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Ali A, Clarke DF. Digital measures in epilepsy in low-resourced environments. Expert Rev Pharmacoecon Outcomes Res 2024; 24:705-712. [PMID: 37818647 DOI: 10.1080/14737167.2023.2270163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/09/2023] [Indexed: 10/12/2023]
Abstract
INTRODUCTION Digital measures and digital health-care delivery have been rarely implemented in lower-and-middle-income countries (LMICs), contributing to worsening global disparities and inequities. Sustainable ways to implement and use digital approaches will help to improve time to access, management, and quality of life in persons with epilepsy, goals that remain unreachable in under-resourced communities. As under-resourced environments differ in human and economic resources, no one approach will be appropriate to all LMICs. AREAS COVERED Digital health and tools to monitor and measure digital endpoints and metrics of quality of life will need to be developed or adapted to the specific needs of under-resourced areas. Portable technologies may partially address the urban-rural divide. Careful delineation of stakeholders and their engagement and alignment in all efforts is critically important if these initiatives are to be successfully sustained. Privacy issues, neglected in many regions globally, must be purposefully addressed. EXPERT OPINION Epilepsy care in under-resourced environments has been limited by the lack of relevant technologies for diagnosis and treatment. Digital biomarkers, and investigative technological advances, may finally make it feasible to sustainably improve care delivery and ultimately quality of life including personalized epilepsy care.
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Affiliation(s)
- Amza Ali
- Department of Medicine, Faculty of Medical Sciences, Mona, Kingston, Jamaica
| | - Dave F Clarke
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
- Department of Pediatric Epilepsy, Dell Children's Medical Center of Central Texas, Austin, TX, USA
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2
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Grootjans Y, Harrewijn A, Fornari L, Janssen T, de Bruijn ERA, van Atteveldt N, Franken IHA. Getting closer to social interactions using electroencephalography in developmental cognitive neuroscience. Dev Cogn Neurosci 2024; 67:101391. [PMID: 38759529 PMCID: PMC11127236 DOI: 10.1016/j.dcn.2024.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/12/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024] Open
Abstract
The field of developmental cognitive neuroscience is advancing rapidly, with large-scale, population-wide, longitudinal studies emerging as a key means of unraveling the complexity of the developing brain and cognitive processes in children. While numerous neuroscientific techniques like functional magnetic resonance imaging (fMRI), functional near-infrared spectroscopy (fNIRS), magnetoencephalography (MEG), and transcranial magnetic stimulation (TMS) have proved advantageous in such investigations, this perspective proposes a renewed focus on electroencephalography (EEG), leveraging underexplored possibilities of EEG. In addition to its temporal precision, low costs, and ease of application, EEG distinguishes itself with its ability to capture neural activity linked to social interactions in increasingly ecologically valid settings. Specifically, EEG can be measured during social interactions in the lab, hyperscanning can be used to study brain activity in two (or more) people simultaneously, and mobile EEG can be used to measure brain activity in real-life settings. This perspective paper summarizes research in these three areas, making a persuasive argument for the renewed inclusion of EEG into the toolkit of developmental cognitive and social neuroscientists.
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Affiliation(s)
- Yvette Grootjans
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, the Netherlands.
| | - Anita Harrewijn
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, the Netherlands
| | - Laura Fornari
- Department of Clinical, Neuro, and Developmental Psychology & Institute LEARN!, Vrije Universiteit Amsterdam, the Netherlands
| | - Tieme Janssen
- Department of Clinical, Neuro, and Developmental Psychology & Institute LEARN!, Vrije Universiteit Amsterdam, the Netherlands
| | | | - Nienke van Atteveldt
- Department of Clinical, Neuro, and Developmental Psychology & Institute LEARN!, Vrije Universiteit Amsterdam, the Netherlands
| | - Ingmar H A Franken
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, the Netherlands
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Komal K, Cleary F, Wells JSG, Bennett L. A systematic review of the literature reporting on remote monitoring epileptic seizure detection devices. Epilepsy Res 2024; 201:107334. [PMID: 38442551 DOI: 10.1016/j.eplepsyres.2024.107334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Early detection and alert notification of an impending seizure for people with epilepsy have the potential to reduce Sudden Unexpected Death in Epilepsy (SUDEP). Current remote monitoring seizure detection devices for people with epilepsy are designed to support real-time monitoring of their vital health parameters linked to seizure alert notification. An understanding of the rapidly growing literature on remote seizure detection devices is essential to address the needs of people with epilepsy and their carers. AIM This review aims to examine the technical characteristics, device performance, user preference, and effectiveness of remote monitoring seizure detection devices. METHODOLOGY A systematic review referenced to PRISMA guidelines was used. RESULTS A total of 1095 papers were identified from the initial search with 30 papers included in the review. Sixteen non-invasive remote monitoring seizure detection devices are currently available. Such seizure detection devices were found to have inbuilt intelligent sensor functionality to monitor electroencephalography, muscle movement, and accelerometer-based motion movement for detecting seizures remotely. Current challenges of these devices for people with epilepsy include skin irritation due to the type of patch electrode used and false alarm notifications, particularly during physical activity. The tight-fitted accelerometer-type devices are reported as uncomfortable from a wearability perspective for long-term monitoring. Also, continuous recording of physiological signals and triggering alert notifications significantly reduce the battery life of the devices. The literature highlights that 3.2 out of 5 people with epilepsy are not using seizure detection devices because of the cost and appearance of the device. CONCLUSION Seizure detection devices can potentially reduce morbidity and mortality for people with epilepsy. Therefore, further collaboration of clinicians, technical experts, and researchers is needed for the future development of these devices. Finally, it is important to always take into consideration the expectations and requirements of people with epilepsy and their carers to facilitate the next generation of remote monitoring seizure detection devices.
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Affiliation(s)
- K Komal
- School of Health Sciences, South East Technological University, Cork Road, Waterford, Ireland; Walton Institute, South East Technological University, Cork Road, Waterford, Ireland.
| | - F Cleary
- Walton Institute, South East Technological University, Cork Road, Waterford, Ireland
| | - J S G Wells
- School of Health Sciences, South East Technological University, Cork Road, Waterford, Ireland
| | - L Bennett
- School of Health Sciences, South East Technological University, Cork Road, Waterford, Ireland
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Rezaei SJ, Cissé FA, Touré ML, Duan R, Rice DR, Ham AS, de Walque D, Mateen FJ. E = mc 2 : Education (E), medication (m), and conditional cash (c 2 ) to improve uptake of antiseizure medications in a low-resource population: Protocol for randomized trial. Epilepsia Open 2024; 9:445-454. [PMID: 38131270 PMCID: PMC10839367 DOI: 10.1002/epi4.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE Most people with epilepsy (PWE) could live seizure-free if treated with one or more antiseizure medications (ASMs). The World Health Organization (WHO) estimates that 75% of PWE in low-resource settings lack adequate antiseizure treatment. Limited education surrounding epilepsy and the out-of-pocket costs of ASMs in particular pose barriers to managing epilepsy in resource-poor, low-income settings. The aim of this study is to implement and test a novel strategy to improve outcomes across the epilepsy care cascade marked by (1) retention in epilepsy care, (2) adherence to ASMs, and (3) seizure reduction, with the measured goal of seizure freedom. METHODS A randomized, double-blinded clinical trial will be performed, centered at the Ignace Deen Hospital in Conakry, Republic of Guinea, in Western Sub-Saharan Africa. Two hundred people with clinically diagnosed epilepsy, ages 18 years and above, will receive education on epilepsy and then be randomized to (i) free ASMs versus (ii) conditional cash, conditioned upon return to the epilepsy clinic. Participants will be followed for 360 days with study visits every 90 days following enrollment. SIGNIFICANCE We design a randomized trial for PWE in Guinea, a low-resource setting with a high proportion of untreated PWE and a nearly completely privatized healthcare system. The trial includes a conditional cash transfer intervention, which has yet to be tested as a targeted means to improve outcomes for people with a chronic neurological disorder. The trial aims to provide an evidence base for the treatment of epilepsy in such settings. PLAIN LANGUAGE SUMMARY We present a clinical trial protocol for a randomized, blinded study of 200 people with epilepsy in the low-resource African Republic of Guinea, providing an educational intervention (E), and then randomizing in a 1:1 allocation to either free antiseizure medication (m) or conditional cash (c2 ) for 360 days. Measured outcomes include (1) returning to outpatient epilepsy care, (2) adherence to antiseizure medications (ASMs), and (3) reducing the number of seizures. This study is an initial look at giving small amounts of cash for desired results (or "nudges") for improving epilepsy outcomes in the sub-Saharan African and brain disorder contexts.
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Affiliation(s)
- Shawheen J. Rezaei
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Fodé Abass Cissé
- Department of NeurologyIgnace Deen Teaching HospitalConakryGuinea
| | | | - Rui Duan
- Department of BiostatisticsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Dylan R. Rice
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Andrew Siyoon Ham
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | | | - Farrah J. Mateen
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
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Spenard S, Ivan Salazar Cerda C, Cizmeci MN. Neonatal Seizures in Low- and Middle-Income Countries: A Review of the Literature and Recommendations for the Management. Turk Arch Pediatr 2024; 59:13-22. [PMID: 38454256 PMCID: PMC10837585 DOI: 10.5152/turkarchpediatr.2024.23250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 03/09/2024]
Abstract
Neonatal seizures are a common cause of neonatal intensive care unit (NICU) admission and a significant source of morbidity and mortality worldwide. Over the recent decades, there have been significant improvements in perinatal and neonatal medicine and electroencephalograp hic monitoring that have enhanced the diagnosis and treatment of neonatal seizures in highincome countries. However, the management of neonatal seizures remains a major challenge in low- to middle-income countries, where the availabilityof resources is limited. The purpose of this article is to present a comprehensive review of the current evidence on the etiology, pathophysiology, diagnosis, and treatment of neonatal seizures and to offer practical management recommendations that could be implemented in resource-limited settings. Cite this article as: Spenard S, Ivan Salazar Cerda C, Cizmeci MN. Neonatal seizures in low and middleincome countries: Review of the literature and recommendations for the management. Turk Arch Pediatr. 2024;59(1):13-22.
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Affiliation(s)
- Sarah Spenard
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Carlos Ivan Salazar Cerda
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mehmet N. Cizmeci
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Knight A, Gschwind T, Galer P, Worrell GA, Litt B, Soltesz I, Beniczky S. Artificial intelligence in epilepsy phenotyping. Epilepsia 2023:10.1111/epi.17833. [PMID: 37983589 PMCID: PMC11102939 DOI: 10.1111/epi.17833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 11/17/2023] [Indexed: 11/22/2023]
Abstract
Artificial intelligence (AI) allows data analysis and integration at an unprecedented granularity and scale. Here we review the technological advances, challenges, and future perspectives of using AI for electro-clinical phenotyping of animal models and patients with epilepsy. In translational research, AI models accurately identify behavioral states in animal models of epilepsy, allowing identification of correlations between neural activity and interictal and ictal behavior. Clinical applications of AI-based automated and semi-automated analysis of audio and video recordings of people with epilepsy, allow significant data reduction and reliable detection and classification of major motor seizures. AI models can accurately identify electrographic biomarkers of epilepsy, such as spikes, high-frequency oscillations, and seizure patterns. Integrating AI analysis of electroencephalographic, clinical, and behavioral data will contribute to optimizing therapy for patients with epilepsy.
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Affiliation(s)
| | - Tilo Gschwind
- Department of Neurosurgery, Stanford University, Stanford, USA
| | - Peter Galer
- Center for Neuroengineering and Therapeutics; Department of Bioengineering; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, USA
| | | | - Brian Litt
- Center for Neuroengineering and Therapeutics; Department of Bioengineering; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, USA
| | - Ivan Soltesz
- Department of Neurosurgery, Stanford University, Stanford, USA
| | - Sándor Beniczky
- Danish Epilepsy Centre Filadelfia, Dianalund, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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The utility of mobile telephone-recorded videos as adjuncts to the diagnosis of seizures and paroxysmal events in children with suspected epileptic seizures. S Afr Med J 2022; 113:42-48. [PMID: 36537547 DOI: 10.7196/samj.2023.v113i1.16661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Epilepsy is often diagnosed through clinical description, but inter-observer interpretations can be diverse and misleading. OBJECTIVE To assess the utility of smartphone videos in the diagnosis of paediatric epilepsy. METHODS The literature was reviewed for evidence to support the use of smartphone videos, inclusive of advantages, ethical practice and potential disadvantages. An existing adult-based quality of video (QOV) scoring tool was adapted for use in children. A pilot study used convenience sampling of videos from 25 patients, which were reviewed to assess the viability of the adapted QOV tool against the subsequent diagnosis for the patients with videos. The referral mechanism of the videos was reviewed for the source and consent processes followed. RESULTS A total of 14 studies were identified. Methodologies varied; only three focused on videos of children, and QOV was formally scored in three. Studies found that smartphone videos of good quality assisted the differentiation of epilepsy from non-epileptic events, especially with accompanying history and with more experienced clinicians. The ethics and risks of circulation of smartphone videos were briefly considered in a minority of the reports. The pilot study found that the adapted QOV tool correlated with videos of moderate and high quality and subsequent diagnostic closure. CONCLUSIONS Data relating to the role of smartphone video of events in children is lacking, especially from low- and middle-income settings. Guidelines for caregivers to acquire good-quality videos are not part of routine practice. The ethical implications of transfer of sensitive material have not been adequately addressed for this group. Prospective multicentre studies are needed to formally assess the viability of the adapted QOV tool for paediatric videos.
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8
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Rominger C, Gubler DA, Makowski LM, Troche SJ. More creative ideas are associated with increased right posterior power and frontal-parietal/occipital coupling in the upper alpha band: A within-subjects study. Int J Psychophysiol 2022; 181:95-103. [PMID: 36057407 DOI: 10.1016/j.ijpsycho.2022.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/26/2022]
Abstract
The neurophysiological investigation of creative idea generation is a growing research area. EEG studies congruently reported the sensitivity of upper alpha power (10-12 Hz) for the creative ideation process and its outcome. However, the majority of studies were between-subject design studies and research directly comparing the neurophysiological activation pattern when generating more and less creative ideas within a person are rare. Therefore, the present study was specifically focused on investigating brain activation patterns associated with the generation of more vs. less creative ideas. We applied an alternate uses task (AU-task; i.e., finding original uses for everyday objects such as a brick) in a sample of 74 participants and recorded the brain activation during the AU-task and reference period. A portable EEG system with 21 dry electrodes arranged in the international 10-20 system and linked ear as reference was used. We found a higher increase of upper alpha power during creative ideation (relative to reference period, i.e., task-related power, TRP) over right posterior sites when people generated more compared to less creative ideas. This was accompanied by an increase of functional coupling (i.e., task-related coherence increase) between frontal and parietal/occipital sites, which suggests higher internal attention and more control over sensory processes. Taken together, these findings complement the existing creativity research literature and indicate the importance of alpha power for the creative ideation process also within people.
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Affiliation(s)
| | | | - Lisa M Makowski
- Department of Psychology, University of Bern, Bern, Switzerland
| | - Stefan J Troche
- Department of Psychology, University of Bern, Bern, Switzerland
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9
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Xu K, Torgrimson SJ, Torres R, Lenartowicz A, Grammer JK. EEG Data Quality in Real-World Settings: Examining Neural Correlates of Attention in School-Aged Children. MIND, BRAIN AND EDUCATION : THE OFFICIAL JOURNAL OF THE INTERNATIONAL MIND, BRAIN, AND EDUCATION SOCIETY 2022; 16:221-227. [PMID: 38169954 PMCID: PMC10760994 DOI: 10.1111/mbe.12314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/27/2021] [Indexed: 01/05/2024]
Abstract
Advances in mobile electroencephalography (EEG) technology have made it possible to examine covert cognitive processes in real-world settings such as student attention in the classroom. Here, we outline research using wired and wireless EEG technology to examine attention in elementary school children across increasingly naturalistic paradigms in schools, ranging from a lab-based paradigm where children met one-on-one with an experimenter in a field laboratory to mobile EEG testing conducted in the same school during semi-naturalistic classroom lessons. Despite an increase of data loss with the classroom-based paradigm, we demonstrate that it is feasible to collect quality data in classroom settings with young children. We also provide a test case for how robust EEG signals, such as alpha oscillations, can be used to identify measurable differences in covert processes like attention in classrooms. We end with pragmatic suggestions for researchers interested in employing naturalistic EEG methods in real-world, multisensory contexts.
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Affiliation(s)
- Keye Xu
- School of Education and Information Studies, University of California, Los Angeles
| | - Sarah Jo Torgrimson
- School of Education and Information Studies, University of California, Los Angeles
| | - Remi Torres
- School of Education and Information Studies, University of California, Los Angeles
| | - Agatha Lenartowicz
- Semel Institute for Neuroscience and Behavior, University of California, Los Angeles
| | - Jennie K. Grammer
- School of Education and Information Studies, University of California, Los Angeles
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10
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Lopez KL, Monachino AD, Morales S, Leach SC, Bowers ME, Gabard-Durnam LJ. HAPPILEE: HAPPE In Low Electrode Electroencephalography, a standardized pre-processing software for lower density recordings. Neuroimage 2022; 260:119390. [PMID: 35817295 PMCID: PMC9395507 DOI: 10.1016/j.neuroimage.2022.119390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 11/04/2022] Open
Abstract
Lower-density Electroencephalography (EEG) recordings (from 1 to approximately 32 electrodes) are widely-used in research and clinical practice and enable scalable brain function measurement across a variety of settings and populations. Though a number of automated pipelines have recently been proposed to standardize and optimize EEG pre-processing for high-density systems with state-of-the-art methods, few solutions have emerged that are compatible with lower-density systems. However, lower-density data often include long recording times and/or large sample sizes that would benefit from similar standardization and automation with contemporary methods. To address this need, we propose the HAPPE In Low Electrode Electroencephalography (HAPPILEE) pipeline as a standardized, automated pipeline optimized for EEG recordings with lower density channel layouts of any size. HAPPILEE processes task-free (e.g., resting-state) and task-related EEG (including event-related potential data by interfacing with the HAPPE+ER pipeline), from raw files through a series of processing steps including filtering, line noise reduction, bad channel detection, artifact correction from continuous data, segmentation, and bad segment rejection that have all been optimized for lower density data. HAPPILEE also includes post-processing reports of data and pipeline quality metrics to facilitate the evaluation and reporting of data quality and processing-related changes to the data in a standardized manner. Here the HAPPILEE steps and their optimization with both recorded and simulated EEG data are described. HAPPILEE's performance is then compared relative to other artifact correction and rejection strategies. The HAPPILEE pipeline is freely available as part of HAPPE 2.0 software under the terms of the GNU General Public License at: https://github.com/PINE-Lab/HAPPE.
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Affiliation(s)
- K L Lopez
- Northeastern University, 360 Huntington Ave, Boston, MA, United States
| | - A D Monachino
- Northeastern University, 360 Huntington Ave, Boston, MA, United States
| | - S Morales
- University of Maryland, College Park, MD, United States
| | - S C Leach
- University of Maryland, College Park, MD, United States
| | - M E Bowers
- University of Maryland, College Park, MD, United States
| | - L J Gabard-Durnam
- Northeastern University, 360 Huntington Ave, Boston, MA, United States.
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11
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Abstract
Artificial intelligence is already innovating in the provision of neurologic care. This review explores key artificial intelligence concepts; their application to neurologic diagnosis, prognosis, and treatment; and challenges that await their broader adoption. The development of new diagnostic biomarkers, individualization of prognostic information, and improved access to treatment are among the plethora of possibilities. These advances, however, reflect only the tip of the iceberg for the ways in which artificial intelligence may transform neurologic care in the future.
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Affiliation(s)
- James M Hillis
- Digital Clinical Research Organization, Data Science Office, Mass General Brigham, Boston, Massachusetts.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bernardo C Bizzo
- Digital Clinical Research Organization, Data Science Office, Mass General Brigham, Boston, Massachusetts.,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Saadi A, Mendizabal A, Mejia NI. Teleneurology and Health Disparities. Semin Neurol 2022; 42:60-66. [PMID: 35576930 DOI: 10.1055/s-0041-1742194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The disparate access to, and use of, telemedicine reflects those of in-person health. These disparities are perpetuated as a result of individual, social, and structural factors like low digital literacy, unequal availability of broadband services, and systemic racism. This review focuses on extant literature on disparities in teleneurology, including racial or ethnic disparities, language inequities, and the global context. Understanding social and structural barriers to equitable access to quality teleneurology is critical to addressing and preventing health disparities, ensuring effective and equitable neurological care for all patients.
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Affiliation(s)
- Altaf Saadi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Adys Mendizabal
- Department of Neurology, University of California Los Angeles, Los Angeles, California
| | - Nicte I Mejia
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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13
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Biondi A, Santoro V, Viana PF, Laiou P, Pal DK, Bruno E, Richardson MP. Noninvasive mobile EEG as a tool for seizure monitoring and management: A systematic review. Epilepsia 2022; 63:1041-1063. [PMID: 35271736 PMCID: PMC9311406 DOI: 10.1111/epi.17220] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
In the last two decades new noninvasive mobile electroencephalography (EEG) solutions have been developed to overcome limitations of conventional clinical EEG and to improve monitoring of patients with long-term conditions. Despite the availability of mobile innovations, their adoption is still very limited. The aim of this study is to review the current state-of-the-art and highlight the main advantages of adopting noninvasive mobile EEG solutions in clinical trials and research studies of people with epilepsy or suspected seizures. Device characteristics are described, and their evaluation is presented. Two authors independently performed a literature review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A combination of different digital libraries was used (Embase, MEDLINE, Global Health, PsycINFO and https://clinicaltrials.gov/). Twenty-three full-text, six conference abstracts, and eight webpages were included, where a total of 14 noninvasive mobile solutions were identified. Published studies demonstrated at different levels how EEG recorded via mobile EEG can be used for visual detection of EEG abnormalities and for the application of automatic-detection algorithms with acceptable specificity and sensitivity. When the quality of the signal was compared with scalp EEG, many similarities were found in the background activities and power spectrum. Several studies indicated that the experience of patients and health care providers using mobile EEG was positive in different settings. Ongoing trials are focused mostly on improving seizure-detection accuracy and also on testing and assessing feasibility and acceptability of noninvasive devices in the hospital and at home. This review supports the potential clinical value of noninvasive mobile EEG systems and their advantages in terms of time, technical support, cost, usability, and reliability when applied to seizure detection and management. On the other hand, the limitations of the studies confirmed that future research is needed to provide more evidence regarding feasibility and acceptability in different settings, as well as the data quality and detection accuracy of new noninvasive mobile EEG solutions.
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Affiliation(s)
- Andrea Biondi
- Department of Basic and Clinical NeuroscienceInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Viviana Santoro
- Department of Basic and Clinical NeuroscienceInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Pedro F. Viana
- Department of Basic and Clinical NeuroscienceInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK,Faculty of MedicineUniversity of LisbonLisbonPortugal
| | - Petroula Laiou
- Department of Biostatistics and Health InformaticsInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Deb K. Pal
- Department of Basic and Clinical NeuroscienceInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Elisa Bruno
- Department of Basic and Clinical NeuroscienceInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Mark P. Richardson
- Department of Basic and Clinical NeuroscienceInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
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14
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Bernstein J, Kashyap S, Kortz MW, Zakhary B, Takayanagi A, Toor H, Savla P, Wacker MR, Ananda A, Miulli D. Utilization of epilepsy surgery in the United States: A study of the National Inpatient Sample investigating the roles of race, socioeconomic status, and insurance. Surg Neurol Int 2021; 12:546. [PMID: 34877032 PMCID: PMC8645483 DOI: 10.25259/sni_824_2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/11/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Epilepsy is estimated to affect 70 million people worldwide and is medically refractory in 30% of cases. Methods: This is a retrospective cross-sectional study using a US database from 2012 to 2014 to identify patients aged ≥18 years admitted to the hospital with epilepsy as the primary diagnosis. The sampled population was weighted using Healthcare Cost and Utilization Project guidelines. Procedural ICD-9 codes were utilized to stratify the sampled population into two cohorts: resective surgery and implantation or stimulation procedure. Results: Query of the database yielded 152,925 inpatients, of which 8535 patients underwent surgical intervention. The nonprocedural group consisted of 76,000 White patients (52.6%) and 28,390 Black patients (19.7%) while the procedural group comprised 5550 White patients (64%) and 730 Black patients (8.6%) (P < 0.001). Patients with Medicare were half as likely to receive a surgical procedure (14.8% vs. 28.4%) while patients with private insurance were twice as likely to receive a procedure (53.4% vs. 29.3%), both were statistically significant (P < 0.01). Those in the lowest median household income quartile by zip code (<$40,000) were 68% less likely to receive a procedure (21.5% vs. 31.4%) while the highest income quartile was 133% more likely to receive a procedure (26.1% vs. 19.5%). Patients from rural and urban nonteaching hospitals were, by a wide margin, less likely to receive a surgical procedure. Conclusion: We demonstrate an area of need and significant improvement at institutions that have the resources and capability to perform epilepsy surgery. The data show that institutions may not be performing enough epilepsy surgery as a result of racial and socioeconomic bias. Admissions for epilepsy continue to increase without a similar trend for epilepsy surgery despite its documented effectiveness. Race, socioeconomic status, and insurance all represent significant barriers in access to epilepsy surgery. The barriers can be remedied by improving referral patterns and implementing cost-effective measures to improve inpatient epilepsy services in rural and nonteaching hospitals.
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Affiliation(s)
- Jacob Bernstein
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Samir Kashyap
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Michael W Kortz
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Bishoy Zakhary
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Ariel Takayanagi
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Harjyot Toor
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Paras Savla
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Margaret R Wacker
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Ajay Ananda
- Department of Neurosurgery, Kaiser Sunset Medical Center, Los Angeles, California, United States
| | - Dan Miulli
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
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15
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Guelngar CO, Mohamed Lamine T, Mamadou Ciré B, Mamady D, Mahadi K, Bachir Abdoul DH, Foksouna S, Fatimata DH, Naby C, Dago François K, Fatimatou Korka B, Doussou C, Victorine M, Salematou C, Aminata S, Mohamed Tafsir D, Souleymane Djigué B, Mamadou Saliou D, Fodé Mohamed S, Aminou SY, Daouya DG, Said Abdallah R, Mamady K, Souleymane Mbara D, Fodé Abass C, Amara C. Rasmussen syndrome in a tropical environment: a study of six (6) observations. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00409-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In sub-Saharan Africa, encephalitis of various etiologies is a major public health problem and Rasmussen syndrome is rarely diagnosed due to under-medicalization. The objective of this study is to describe the clinical and neuroradiological forms, especially since this affection is little known in sub-Saharan Africa as evidenced by the scarcity of publications.
Results
A retrospective, descriptive and analytical study of six (6) cases of Rasmussen syndrome, shows that it is an unrecognized disease in Africa. Men were more represented with a frequency of 67% with a young age. The clinical picture dominated by 100% seizures, mental deterioration and hemiparesis. The etiology is still questionable, probably autoimmune in our study.
Conclusion
Rasmussen syndrome accounts for 3% in 219 patients hospitalized for epileptic conditions. This study shows a clinical profile dominated by recurrent epileptic seizures refractory to the drugs Phenobarbital, Valproic Acid and Carbamazepine, the only antiepileptics available in the country. These results are valid for therapeutic and prognostic discussion.
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16
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Benson A, Shahwan A. Monitoring the frequency and duration of epileptic seizures: "A journey through time". Eur J Paediatr Neurol 2021; 33:168-178. [PMID: 34120833 DOI: 10.1016/j.ejpn.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/19/2021] [Accepted: 05/25/2021] [Indexed: 11/28/2022]
Abstract
Seizure monitoring plays an undeniably important role in diagnosing and managing epileptic seizures. Establishing the frequency and duration of seizures is crucial for assessing the burden of this chronic neurological disease, selecting treatment methods, determining how frequently these methods are applied, and informing short and long-term therapeutic decisions. Over the years, seizure monitoring tools and methods have evolved and become increasingly sophisticated; from home seizure diaries to EEG monitoring to cutting-edge responsive neurostimulation systems. In this article, the various methods of seizure monitoring are reviewed.
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Affiliation(s)
- Ailbhe Benson
- Department of Clinical Neurophysiology & Neurology, CHI at Temple Street, Dublin, Ireland.
| | - Amre Shahwan
- Department of Clinical Neurophysiology & Neurology, CHI at Temple Street, Dublin, Ireland.
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17
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Cossu A, Lo Barco T, Darra F, Fontana E, Fiorini E, Marangone M, Biban P, Dalla Bernardina B, Cantalupo G. Remote Teamwork Management of NORSE During the COVID-19 Lockdown. Neurol Clin Pract 2020; 11:e170-e173. [PMID: 33842087 DOI: 10.1212/cpj.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/30/2020] [Indexed: 11/15/2022]
Abstract
New-onset refractory status epilepticus (NORSE) is rare condition, and sharing knowledge is vital in its management, based on strict collaboration between multiple specialists, continuous EEG (c-EEG) monitoring, and prompt therapy modification. The coronavirus disease 2019 (COVID-19) pandemic challenged many of these established practices because of "social distancing" measures, making it necessary to work around physical restrictions. We report a case of a 10-year-old with NORSE admitted in a pediatric intensive-care unit and monitored with c-EEG and amplitude-integrated EEG. The monitoring interface was livestreamed using videoconference web-based platforms allowing remote viewing. Multiple daily web meetings took place between team members, where real-time therapy response was evaluated and confronted with medium-term trends in the epileptic activity, dictating further treatment and diagnostic steps. In addition to the known use of telemedicine in chronic conditions, we report how its use can be exploited to treat urgent conditions such as NORSE. By taking advantage of new tools and virtual environments, we were able to share treatment and diagnostic decisions and guarantee real-time therapy adjustments and a coherent course in treatment despite restrictions necessary for the COVID-19 pandemic. The constant specialist monitoring and the coherent and on-time communication of the patient's condition relieved the family stress, usually complained in these situations.
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Affiliation(s)
- Alberto Cossu
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Tommaso Lo Barco
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Francesca Darra
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Elena Fontana
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Elena Fiorini
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Martina Marangone
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Paolo Biban
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Bernardo Dalla Bernardina
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
| | - Gaetano Cantalupo
- Child Neuropsychiatry (FD, TLB, FD, GC), Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona; Clinical and Experimental Medicine PhD Program (TLB), University of Modena and Reggio Emilia; Child Neuropsychiatry Unit (FD, E. Fontana, E. Fiorini, MM, GC), and Pediatric Intensive Care Unit (PB), University-Hospital of Verona; and Center for Research on Epilepsies in Pediatric Age (CREP) (BDB), Verona, Italy
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18
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Verhagen LM, de Groot R, Lawrence CA, Taljaard J, Cotton MF, Rabie H. COVID-19 response in low- and middle-income countries: Don't overlook the role of mobile phone communication. Int J Infect Dis 2020; 99:334-337. [PMID: 32763447 PMCID: PMC7402274 DOI: 10.1016/j.ijid.2020.07.069] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/22/2020] [Accepted: 07/26/2020] [Indexed: 01/25/2023] Open
Abstract
Estimates of health capacities in the context of the coronavirus disease 2019 (COVID-19) pandemic indicate that most low- and middle-income countries (LMICs) are not operationally ready to manage this health emergency. Motivated by worldwide successes in other infectious disease epidemics and our experience in Sub-Saharan Africa, we support mobile phone communication to improve data collection and reporting, communication between healthcare workers, public health institutions, and patients, and the implementation of disease tracking and subsequent risk-stratified isolation measures. Programmatic action is needed for centrally coordinated reporting and communication systems facilitating mobile phones in crisis management plans for addressing the COVID-19 pandemic in LMICs. We summarize examples of worldwide mobile phone technology initiatives that have enhanced patient care and public health outcomes in previous epidemics and the current COVID-19 pandemic. In addition, we provide an overview of baseline conditions, including transparency about privacy guarantees, necessary for the successful use of mobile phones in assisting in the fight against COVID-19 spread.
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Affiliation(s)
- Lilly M Verhagen
- Department of Paediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Paediatrics and Child Health, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa.
| | - R de Groot
- Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C A Lawrence
- Western Cape Government, Department of Health, Health Programmes, Communicable Disease Control and Surveillance, Cape Town, South Africa
| | - J Taljaard
- Division of Infectious Diseases, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - M F Cotton
- Department of Paediatrics and Child Health, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - H Rabie
- Department of Paediatrics and Child Health, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa
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19
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Sokolov E, Abdoul Bachir DH, Sakadi F, Williams J, Vogel AC, Schaekermann M, Tassiou N, Bah AK, Khatri V, Hotan GC, Ayub N, Leung E, Fantaneanu TA, Patel A, Vyas M, Milligan T, Villamar MF, Hoch D, Purves S, Esmaeili B, Stanley M, Lehn-Schioler T, Tellez-Zenteno J, Gonzalez-Giraldo E, Tolokh I, Heidarian L, Worden L, Jadeja N, Fridinger S, Lee L, Law E, Fodé Abass C, Mateen FJ. Tablet-based electroencephalography diagnostics for patients with epilepsy in the West African Republic of Guinea. Eur J Neurol 2020; 27:1570-1577. [PMID: 32359218 DOI: 10.1111/ene.14291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/24/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- E Sokolov
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | - F Sakadi
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | - J Williams
- Department of Neurology, Mater Misericordiae University Hospital and Dublin Neurological Institute, Dublin, Ireland
| | - A C Vogel
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | - N Tassiou
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | - A K Bah
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | - V Khatri
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - G C Hotan
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Boston, MA, USA
| | - N Ayub
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - E Leung
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, USA.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, USA
| | - T A Fantaneanu
- Division of Neurology, The Ottawa Hospital, Ottawa, ON, Canada
| | - A Patel
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - M Vyas
- Division of Neurology, University of Toronto, Toronto, ON, USA
| | - T Milligan
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - M F Villamar
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - D Hoch
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - S Purves
- University of British Columbia, Vancouver, BC, Canada
| | - B Esmaeili
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - M Stanley
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - J Tellez-Zenteno
- University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | | | - I Tolokh
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - L Worden
- Children's Hospital of Philadelphia, PA, USA
| | - N Jadeja
- University of Massachusetts School of Medicine, Boston, MA, USA
| | - S Fridinger
- Children's Hospital of Philadelphia, PA, USA
| | - L Lee
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - E Law
- University of Waterloo, Waterloo, ON, Canada
| | - C Fodé Abass
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | - F J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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