in rural compared with urban settlements in SSA.

Teachers and epilepsy: What they know, do not know, and need to know: A cross-sectional study of Taif City

Objective

The main aim of this study was to assess schoolteachers' knowledge of and attitudes toward epilepsy in Taif City, in the western region of Saudi Arabia.

Method

A structured 28-item questionnaire was distributed to and collected from 290 schoolteachers between November 2017 and November 2018 in Taif City.

Results

Generally, a negative attitude toward epilepsy was observed in this study. Of the 290 schoolteachers in this study, 80% had prior knowledge regarding epilepsy and 72% had witnessed a seizure. Only 2% of the participants expressed the thought that epilepsy is contagious but 59% of them expressed the thought that epilepsy is a mental disease. With respect to attitude, 64% of the participants reported that they would not approve of their daughter/son marrying someone with epilepsy. This attitude correlates with age and marital status as the prevalence of this attitude was higher among those who were either over 40 years old or married (P < 0.05). Although 73% of the participants stated that they know the correct management procedure to follow when helping an epilepsy patient during a seizure, inadequate practices are still performed by many. Finally, almost two-thirds of the respondents (66%) expressed the opinion that top-ranking professions are not suitable for people with epilepsy. This belief was twice as common among older respondents as it was among younger respondents (P < 0.05).

Conclusion

This study concludes that schoolteachers' knowledge regarding epilepsy is limited and that an immediate intervention through educational campaigns is required to develop a well-informed community.

Epilepsy care cascade, treatment gap and its determinants in rural South Africa

•

Most people with active convulsive epilepsy in rural South Africa are diagnosed.

•

Most individuals diagnosed have some blood level of anti-seizure medication.

•

Most individuals do not have optimal levels of medication.

•

The epilepsy treatment gap is high in rural South Africa, especially in children.

•

Identifying the epilepsy care cascade may better allow for targeting of interventions.

Purpose

The percentage of people who are diagnosed with epilepsy (diagnostic gap), access, receive and adhere (treatment gap) to anti-seizure medication (ASM) in low- and middle- income countries remains low. We explored the epilepsy care cascade, measured the diagnostic and treatment gaps, and examined socio-demographic factors associated with adherence to ASMs in rural South Africa.

Methods

Utilizing a population-based cohort of 311 people with active convulsive epilepsy (ACE) residing in rural northeastern South Africa, a questionnaire was administered to examine associations between demographic and socioeconomic factors and the epilepsy treatment gap. Blood was taken to measure levels of ASMs.

Results

Of the 311 individuals diagnosed, 93 % of individuals reported being previously told they had epilepsy and 94 % reported previously attending a health facility for their epilepsy. ASMs were detected in 138 individuals (76 %) and optimal levels were detected in 67 individuals, resulting in a treatment gap of 63 % (95 % confidence interval [95 %CI]: 56 %–70 %). Self-reported specificity of ASM use was 23 % (95 %CI: 12–39 %) and individuals ≥18 years were significantly more likely to report taking ASM than children and were significantly (p = 0.011) more likely to be adherent.

Conclusion

Most people with epilepsy in rural South Africa had been previously diagnosed with epilepsy and had accessed care for epilepsy, yet the level of ASM adherence remained low, significantly lower amongst children. Understanding ways of improving knowledge of and adherence to ASM in rural South Africa is necessary, especially amongst children. The epilepsy care cascade can be useful in identifying gaps in care and targeting interventions to reduce these gaps.

Assessment and treatment of childhood epilepsy in Haiti

OBJECTIVE

The global burden of pediatric epilepsy is disproportionately concentrated in low- and middle-income countries (LMICs). However, little is known about the effectiveness of current treatment programs in this setting. We present the outcomes of children who were assessed and treated at the Clinique D'Épilepsie de Port-au-Prince (CLIDEP), the only pediatric epilepsy referral center in Haiti.

METHODS

A 10-year retrospective review of children consecutively assessed and treated at CLIDEP was performed. The primary outcome was seizure control following treatment for epilepsy. The secondary outcome was an accurate determination of the diagnosis of epilepsy. A data-driven principle component regression (PCR) analysis was used to identify variables associated with outcomes of interest.

RESULTS

Of the 812 children referred for evaluation, most children (82%) underwent electroencephalography to investigate a possible epilepsy diagnosis. Very few children (7%) underwent cranial imaging. Although many patients were lost to follow-up (24%), most children who returned to clinic had less frequent seizures (51%) and compliance with medication was relatively high (79%). Using PCR, we identified a patient phenotype that was strongly associated with poor seizure control which had strong contributions from abnormal neurological examination, higher number of antiepileptic drugs, comorbid diagnoses, epileptic encephalopathy or epilepsy syndrome, and developmental delay. Head circumference also contributed to epilepsy outcomes in Haiti with smaller head sizes being associated with a poor seizure outcome. A dissociable phenotype of febrile seizures, suspected structural abnormality, epileptic encephalopathy or epilepsy syndrome, and higher seizure frequency was associated with a diagnosis of epilepsy.

SIGNIFICANCE

We describe the current landscape of childhood epilepsy in Haiti with an emphasis on diagnosis, treatment and outcomes. The findings provide evidence for the effectiveness of programs aimed at the diagnosis and management of epilepsy in LMICs and may inform the allocation of resources and create more effective referral structures.

Non-Dose-Dependent Changes in Liver Enzyme Levels of Children With Epilepsy on Treatment With Sodium Valproate

Background:

Sodium valproate (VPA) is considered as the drug of choice for the treatment of generalized epilepsy in children. Sodium Valproate may be hepatotoxic.

Aim:

To assess the level of derangement of liver enzymes in children with epilepsy on treatment with sodium valproate.

Methods:

A cohort study. One hundred fifty-three children, comprising 51 with epilepsy on treatment with VPA (group I), 51 with epilepsy on treatment with other antiepileptic drugs (AEDs) but not VPA (group II), and 51 with nonconvulsive disorders (group III) had liver function tests performed for them. Data were analyzed by SPSS version 23.0.

Results:

There were 85 males and 68 females, aged 6 months to 14 years (median = 7.0 years). There was no significant difference in the mean plasma levels of alanine transaminase (ALT), alkaline phosphatase, and gamma glutamyl transferase across the three groups of children. The mean aspartate transaminase level was significantly higher in children in group III. There was a statistically significant negative correlation between the duration of AED therapy and the mean serum level of AST (r = −0.266, P = 0.016). The serum ALT level showed a statistically significant positive correlation with the duration of AED therapy (r = 0.268, P = 0.015).

Conclusion:

Sodium valproate monotherapy does not appear to be associated with significant hepatotoxicity in children in our cohort.

Correlates of depression and quality of life among patients with epilepsy in Nigeria

OBJECTIVES

To determine the prevalence of Major Depressive Disorders (MDD) and its relationship to Quality of life.

DESIGN

A cross-sectional observational study.

SETTING

Out-Patient Clinic of the Neuropsychiatric Hospital, Abeokuta, Nigeria.

SUBJECTS

Patients with diagnosis of Epilepsy with Electroencephalogram (EEG) confirmation.

OUTCOME MEASURES

Depression and Quality of life.

RESULTS

The prevalence of current MDD was 11.9 %, and patients having at least 1 seizure per week were 5 times more likely to develop MDD (OR = 5.104, p = 0.014). The mean (SD) QOLIE-31 scores was 77.98 (13.32), with presence of MDD (β = -11.101, p = 0.0001); having at least 1 seizure/week (β = -6.653, p = 0.037) being independent predictors.

CONCLUSION

Depression is a common comorbidity in patients with epilepsy and is associated with a lower quality of life.

Differences in knowledge about epilepsy and antiepileptic drugs among pharmacy-dispensing workers in Cambodia and in Lao PDR

Epilepsy is the most common neurological disorder encountered in primary care in Southeast Asia. People with epilepsy require long-term therapy management. Nonadherence to antiepileptic drugs (AEDs) has been identified as a major factor in suboptimal control of epilepsy. Pharmacies offer patients a first-line point of contact with the healthcare system. Many pharmacies operate with limited or nonqualified human resources that can lead to insufficient knowledge, inappropriate supply of medicines, and insufficient counseling.

OBJECTIVE

The aim of this study was to evaluate the qualification and knowledge concerning epilepsy and AEDs among pharmacy-dispensing workers who sell drugs to people with epilepsy.

METHOD

A cross-sectional qualitative study was conducted in public and private pharmacies, in both urban and rural areas of Cambodia and Lao People's Democratic Republic (Lao PDR). The knowledge was collected through a questionnaire.

RESULTS

A total of 180 respondents from 123 outlets in the two countries were included in this study. A proportion of 40.8% (31) of respondents in Cambodia and 38.5% (40) in Lao PDR were pharmacists, followed by sellers who did not received any healthcare training with a proportion of 18.4% (14) in Cambodia compared to 20.2% (21) in Lao PDR. Head trauma was cited as the main cause of epilepsy by 72.4% (55) in Cambodia and 27.2% (28) in Lao PDR (p < 0.001). Epilepsy was considered as a contagious disease by 6.6% (5) of respondents in Cambodia compared to 18.4% (19) in Lao PDR (p = 0.03). Eighty-seven percent (66) of respondents in Cambodia knew at least one long-term AED versus 67.3% (70) in Lao PDR (p = 0.003). Phenobarbital was mentioned in more than 90.0% of cases in both countries. In overall, 15.4% (21) thought that if seizures are controlled for some months, people with epilepsy could stop taking their AEDs. Only one respondent from Lao PDR was aware of drug-drug interaction between AEDs and oral contraception.

CONCLUSION

An educational intervention should be implemented to improve the knowledge of epilepsy and AEDs for pharmacy-dispensing workers. This could include advice for all pharmacy-dispensing workers in order to improve AED management and follow-up of therapeutic adherence.

Overview of therapeutic changes in antiepileptic drugs in adult patients

Background Previous studies suggest a highly variable response of antiepileptic drugs (AEDs). This may be because the response to AEDs has been changed to sustained period of freedom from seizures. This study was conducted to determine whether therapeutic changes of AEDs in the treatment of seizure would be observable in an Indonesian population. Methods The study was conducted at the outpatient neurology polyclinic at the Universitas Airlangga Hospital, Surabaya, Indonesia. This was an observational retrospective cohort study, examining the outcomes of 41 cases of switching AEDs (increase or decrease of the dose, switch to branded or generic, or added or reduced type of AEDs). Results After treatment with the switched AED, seizure did not show any significant improvement. However, the incidence of seizure during and after the therapeutic change showed a downward trend (from 44% to 32%). Conclusions According to the present study, mere optimization of antiepileptic therapy may not result in a steep decrease in seizure events, particularly in polytherapy with AEDs. On the other hand, monotherapy with AEDs evidences to decreasing tendency of seizures.

Epilepsy treatment gap and stigma reduction in Pakistan: A tested public awareness model

High epilepsy treatment gap (ETG) and stigma remain a major issue globally. Addressing the basic problems is necessary, for advances in management to be effective. According to the 1987 population-based study, prevalence of active epilepsy in Pakistan is 0.98% with 98.1% ETG in rural and 72.5% in urban population and the presence of stigma. These dismal figures were a stimulus for our reported activities. Recognizing the problems faced by 2.2 million people with epilepsy (PWE) in the country, a group of volunteers mostly from the medical community has attempted to address these issues with an ongoing sustained awareness program over the last 18 years, working within the constraints of prevailing healthcare system, with gratifying results. In 2001, under a nongovernmental organization (NGO), the Comprehensive Epilepsy Control Programme of Pakistan (CECP) was launched to address the various paucities in knowledge, attitude, and practice about epilepsy; especially ETG and stigma. The CECP has two primary components: Epilepsy Support Pakistan (CECP-ESP) for awareness and mass education and National Epilepsy Centre (CECP-NEC) for holistic management of PWE, professional education, and research. Both work in tandem, and there is an overlap of their activities. This article only evaluates the outcome of sustained awareness activities of the CECP-ESP, through direct and indirect measures after 5 years of its initiation. A significant reduction in ETG and stigma exclusively through public awareness has been possible. This model can be easily replicated by any country, with involvement of the local population.

Community's Perception and Attitude towards People with Epilepsy in Ethiopia

Introduction

Most people with epilepsy suffer from a dual burden. In one hand, they struggle with the symptoms and disabilities on the other hand from misconceptions and stigma associated with it. But there are no recent studies which assess the community's perception and attitude.

Objective

To assess the perception and attitude of the community towards people with epilepsy and identify associated factors.

Methods

A community-based cross-sectional study was conducted in South Ethiopia from a total of 701 participants. Data were collected with face to face interview using a structured questionnaire developed based on the Health Belief Model (HBM). Data were presented with frequencies, tables, and figures. Univariate and multivariable logistic regression was done to identify significantly important variables. The presence of association was presented by odds ratio and 95% confidence interval. Ethical clearance was obtained from Wolaita Sodo University.

Results

The most frequently mentioned perceived causes for epilepsy were stress (91%), substance use (61.8%), and bad spirit (49.8%) while loss of consciousness and falling (80.7%) and sleep problems (78%) were considered symptoms of epilepsy. Only 13.1% of the participants think that they may be susceptible for epilepsy. Six hundred sixty (94.2%) participants will not employ a person with epilepsy while only 47 (6.7%) of the participants will allow a family member to marry a person with epilepsy. In multivariable analysis, understanding the illness as a medical problem was associated with perceived susceptibility and perceived benefit of modern treatment was significantly associated with having a current medical problem.

Conclusions

The knowledge about the cause, possible susceptibility, better treatment options, and attitude of the participants were similar to other low-income settings. The negative attitude was high and multidimensional. All stakeholders must work to increase awareness about the cause, symptoms, and treatment options for epilepsy and to decrease the negative attitude of the community.

WITHDRAWN: Teachers and epilepsy: What they know, do not know, and need to know: A cross-sectional study of Taif City

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Self-reported attitudes about medication in Lebanese people with epilepsy

BACKGROUND

Epilepsy is a common worldwide neurological disorder. For people with epilepsy (PWE), adherence and attitudes towards medication is a crucial step to improve efficacy of prescribed treatment and to prevent seizures.

OBJECTIVES

The first aim of this study was to evaluate attitudes towards antiepileptic medications in Lebanese population. Secondary aims were to assess factors affecting attitudes and associated with epilepsy control.

MATERIAL AND METHODS

A cross-sectional study was conducted in outpatient neurology clinics located in Beirut-Lebanon. Data were collected using a structured questionnaire. Self-report of medication taking behaviors were assessed using the abbreviated (4 items) Morisky Medication Adherence Scale (MMAS-4). Epilepsy was considered as controlled if the patient had no seizures in the last 6 months.

RESULTS

Among 250 PWE recruited in this study, male-to-female ratio was 0.87 (116/134), and 50.8% were married. Mean duration of epilepsy was 13.7 ± 12.8 years. Valproate was the most common antiepileptic drug (AED) used followed by levetiracetam and carbamazepine. About 60.8% of the population presented partial epilepsy. Uncontrolled epilepsy was present in more than half of participants (55.2%), with only 32.4% had positive attitudes to their medication. Positive attitudes towards antiepileptic increased in people who found that their treatment was efficacious (odds ratio (OR) = 4.9; 95% confidence interval (CI): 1.2-20.0; p = 0.03), who had controlled epilepsy (OR = 3.4; 95%CI 1.6-7.1; p = 0.001), and who were diagnosed as PWE between the age of 12-20 years (OR = 3.1; 95%CI 1.1-8.4; p = 0.03). Oppositely, these attitudes decreased in participants who felt their treatment as an economic burden (OR = 0.2; 95%CI 0.1-0.4; p ≪ 0.001), and in people with depression (OR = 0.4; 95%CI 0.2-0.9; p = 0.04). Controlled epilepsy was higher in people who contacted a neurologist if seizure occurred, in people with positive attitudes, and after a long duration of disease, but it decreased if patient did not follow neurologist's instructions in fasting period.

CONCLUSIONS

Lebanese PWE were less likely to have positive attitudes towards medication, which may lead to poor epilepsy control. Depression and economic burden were the major factors that decreased these attitudes. Identifying factors affecting attitudes to medication and leading to controlled epilepsy may help clinicians to elaborate educational programs to optimize medication adherence.

Lymphedema-associated comorbidities and treatment gap

BACKGROUND

Lymphedema (LE) has been called the forgotten vascular disease, given such scant knowledge about LE-associated comorbidities or causes. Such knowledge of the comorbidities and treatment of LE may assist in diagnostic decisions and health care planning.

METHODS

To determine the proportion of LE patients with various LE-associated comorbidities as well as the rate of associated treatment, deidentified Health Insurance Portability and Accountability Act-compliant commercial administrative claims from the Blue Health Intelligence (BHI) research database (165 million Blue Cross Blue Shield members) were queried. We analyzed a BHI study sample of 26,902 patients with LE who had been enrolled with continuous medical benefits for 12 months before and after the index date for the complete years 2012 through 2016. Patients were first identified by comorbidity and then grouped into those receiving no treatment for LE and those receiving any treatment for LE. Any treatment was defined as receiving manual lymphatic drainage, physical therapy, compression garments, or a pneumatic compression device. The purpose of this study was to determine the proportion of LE patients comorbid with various known LE-associated conditions and the treatment rates of LE patients with each comorbidity.

RESULTS

Among the 84,579,269 BHI patients enrolled during the study window, 81,366 patients were identified with LE. From this LE group, our study focused on the 26,902 patients who were enrolled with continuous medical and pharmacy benefits for 12 months before and after the index date. Among these 26,902 LE patients, breast cancer was the most frequent comorbidity with LE (32.1%), and these patients almost universally received any treatment (94.2%); other cancer types, such as melanoma (2.1%) and prostate cancer (0.7%), were less frequent and received any treatment less often, 75% and 82% of the time, respectively. Venous leg ulcer was the most common non-cancer-linked comorbidity for LE (9.6%), but only 81.7% of venous leg ulcer patients received any treatment for LE.

CONCLUSIONS

To our knowledge, this is the largest study to date detailing the comorbidities associated with LE and LE treatment rates within each. Our findings suggest that a sizable proportion of cancer-related LE patients do not receive appropriate treatment. Furthermore, this study highlights the role of advanced venous disease as an LE comorbidity that is frequently untreated and its associated gap in treatment.

Investigative practice into sudden death in epilepsy: A global survey

OBJECTIVES

Sudden death is a recognized consequence of epilepsy. Little is known about the practice of confirming the cause of sudden death from most nations. We sought to determine how often autopsy is undertaken, clinician confidence in cause of death and identify the factors which may influence autopsy utilization.

MATERIALS & METHODS

An online questionnaire survey was sent to all International League Against Epilepsy (ILAE) chapters chairpersons, asking them to complete the survey based on their perceptions in their country. Questions included: confidence in cause of death in people with epilepsy, frequency of autopsy uptake, and perceived barriers to an accurate diagnosis and ongoing research work. Data were analyzed by chi-squared, Kruskal-Wallis and Spearman rank analysis.

RESULTS

Responses were obtained from 77 of 114 individual chapter leaders (68%). Legal, coronial, family attitudes, including cultural and religious factors, to autopsy were considered the major barriers to obtaining an accurate diagnosis. Only 13% had a high level of confidence in the accuracy of the cause of death. There was greater confidence in the diagnosis of the causes of sudden death in epilepsy in the countries with higher autopsy rates. Sixty-six percent of responders were not aware of published or unpublished research or audits on sudden death in epilepsy in their country in the last decade.

CONCLUSIONS

Significant disparities exist in the investigation of sudden death in epilepsy across countries and identified factors in this study provide an opportunity to formulate a global public health strategy to help overcome this gap.

An ambispective cohort study on treatment outcomes of patients with epilepsy in a tertiary epilepsy center in Rwanda and recommendations for improved epilepsy care

OBJECTIVE

Because outcome data inform and drive healthcare decisions and improvement of patient care, this study aimed to gain a deep understanding of sociodemographic profiles and treatment outcomes of newly presenting and recently diagnosed persons living with epilepsy (PwE) at a tertiary epilepsy center in Rwanda.

METHODS

In June 2016 (T1), as a first stage of this single-center cohort study, an ambispective chart review was conducted on baseline sociodemographic and disease characteristics of PwE using a structured questionnaire. Missing data were obtained by phone interview. In 2017, follow-up data were collected by phone interview on treatment outcomes after 15-months (T2).

RESULTS

Of 406 PwE screened, 235 were included at T1 and outcomes on 166 PwE were obtained at T2. More than 70% were <20 years of age, with a male preponderance. A high number of patients were aged ≥20 years, were single (67.4%), unemployed (41.5%), and had no formal education or primary level education (53.9%), possibly reflecting stigma. A mean delay in diagnosis since first seizure increased with age at first seizure, amounting to 3 years for patients aged ≥20 years. At T2, 69.6% of 166 patients who could be contacted reported no seizures in the previous month. Valproate monotherapy was the most frequently prescribed treatment. At T2, 47% had discontinued treatment, which was often not recommended by a physician, despite medical insurance coverage in >90% of patients. Only 19% reported an adverse event. Marked and partial improvement in quality of life (QoL) was reported by, respectively, 50.9% and 32.7% of patients.

SIGNIFICANCE

Encouraging results on improved seizure control and QoL were observed at follow-up. The treatment gap remains high due to loss to follow-up and treatment discontinuation. In this article, we discuss needs and recommendations for improving patient care, requiring concerted efforts of stakeholders at all levels of the healthcare system.

Knowledge, attitudes, and practices of health sciences students regarding epilepsy at the end of their curriculum in Benin

OBJECTIVE

The main objective of this study was to evaluate the knowledge, attitudes, and practices (KAP) of health sciences students regarding epilepsy at the end of their curriculum in Benin.

METHODS

We conducted a cross-sectional survey among medical, pharmacy, nursing, and midwife students in their last year of health sciences training in the University of Abomey-Calavi in Benin. Students completed a self-administered questionnaire, containing items addressing demographics, epilepsy treatment, diagnosis, clinical practice, and social tolerance regarding a person with epilepsy (PWE).

RESULTS

The response rate to our survey was 87.7% (n = 164). The sample consisted of 64 medical students, 22 pharmacy students, 43 nursing students, and 35 midwife students. They were divided into 95 female subjects and 69 males; sex ratio was 0.7. The mean age of participants was 23.6 ± 1.8 years. The mean scores for epilepsy knowledge, practices, and attitudes were respectively 7.6 ± 1.7 out of a maximum score of 11, 3.9 ± 1.8 out of 8, and 9.6 ± 0.8 out of 10. The KAP overall score was 21.1 ± 3.4 out of a maximum score of 29.0. The variables associated with the overall KAP score were training school, gender, having heard about epilepsy before health sciences studies (p = 0.017), and having a relative with epilepsy (p = 0.001). Male students and medical school students had significantly better overall KAP score than female students or the other training schools respectively (p < 0.001).

SIGNIFICANCE

These findings support the need to improve the health sciences students' knowledge of epilepsy, in particular, during their training.

What Saudi teachers know about epilepsy: A cross-sectional study of Tabuk City

PURPOSE

This study was conducted to evaluate awareness, knowledge, and attitudes of teachers toward the disease in Tabuk City in north Saudi Arabia and identify areas in which training and education are required.

METHOD

Data were collected from 349 school teachers using a structured 28-item questionnaire. Data were collected between December 2017 and May 2018 in Tabuk City.

RESULTS

In general, the study shows a negative trend in knowledge and attitude toward epilepsy. The majority of the participants (84%) have read or heard about epilepsy, and more than half (67%) had witnessed a seizure. Epilepsy was considered contagious and psychological by 1.7% and 56%, respectively. Regarding attitude, 68% would not approve a son/daughter marriage to a person with epilepsy. This attitude correlates to the level of education as the percentage is higher for those who hold a Bachelor's or Master's degree, p < 0.05. Even though 84% of the participants reported knowing how to help a patient during a seizure, the majority of the participants had incorrect procedures, holding the legs and arms and believing that smelling onions is helpful to end the seizure. Moreover, almost half of the participants (46%) believed that a person with epilepsy cannot be successful in high-ranking professions. This belief was found to be more common in females than their counterparts, p < 0.05.

CONCLUSION

School teachers' knowledge about epilepsy needs improvement. A focus on educational interventions about epilepsy are needed to develop a well-informed and tolerant community.

Attitudes toward epilepsy among medical staffs in basic-level hospitals from southern China

OBJECTIVE

The objectives of the study were to assess attitudes toward epilepsy among medical staffs from basic-level hospitals in southern China and identify significant predictive factors for future stigma reduction interventions.

METHODS

The Public Attitudes Toward Epilepsy (PATE) scale, a two dimensional 14-item scale addressing two major domains: general domain and personal domain, was administered to 448 medical staffs from basic-level hospitals in southern China. Positively stated items in the PATE scale were reversely scored; in this case, a higher score would indicate a more negative attitude. Also, we compared the overall score and per-item scores of the medical staffs versus those of the general population reported in the previous studies using the same scale.

RESULTS

The cumulative score of the medical staffs was 41.65 ± 6.99, which is significantly lower as compared with 51.38 ± 6.80 of the general population (t (645) = -16.473, p < 0.001). The general average score (t (645) = -16.473, p < 0.001) and the mean score in the general domain (t (645) = -22.573, p < 0.001) of the PATE scale were both significantly lower in the medical staffs compared with the general population, whereas there was no significant difference between the two groups in the personal domain (t(645) = -0.180, p = 0.857). Age or years in clinical practice, specialty, and title had a significant impact on both the general domain and personal domain. Residence was the only factor found affecting the medical staffs' attitudes toward epilepsy in the personal domain but not in the general domain.

CONCLUSION

Medical staffs from basic-level hospitals in southern China demonstrate significant positive attitudes toward people with epilepsy in general aspects when compared with the general population. However, they still showed negative and conservative attitudes when it comes to the personal domain. Future strategies for stigma-reducing public interventions could focus on increasing better understanding of epilepsy among medical staffs in basic-level hospitals in China.

Is there a delay in seeking medical care after the first seizure in "resource limited settings": a pilot study from Sri Lanka

Objectives

Current guidelines suggest that patients presenting with the first seizure should be assessed by a specialist, preferably with investigations such as electroencephalography and imaging to reach a definitive diagnosis. We conducted a cross sectional study among patients with confirmed epilepsy, at a tertiary level neurology clinic in Sri Lanka with the aim of assessing delays in first contact with a medical doctor and in performing key investigations after the first seizure.

Results

Majority had sought medical attention within 24 h of the first seizure (71.2%) and had seen a specialist within the 1st week since the seizure (61%). Also a significant proportion had completed key investigations such as electroencephalography (63.2%) and brain imaging within a month (51%) since the first medical consultation. Of many socio-demographic and illness related factors examined, only a non-generalized tonic–clonic presentation was significantly associated with delay in seeking medical help.

Experiences and perspectives of stigmatization and discrimination against people with epilepsy in Accra, Ghana

A qualitative research approach was utilized to investigate experiences and perspectives of people with epilepsy (PWE) and key informants. Twenty participants (14 PWE and 6 key informants) were purposively selected as participants for the study and in-depth interviews were conducted. The interviews were audio-recorded, transcribed, and analyzed to identify emerging themes that addressed objectives of the study. The findings indicated that PWE and key informants included in this study perceived epilepsy as a spiritual, curable, and medical condition. Besides, it was found that for fear of being infected by epilepsy, some people stigmatized and discriminated against PWE. Additionally, the study provided evidence that PWE were stigmatized and discriminated against in employment and intimate relationships with the incidence of seizures being the major reason. Furthermore, the study revealed that PWE adopted various strategies (concealment, not responding to demeaning comments made by people, involvement in religious activities, and joining support groups) to manage stigma and discrimination. The findings suggest the need for public education about epilepsy in order to modify people's beliefs and views about the disease. Moreover, the provision of counseling services would help enhance the psychosocial wellbeing of PWE.

Epilepsy in Asia: Disease burden, management barriers, and challenges

This article reviews the burden of epilepsy in Asia, the challenges faced by people with epilepsy, and the management of epilepsy. Comparison is made with other parts of the world. For this narrative review, data were collected using specified search criteria. Articles investigating the epidemiology of epilepsy, diagnosis, comorbidities and associated mortality, stigmatization, and treatment were included. Epilepsy is a global health care issue affecting up to 70 million people worldwide. Nearly 80% of people with epilepsy live in low- and middle-income countries with limited resources. People with epilepsy are prone to physical and psychological comorbidities, including anxiety and depression, which can negatively impact their quality of life. Furthermore, people with epilepsy are at higher risk of premature death than people without epilepsy. Discrimination or stigmatization of people with epilepsy is common in Asia and can affect their education, work, and marriage opportunities. Access to epilepsy treatment varies throughout Asia. Although highly advanced treatment is available in some countries, up to 90% of people with epilepsy are not adequately treated or are not treated with conventional antiepileptic therapy in resource-limited countries. People in remote areas often do not receive any epilepsy care. First-generation antiepileptic drugs (AEDs) are available, but usually only in urban areas, and second-generation AEDs are not available in all countries. Newer AEDs tend to have more favorable safety profiles than first-generation AEDs and provide options to tailor therapy for individual patients, especially those with comorbidities. Active epilepsy surgery centers are present in some countries, although epilepsy surgery is often underutilized given the number of patients who could benefit. Further epidemiologic research is needed to provide accurate epilepsy data across the Asian region. Coordinated action is warranted to improve access to treatment and care.

Investigating the awareness, behavior, and attitude toward epilepsy among university students in Benghazi, Libya

OBJECTIVE

The aim of this study was to explore the level of knowledge regarding epilepsy and attitudes prevalent toward people with epilepsy (PWE) among Libyan university students in comparison with international data.

METHODS

A self-administrated questionnaire on awareness regarding epilepsy and behaviors toward PWE was distributed among undergraduate students enrolled in the University of Benghazi. The collected data were analyzed against responses from an Italian survey that utilized a similar questionnaire to explore epilepsy-related knowledge and attitudes among Italian university students in Rome (Mecarelli et al., 2007).

RESULTS

Out of the 500 interviewed students, 96% successfully completed the survey. Further, 96.6% asserted that they possessed some knowledge regarding epilepsy, gained mainly from their families (76.6%). A total of 57.5% considered epilepsy to be a psychiatric disorder while 11.6% recommended psychological tests for the diagnosis of epilepsy. Moreover, 37.5% believed in ancient superstitions, such as possession by evil forces, as the underlying cause of the condition, and 31.8% recommended traditional remedies to cure it. Further, 66.6% deemed epilepsy as a barrier for career prospects, 41% indicated that it presents an impediment in participation in sports, and 35% considered it as an obstacle in marriage. Additionally, epilepsy was perceived as a severe illness by 53.3% of the respondents and considered to be a moderately severe condition by 43.7%. The responses were found to be statistically significant (P<0.05) against the responses from the Italian study.

CONCLUSION

There is a reasonable level of awareness regarding epilepsy among Libyan students, though a lack of accuracy in the acquired knowledge exists. The ancient misconceptions regarding the nature of epilepsy and negative attitudes toward PWE appear to be rather common among the Libyan students. Consequently, the discrepancies in the views between the two surveys concerning the ways in which epilepsy is perceived and PWE are treated were extremely evident, thus reflecting the already established view that epilepsy faces greater stigma as a health condition in developing countries in comparison with Western nations.

Epidemiologist's view: Addressing the epilepsy surgery treatment gap with minimally-invasive techniques

Despite the fact that epilepsy surgery is both safe and effective, a considerable "surgical treatment gap" remains in that most persons who are eligible for surgery do not receive it. It has been argued that epilepsy surgery is one of the most underutilized of all accepted medical treatments in the world. In this article, we review the epidemiology of the epilepsy surgery treatment gap, and consider the role minimally-invasive epilepsy surgery may play in reducing this gap.

Interventional programs to improve therapeutic management of people with epilepsy in low- and middle-income countries

OBJECTIVE

To assess the current status of initiatives carried out in developing countries to improve therapeutic management of people with epilepsy.

METHODS

A literature review was performed in 2015 to identify and analyze interventional programs carried out in countries with low- and middle-income economies. Electronic databases were reviewed with no time restriction. Each intervention was categorized according to the level of evidence achieved (A: blind randomized controlled trial, B: randomized controlled trial, C1: randomized trial, C2: controlled trial, D: prospective cohort, E: retrospective evaluation).

RESULTS

A total of 46 intervention projects were identified, 13 with no quantitative assessment. The 31 remaining projects were carried out in 18 countries, 52% (16) in Africa, 42% (13) in Asia, and 6% (2) in Latin America. Among those, 13% (4) were level B, 3% (1) C1, 6% (2) C2, 74% (23) D, and 3% (1) were level E. The effectiveness of the intervention, assessed by the efficacy of antiepileptic drugs, was the primary objective in 81% (25). People with epilepsy were on average seizure-free in 44.6%±14.4% of cases at one year, ranging from 25.0% to 78.4%. At two years, on average 50.9%±29.7% are seizure-free, ranging from 4.6 to 92.7%. The median compliance was 79.3% with a minimum of 21.6% and a maximum of 100.0%.

DISCUSSION

No blind randomized controlled trial has been used to assess the efficacy of a program to improve access to antiepileptic drugs (AEDs) in developing countries, and the level of evidence was globally low. Phenobarbital remains the AED predominantly used in programs. Adherence to treatment management has been pointed out to be a key element in the success of a program, sometimes not sufficiently considered. Monthly supply of AEDs, at specific and community level, reducing the costs and time spent traveling, appeared to be the most effective strategies. Homogenization and standardization of evaluation practices of programs to improve the management of epilepsy in resource-limited settings would lead to comparison and meta-analysis which would ultimately improve strategies of support for not only epilepsy but also other noncommunicable diseases in developing countries.

Anticonvulsant effect of the hydroethanolic leaf extract of Psydrax subcordata (DC.) Bridson in murine models

ETHNOPHARMACOLOGICAL RELEVANCE

Psydrax subcordata (DC.) Bridson is a tropical medicinal plant used traditionally for the management of epilepsy. However, there is little scientific evidence to support its use.

AIM OF STUDY

The current study investigated the anticonvulsant properties of the hydroethanolic leaf extract of Psydrax subcordata (PSE) in animal models.

MATERIALS AND METHODS

The anticonvulsant effects were evaluated in mouse models of acute seizures (pentylenetetrazole-, picrotoxin-, 4-aminopyridine-, strychnine- and maximal electroshock-induced seizure tests) and status epilepticus (Lithium/pilocarpine-induced SE). The role of GABAergic mechanisms in the actions of the extract was also examined by pre-treatment of animals with flumazenil in the pentylenetetrazole test.

RESULTS

The extract (30, 100 and 300mg/kg, p.o.) significantly delayed the onset and decreased the duration and frequency of pentylenetetrazole- and picrotoxin-convulsions. PSE also reduced the duration of tonic hind limb extensions in the maximal electroshock-induced seizure test. Furthermore, PSE pre-treatment significantly delayed the onset of seizures and improved survival in the 4-aminopyridine-induced seizure test. In the strychnine-induced seizure test, PSE treatment did not significantly affect the latency to convulsions and time until death when compared to controls. PSE exhibited anticonvulsant effects in the lithium/pilocarpine test by delaying the onset of seizures and status epilepticus as well as reducing the severity of seizures and mortality of mice. Again, the anticonvulsant effect of PSE (100mg/kg, p.o.) was blocked by pre-treatment with flumazenil in the PTZ test.

CONCLUSION

PSE has anticonvulsant activity in animal models, and this effect may be mediated, at least partly, through GABAergic mechanisms.

Community-based rehabilitation offers cost-effective epilepsy treatment in rural Guinea-Bissau

Treatment of epilepsy in low-income countries is a challenge considering the lack of resources, availability of antiepileptic drugs, and cultural beliefs. We used a community-based rehabilitation (CBR) service for the detection, monitoring, and treatment of epilepsy. A local network of trained community volunteers provided education, good quality antiepileptic drugs, and clinical follow-up for people with epilepsy (PWE). In a period of 2years, approximately 22,500 people were screened in central Guinea-Bissau, and 112 PWE were identified and registered. Monthly check-ups were offered to monitor treatment effect and increase compliance. Retrospective analysis on 81 records of patients under treatment in June 2016 showed a decrease of seizure frequency in 88.8% after treatment initiation and was maintained throughout the clinical follow-up of 15months. A conservative estimation of the treatment and monitoring of a single person with epilepsy revealed a daily cost of $0.73. Despite acknowledging epilepsy as a neglected condition by the World Health Organization (WHO), most PWE still lack appropriate treatment. Although CBR service has been suggested as efficient strategy to reduce the treatment gap, little information is available on the efficacy of the programs. Our experiences show that CBR service is a cost-effective approach to monitor treatment and increase compliance in PWE. This experience may be of value for other resource-poor settings.

Active epilepsy prevalence, the treatment gap, and treatment gap risk profile in eastern China: A population-based study

We measured the prevalence of active epilepsy and investigated the treatment gap and treatment gap risk profile in eastern China. This was a cross-sectional population-based survey conducted in Zhejiang, China, from October 2013 to March 2014. A total 54,976 people were selected using multi-stage cluster sampling. A two-stage questionnaire-based process was used to identify patients with active epilepsy and to record their demographic, socioeconomic, and epilepsy-related features. Logistic regression analysis was used to analyze risk factors of the treatment gap in eastern China, as adjusted for age and sex. We interviewed 50,035 people; 118 had active epilepsy (2.4‰), among which the treatment gap was 58.5%. In multivariate analysis, failure to receive appropriate antiepileptic treatment was associated with higher seizure frequency of 12-23 times per year (adjusted odds ratio=6.874; 95% confidence interval [CI]=2.372-19.918), >24 times per year (adjusted odds ratio=19.623; 95% CI=4.999-77.024), and a lack of health insurance (adjusted odds ratio=7.284; 95% CI=1.321-40.154). Eastern China has relatively lower prevalence of active epilepsy and smaller treatment gap. Interventions aimed at reducing seizure frequency, improving the health insurance system should be investigated as potential targets to further bridge the treatment gap.

Parental knowledge and attitudes towards epilepsy -A study from Jordan

PURPOSE

To explore the knowledge, attitudes and behaviors of parents whose children were diagnosed with epilepsy.

METHODS

Cross-sectional questionnaire based study of parents who accompanied their children with epilepsy to the child neurology clinics at three university hospitals in Jordan.

RESULTS

Most parents (427, 90.3%) knew that epilepsy is not related to a psychiatric disease. Approximately half of the parents (245, 51.8%) used the internet as their source of knowledge, and most used Arabic websites. Searching the word epilepsy was rarely used (51, 10.8%). Most of the parents (428,90.5%) were not restricting their children from watching TV or from using the computer (358,75.5%).However, many parents (280,59.2%) were restricting them from participating in sports. Parents had negative attitudes towards epilepsy; 189 (40.0%)thought that epileptic children can have normal intelligence, and 292 (61.7%) thought that they can continue into higher education. Greater parental knowledge of epilepsy was found to be correlated with the parental education level (p<0.05).Positive attitudes and behaviors towards epilepsy were found to be correlated with a higher parental education level, control of epilepsy,an absence of associated co morbidities, a higher income and internet use (p<0.05).

CONCLUSION

This study sheds an important light on the current knowledge status and attitudes of parents of children with epilepsy, and is an invaluable tool for tailoring the delivery of information and support resources for families in our region.

The epidemiological and clinical characteristics study on epilepsy in 8 ethnic groups of China

To survey the epidemiological characteristics and clinical features on epilepsy in eight ethnic groups in Yunnan province of China.

METHODES

The investigation was based on the WHO questionnaire and ICBERG screening questionnaire. This study was performed through random cluster sampling and door-to-door survey.

RESULTS

A total of 76,302 individuals from eight ethnic groups were surveyed. The crude prevalence of epilepsy ranged from 1.2/1000 to 6.5/1000 in the eight ethnic groups, and the age-adjusted prevalence of epilepsy was from 2.1/1000 to 7.3/1000. The prevalence of active epilepsy varied from 1.0/1000 to 5.2/1000 in the eight ethnic groups, and the age-adjusted prevalence of active epilepsy was from 1.8/1000 to 6.7/1000. The age peak for seizures was below twenty, the patients of 61.1%-95.0% suffered from generalized seizures and 5%-21.2% had partial seizures. More than 60% of the cases in five ethnic groups, and the frequency of seizures were more than 10 events per year. More than 50% in other three ethnic groups, and the seizures had occurred less than 10 events per year. The treatment gap for active epilepsy ranged from 43.7% to 100.0% among the eight ethnic groups, while the natural remission rate varied from 5.6% to 21.0%.

CONCLUSION

There were both disparity and similarity in the epidemiological and clinical features of epilepsy in different ethnic group communities.

Effect of the Leaf Essential Oil from Cinnamosma madagascariensis Danguy on Pentylenetetrazol-induced Seizure in Rats

In the Malagasy traditional practices, the smoke from burning leaves of Cinnamosma madagascariensis Danguy is inhaled to treat brain disorders such as dementia, epilepsy, and headache. In the present work, we have evaluated the in vivo anticonvulsant effects of the essential oil from leaves of C. madagascariensis (CMEO). CMEO was isolated by steam distillation. The anticonvulsant activity of CMEO (0.4 and 0.8 ml/kg bw) administered subcutaneously was evaluated on pentylenetetrazol (PTZ)-induced seizures in Wistar rats; diazepam was used as positive control. Linalool, limonene, and myrcene were the major CMEO constituents. At the dose of 0.8 ml/kg, CMEO completely arrested the PTZ-induced convulsions with moderate sedative effects. The traditional anticonvulsant use of C. madagascariensis was confirmed allowing us to candidate molecules from CMEO as potential drugs to treat convulsions associated with strong agitation.

Knowledge, attitude, and practice about epilepsy among teachers at Ethio-National School, Addis Ababa, Ethiopia

BACKGROUND

Epilepsy is one of the most common serious chronic brain disorders and is poorly understood by the public and has been associated with numerous misconceptions and beliefs. This, coupled with its dramatic clinical manifestations, has resulted in a strong social stigma. Since teachers have a key role in society as educators, the purpose of this study was to find out the knowledge, attitude, and practice towards epilepsy among school teachers.

METHODS

A cross-sectional study design was used to assess the knowledge, attitude, and practice of 135 teachers about epilepsy using a semi-structured, self-administered questionnaire. Data were entered into IBM SPSS version 20.0 and analyzed. Descriptive statistics including frequencies, means, and standard deviations were used to describe the data. Associations were computed using a chi-square test and p-value<0.05 was considered significant.

RESULTS

Nearly all teachers 122 (96.3 %) were aware of epilepsy. Only 41% of the respondents had good knowledge about epilepsy whereas 26.8% and 32.3% had fair and poor knowledge about the disease, respectively. About 74% of them had a positive attitude about epilepsy. Only 60.3% of the respondents had proper first aid training. Literacy status and years of experience were not significantly associated with the level of knowledge about epilepsy.

CONCLUSION

A significant proportion of teachers had deficits in terms of general knowledge, attitude, and the appropriate management of epilepsy in the classroom. Therefore, it is important to train and update teachers on epilepsy by the responsible health authorities.

Health service provision for people with epilepsy in sub-Saharan Africa: A situational review

BACKGROUND

Epilepsy is a public health issue in sub-Saharan Africa (SSA) where many people with the condition receive no treatment. Health-care services for epilepsy in this region have not been comprehensively assessed. We examined key features of epilepsy health services provided in SSA.

METHODOLOGY

This was a scoping review conducted using pre-specified protocols. We implemented an electronic search strategy to identify relevant citations using PUBMED, EMBASE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), African Index Medicus (AIM), Open Grey, Cochrane database, and Google Scholar. Articles eligible for full-text review were screened and data of interest were reported.

RESULT

The search identified 81 eligible articles, forty-nine from East Africa, 19 from West Africa, 8 from South Africa, and 5 from Central Africa. A variety of care services were identified, with reporting of rural epilepsy care in 75% of retrieved articles mainly from East and South African countries. The majority of the rural epilepsy clinics were health worker- or nurse-led, reporting good seizure control in about two-thirds of patients using phenobarbital as the most commonly prescribed antiepileptic drug. Funding for rural epilepsy care came mainly from external donor agencies.

CONCLUSION

We attempted to provide a 'snapshot' of epilepsy care services in SSA. The successes achieved in some of the centers are due to the use of existing primary health-care systems and employing non-physician health-care personnel. The true picture of epilepsy care coverage is not apparent due to the lack of data and proper health system structure in most parts of SSA. As more individuals begin to receive care, the long-term funding for epilepsy care in African countries will depend on the commitment of their respective governments.

Magnitude and factors associated with nonadherence to antiepileptic drug treatment in Africa: A cross-sectional multisite study

Objectives

The epilepsy treatment gap is large in low‐ and middle‐income countries, but the reasons behind nonadherence to treatment with antiepileptic drugs (AEDs) across African countries remain unclear. We investigated the extent to which AEDs are not taken and associated factors in people with active convulsive epilepsy (ACE) identified in cross‐sectional studies conducted in five African countries.

Methods

We approached 2,192 people with a confirmed diagnosis of ACE for consent to give blood voluntarily. Participants were asked if they were taking AEDs, and plasma drug concentrations were measured using a fluorescence polarization immunoassay analyzer. Information about possible risk factors was collected using questionnaire‐based clinical interviews. We determined factors associated with nonadherence to AED treatment in children and adults, as measured by detectable and optimal levels, using multilevel logistic regression.

Results

In 1,303 samples assayed (43.7% were children), AEDs were detected in 482, but only 287 had optimal levels. Of the 1,303 samples, 532 (40.8%) were from people who had reported they were on AEDs. The overall prevalence of nonadherence to treatment was 63.1% (95% confidence interval [CI] 60.5–65.6%) as measured by detectable AED levels and 79.1% (95% CI 73.3–84.3%) as measured by optimal AED levels; self‐reported nonadherence was 65.1% (95% CI 45.0–79.5%). Nonadherence was significantly (p < 0.001) more common among the children than among adults for optimal and detectable levels of AEDs, as was the self‐reported nonadherence. In children, lack of previous hospitalization and learning difficulties were independently associated with nonadherence to treatment. In adults, history of delivery at home, absence of burn marks, and not seeking traditional medicine were independently associated with the nonadherence to AED treatment.

Significance

Only about 20% of people with epilepsy benefit fully from antiepileptic drugs in sub‐Saharan Africa, according to optimum AEDs levels. Children taking AEDs should be supervised to promote compliance.

Epilepsy and treatment gap in urban and rural areas of the Southern Kazakhstan in adults

PURPOSE

There are no data in the English literature about the epidemiology of epilepsy in the large countries in the Asian region of the former Soviet Union. This paper presents the results of epidemiological studies of active epilepsy in the population 14years of age and older in the Province of South Kazakhstan.

METHODS

The study population consisted of 306.44 thousand persons: 139.42 in the urban Enbekshinskiy district of the city of Shymkent and 167.02 in the rural Sairam district. To collect patient's data, multiple medical sources were used. For each person with epilepsy (PWE), a questionnaire was completed by members of the research team. Clinical profiles, seizure type, clinical syndrome, etiology, seizure frequency, therapy, educational level, and social status were abstracted.

RESULTS

Overall, 1351 PWE were identified: 459 in the urban district and 892 in the rural district. The age-adjusted prevalence of epilepsy was 3.14/1000 (CI95%: 2.86-3.45) in the urban district and 4.95/1000 (CI95%: 4.62-5.30) in the rural district. Prevalence for men was higher than for women. Focal seizures predominated in both regions. Traumatic brain injury was the most frequently identified cause of epilepsy. The other important antecedents were pre/perinatal disorders, CNS infection, and cerebrovascular disease. Half of PWE experienced more than 12seizures per year. Substantial social impacts of epilepsy were observed: 44% of PWE received disability pensions from the government; only 15.5% were employed. About a quarter of all PWE were not taking AEDs at the time of the record review. For those on treatment, regimens were frequently suboptimal.

CONCLUSION

In the first study performed according to the guidelines for epidemiologic studies on epilepsy of ILAE in the Asian part of the former Soviet Union, poor seizure control and a substantial treatment gap were identified. The need for improvement of epilepsy care was highlighted, especially in the rural regions.

Development and validation of AIIMS modified INCLEN diagnostic instrument for epilepsy in children aged 1 month-18 years

OBJECTIVES

There is shortage of specialists for the diagnosis of children with epilepsy, especially in resource limited settings. Existing INCLEN (International Clinical Epidemiology Network) instrument was validated for children aged 2-9 years. The current study validated modifications of the same including wider symptomatology and age group.

METHODS

The Modified INCLEN tool was validated by a team of experts by modifying the existing tools (2-9 years) to widen the age range from 1 month to 18 years and include broader symptomatology in a tertiary care teaching hospital of North India between January and June 2015. A qualified medical graduate applied the candidate tool which was followed by gold standard evaluation by a Pediatric Neurologist (both blinded to each other).

RESULTS

A total of 197 children {128 boys (65%) and 69 girls (35%)}, with a mean age of 72.08 (±50.96) months, completed the study. The sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio of the modified epilepsy tool were 91.5% (84.5-96.1), 88.6% (80.0-93.5), 89.7% (81.9-95.3), 90.8% (83.7-95.7), 8 (6.6-9.8) and 0.09 (0.07-0.12) respectively.

SIGNIFICANCE

The new modified diagnostic instruments for epilepsy is simple, structured and valid instruments covering 1month to 18 years for use in resource limited settings with acceptable diagnostic accuracy. All seizure semiologies as well as common seizure mimics like breath-holding spells are included in the tool. It also provides for identification of acute symptomatic and febrile seizures.

Premature mortality of epilepsy in low- and middle-income countries: A systematic review from the Mortality Task Force of the International League Against Epilepsy

To determine the magnitude of risk factors and causes of premature mortality associated with epilepsy in low- and middle-income countries (LMICs). We conducted a systematic search of the literature reporting mortality and epilepsy in the World Bank-defined LMICs. We assessed the quality of the studies based on representativeness; ascertainment of cases, diagnosis, and mortality; and extracted data on standardized mortality ratios (SMRs) and mortality rates in people with epilepsy. We examined risk factors and causes of death. The annual mortality rate was estimated at 19.8 (range 9.7-45.1) deaths per 1,000 people with epilepsy with a weighted median SMR of 2.6 (range 1.3-7.2) among higher-quality population-based studies. Clinical cohort studies yielded 7.1 (range 1.6-25.1) deaths per 1,000 people. The weighted median SMRs were 5.0 in male and 4.5 in female patients; relatively higher SMRs within studies were measured in children and adolescents, those with symptomatic epilepsies, and those reporting less adherence to treatment. The main causes of death in people with epilepsy living in LMICs include those directly attributable to epilepsy, which yield a mean proportional mortality ratio (PMR) of 27.3% (range 5-75.5%) derived from population-based studies. These direct causes comprise status epilepticus, with reported PMRs ranging from 5 to 56.6%, and sudden unexpected death in epilepsy (SUDEP), with reported PMRs ranging from 1 to 18.9%. Important causes of mortality indirectly related to epilepsy include drowning, head injury, and burns. Epilepsy in LMICs has a significantly greater premature mortality, as in high-income countries, but in LMICs the excess mortality is more likely to be associated with causes attributable to lack of access to medical facilities such as status epilepticus, and preventable causes such as drowning, head injuries, and burns. This excess premature mortality could be substantially reduced with education about the risk of death and improved access to treatments, including AEDs.