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Mastick ML, Tshering L, Dema U, Chhetri B, Dorji C, Nirola DK, Subedi P, Lhamo S, Diyali K, Chodden SR, Ham AS, Mateen FJ. A quality of care assessment for women of childbearing potential with epilepsy in Bhutan: An observational study. Epilepsy Behav 2024; 156:109819. [PMID: 38704988 DOI: 10.1016/j.yebeh.2024.109819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/26/2024] [Accepted: 04/28/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND & OBJECTIVE In lower-middle income countries such as Bhutan, the treatment gap for epilepsy is over 50% as compared to a treatment gap of less than 10% in high-income countries. We aim to analyze the quality of epilepsy care for women of childbearing potential in Bhutan using the Quality Indicators in Epilepsy Treatment (QUIET) tool, and to assess the usefulness of the tool's section for women with active epilepsy (WWE) in the Bhutanese setting. METHODS A prospective convenience cohort was enrolled in Thimphu, Paro, Punakha, and Wangdue, Kingdom of Bhutan, in 2022. Bhutanese women of childbearing potential at the time of enrollment (18-44 years old) were evaluated for the diagnosis of active epilepsy and underwent a structured survey-based interview with Bhutanese staff. Participants were surveyed on their epilepsy, pregnancy, and antiseizure medicine (ASM) histories. The clinical history and quality of epilepsy care of adult WWE were assessed using a section of the QUIET tool for women, an instrument originally developed by the U.S. Department of Veterans Affairs to analyze the quality of epilepsy care for American adults. RESULTS There were 82 Bhutanese WWE of childbearing potential, with mean age of 30.6 years at enrollment (range 18-44, standard deviation (SD) 6.6) and mean age of 20.3 years at epilepsy diagnosis (range 3-40, SD 8.0)). 39 % (n = 32) had a high school or above level of education, and 42 % (n = 34) were employed. 35 % (n = 29) reported a seizure within the prior week, and 88 % (n = 72) reported a seizure within the prior year. 49 % (n = 40) of participants experienced > 100 lifetime seizures. All but one participant took antiseizure medications (ASMs). At enrollment, participants presently took no (n = 1), one (n = 3), two (n = 37), three (n = 25), four (n = 11), or over five (n = 5) ASMs. The most common ASMs taken were levetiracetam (n = 40), phenytoin (n = 27), carbamazepine (n = 23), phenobarbital (n = 22), and sodium valproate (n = 20). 61 % of all WWE took folic acid. Of the 40 previously pregnant WWE, eight (20 %) took folic acid during any time of their pregnancy. 35 % (n = 29) used betel nut (doma, quid) and 53 % (n = 21) of pregnant WWE used betel nut during pregnancy. CONCLUSIONS Based on data about WWE participants' ASM, supplement, and substance use, our study identified the high use of first generation ASMs (including valproate), frequently in polytherapy, and betel nut use as treatment gaps in women of childbearing potential age with active epilepsy in Bhutan. To address these gaps for locations such as Bhutan, we propose modifications to the QUIET tool's "Chronic Epilepsy Care for Women" section.
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Affiliation(s)
- Maya L Mastick
- Harvard College, Cambridge, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Lhab Tshering
- Jigme Dorji Wangchuck National Referral Hospital of Bhutan, Thimphu, Kingdom of Bhutan
| | - Ugyen Dema
- Jigme Dorji Wangchuck National Referral Hospital of Bhutan, Thimphu, Kingdom of Bhutan
| | - Bikram Chhetri
- Jigme Dorji Wangchuck National Referral Hospital of Bhutan, Thimphu, Kingdom of Bhutan
| | - Chencho Dorji
- Jigme Dorji Wangchuck National Referral Hospital of Bhutan, Thimphu, Kingdom of Bhutan
| | - Damber K Nirola
- Jigme Dorji Wangchuck National Referral Hospital of Bhutan, Thimphu, Kingdom of Bhutan
| | - Puja Subedi
- Jigme Dorji Wangchuck National Referral Hospital of Bhutan, Thimphu, Kingdom of Bhutan
| | - Sonam Lhamo
- Gidakon Hospital, Thimphu, Kingdom of Bhutan
| | - Kiran Diyali
- Jigme Dorji Wangchuck National Referral Hospital of Bhutan, Thimphu, Kingdom of Bhutan
| | - Sonam R Chodden
- Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Kingdom of Bhutan
| | - Andrew S Ham
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Ham AS, Hacker CT, Guo J, Sorby-Adams A, Kimberly WT, Mateen FJ. Feasibility and tolerability of portable, low-field brain MRI for patients with multiple sclerosis. Mult Scler Relat Disord 2024; 85:105515. [PMID: 38489947 DOI: 10.1016/j.msard.2024.105515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/22/2024] [Accepted: 02/24/2024] [Indexed: 03/17/2024]
Abstract
Low-field, portable MRI (LF-MRI) promises to expand neuroimaging access for patients with multiple sclerosis (MS). We aimed to measure the feasibility and tolerability of LF-MRI for clinical use in 50 people with MS (mean age 46.5 ± 15.3 years; 72 % female; median disease duration 5.9 years), 38 % of whom reported barriers to undergoing MRI, and 34 % of whom were low-income or unemployed. Experience ratings of LF-MRI were strongly positive (mean rating of 9.2 on a ten-point scale). Seventy percent of participants were willing to receive future LF-MRI scans, and 46 % preferred LF-MRI to standard MRI (35 % undecided). The overall feasibility and tolerability of LF-MRI support its integration into a one-stop, patient-centered model of outpatient MS care.
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Affiliation(s)
- Andrew Siyoon Ham
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Jennifer Guo
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Annabel Sorby-Adams
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Saadi A, Prabhu M, Snyder SA, Daboul L, Mateen FJ. Neurological Care of Refugees and Other Forcibly Displaced Persons. Semin Neurol 2024; 44:217-224. [PMID: 38499195 DOI: 10.1055/s-0044-1782495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.
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Affiliation(s)
- Altaf Saadi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meha Prabhu
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Sara A Snyder
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lynn Daboul
- Mass General Brigham Neurology Residency Program, Boston, Massachusetts
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Udawatta M, Mateen FJ. Nicolau syndrome following glatiramer acetate for multiple sclerosis: Case and review of reports. Ann Clin Transl Neurol 2024; 11:1080-1085. [PMID: 38483009 PMCID: PMC11021678 DOI: 10.1002/acn3.52044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 04/18/2024] Open
Abstract
Nicolau syndrome is a rare, iatrogenic skin reaction after parental drug administration, characterized by severe pain at an injection site, followed by hemorrhage, ulceration, and often necrosis. We present a case of a patient on glatiramer acetate for many years (initially Copaxone then Glatopa) who developed Nicolau syndrome, the second reported case after generic glatiramer acetate. All reported cases of Nicolau syndrome after glatiramer acetate are reviewed. The case highlights the importance of prompt recognition of this skin reaction by neurologists and raises awareness of the risks of skin reactions even in low-risk injectable DMTs.
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Affiliation(s)
- Methma Udawatta
- Department of NeurologyBrigham and Women's HospitalBostonMassachusettsUSA
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Farrah J. Mateen
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
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Hjerthen IG, Trápaga Hacker C, Meador W, Obeidat AZ, Horta L, Mateen FJ. Impact of neuromyelitis optica spectrum disorder on employment and income in the United States. Ann Clin Transl Neurol 2024; 11:1011-1020. [PMID: 38374778 PMCID: PMC11021617 DOI: 10.1002/acn3.52021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/18/2024] [Accepted: 02/03/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES We aim to characterize the sociodemographic and clinical factors associated with loss of jobs, income, and work hours in people with neuromyelitis optica spectrum disorder (NMOSD) in the United States. METHODS A REDCap-based survey was administered to working-age NMOSD patients (18-70 years old) querying demographic information, symptoms, immunosuppression, work hours, income, and caregiver work (11/2022-07/2023). Regression models were developed using MATLAB. RESULTS Of 127 participants (97 female; 55% AQP4-antibody, 19% MOG antibody; 69% Caucasian, 7% Hispanic), with an average diagnosis age of 38.7 years, average disease duration of 6.4 years, mean 3.1 attacks, and 94% of whom were treated with immune system-directed therapy (53% rituximab, 8% satralizumab, 7% eculizumab, 6% mycophenolate mofetil, 4% inebilizumab, 2% azathioprine, 10% IVIg, 10% other), 56% lost a job due to NMOSD. Employment decreased 12% (80% pre- to 68% post-diagnosis). Thirty-six percent of participants said they no longer worked outside the home. Significant predictors for post-NMOSD diagnosis employment status included younger age, lower pain level, no walking aids, and having a job prediagnosis. Sixty-eight percent of those employed prediagnosis reduced their work hours, dropping an average of 18.4 h per month since being diagnosed (±10.1 h). Average annual income grew slowly at $1998 during the average 6.4 years of disease duration (14% of the value predicted by the U.S. Bureau of Labor Statistics). Sixty percent of participants had a regular unpaid caregiver; 34% of caregivers changed their work hours or job to help manage NMOSD. DISCUSSION We provide a structured analysis of the impact of NMOSD on employment, work hours, and income in the United States, demonstrating its major effect on the livelihoods of patients and their caregivers.
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Affiliation(s)
- Isabella Gomez Hjerthen
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
- School of Engineering and Applied SciencesHarvard CollegeCambridgeMassachusettsUSA
| | | | - William Meador
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Ahmed Z. Obeidat
- Department of NeurologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Lucas Horta
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Farrah J. Mateen
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Galetta K, Ham AS, Vishnevetsky A, Bhattacharyya S, Mateen FJ. Disease modifying therapy in the treatment of tumefactive multiple sclerosis: A retrospective cohort study. J Neuroimmunol 2024; 388:578299. [PMID: 38364529 DOI: 10.1016/j.jneuroim.2024.578299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 02/18/2024]
Abstract
Tumefactive multiple sclerosis (TMS) is characterized by large demyelinating brain lesions. This was a retrospective cohort study of 67 patients with TMS between January 2015-2023, examining different disease modifying therapy impact on expanded disability scale score change at follow-up. Median age was 36 with a female predominance. Mean EDSS was 3.3 ± 2.3 at TMS onset, 2.1 ± 1.9 at year one, and 2.1 ± 1.9 at last follow-up. A multilinear regression model found higher presentation EDSS and post-diagnosis non-B-cell high efficacy therapies were each independently associated with higher EDSS at last follow up. Further research is needed to determine the value of B-cell therapy in TMS.
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Affiliation(s)
- Kristin Galetta
- Department of Neurology, Stanford University, Palo Alto, CA, USA; Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Andrew Siyoon Ham
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | | | | | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Briggs FB, Trapl ES, Mateen FJ, Nadai AD, Conway DS, Gunzler DD. Common Social and Health Disparities Contribute to Racial Differences in Ambulatory Impairment in Multiple Sclerosis. Int J MS Care 2024; 26:36-40. [PMID: 38213671 PMCID: PMC10779710 DOI: 10.7224/1537-2073.2023-004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND We previously reported more rapid accrual of ambulatory impairments in Black compared to White individuals with relapsing remitting multiple sclerosis (RRMS) and higher body mass index (BMI). Hypertension and lower neighborhood socioeconomic status (SES) were associated with greater impairment, irrespective of race. We hypothesize that these common social and health inequities may explain a substantial portion of the racial differences in ambulation in American individuals with RRMS. METHODS Causal mediation analyses investigated baseline and change-over-time mediators of ambulatory impairment differences between 1795 Black and White individuals with RRMS using a retrospective cohort study comprised of electronic health record data from 8491 clinical encounters between 2008 and 2015 where Timed 25-Foot Walk (T25FW) speeds without assistive devices were recorded. The hypothesis was that BMI, neighborhood SES, and hypertension were possible mediators. RESULTS At baseline, Black individuals with RRMS (n = 175) had significantly slower T25FW speeds (5.78 vs 5.27 ft/s), higher BMI, a higher prevalence of hypertension, and they were more likely to live in lower-income neighborhoods than White individuals (n = 1,620). At baseline, a significant proportion (33.7%; 95% CI, 18.9%-59.4%) of the T25FW difference between Black and White individuals was indirectly due to a higher BMI (12.5%), hypertension burden (9.5%), and living in lower-income neighborhoods (11.2%). Once baseline mediation relationships were accounted for, there were no significant longitudinal mediation relationships. CONCLUSIONS The findings implicate social and health disparities as prominent drivers of ambulatory differences between Black and White individuals with RRMS, suggesting that wellness and health promotion are essential components of MS care, particularly for Black individuals.
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Affiliation(s)
- Farren B.S. Briggs
- From the Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA (FBSB)
| | - Erika S. Trapl
- The Department of Population and Quantitative Health Sciences (FBSB, EST, DDG), the Prevention Research Center for Healthy Neighborhoods (EST), and the Center for Health Care Research and Policy (DDG), School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Farrah J. Mateen
- The Department of Neurology, Division of Neuroimmunology and Neuroinfectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA (FJM)
| | | | - Devon S. Conway
- The Department of Neurology, Neurological Institute, Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic Foundation, Cleveland, OH, USA (DSC)
| | - Douglas D. Gunzler
- The Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA (DSC)
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Rice DR, Guelngar CO, Traoré M, Condé ML, Diallo D, Lee NJ, Ham AS, Cissé FA, Mateen FJ. Impact of a free medication intervention on seizure recurrence and anxious and depressive symptoms in people living with epilepsy in the Republic of Guinea. Trop Med Int Health 2024; 29:33-41. [PMID: 38031206 DOI: 10.1111/tmi.13950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Of ~5 million people living with epilepsy (PLWE) in Sub-Saharan Africa, roughly one-third experience depression and over one third experience anxiety. In Guinea, these issues may be compounded by fewer available resources, such as appropriate anti-seizure medications (ASMs). We aim to quantify seizure frequency, anxiety and depression in PLWE in Guinea, before and after a free ASM intervention and neurologist's consultation. METHODS Guinean participants >12 years old with ≥2 unprovoked seizure were prospectively recruited. As part of a broader interview, participants reported prior 30-day seizure frequency and screened for depression (PHQ-9) (range 0-27 points) and anxiety (GAD-7) (range 0-21 points) with re-evaluation at 90 days. RESULTS Of 148 participants enrolled (mean age = 27.3 years, range 12-72; 45% female), 62% were currently taking ASMs. For the 30 days pre-enrolment, average seizure frequency was 3.2 (95%CI 2.3, 4.2); 28% of participants were seizure-free. ASM regimens were modified for 95% of participants, mostly initiating levetiracetam (n = 115, 80% of modifications). 90-day study retention was 76% (n = 113) among whom 87% reported full adherence to the ASM. After 90 days, the average seizure frequency over the prior 30 days was 1.5 (95%CI 0.5, 2.6), significantly lower than at baseline (p = 0.002). 66% were seizure-free. At baseline, average PHQ-9 score was 21.2 (95%CI [20.2, 22.2]), indicating severe depressive symptoms. Average GAD-7 score was 16.5 [15.6, 17.4], indicating severe anxious symptoms. At 90-days, average PHQ-9 score was 17.5[16.4, 18.5] and significantly lower than baseline (p < 0.001). Average GAD-7 score was 14.4 [13.6, 15.3] and significantly lower than baseline (p = 0.002). Seizure frequency was not correlated with PHQ-9 nor GAD-7 scores at baseline but was at 90 days for both PHQ-9 (r = 0.24, p = 0.01) and GAD-7 (r = 0.22, p = 0.02) scores. The prevalence of suicidal ideation dropped from 67% to 47% of participants (p = 0.004). DISCUSSION ASM management has dual importance for PLWE in resource-limited settings, improving both seizure control and mental health.
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Affiliation(s)
- Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Mohamed Traoré
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea
| | - Mohamed Laminé Condé
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea
| | - Djenabou Diallo
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea
| | - Nathanael J Lee
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew Siyoon Ham
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fodé Abass Cissé
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Mateen FJ, Trápaga Hacker C. Perceptions of people with multiple sclerosis on social determinants of health: Mixed methods. Mult Scler Relat Disord 2023; 80:105089. [PMID: 37897932 DOI: 10.1016/j.msard.2023.105089] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/18/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE To explore the social determinants of health (SDOH) in people with multiple sclerosis (MS) with SDOH, elucidating the SDOH variables of highest salience in this geographical region. METHODS Focus groups and a structured survey of Massachusetts residents with SDOH and a diagnosis of MS were conducted by a neurologist and staff, December 2022-July 2023, via Zoom™. Twenty-one consecutively-recruited, convenience-sampled adults participated in four groups. A thematic inductive approach was taken. RESULTS Participants (average age 45 years old; average time since MS diagnosis 13.7 years; 14 cisgender female, 1 transgender female, 5 cisgender male, 1 non-binary; 33 % white, 57 % black, 5 % Asian, 5 % other; 18 % Hispanic/Latinx; modal response of 5 SDOH) identified the following key SDOH: (1) race and ethnicity, related to (a) diagnostic delays in MS, (b) limited familiarity with MS and its etiology, and (c) value of ongoing MS care; (2) gender, focused on limited published data in African American men and transgender people; (3) social and community contexts; and (4) financial burdens, related to (a) out-of-pocket costs of MS disease modifying therapies, (b) lost work time, and (c) transportation. Lower frequency SDOH variables were access to public toilets, lost job promotions, environmental exposures, and concern about discrimination. Unmet needs emphasized (1) public understanding of MS; (2) financial support for DMT costs, closer access to infusion centers, and culturally competent care; (3) support for research participation; (4) reliable transportation; and (5) patient awareness of extant services and support programs. CONCLUSIONS This in-depth assessment of people with MS who possess multiple SDOH identified the most salient and commonly experienced SDOH, common themes related to the SDOH in MS, unmet needs, and future opportunities.
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Affiliation(s)
- Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, United States; Harvard Medical School, United States.
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Plantone D, Sabatelli E, Locci S, Marrodan M, Laakso SM, Mateen FJ, Feresiadou A, Buelens T, Bianco A, Fiol MP, Correale J, Tienari P, Calabresi P, De Stefano N, Iorio R. Clinically relevant increases in serum neurofilament light chain and glial fibrillary acidic protein in patients with Susac syndrome. Eur J Neurol 2023; 30:3256-3264. [PMID: 37335505 DOI: 10.1111/ene.15939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND AND PURPOSE Serum levels of neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) are promising neuro-axonal damage and astrocytic activation biomarkers. Susac syndrome (SS) is an increasingly recognized neurological condition and biomarkers that can help assess and monitor disease evolution are highly needed for the adequate management of these patients. sNfL and sGFAP levels were evaluated in patients with SS and their clinical relevance in the relapse and remission phase of the disease was assessed. METHODS As part of a multicentre study that enrolled patients diagnosed with SS from six international centres, sNfL and sGFAP levels were assessed in 22 SS patients (nine during a relapse and 13 in remission) and 59 age- and sex-matched healthy controls using SimoaTM assay Neurology 2-Plex B Kit. RESULTS Serum NfL levels were higher than those of healthy controls (p < 0.001) in SS patients and in both subgroups of patients in relapse and in remission (p < 0.001 for both), with significantly higher levels in relapse than in remission (p = 0.008). sNfL levels showed a negative correlation with time from the last relapse (r = -0.663; p = 0.001). sGFAP levels were slightly higher in the whole group of patients than in healthy controls (p = 0.046) and were more pronounced in relapse than in remission (p = 0.013). CONCLUSION In SS patients, both sNFL and sGFAP levels increased compared with healthy controls. Both biomarkers had higher levels during clinical relapse and much lower levels in remission. sNFL was shown to be time sensitive to clinical changes and can be useful to monitor neuro-axonal damage in SS.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Eleonora Sabatelli
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | - Sara Locci
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Sini M Laakso
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amalia Feresiadou
- Department of Neurology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Section of Neurology, Uppsala University, Uppsala, Sweden
| | - Tom Buelens
- Department of Ophthalmology, CHU St Pierre and Brugmann, Brussels, Belgium
| | - Assunta Bianco
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | | | - Jorge Correale
- Neurology Department, Fleni, Buenos Aires, Argentina
- Institute of Biological Chemistry and Biophysics (IQUIFIB) CONICET, University of Buenos Aires, Buenos Aires, Argentina
| | - Pentti Tienari
- Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
- Research Program of Translational Immunology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Ham AS, Traore M, Othon GC, Conde ML, Lamine TM, Djigué BS, Kaba C, Karinka D, Idrissa D, Idrissa C, Diallo D, Duan R, Rice DR, Cisse FA, Mateen FJ. Improvement in health perception but not quality of life with an antiseizure medication intervention in people with epilepsy in Guinea: A cohort study. Seizure 2023; 111:30-35. [PMID: 37506562 DOI: 10.1016/j.seizure.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND This study assesses perceptions of quality of life (QOL) and overall health in people with epilepsy (PWE) in Guinea after a clinical intervention providing modified and new antiseizure medicine (ASM) regimens. METHODS Participants 12 years and older diagnosed with active epilepsy were prospectively and consecutively enrolled at two health centers in the Republic of Guinea (one urban, one rural) in 2022. 95% of participants were prescribed new/increased ASM doses, and interviewed for QOL and overall health perceptions at enrollment and three- and six-month follow ups. Univariate and linear mixed models were used to evaluate effects on QOL and overall health over time. RESULTS The mean QOLIE-31 score (±SD) among 148 Guinean PWE (82 male, 66 female; mean age 27.3; 137 with >1 seizure in prior year) was 51.7 ± 12.8 at enrollment, 57.6 ± 16.0 after three months (n = 116), and 52.2 ± 9.9 after six months (n = 87). Overall health scores were 53.1 ± 26.9, 72.6 ± 21.5, and 65.7 ± 20.2 respectively. After three months, PWE had improved overall health and QOLIE-31 scores (p<0.0001, p = 0.003), but these improvements persisted for overall health and not QOLIE-31 after six months (p = 0.001, p = 0.63). Seizure freedom (prior 30 days) was 26% initially, and 62 (42%) of the remaining PWE experiencing seizures achieved seizure freedom at either the first or second follow-ups. CONCLUSIONS A noticeable discrepancy exists between Guinean PWE's self-rated perceptions of QOL and overall health. Purely clinical interventions may not be sufficient to improve QOL, especially in people that experience severe, previously-untreated epilepsy in lower income settings.
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Affiliation(s)
| | - Mohamed Traore
- National Ignace Deen Hospital, University of Conakry, Guinea
| | | | | | | | | | - Condé Kaba
- National Ignace Deen Hospital, University of Conakry, Guinea
| | - Diawara Karinka
- National Ignace Deen Hospital, University of Conakry, Guinea
| | | | - Camara Idrissa
- National Ignace Deen Hospital, University of Conakry, Guinea
| | - Djenabou Diallo
- National Ignace Deen Hospital, University of Conakry, Guinea
| | - Rui Duan
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Farrah J Mateen
- Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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13
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Schiess N, Kulo V, Anand P, Bearden DR, Berkowitz AL, Birbeck GL, Cervantes-Arslanian A, Chan P, Chishimba LC, Chow FC, Elicer I, Fleury A, Kinikar A, Kvalsund M, Mateen FJ, Mbonde AA, Meyer ACL, O'Carroll CB, Ogunniyi A, Patel AA, Rubenstein M, Siddiqi OK, Spudich S, Tackett SA, Thakur KT, Vora N, Zunt J, Saylor DR. Consensus Competencies for Postgraduate Fellowship Training in Global Neurology. Neurology 2023; 101:357-368. [PMID: 36997322 PMCID: PMC10449442 DOI: 10.1212/wnl.0000000000207184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/27/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Use a modified Delphi approach to develop competencies for neurologists completing ≥1 year of advanced global neurology training. METHODS An expert panel of 19 United States-based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, United States-based neurologists participated in 3 rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of 7 neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies. RESULTS Three rounds of surveys, a conference call with United States-based experts, and a semistructured questionnaire and focus group discussion with LMIC experts were used to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across 8 domains: (1) cultural context, social determinants of health and access to care; (2) clinical and teaching skills and neurologic medical knowledge; (3) team-based practice; (4) developing global neurology partnerships; (5) ethics; (6) approach to clinical care; (7) community neurologic health; (8) health care systems and multinational health care organizations. DISCUSSION These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.
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Affiliation(s)
- Nicoline Schiess
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Violet Kulo
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Pria Anand
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - David R Bearden
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Aaron L Berkowitz
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Gretchen L Birbeck
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Anna Cervantes-Arslanian
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Phillip Chan
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Lorraine Chishimba Chishimba
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Felicia C Chow
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Isabel Elicer
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Agnes Fleury
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Aarti Kinikar
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Michelle Kvalsund
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Farrah J Mateen
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Amir A Mbonde
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Ana-Claire L Meyer
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Cumara B O'Carroll
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Adesola Ogunniyi
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Archana A Patel
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Michael Rubenstein
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Omar K Siddiqi
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Serena Spudich
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Sean A Tackett
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Kiran T Thakur
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Nirali Vora
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Joseph Zunt
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Deanna R Saylor
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle.
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Abstract
The standard of care for patients with neuromyelitis optica (NMO) has become highly unequal globally. Sufficient data have been published to demonstrate that NMO is a disabling-and at times, fatal-disease needing preventive immunosuppressive treatment. Since 2019, there are multiple regulatory authority-approved disease-modifying therapies (DMTs) for aquaporin-4 antibody seropositive NMO for patients. Reframing the picture of NMO globally is now needed. When considered as a disease of high mortality when left untreated, parallel programs to those for cancer, HIV/AIDS, or tuberculosis can be considered. Nine collective goals for rectifying global inequities in NMO diagnosis and treatment are proposed.
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Affiliation(s)
- Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
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Mateen FJ, Hanafi I, Birbeck GL, Saadi A, Schmutzhard E, Wilmshurst JM, Silsbee H, Jones LK. Neurologic Care of Forcibly Displaced Persons: Emerging Issues in Neurology. Neurology 2023; 100:962-969. [PMID: 36859408 PMCID: PMC10186241 DOI: 10.1212/wnl.0000000000206857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/07/2022] [Indexed: 03/03/2023] Open
Abstract
There is a growing number of forcibly displaced persons (FDPs) worldwide. With more than 100 million people forcibly displaced today, there is an urgent mandate to understand the neurologic care needs of this population and how neurologists and other health care workers can most effectively provide that care. In this Emerging Issues in Neurology article, we attempt to (1) define the scope of the problem of providing neurologic care to FDPs, (2) highlight commonly encountered clinical challenges related to neurologic care of FDPs, and (3) provide useful clinical information for neurologists and other clinicians who deliver care to FDPs with neurologic needs. We address the terminology of forcible displacement and how terms may differ across a person's migration journey. Common challenges encountered by FDPs with neurologic needs across settings include loss of support systems, loss of personal health information, language barriers and differing expression of symptoms, differing belief systems, epidemiologic patterns of disease unfamiliar to the clinician, and patients' fear and perceived risks of engaging with health systems. Practical approaches are shared for clinicians who encounter an FDP with a neurologic presentation. Finally, the article discusses many unmet neurologic needs of FDPs, which require significant investment. These include addressing lapses in neurologic care during displacement and understanding the effects of forcible displacement on people with chronic neurologic conditions. Future research and educational resources should focus on improving epidemiologic intelligence for neurologic conditions across geographies, developing curricula for optimizing the neurologic care of FDPs, and evaluating the most appropriate and effective uses of health technologies in humanitarian settings.
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Affiliation(s)
- Farrah J Mateen
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN
| | - Ibrahem Hanafi
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN
| | - Gretchen L Birbeck
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN
| | - Altaf Saadi
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN
| | - Erich Schmutzhard
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN
| | - Jo M Wilmshurst
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN
| | - Heather Silsbee
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN.
| | - Lyell K Jones
- From the Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Department of Neurology (I.H.), University Hospital of Würzburg, Germany; Department of Neurology (G.L.B.), University of Rochester Medical Center, NY; Department of Neurology (A.S.), Massachusetts General Hospital, Boston; Department of Neurology (E.S.), Medical University Innsbruck, Austria; Department of Paediatric Neurology (J.M.W.), University of Cape Town, South Africa; American Academy of Neurology (H.S.), Minneapolis, MN; and Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN
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Manzano GS, Rice DR, Zurawski J, Jalkh Y, Bakshi R, Mateen FJ. Familial Mediterranean Fever and multiple sclerosis treated with ocrelizumab: Case report. J Neuroimmunol 2023; 379:578099. [PMID: 37172371 DOI: 10.1016/j.jneuroim.2023.578099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 03/25/2023] [Accepted: 05/02/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND Familial Mediterranean Fever (FMF) is associated with increased risk of multiple sclerosis (MS). Optimal treatment of patients with comorbid FMF and MS remains uncertain. CASE A 28-year-old woman with FMF, treated with colchicine, had symptomatic onset of relapsing remitting MS following four simultaneous vaccines. MRI brain with a 7-Tesla magnet demonstrated several areas of leptomeningeal enhancement with predominant linear, spread/fill and rare nodular patterns. Central vein signs were present in supratentorial white matter lesions. She received four cycles of ocrelizumab and achieved no evidence of disease activity (NEDA-3) at 20 months' follow up. DISCUSSION FMF with incident CNS demyelinating disease demonstrated neuroimaging features typical for classic RRMS including the central vein sign and leptomeningeal enhancement. Treatment with B-cell depleting therapy for FMF-MS led to clinical stability and symptomatic improvement at 20 months' follow up. We add to the sparse literature characterizing the course of FMF as a genetic risk factor for CNS demyelinating disease, demonstrating pathognomonic imaging features of MS on 7 T imaging and treatment efficacy with B-cell depletion.
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Affiliation(s)
- Giovanna S Manzano
- Department of Neurology, Massachusetts General Hospital, Boston, USA; Department of Neurology, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, MA, USA
| | - Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, USA
| | - Jonathan Zurawski
- Department of Neurology, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, MA, USA
| | - Youmna Jalkh
- Department of Neurology, Brigham and Women's Hospital, Boston, USA
| | - Rohit Bakshi
- Department of Neurology, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, USA; Harvard Medical School, Boston, MA, USA.
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McInnis RP, Ayub MA, Jing J, Halford JJ, Mateen FJ, Westover MB. Epilepsy diagnosis using a clinical decision tool and artificially intelligent electroencephalography. Epilepsy Behav 2023; 141:109135. [PMID: 36871319 PMCID: PMC10082472 DOI: 10.1016/j.yebeh.2023.109135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/10/2022] [Accepted: 02/02/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE To construct a tool for non-experts to calculate the probability of epilepsy based on easily obtained clinical information combined with an artificial intelligence readout of the electroencephalogram (AI-EEG). MATERIALS AND METHODS We performed a chart review of 205 consecutive patients aged 18 years or older who underwent routine EEG. We created a point system to calculate the pre-EEG probability of epilepsy in a pilot study cohort. We also computed a post-test probability based on AI-EEG results. RESULTS One hundred and four (50.7%) patients were female, the mean age was 46 years, and 110 (53.7%) were diagnosed with epilepsy. Findings favoring epilepsy included developmental delay (12.6% vs 1.1%), prior neurological injury (51.4% vs 30.9%), childhood febrile seizures (4.6% vs 0.0%), postictal confusion (43.6% vs 20.0%), and witnessed convulsions (63.6% vs 21.1%); findings favoring alternative diagnoses were lightheadedness (3.6% vs 15.8%) or onset after prolonged sitting or standing (0.9% vs 7.4%). The final point system included 6 predictors: Presyncope (-3 points), cardiac history (-1), convulsion or forced head turn (+3), neurological disease history (+2), multiple prior spells (+1), postictal confusion (+2). Total scores of ≤1 point predicted <5% probability of epilepsy, while cumulative scores ≥7 predicted >95%. The model showed excellent discrimination (AUROC: 0.86). A positive AI-EEG substantially increases the probability of epilepsy. The impact is greatest when the pre-EEG probability is near 30%. SIGNIFICANCE A decision tool using a small number of historical clinical features accurately predicts the probability of epilepsy. In indeterminate cases, AI-assisted EEG helps resolve uncertainty. This tool holds promise for use by healthcare workers without specialty epilepsy training if validated in an independent cohort.
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Affiliation(s)
- Robert P. McInnis
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, University of San Francisco, California, San Francisco, CA, United States
| | - Muhammad Abubakar Ayub
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Lousiana State University Health Sciences Center, Shreveport, LA, United States
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jonathan J. Halford
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
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18
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Mateen FJ, Trápaga Hacker CM. Understanding the employment impact of neuromyelitis optica spectrum disorder in the USA: Mixed methods. Front Neurol 2023; 14:1142640. [PMID: 36970509 PMCID: PMC10033531 DOI: 10.3389/fneur.2023.1142640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/17/2023] [Indexed: 03/11/2023] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare and disabling neurological disorder, marked by recurrent attacks of the central nervous system. NMO has a high female predominance and disproportionately affects racial and ethnic groups who are under- and unemployed in the USA. Three focus groups, involving 20 working age adults with NMOSD in the USA, were convened via Zoom online, to discuss the topic of employment in NMOSD. Consolidated Criteria for Reporting Qualitative research (COREQ) were followed. Discussions were coded for major themes using an inductive approach. The following themes emerged: (1) Barriers due to NMOSD on employment including (i) visible and invisible symptoms, (ii) the burden of treatment, and (iii) time to diagnosis; (2) Mitigating factors when NMOSD affects employment; (3) Impact of COVID-19; (4) Impact on income; (5) Impact on new and future employment and higher education opportunities; and (6) Unmet needs that are pragmatically addressable, outside of major policy or scientific changes.
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Rice DR, Holroyd KB, Pua DK, Levy M, Mateen FJ, Bhattacharyya S. Quantifying the economic burden to patients of relapse events from neuromyelitis optica spectrum disorders: A cross-sectional survey. Mult Scler Relat Disord 2023; 71:104580. [PMID: 36805175 DOI: 10.1016/j.msard.2023.104580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/09/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
We surveyed 103 adults (mean age 46 years; 85% female) with neuromyelitis optica spectrum disorders (NMOSD) through social media about their personal economic burden of NMOSD emergency department visits and hospitalizations ("relapse events"). The average number of relapse events over the prior 3 years was 5.3. Participants reported direct, out-of-pocket costs for 52% of events (mean cost per event 3326 USD, 95% CI [2378,4274]) and indirect costs (e.g., childcare) for 26% (mean cost per event 1907 USD, 95% CI [1159,2655]). Sixty-nine percent reported lost income due to hospital visits. Future work should identify and support subgroups with higher economic burden from NMOSD.
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Affiliation(s)
- Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Kathryn B Holroyd
- Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA
| | - Danielle Kei Pua
- Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Shamik Bhattacharyya
- Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA.
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20
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Abstract
This scoping review assesses the use of conditional cash transfer (CCT) interventions - direct distribution of money to individuals conditional on their compliance to certain requirements - in randomised controlled trials, quasi-experimental studies and large community-based randomised trials with health-focused outcomes. Five databases were searched to identify 68 records published 2004-2021 from 25 countries (8 low- (32%), 5 lower middle- (20%), 6 upper middle- (24%) and 6 high-income (24%), according to the World Bank Categorisation (2017). Forty-six studies were unique (after excluding multiple publications on a single study). The most common outcomes assessed were infectious diseases (30%); maternal health (24%); vaccination rates (17%); and childhood developmental measures (17%). The number of participants receiving CCT in each study ranged from 47 to 5,788, with a median of 487 individuals. The number of total participants ranged from 72 to 14,000, with a median of 1,289 individuals. Fifteen percent of studies involved mobile CCT disbursement. More than a quarter of payments were greater than 50 USD (29%), and most payments were 20 USD or less (58%). Seventy-eight percent of unique full-length studies reported statistically significant CCT effects. Although CCTs remain controversial, a growing evidence base is emerging for their potential impact in specific health conditions.
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Affiliation(s)
- Shawheen J Rezaei
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA
| | | | - Farrah J Mateen
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA
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21
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Mateen FJ. Progress towards the 2030 sustainable development goals: direct and indirect impacts on neurological disorders. J Neurol 2022; 269:4623-4634. [PMID: 35583660 DOI: 10.1007/s00415-022-11180-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
The United Nations' Sustainable Development Goals (SDGs) were set forth in 2015 as a blueprint for all nations to create a more sustainable future together. These 17 social, environmental, and economic goals have established targets to meet globally by the year 2030, with a focus on pro-poor initiatives, gender equality, and ending hunger. The relationship of the SDGs with neurological disorders and how the achievement of the SDGs intersects with the future of neurological practice have not been comprehensively examined. However, the incidence of neurological disorders, the outcomes of people living with neurological disorders, and the training of future neurologists can be interlinked, directly or indirectly, with programming for the SDGs and their eventual achievement. Each SDG is reviewed in the context of neurology. This lens can inform programming and policy, enhance research and training, and improve inter-sectoral action for neurological disorders worldwide.
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Affiliation(s)
- Farrah J Mateen
- Department of Neurology, Neurological Clinical Research Institute, Massachusetts General Hospital, 165 Cambridge Street, #627, Boston, MA, 02114, USA.
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22
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Rice DR, Vogel AC, Ismail SS, Okeng'o K, Lugemwa GK, Henry J, Kourkoulis C, Mateen FJ. Apolipoprotein E genotypes in stroke patients from urban Tanzania. J Neurol Sci 2022; 440:120331. [DOI: 10.1016/j.jns.2022.120331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
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Rice DR, Balamo A, Thierry AR, Gueral A, Fidele D, Mateen FJ, Sakadi F. COVID-19 vaccine acceptance and hesitancy in N'Djamena, Chad: A cross-sectional study of patients, community members, and healthcare workers. PLOS Glob Public Health 2022; 2:e0000608. [PMID: 36962369 PMCID: PMC10022375 DOI: 10.1371/journal.pgph.0000608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/17/2022] [Indexed: 06/18/2023]
Abstract
As of March 2022, the COVID-19 vaccination rate in Chad approximated 1%. There are no published reports of COVID-19 vaccine hesitancy or beliefs in Chad. We aimed to study COVID-19 vaccine acceptance and hesitancy among community members, patients, and health care workers in urban Chad. We recruited a prospective convenience sample of adult patients, community members, and healthcare workers from N'Djamena, Chad between August-October 2021. Participants completed a 15-minute, 25-question survey instrument exploring demographic, social, and clinical variables related to COVID-19 and an adapted WHO SAGE Vaccine Hesitancy Survey. Primary outcomes were vaccine acceptance and vaccine hesitancy. Regression models were fit to assess associations between Vaccine Hesitancy Scale (VHS) scores, ranging from 10 (least hesitant) to 50 (most hesitant) points, and pre-selected variables of interest. An inductive thematic analysis was used to analyze the qualitative vaccine hesitancy responses. Of 508 participants (32% female; mean age 32 years), 162 were patients, 153 were community members, and 193 were healthcare workers. COVID-19 vaccine acceptance was significantly higher among patients (67%) than community members (44%) or healthcare workers (47%), p < .001. The average VHS score was 29 points (patients = 27.0, community members = 28.9, healthcare workers = 29.4), and more than one-third of participants were classified as highly vaccine hesitant (score >30 points). Knowing someone who died from COVID-19, believing local healthcare workers support vaccination, trusting the government, having a higher socioeconomic status (i.e. having electricity), and reporting medical comorbidities were each associated with less vaccine hesitancy (all p < .05). The vaccine concerns most frequently endorsed were: vaccine side effects (48%), efficacy (38%), safety (34%), concerns about the pharmaceutical industry (27%), and lack of government trust (21%). Four main themes arose from qualitative vaccine hesitancy responses (n = 116): education, trust, clinical concerns, and misinformation and false beliefs. Overall, COVID-19 vaccine acceptance was low, including among health care workers, and reasons for vaccine hesitancy were broad. We detail the most commonly reported concerns of urban Chadians for receiving the COVID-19 vaccine; we also identify subgroups most likely to endorse vaccine hesitancy. These analyses may inform future vaccination outreach campaigns in N'Djamena.
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Affiliation(s)
- Dylan R. Rice
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Anatole Balamo
- Neurology Unit, National Reference Teaching Hospital, N’Djamena, Chad
| | | | - Aremadji Gueral
- Neurology Unit, National Reference Teaching Hospital, N’Djamena, Chad
| | - Djerakoula Fidele
- Neurology Unit, National Reference Teaching Hospital, N’Djamena, Chad
| | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Foksouna Sakadi
- Neurology Unit, National Reference Teaching Hospital, N’Djamena, Chad
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24
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Manzano GS, Salky R, Mateen FJ, Klawiter EC, Chitnis T, Levy M, Matiello M. Positive Predictive Value of MOG-IgG for Clinically Defined MOG-AD Within a Real-World Cohort. Front Neurol 2022; 13:947630. [PMID: 35795797 PMCID: PMC9251463 DOI: 10.3389/fneur.2022.947630] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
Myelin oligodendrocyte glycoprotein antibody associated disease (MOG-AD) is a CNS demyelinating disease, typically presenting with optic neuritis, transverse myelitis, and/or ADEM-like syndromes. The positive predictive value (PPV) of MOG-IgG testing by live cell-based assay was reported to be 72% in a study performed at the Mayo Clinic using a cut-off of 1:20. PPV may vary depending upon the tested population, thus supporting further investigation of MOG-IgG testing at other centers. In this real-world institutional cohort study, we determined the PPV of serum MOG-IgG for clinically defined MOG-AD in our patient population. The Massachusetts General Brigham Research Patient Data Registry database was queried for patients with positive serum MOG-IgG detection, at least once, between January 1, 2017 and March 25, 2021. All were tested via the MOG-IgG1 fluorescence-activated cell sorting assay (Mayo Laboratories, Rochester, MN). MOG-IgG positive cases were reviewed for fulfillment of typical MOG-AD clinical features, determined by treating neurologists and study authors. Of 1,877 patients tested, 78 (4.2%) patients tested positive for MOG-IgG with titer ≥1:20, and of these, 67 had validated MOG-AD yielding a PPV of 85.9%. Using a ≥1:40 titer cutoff, 65 (3.5%) tested positive and PPV was 93.8%. Three MOG positive cases had a prototypical multiple sclerosis diagnosis (RRMS n = 2, titers 1:20 and 1:40; PPMS n = 1; 1:100). The treating diagnosis for one RRMS patient with a 1:40 titer was subsequently modified to MOG-AD by treating neurologists. Validated diagnoses of the remaining positive patients without MOG-AD included: migraine (n = 2, titers 1:20, 1:100), inclusion body myositis (n = 1, titer 1:100), autoimmune encephalitis (n = 2, titers 1:20, 1:20), hypoxic ischemic brain injury (n = 1, titer 1:20), IgG4-related disease (n = 1, titer 1:20), and idiopathic hypertrophic pachymeningitis (n = 1, titer 1:20). In our cohort, the PPV for MOG-IgG improved utilizing a titer cut-off of ≥1:40. The presence of positive cases with and without demyelinating features, emphasizes a need for testing in the appropriate clinical context, analysis of titer value and clinical interpretation.
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Affiliation(s)
- Giovanna S. Manzano
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Giovanna S. Manzano
| | - Rebecca Salky
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Eric C. Klawiter
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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25
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Abstract
Several clinical and ethical dilemmas arise when caring for refugees with complex, costly, and chronic conditions in low- and middle-income countries where they often first seek asylum. This commentary responds to a case involving a patient asylee with a malignant brain tumor and considers these questions: (1) Should refugee care costs be allocated as a specific amount per refugee or designated to fund only specific interventions? (2) Should interventions not available to host population members with low incomes be available to refugees? (3) Should refugee cancer care focus on cure, rehabilitation, and palliation or on just one or two of these areas? This commentary responds to these questions by considering how to approach trade-offs between numbers of patients treated and per patient expenditures.
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Affiliation(s)
- Farrah J Mateen
- Associate professor at Harvard Medical School in Boston, Massachusetts
| | - Paul B Spiegel
- Director of the Johns Hopkins Center for Humanitarian Health and a professor in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland
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26
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Manzano GS, Rice DR, Klawiter EC, Matiello M, Gillani RL, Tauhid SS, Bakshi R, Mateen FJ. Anti-SARS-CoV-2 monoclonal antibodies for the treatment of active COVID-19 in multiple sclerosis: An observational study. Mult Scler 2022; 28:1146-1150. [PMID: 35475382 DOI: 10.1177/13524585221092309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Monoclonal antibodies (mAbs) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) received emergency use authorization for the acute treatment of COVID-19. We are not aware of published data on their use in immunosuppressed people with multiple sclerosis (pwMS). We report 23 pwMS (mean age = 49 years, ocrelizumab (n = 19), fingolimod (n = 2), vaccinated with at least an initial series (n = 19)) who received mAb for acute COVID-19. Following mAb receipt, approximately half recovered in <7 days (48%). There were no adverse events or deaths. Use of mAb for pwMS treated with fingolimod or ocrelizumab was not observed to be harmful and is likely helpful for treatment of acute COVID-19.
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Affiliation(s)
- Giovanna S Manzano
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Dylan R Rice
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Eric C Klawiter
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Marcelo Matiello
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Rebecca L Gillani
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Shahamat S Tauhid
- Harvard Medical School, Boston, MA, USA/Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Rohit Bakshi
- Harvard Medical School, Boston, MA, USA/Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Farrah J Mateen
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
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Mateen FJ. Low-dose rituximab should be used for treating MS in resource-limited settings: No. Mult Scler 2022; 28:1030-1032. [PMID: 35437067 PMCID: PMC9131394 DOI: 10.1177/13524585221089889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Mateen FJ, Massawe E, Mworia NA, Ismail S, Rice DR, Vogel AC, Kapina B, Mukyanuzi N, Buma DC, Gluckstein J, Wasserman M, Fasoli SE, Chiwanga F, Okeng’o K. Measuring Ambulation, Motor, and Behavioral Outcomes with Post-stroke Fluoxetine in Tanzania: The Phase II MAMBO Trial. Am J Trop Med Hyg 2022; 106:970-978. [PMID: 34872059 PMCID: PMC8922504 DOI: 10.4269/ajtmh.21-0653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/21/2021] [Indexed: 11/07/2022] Open
Abstract
We test the safety of fluoxetine post-ischemic stroke in sub-Saharan Africa. Adults with acute ischemic stroke, seen <14 days since new-onset motor deficits, were enrolled from November 2019 to October 2020 in a single-arm, open-label phase II trial of daily fluoxetine 20 mg for 90 days at Muhimbili National Hospital, Dar es Salaam, Tanzania. The primary outcome was safety with secondary outcomes of medication adherence and tolerability. Thirty-four patients were enrolled (11 were female; mean age 52.2 years, 65% < 60 years old; mean 3.3 days since symptom onset). Participants had hypertension (74%), diabetes (18%), and smoked cigarettes (18%). The median National Institutes of Health Stroke Scale score at enrollment was 10.5. The median Fugl-Meyer Motor Scale score was 28.5 (upper extremity 8, lower extremity 17.5). 32/34 participants (91%) survived to 90 days. There were eight serious and two nonserious adverse events. Deaths occurred due to gastrointestinal illness with low serum sodium (nadir 120 mmol/L) with seizure and gastrointestinal bleed from gastric cancer. The average sodium level at 90 days was 139 mmol/L (range 133-146) and alanine transaminase was 28 U/L (range 10-134). Fluoxetine adherence was 96%. The median modified Rankin Scale score among survivors at 90 days was 2 and Fugl-Meyer Motor Scale score was 66 (upper extremity 40, lower extremity 27). Median 90-day Patient Health Questionnaire-9 and Montgomery-Åsberg scores were 3.5 and 4 (minimal depression). Fluoxetine administration for 90 days poststroke in sub-Saharan Africa was generally safe and well-tolerated, but comorbid illness presentations were fatal in 2/34 cases, even after careful participant selection.
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Affiliation(s)
- Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts;,Address correspondence to Farrah Mateen, Department of Neurology, Massachusetts General Hospital, 165 Cambridge St., #627, Boston, MA 02114. E-mail:
| | - Emmanuel Massawe
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Notburga A. Mworia
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Seif Ismail
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Dylan R. Rice
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andre C. Vogel
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Boniface Kapina
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Novath Mukyanuzi
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Deus C. Buma
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Jef Gluckstein
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Wasserman
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Faraja Chiwanga
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
| | - Kigocha Okeng’o
- Department of Neurology, Muhimbili National Hospital, Dar es Salaam, United Republic of Tanzania
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Rice DR, Nishiyama S, Pardo S, Cabal Herrera AM, Levy M, Mateen FJ. A point-of-care diagnostic test for aquaporin-4 antibody seropositive neuromyelitis optica. Mult Scler Relat Disord 2022; 60:103716. [PMID: 35247751 DOI: 10.1016/j.msard.2022.103716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Given the need for specialized laboratory techniques, diagnostic testing for serum antibodies to aquaporin-4, a protein associated with neuromyelitis optica spectrum disorder (NMOSD), is not globally accessible. We aimed to evaluate a novel point-of-care, filter paper-based test for serum AQP4 antibodies (AQP4-Ab). METHODS Adults with AQP4-Ab seropositive NMOSD and seronegative controls (with other central nervous system demyelinating diagnoses) used lancets to place blood drops (∼1 mL) on filter paper cards. Samples were analyzed after an average of 9.4 days using transfected AQP4-GFP HEK293 cells, and results were compared to participants' prior serum AQP4-Ab test results by blinded laboratory staff. RESULTS Of 40 participants (mean age 53.7 years; 83% female), 25 were cases and 15 were controls. The most common diagnosis of controls was multiple sclerosis (73%). The average NMOSD disease duration was 6.3 years. All AQP4-Ab seropositive participants were on disease modifying therapies at the time of participation. The point-of-care test yielded a sensitivity of 80% and specificity of 93% (positive and negative predictive values 95% and 74%). CONCLUSION This point-of-care AQP4-Ab testing method may become a pragmatic option to diagnose AQP4-Ab seropositive NMOSD in difficult-to-reach settings. This method should be confirmed with other testing parameters and field tested in new populations.
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Affiliation(s)
- Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Shuhei Nishiyama
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America; Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Santiago Pardo
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Ana M Cabal Herrera
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Michael Levy
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
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Rice DR, Okeng'o K, Massawe E, Ismail S, Mworia NA, Chiwanga F, Kapina B, Wasserman M, Mateen FJ. Efficacy of Fluoxetine for Post-Ischemic Stroke Depression in Tanzania. J Stroke Cerebrovasc Dis 2022; 31:106181. [PMID: 34740138 PMCID: PMC8766895 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Post-stroke fluoxetine trials are primarily conducted in high-income countries. We characterize post-ischemic stroke depression in fluoxetine-treated and -untreated study participants in urban Tanzania. METHODS Adults (>18 years old) within 14 days of CT-confirmed acute ischemic stroke onset were enrolled at Muhimbili National Hospital, Tanzania. The fluoxetine-treated group took 20mg fluoxetine daily for 90 days in a phase II trial and were compared to fluoxetine-untreated historical controls. The primary outcome was depression at 90 days, measured by the Patient Health Questionnaire-9 (PHQ-9). PHQ-9 scores were compared between fluoxetine-treated and -untreated groups. A score >=9 points was considered to reflect depression. A multivariable linear regression model assessed associations with post-stroke PHQ-9 scores. RESULTS Of the fluoxetine-treated (n=27) and -untreated (n=32) participants, the average age was 56.8 years old (39% women, 100% Black/African). The average presentation NIHSS score was 12.1 points and modified Rankin Scale (mRS) score was 3.5. The average mRS score at 90-day follow-up was 2.3. There was no significant difference between 90-day PHQ-9 scores in the fluoxetine-treated (mean=4.1 points, standard deviation=3.2; 11% depression) and untreated (mean=4.4, standard deviation=4.8; 19% depression) groups, p=.69. In the multivariable analysis, older age (β=0.08, p=.03) and higher NIHSS score (β=0.15, p=.04), but neither fluoxetine (β=0.57, p=.59) nor sex (β=-0.51, p=.63), were significantly associated with more depressive symptoms. CONCLUSIONS Our findings parallel results from trials from higher income settings that fluoxetine does not significantly improve post-ischemic stroke depression, although our sample size was small. More work is needed to depict the longitudinal nature and treatment of post-stroke depression in Sub-Saharan Africa.
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Affiliation(s)
- Dylan R Rice
- Massachusetts General Hospital, Boston, MA, United States
| | | | | | - Seif Ismail
- Muhimbili National Hospital, Dar es Salaam, Tanzania
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Cabal-Herrera AM, Mateen FJ. Randomized Controlled Trials for Neuromyelitis Optica Spectrum Disorder: A Review of Trial Architecture. Neurologist 2021; 27:14-20. [PMID: 34855669 DOI: 10.1097/nrl.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorder (NMOSD) is a relapsing inflammatory disease that primarily affects the optic nerves and the spinal cord. Randomized controlled trials (RCTs) assessing treatments for NMOSD have only been performed in the past decade, and to date, there are 3 drugs approved by the US Food and Drug Administration (FDA) for antiaquaporin-4 immunoglobulin G seropositive NMOSD. This review assesses the characteristics and challenges of RCTs when evaluating treatments for NMOSD. REVIEW SUMMARY We conducted a review using the terms ("neuromyelitis optica" OR "NMO" OR "NMOSD") AND "clinical trial" in any language on March 28, 2021. Seven RCTs were included, and the trials' architecture was analyzed and synthesized. Overall, 794 subjects were randomized [monoclonal antibody intervention group, n= 493 (62.1%), placebo, n=196 (24.7%), and active control, n=105 (13.2%)]; 709 (89.3%) were females; and 658 (82.9%) were aquaporin-4 (AQP4) antibody seropositive. The primary outcome was time to relapse in 6/7 of the trials, and annualized relapse rate in the remaining one. Four RCTs used placebo in their design. Among the seven published RCTs, the trial design differed by the criteria used to define NMOSD relapse, selection of subjects, proportion of AQP4 immunoglobulin G seronegative patients, and baseline characteristics indicating NMO disease severity. CONCLUSIONS Ethical considerations for the use of placebo should change in light of the approval of 3 therapies for seropositive NMOSD. Remaining challenges for clinical trials in NMOSD include the assessment of long-term safety and efficacy, standardization of trial design and endpoints, and head-to-head study designs.
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Briggs FBS, Mateen FJ, Schmidt H, Currie KM, Siefers HM, Crouthamel S, Bebo BF, Fiol J, Racke MK, O'Connor KC, Kolaczkowski LG, Klein P, Loud S, McBurney RN. COVID-19 Vaccination Reactogenicity in Persons With Multiple Sclerosis. Neurol Neuroimmunol Neuroinflamm 2021; 9:9/1/e1104. [PMID: 34753828 PMCID: PMC8579248 DOI: 10.1212/nxi.0000000000001104] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES There are limited data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine reactogenicity in persons with multiple sclerosis (PwMS) and how reactogenicity is affected by disease-modifying therapies (DMTs). The objective of this retrospective cross-sectional study was to generate real-world multiple sclerosis-specific vaccine safety information, particularly in the context of specific DMTs, and provide information to mitigate specific concerns in vaccine hesitant PwMS. METHODS Between 3/2021 and 6/2021, participants in iConquerMS, an online people-powered research network, reported SARS-CoV-2 vaccines, experiences of local (itch, pain, redness, swelling, or warmth at injection site) and systemic (fever, chills, fatigue, headache, joint pain, malaise, muscle ache, nausea, allergic, and other) reactions within 24 hours (none, mild, moderate, and severe), DMT use, and other attributes. Multivariable models characterized associations between clinical factors and reactogenicity. RESULTS In 719 PwMS, 64% reported experiencing a reaction after their first vaccination shot, and 17% reported a severe reaction. The most common reactions were pain at injection site (54%), fatigue (34%), headache (28%), and malaise (21%). Younger age, being female, prior SARS-CoV-2 infection, and receiving the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vs BNT162b2 (Pfizer-BioNTech) vaccine were associated with experiencing a reaction after the first vaccine dose. Similar relationships were observed for a severe reaction, including higher odds of reactions among PwMS with more physical impairment and lower odds of reactions for PwMS on an alpha4-integrin blocker or sphingosine-1-phosphate receptor modulator. In 442 PwMS who received their second vaccination shot, 74% reported experiencing a reaction, whereas 22% reported a severe reaction. Reaction profiles after the second shot were similar to those reported after the first shot. Younger PwMS and those who received the mRNA-1273 (Moderna) vs BNT162b2 vaccine reported higher reactogenicity after the second shot, whereas those on a sphingosine-1-phosphate receptor modulator or fumarate were significantly less likely to report a reaction. DISCUSSION SARS-CoV-2 vaccine reactogenicity profiles and the associated factors in this convenience sample of PwMS appear similar to those reported in the general population. PwMS on specific DMTs were less likely to report vaccine reactions. Overall, the short-term vaccine reactions experienced in the study population were mostly self-limiting, including pain at the injection site, fatigue, headache, and fever.
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Affiliation(s)
- Farren Basil Shaw Briggs
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA.
| | - Farrah J Mateen
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Hollie Schmidt
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Keisha M Currie
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Heather M Siefers
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Slavka Crouthamel
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Bruce F Bebo
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Julie Fiol
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Michael K Racke
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Kevin C O'Connor
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Laura G Kolaczkowski
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Phyllis Klein
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Sara Loud
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
| | - Robert Nicholas McBurney
- From the Department of Population and Quantitative Health Science (F.B.S.B.), School of Medicine, Cleveland, OH; Department of Neurology (F.J.M.), Massachusetts General Hospital, Boston; Accelerated Cure Project for MS (H.S., S.L., R.N.M.), Waltham, MA; Currie Consultancy (K.M.C.), LLC Eastover, SC; International AIDS Vaccine Initiative (H.M.S.), Frederick, MD; Mammoth Hospital (S.C.), Mammoth Lakes, CA; National Multiple Sclerosis Society (B.F.B., J.F.); Medical Affairs (M.K.R.), Quest Diagnostics, Secaucus, NJ; Departments of Neurology and Immunobiology (K.C.O.), Yale University School of Medicine, New Haven, CT; and iConquerMS (L.G.K., P.K.), Waltham, MA
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Manzano GS, McEntire CRS, Martinez-Lage M, Mateen FJ, Hutto SK. Acute Disseminated Encephalomyelitis and Acute Hemorrhagic Leukoencephalitis Following COVID-19: Systematic Review and Meta-synthesis. Neurol Neuroimmunol Neuroinflamm 2021; 8:e1080. [PMID: 34452974 PMCID: PMC8404207 DOI: 10.1212/nxi.0000000000001080] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Since the onset of the COVID-19 pandemic, a growing number of reports have described cases of acute disseminated encephalomyelitis (ADEM) and acute hemorrhagic leukoencephalitis (AHLE) following infection with COVID-19. Given their relatively rare occurrence, the primary objective of this systematic review was to synthesize their clinical features, response to treatments, and clinical outcomes to better understand the nature of this neurologic consequence of COVID-19 infection. METHODS Patients with a history of COVID-19 infection were included if their reports provided adequate detail to confirm a diagnosis of ADEM or AHLE by virtue of clinical features, radiographic abnormalities, and histopathologic findings. Cases purported to be secondary to vaccination against COVID-19 or occurring in the context of a preexisting relapsing CNS demyelinating disease were excluded. Case reports and series were identified via PubMed on May 17, 2021, and 4 additional cases from the authors' hospital files supplemented the systematic review of the literature. Summary statistics were used to describe variables using a complete case analysis approach. RESULTS Forty-six patients (28 men, median age 49.5 years, 1/3 >50 years old) were analyzed, derived from 26 case reports or series originating from 8 countries alongside 4 patient cases from the authors' hospital files. COVID-19 infection was laboratory confirmed in 91% of cases, and infection severity necessitated intensive care in 67%. ADEM occurred in 31 cases, whereas AHLE occurred in 15, with a median presenting nadir modified Rankin Scale score of 5 (bedridden). Anti-MOG seropositivity was rare (1/15 patients tested). Noninflammatory CSF was present in 30%. Hemorrhage on brain MRI was identified in 42%. Seventy percent received immunomodulatory treatments, most commonly steroids, IV immunoglobulins, or plasmapheresis. The final mRS score was ≥4 in 64% of patients with adequate follow-up information, including 32% who died. DISCUSSION In contrast to ADEM cases from the prepandemic era, reported post-COVID-19 ADEM and AHLE cases were often advanced in age at onset, experienced severe antecedent infection, displayed an unusually high rate of hemorrhage on neuroimaging, and routinely had poor neurologic outcomes, including a high mortality rate. Findings are limited by nonstandardized reporting of cases, truncated follow-up information, and presumed publication bias.
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Affiliation(s)
- Giovanna S Manzano
- From the Division of Neuroimmunology and Neuroinfectious Diseases (G.S.M., C.R.S.M., F.J.M., S.K.H.), Department of Neurology, Massachusetts General Hospital, Boston, MA; and Department of Pathology (M.M.-L.), Massachusetts General Hospital, Boston, MA
| | - Caleb R S McEntire
- From the Division of Neuroimmunology and Neuroinfectious Diseases (G.S.M., C.R.S.M., F.J.M., S.K.H.), Department of Neurology, Massachusetts General Hospital, Boston, MA; and Department of Pathology (M.M.-L.), Massachusetts General Hospital, Boston, MA
| | - Maria Martinez-Lage
- From the Division of Neuroimmunology and Neuroinfectious Diseases (G.S.M., C.R.S.M., F.J.M., S.K.H.), Department of Neurology, Massachusetts General Hospital, Boston, MA; and Department of Pathology (M.M.-L.), Massachusetts General Hospital, Boston, MA
| | - Farrah J Mateen
- From the Division of Neuroimmunology and Neuroinfectious Diseases (G.S.M., C.R.S.M., F.J.M., S.K.H.), Department of Neurology, Massachusetts General Hospital, Boston, MA; and Department of Pathology (M.M.-L.), Massachusetts General Hospital, Boston, MA
| | - Spencer K Hutto
- From the Division of Neuroimmunology and Neuroinfectious Diseases (G.S.M., C.R.S.M., F.J.M., S.K.H.), Department of Neurology, Massachusetts General Hospital, Boston, MA; and Department of Pathology (M.M.-L.), Massachusetts General Hospital, Boston, MA.
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Uhr L, Rice DR, Mateen FJ. Sociodemographic and clinical factors associated with depression, anxiety, and general mental health in people with multiple sclerosis during the COVID-19 pandemic. Mult Scler Relat Disord 2021; 56:103327. [PMID: 34666242 PMCID: PMC8523026 DOI: 10.1016/j.msard.2021.103327] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/06/2021] [Accepted: 10/10/2021] [Indexed: 02/08/2023]
Abstract
Background People with multiple sclerosis (PwMS) may be at increased risk for psychological distress during COVID-19. We study the self-reported mental health of U.S. PwMS during COVID-19, prior to vaccine rollout. Methods A cross-sectional survey was distributed online to PwMS through iConquerMS (12/18/2020-02/10/2021). Depressive and anxiety symptom burdens and general mental health status were measured via the Patient-Health Questionnaire-9, Generalized Anxiety Disorder-7, and PROMIS Global Mental Health scales. Linear regression models assessed associations between mental health variables and age, sex, disability status, comorbidities, and social determinants of health. Results Of 610 U.S. PwMS (mean age 56 years, standard deviation 11, range 20-85; female, 81%; relapsing remitting disease, 62%; previous depression diagnosis, 40%), the prevalences of moderate-to-severe depressive and anxiety symptom burden were 27.4% and 14.7%, respectively; 55.1% endorsed fair/poor general mental health. PwMS who tested positive for COVID-19 (n = 47, 7.7%) reported higher depressive and anxiety symptom burdens (p < 0.05). Increased disability status score and social determinants of health were each associated with more depressive symptoms and worse general mental health. Younger age was associated with increased depressive and anxiety symptom burdens and worse general mental health. Female sex was associated with greater anxiety symptoms. Conclusion There are specific associations for worse mental health among PwMS during COVID-19 that reflect a combination of clinical, demographic, and social determinants of health. Multidisciplinary care teams and vigilance are important to address the ongoing mental health impacts of COVID-19 in PwMS.
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Affiliation(s)
- Lauren Uhr
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, 165 Cambridge Street, #627, Boston, MA 02114, United States
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, 165 Cambridge Street, #627, Boston, MA 02114, United States.
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Rice DR, Cisse FA, Djibo Hamani AB, Tassiou NR, Sakadi F, Bah AK, Othon GC, Conde ML, Diawara K, Traoré M, Doumbouya I, Koudaye C, Mateen FJ. Epilepsy stigma in the Republic of Guinea and its socioeconomic and clinical associations: A cross-sectional analysis. Epilepsy Res 2021; 177:106770. [PMID: 34619642 DOI: 10.1016/j.eplepsyres.2021.106770] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/13/2021] [Accepted: 09/19/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We aim to quantify the degree of epilepsy stigma perceived by people living with epilepsy (PLWE) in the Republic of Guinea (2019 gross national income per capita, 930 USD) and analyze the demographic, social, and clinical factors associated with epilepsy stigma in this setting. METHODS A prospective convenience cohort of PLWE was recruited at the Ignace Deen Hospital in Conakry and evaluated by U.S. and Guinean neurology-trained physicians. A survey instrument exploring demographic, social, and clinical variables was designed and administered. The primary outcome measure was the Stigma Scale of Epilepsy (SSE), a 24-item scale with scores ranging from 0 (least stigma)-100 (most). Regression models were fit to assess associations between SSE score and pre-selected demographic, social, and clinical variables of interest. RESULTS 249 PLWE (112 female; mean age 20.0 years; 22 % from rural locales; 14 % of participants >16 years old with no formal schooling; 11 % seizure-free for >=6 months) had an average SSE score of 46.1 (standard deviation = 14.5) points. Children had an average SSE score of 45.2, and adults had an average score of 47.0. There were no significant differences between self- and guardian-reported SSE scores (means = 45.8 and 46.5, respectively), p = .86. In univariate analyses, higher stigma scores were associated with more seizures (p = .005), more depressive symptoms (p = .01), and lower household wealth (p = .03). In a multivariable model including sex, educational level, household wealth, generalized tonic-clonic seizures, seizure frequency, and seizure-related burns, only higher seizure frequency (β = -2.34, p = .03) and lower household wealth (β = 4.05, p = .03) were significantly associated with higher SSE scores. CONCLUSION In this Guinean cohort of people living with poorly-controlled epilepsy, there was a moderate degree of perceived stigma on average. Stigma was associated with higher seizure frequency and lower household wealth-both potentially modifiable factors.
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Affiliation(s)
- Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Foksouna Sakadi
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | | | | | - Mohamed L Conde
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | - Karinka Diawara
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | - Mohamed Traoré
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | | | - Camara Koudaye
- Department of Neurology, Ignace Deen Hospital, Conakry, Guinea
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Reyes S, Cunningham AL, Kalincik T, Havrdová EK, Isobe N, Pakpoor J, Airas L, Bunyan RF, van der Walt A, Oh J, Mathews J, Mateen FJ, Giovannoni G. Update on the management of multiple sclerosis during the COVID-19 pandemic and post pandemic: An international consensus statement. J Neuroimmunol 2021; 357:577627. [PMID: 34139567 PMCID: PMC8183006 DOI: 10.1016/j.jneuroim.2021.577627] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/13/2021] [Accepted: 06/05/2021] [Indexed: 12/16/2022]
Abstract
In this consensus statement, we provide updated recommendations on multiple sclerosis (MS) management during the COVID-19 crisis and the post-pandemic period applicable to neurology services around the world. Statements/recommendations were generated based on available literature and the experience of 13 MS expert panelists using a modified Delphi approach online. The statements/recommendations give advice regarding implementation of telemedicine; use of disease-modifying therapies and management of MS relapses; management of people with MS at highest risk from COVID-19; management of radiological monitoring; use of remote pharmacovigilance; impact on MS research; implications for lowest income settings, and other key issues.
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Affiliation(s)
- Saúl Reyes
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Fundación Santa Fe de Bogotá, Bogotá, Colombia; School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | | | - Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Melbourne, Australia; Melbourne MS Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Eva Kubala Havrdová
- Department of Neurology and Center for Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Noriko Isobe
- Department of Neurology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Julia Pakpoor
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Laura Airas
- Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Reem F Bunyan
- Department of Neurology, Neurosciences Center, King Fahd Specialist Hospital (KFSH)-Dammam, Dammam, Saudi Arabia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Jiwon Oh
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Joela Mathews
- Department of Pharmacy, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK.
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Rice DR, Kaplan TB, Hotan GC, Vogel AC, Matiello M, Gillani RL, Hutto SK, Ham AS, Klawiter EC, George IC, Galetta K, Mateen FJ. Electronic pill bottles to monitor and promote medication adherence for people with multiple sclerosis: A randomized, virtual clinical trial. J Neurol Sci 2021; 428:117612. [PMID: 34392138 DOI: 10.1016/j.jns.2021.117612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/25/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We perform a randomized trial to test the impact of electronic pill bottles with audiovisual reminders on oral disease modifying therapy (DMT) adherence in people with MS (PwMS). METHODS Adults with multiple sclerosis (MS) taking an oral DMT were randomized 1:1 for 90 days to remote smartphone app- and pill bottle-based (a) adherence monitoring, or (b) adherence monitoring with audiovisual medication reminders. Optimal adherence was defined as the proportion of doses taken ±3 h of the scheduled time. Numbers of missed pills and pills taken early, on time, late, and extra were recorded. A multivariable regression model tested possible associations between optimal adherence and age, MS duration, cognitive functioning, and number of daily prescription pills. RESULTS 85 participants (66 female; mean age 44.9 years) took dimethyl/diroximel fumarate (n = 49), fingolimod (n = 26), or teriflunomide (n = 10). Optimal adherence was on average higher in the monitoring with reminders arm (71.4%) than the monitoring only arm (61.6%; p = 0.033). In a multivariable model, optimal adherence was less likely in younger participants (p < 0.001) and those taking more daily prescription pills (p < 0.001). In the monitoring only arm, 4.0% of doses were taken early, 61.6% on time, 5.6% late, 4.4% in excess, and 24.4% were missed. In the reminders arm, these proportions were 3.4%, 71.4%, 3.7%, 8.7%, and 12.8%, respectively. CONCLUSION We map real-world oral DMT adherence patterns using mHealth technology. PwMS who received medication reminders had higher optimal adherence. Nonadherence was more nuanced than simply missing pills. Developing strategies to improve adherence remains important in longitudinal MS care.
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Affiliation(s)
- Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Tamara B Kaplan
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Gladia C Hotan
- Institute of High Performance Computing, Agency for Science, Technology and Research, Singapore
| | - Andre C Vogel
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca L Gillani
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Spencer K Hutto
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Eric C Klawiter
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ilena C George
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Kristin Galetta
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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George IC, Rice DR, Chibnik LB, Mateen FJ. Radiologically isolated syndrome: A single-center, retrospective cohort study. Mult Scler Relat Disord 2021; 55:103183. [PMID: 34365315 DOI: 10.1016/j.msard.2021.103183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/10/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radiologically Isolated Syndrome (RIS) likely represents the earliest detectable form of multiple sclerosis (MS). There are recognized risk factors for conversion of RIS to clinically definite central nervous system (CNS) demyelinating disease. We aim to characterize a new clinical cohort with RIS and to analyze previously established risk factors for conversion to clinically definite disease. METHODS A medical records search was performed for patients who were diagnosed with RIS by their treating neurologist at our institution in Boston, USA, from January 2005 to April 2020. Demographic data, clinical outcomes, and treatment courses were analyzed. The time to first clinical event representing a demyelinating disease attack or last follow up without clinically definite disease was calculated for each person. Hazard ratios (HRs) for known risk factors for the conversion of RIS to clinically definite disease were calculated using Cox proportional hazards models. RESULTS Of 89 patients, the median age at RIS diagnosis was 41.0 years (76% female, 8% with a family history of MS and 16% of any autoimmune disorder, 66% never smokers, 40% BMI >30 kg/m2, 45% with spinal cord MRI lesions). Clinically definite disease was observed in 16 patients (18%) during follow-up (median time to first event 3.4 years; median follow-up duration of full cohort 3.8 years). Median EDSS for those who developed clinically definite disease was 1.25 (range: 0-4) at most recent follow up. Of 84 patients with longitudinal brain imaging, 42 (50%) had new demyelinating lesions. Gadolinium-enhancing lesions were seen in 36 patients (43%) at either baseline (n=24) or follow-up (n=12). Most patients had at least one T1-hypointense lesion (n=70, 83%). Five patients underwent ultra-high field MRI (7 Tesla); all were positive for central vein sign, two demonstrated leptomeningeal enhancement, and one was found to have cortical lesions. Out of 30 patients with susceptibility-weighted imaging acquired during routine clinical care, 8 had at least one paramagnetic rim positive lesion. Previously reported risk factors for conversion to MS were not significant: age ≤37 years HR 1.3 (95% confidence interval (CI), 0.47-3.5), male sex 1.5 (95% CI, 0.41-5.2), and spinal cord lesions 1.3 (0.47-3.4). Nearly one-third of RIS patients (n=26) took a disease modifying therapy (DMT) for MS (median total treatment duration on any DMT=2.7 years). The sub-cohort treated with a DMT had a statistically significantly greater number of recognized risk factors for conversion to clinically definite disease compared with the untreated group (p=0.028). Most patients took a DMT for MRI changes demonstrating new demyelinating disease activity (n=16). Dimethyl fumarate (n=9) and glatiramer acetate (n=7) were the most frequently prescribed DMTs. A second-line DMT was started in 10 patients. CONCLUSION We characterize a new cohort of RIS patients, demonstrating time to clinically evident demyelinating disease from RIS diagnosis of approximately 3.4 years. Our data suggest that early use of a DMT in RIS may mitigate the impact of recognized risk factors on the occurrence of clinically evident disease and reduce the likelihood of conversion to clinically definite CNS demyelinating disease in high-risk individuals.
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Affiliation(s)
- Ilena C George
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Dylan R Rice
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA
| | - Lori B Chibnik
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA; T.H. Chan Harvard School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Farrah J Mateen
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Abstract
BACKGROUND Vaccine willingness among people living with multiple sclerosis (PwMS) requires assessment following the approval of the first COVID-19 vaccines, since there remains uncertainty on multiple aspects of COVID-19 vaccination in immunosuppressed patients. OBJECTIVE To understand COVID-19 and influenza vaccine willingness and its associations among PwMS, following the approval of the first two mRNA COVID-19 vaccines. METHODS A survey was distributed to PwMS via an online platform from December 2020 to February 2021. Logistic regression models were constructed to determine the relationship between (1) COVID-19 and (2) influenza vaccination willingness with demographic and clinical characteristics. RESULTS Of 701 responding PwMS, 76.6% were COVID-19 vaccine willing. COVID-19 vaccine willingness was significantly associated with influenza vaccine willingness (p < 0.001). In multivariable models, older age increased the odds of COVID-19 and influenza vaccine willingness (odds ratios (ORs) > 1) and other race decreased the odds of COVID-19 and influenza vaccine willingness (ORs < 1); higher functional disability decreased the odds of COVID-19 vaccine willingness (OR = 0.88, 95% confidence interval = 0.80-0.96). Prevalent vaccine-related concerns include safety (n = 244) and efficacy (n = 122). CONCLUSION Our findings identify demographic and clinical factors as well as concerns influencing vaccine hesitancy in PwMS. These results may inform effective public health interventions to improve vaccine acceptability in this at-risk group.
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Affiliation(s)
- Lauren Uhr
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
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Mateen FJ. Is It Time for Quotas to Achieve Racial and Ethnic Representation in Multiple Sclerosis Trials? Front Neurol 2021; 12:680912. [PMID: 34054715 PMCID: PMC8155278 DOI: 10.3389/fneur.2021.680912] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/19/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Farrah J Mateen
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
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Hutto SK, Rice DR, Mateen FJ. CNS demyelination with TNFα inhibitor exposure: A retrospective cohort study. J Neuroimmunol 2021; 356:577587. [PMID: 33945946 DOI: 10.1016/j.jneuroim.2021.577587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/21/2021] [Accepted: 04/22/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study long-term outcomes in patients with CNS demyelinating events exposed to TNFa-inhibitors (TNFai), including subsequent clinical relapse, MRI lesions, and use of disease modifying therapy (DMT) for MS. METHODS Adult patients evaluated for a CNS demyelinating disease during TNFai use were identified at Mass General Brigham [01/1998-08/2020] and analyzed in clinically-relevant subgroups. Inclusion criteria required a first neurological event while taking a TNFai, MRI lesions consistent with demyelination, and the absence of a more probable alternative diagnosis. RESULTS 21 cases (mean age 44 years, 20 female, 14 ≥ 2 MS risk factors) had an index neurological event (INE) at a median of 12 months (range 1-176) from onset of TNFai use (adalimumab in 10, etanercept 6, infliximab 5). MRI lesions were most often present in periventricular (16/20, 80%) and spinal zones (10/20, 50%); 37% (7/19) met ≥ 2 Barkhof criteria at onset. CSF testing was abnormal in 64% (7/11). 67% (10/15) with available follow-up MRIs developed new lesions by a median of 29.5 months of MRI surveillance (median MRI surveillance 60 months); 55% (11/20) met ≥ 2 Barkhof criteria. 47% (8/17) suffered a clinical relapse by a median of 40.5 months of clinic follow-up (median clinic follow-up since INE: 26 months). In patients discontinuing TNFai (18/21, 86%) at INE onset, 56% (10/18) had further evidence of CNS demyelination. Six patients (6/21, 29%) started an MS disease modifying therapy (DMT) at INE of whom 50% (3/6) had subsequent disease activity. Continuing or restarting TNFai was followed by relapse in 75% (3/4). 65% (13/20) met 2017 McDonald criteria for MS at INE with another 10% (15/20, 75%) by study conclusion. CONCLUSIONS With extended follow-up, a majority of patients had a relapsing CNS demyelinating disorder-as evidenced by new MRI lesions or clinical relapses-despite TNFai discontinuation.
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Affiliation(s)
- Spencer K Hutto
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Mateen FJ, Cooley CZ, Stockmann JP, Rice DR, Vogel AC, Wald LL. Low-field portable brain MRI in CNS demyelinating disease. Mult Scler Relat Disord 2021; 51:102903. [PMID: 33780808 DOI: 10.1016/j.msard.2021.102903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
A low-field (80 mT), portable MRI scanner has been developed that may address barriers to MRI for people with multiple sclerosis (MS). As a proof of concept study, we imaged two participants with central nervous system demyelinating disease by both a standard 1.5 Tesla MRI and the portable MRI scanner. These images demonstrate the ability to identify a solitary demyelinating lesion in early stage disease and cortical atrophy and chronic white matter changes in late stage disease. In spite of device limitations, including border distortion and lower image quality, the portable device has important implications for addressing barriers to care in people with MS.
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Affiliation(s)
- Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | - Clarissa Zimmerman Cooley
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Jason P Stockmann
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Dylan R Rice
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Andre C Vogel
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Lawrence L Wald
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA, USA
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McEntire CRS, Song KW, McInnis RP, Rhee JY, Young M, Williams E, Wibecan LL, Nolan N, Nagy AM, Gluckstein J, Mukerji SS, Mateen FJ. Neurologic Manifestations of the World Health Organization's List of Pandemic and Epidemic Diseases. Front Neurol 2021; 12:634827. [PMID: 33692745 PMCID: PMC7937722 DOI: 10.3389/fneur.2021.634827] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 01/25/2021] [Indexed: 01/02/2023] Open
Abstract
The World Health Organization (WHO) monitors the spread of diseases globally and maintains a list of diseases with epidemic or pandemic potential. Currently listed diseases include Chikungunya, cholera, Crimean-Congo hemorrhagic fever, Ebola virus disease, Hendra virus infection, influenza, Lassa fever, Marburg virus disease, Neisseria meningitis, MERS-CoV, monkeypox, Nipah virus infection, novel coronavirus (COVID-19), plague, Rift Valley fever, SARS, smallpox, tularemia, yellow fever, and Zika virus disease. The associated pathogens are increasingly important on the global stage. The majority of these diseases have neurological manifestations. Those with less frequent neurological manifestations may also have important consequences. This is highlighted now in particular through the ongoing COVID-19 pandemic and reinforces that pathogens with the potential to spread rapidly and widely, in spite of concerted global efforts, may affect the nervous system. We searched the scientific literature, dating from 1934 to August 2020, to compile data on the cause, epidemiology, clinical presentation, neuroimaging features, and treatment of each of the diseases of epidemic or pandemic potential as viewed through a neurologist's lens. We included articles with an abstract or full text in English in this topical and scoping review. Diseases with epidemic and pandemic potential can be spread directly from human to human, animal to human, via mosquitoes or other insects, or via environmental contamination. Manifestations include central neurologic conditions (meningitis, encephalitis, intraparenchymal hemorrhage, seizures), peripheral and cranial nerve syndromes (sensory neuropathy, sensorineural hearing loss, ophthalmoplegia), post-infectious syndromes (acute inflammatory polyneuropathy), and congenital syndromes (fetal microcephaly), among others. Some diseases have not been well-characterized from a neurological standpoint, but all have at least scattered case reports of neurological features. Some of the diseases have curative treatments available while in other cases, supportive care remains the only management option. Regardless of the pathogen, prompt, and aggressive measures to control the spread of these agents are the most important factors in lowering the overall morbidity and mortality they can cause.
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Affiliation(s)
- Caleb R. S. McEntire
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - Kun-Wei Song
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - Robert P. McInnis
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - John Y. Rhee
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - Michael Young
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - Erika Williams
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - Leah L. Wibecan
- Massachusetts General Hospital (MGH)-Brigham Pediatric Neurology Residency Program, Boston, MA, United States
| | - Neal Nolan
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - Amanda M. Nagy
- Massachusetts General Hospital (MGH)-Brigham Pediatric Neurology Residency Program, Boston, MA, United States
| | - Jeffrey Gluckstein
- Massachusetts General Hospital (MGH)-Brigham Neurology Residency Program, Boston, MA, United States
| | - Shibani S. Mukerji
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
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McEntire CR, Fong KT, Jia DT, Cooper ER, Cervantes-Arslanian AM, Mateen FJ, Anand P, Thakur KT. Central nervous system disease with JC virus infection in adults with congenital HIV. AIDS 2021; 35:235-244. [PMID: 33394671 PMCID: PMC7945987 DOI: 10.1097/qad.0000000000002734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to describe the natural history of individuals with congenital HIV who develop JC virus (JCV) infection of the central nervous system (CNS). METHODS We retrospectively evaluated individuals with congenital HIV who met criteria for progressive multifocal leukoencephalopathy (PML) or JCV granule cell neuronopathy (JCV GCN) at three major healthcare centres in the northeast USA. Data on adherence to combined antiretroviral therapy (cART), neurologic symptoms, serum markers of immunity and HIV infection, cerebrospinal fluid (CSF) analyses, radiographic features, modified Rankin Scale (mRS) scores and survival were collected from the electronic medical record up to a censoring date of 1 August 2020. RESULTS Among 10 adults with congenitally acquired HIV, nine were diagnosed with definitive PML and one was diagnosed with probable JCV GCN. Individuals presented at the time of their PML or JCV GCN diagnosis with a mean mRS of 2.0 (standard deviation 1.0). A premorbid mRS was documented for six patients and was zero in all cases. The most common risk factor was confirmed cART nonadherence in nine individuals. Five individuals with PML and one with JCV GCN died, with a latency from symptom onset to death of approximately 3 months for three individuals, and approximately 2 years for the remaining two. CONCLUSION Youth-adulthood transition is a high-risk point for dropping off from medical care. The study of this timepoint in people living with HIV could help inform effective care in these individuals.
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Affiliation(s)
| | - Kathryn T. Fong
- Department of Neurology, Columbia University Irving Medical Center, New York, NY 10032
| | - Dan Tong Jia
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL 60611
| | - Ellen R. Cooper
- Department of Pediatrics, Boston University School of Medicine, Boston, MA 02215
| | - Anna M. Cervantes-Arslanian
- Departments of Neurology, Neurosurgery, and Medicine (Infectious Disease), Boston Medical Center, Boston, MA 02118
| | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114
| | - Pria Anand
- Departments of Neurology, Neurosurgery, and Medicine (Infectious Disease), Boston Medical Center, Boston, MA 02118
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY 10032
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Abstract
OBJECTIVE To give an overview of the recently reported literature on the aetiologies of meningitis and encephalitis in western sub-Saharan Africa. METHODS We conducted a scoping review following PRISMA guidance on published meningitis and encephalitis cases in the 16 countries of the United Nations-defined western sub-Saharan African region as identified in cohort studies, case series, and case reports, published 01/01/2000-08/01/2020, and available in four databases in August 2020 with an abstract in English, French or Italian. RESULTS There were 38 distinct pathogens identified from 91 cohort studies' data and 48 case reports or case series' data. In cohort-level data, the majority of cases were caused by Neisseria meningitidis (71.5%), Streptococcus pneumoniae (17.6%) and Haemophilus influenzae (7.3%). In case report- and case series-level data, 40.5% of patients were <18 years old, 28.6% were female, and 28.6% were known to be immunocompromised. The case fatality rate was 39.3%. The most commonly reported pathogens among immunocompetent patients were Salmonella species (13 cases) and Ebola virus (9 cases), and the most commonly reported pathogen among immunocompromised patients was Cryptococcus neoformans (18 cases). Most cohort cases (52.3%) derived from Niger followed by Burkina Faso (28.6%). Most cases from single reports or series were reported from Nigeria (21.4%), Mali (20.2%) and Burkina Faso (19.0%). CONCLUSIONS Given the small number of pathogens reported, our findings underscore the need to better screen, diagnose and monitor populations in western sub-Saharan Africa for additional CNS pathogens, including those posing significant outbreak risks.
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Affiliation(s)
- Shawheen J Rezaei
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Michael J. Young
- Departments of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Rachel A. Caplan
- Departments of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ian Connolly
- Departments of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Marcelo Matiello
- Departments of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Farrah J. Mateen
- Departments of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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Collens SI, Wilcox DR, Mukerji S, Mateen FJ, Solomon IH. 346. Eastern Equine Encephalitis and Use of Intravenous Immunoglobulin Therapy and High-Dose Steroids. Open Forum Infect Dis 2020. [PMCID: PMC7777322 DOI: 10.1093/ofid/ofaa439.541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Eastern equine encephalitis (EEE) is a mosquito-borne viral infection with significant neurological morbidity and mortality. The clinical presentation and patient outcomes after treatment with IVIG, high-dose steroids, or standard of care alone in EEE remains unclear. Methods A retrospective observational study of patients admitted to two tertiary academic medical centers in Boston, Massachusetts with EEE from 2005 to 2019. Results Of 17 patients (mean [SD] age, 50 [26] years; 10 (59%) male, and 16 (94%) White race), 17 patients had fever (100%), 15 had encephalopathy (88%), and 12 had headache (71%). Eleven of 14 patients with cerebrospinal fluid (CSF) cell count differential had a neutrophil predominance (mean [SD], 60.6% of white blood cells [22.8]) with an elevated protein level (mean [SD], 112 mg/dL [48.8]). Affected neuroanatomical regions included the basal ganglia (n=9/17), thalamus (n=7/17), and mesial temporal lobe (n=7/17). A total of 11 patients (65%) received IVIG; 8 (47%) received steroids. Of the patients who received IVIG, increased time from hospital admission to IVIG administration correlated with worse long-term disability as assessed by modified Rankin Score (mRS) (r=0.72, p=0.02); steroid use was not associated with mRS score. The mortality was 12%. Figure 1. Imaging Characteristics: Typical Pattern of MRI Involvement and Affected Neuroanatomical Regions in Patients with Eastern Equine Encephalitis. All images displayed are the T2-FLAIR sequence. (A) Representative images of pattern of typical neuroanatomical region involved in one patient with demonstrated involvement of the temporal lobe and pons, temporal lobe and midbrain, and basal gangial by T2-FLAIR hyperintensity (panels left to right). (B) Representative images of patients with mild (mRS 0–2), moderate (mRS 3–4), and severe (mRS 5–6) disability score at discharge. (C) Representative images of one patient over course of hospitalization at days 1, 4, and 10 after admission. (D) Quantification of neuroanatomical region involvement in initial MRI of patients with EEE as determined by T2-FLAIR hyperintensity. An area was scored as abnormal only once per patient. ![]()
Figure 2. Outcomes in Patients with Eastern Equine Encephalitis. Patient disability by modified Rankin Score (mRS) of EEE patients at admission to the hospital, discharge from the hospital, and last recorded follow-up (A). Time to IVIG administration compared to mRS at discharge (B), and most recent clinical follow-up (C). ![]()
Table 1. Demographics, Clinical Characteristics, and Laboratory Data in Patients with Eastern Equine Encephalitis. Abbreviations: CSF = cerebrospinal fluid, WBC = white clood count, EEG = electroencephalogram, ALT = alanine aminotransferase, AST = aspartate transaminase. Demographic data was collected for all patients with confirmed EEE. Altered mental status included any description of encephalopathy, confusion, or difficulty with attention. Seizures were defined as clinical events with a high-degree of suspicion to be true seizures, and were entirely comprised of generalized tonic-clonic seizures. ![]()
Conclusion Clinicians should suspect EEE in immunocompetent patients with early subcortical neuroimaging abnormalities and CSF neutrophilic predominance. This study suggests a lower mortality than previously reported, but a high morbidity rate in EEE. IVIG as an adjunctive to standard of care may be considered early during hospitalization. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | - Douglas R Wilcox
- Massachusetts General Hospital, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Farrah J Mateen
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Suchy-Dicey A, Noonan C, Burduli E, Mateen FJ, Longstreth W, Buchwald D, Navas-Acien A. Urinary Arsenic and Cadmium Associations with Findings from Cranial MRI in American Indians: Data from the Strong Heart Study. Environ Health Perspect 2020; 128:127009. [PMID: 33332184 PMCID: PMC7745762 DOI: 10.1289/ehp6930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 05/28/2023]
Abstract
BACKGROUND Arsenic and cadmium are known cardiovascular toxicants that pose disproportionate risk to rural communities where environmental exposures are high. American Indians have high vascular risk, which may be attributable in part to these exposures. OBJECTIVE We examined urine metal concentrations in association with magnetic resonance imaging findings of vascular brain injury or cerebral atrophy in adult American Indians. METHODS We measured arsenic and cadmium in American Indian participants from the Strong Heart Study (1989-1991) and evaluated these associations with later (2010-2013) measures of infarct, hemorrhage, white matter hyperintensity (WMH) grade, brain and hippocampal volume, and sulcal and ventricle atrophy using nested multivariate regression analyses. RESULTS Among participants with available data (N=687), the median urine arsenic:creatinine ratio was 7.54μg/g [interquartile range (IQR): 4.90-11.93] and the cadmium:creatinine ratio was 0.96μg/g (IQR: 0.61-1.51). Median time between metal measurement and brain imaging was 21 y (range: 18-25 y). Statistical models detected significant associations between arsenic and higher burden of WMH [grade increase=0.014 (95% CI: 0.000, 0.028) per 10% increase in arsenic]; and between cadmium and presence of lacunar infarcts [relative risk (RR)=1.024 (95% CI: 1.004, 1.045) per 10% increase in cadmium]. DISCUSSION This population-based cohort of American Indian elders had measured values of urine arsenic and cadmium several times higher than previous population- and clinic-based studies in the United States and Mexico, and comparable values with European industrial workers. Our findings of associations for arsenic and cadmium exposures with vascular brain injury are consistent with established literature. Environmental toxicant accumulation is modifiable; public health policy may benefit from focusing on reductions in environmental metals. https://doi.org/10.1289/EHP6930.
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Affiliation(s)
- Astrid Suchy-Dicey
- Elson S. Floyd College of Medicine, Washington State University (WSU), Spokane, Washington, USA
- Institute for Research and Education to Advance Community Health, WSU, Seattle, Washington, USA
| | - Carolyn Noonan
- Elson S. Floyd College of Medicine, Washington State University (WSU), Spokane, Washington, USA
- Institute for Research and Education to Advance Community Health, WSU, Seattle, Washington, USA
| | | | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital; Harvard Medical School, Boston, Massachusetts, USA
| | - W.T. Longstreth
- Department of Epidemiology, School of Public Heath, University of Washington (UW), Seattle, Washington, USA
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Dedra Buchwald
- Elson S. Floyd College of Medicine, Washington State University (WSU), Spokane, Washington, USA
- Institute for Research and Education to Advance Community Health, WSU, Seattle, Washington, USA
| | - Ana Navas-Acien
- Department of Environmental Health Sciences, Mailman School of Public Heath, Columbia University, New York, New York, USA
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Bacsu J, Mateen FJ, Johnson S, Viger MD, Hackett P. Improving Dementia Care Among Family Physicians: From Stigma to Evidence-Informed Knowledge. Can Geriatr J 2020; 23:340-343. [PMID: 33282053 PMCID: PMC7704071 DOI: 10.5770/cgj.23.426] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Juanita Bacsu
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK.,Saskatchewan Population Health and Evaluation Research Unit (SPHERU), University of Saskatchewan, Saskatoon, SK, Canada
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shanthi Johnson
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Marc D Viger
- Department of Family Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Paul Hackett
- Department of Geography, SPHERU, University of Saskatchewan, Saskatoon, SK Canada
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Sylla M, Vogel AC, Bah AK, Tassiou NR, Barry SD, Djibo BA, Toure ML, Foksona S, Konate M, Cisse FA, Mateen FJ. Prevalence, severity, and associations of depression in people with epilepsy in Guinea: A single-center study. Epilepsy Behav 2020; 113:107475. [PMID: 33189054 PMCID: PMC7736546 DOI: 10.1016/j.yebeh.2020.107475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/10/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Depression has long been recognized as a comorbidity of epilepsy in high-income countries, ranging from 17 to 49% of people with epilepsy (PWE). Of the limited studies from sub-Saharan Africa (SSA), where most people have uncontrolled seizures, an even higher prevalence of depression is reported among PWE at times exceeding 80%. We sought to assess the prevalence and severity of depression and its associated factors among PWE in Guinea, a sub-Saharan West African country where most PWE have poorly controlled seizures. METHODS People with epilepsy from the community, age 16 years old and above, were consecutively recruited into a convenience cohort at the Ignace Deen Hospital in the capital city, Conakry, in summer 2018 as part of a larger study characterizing PWE in Guinea. Each participant was evaluated by a team of Guinean physicians and a U.S.-based neurologist to confirm the diagnosis of epilepsy. Inperson interviews were performed to measure demographic, clinical, socioeconomic, and related variables. Depression was measured via the Patient Health Questionniare-9 in the language of the participant's preference with a cutoff of 5 or more points being categorized as depressed. Regression analyses were performed to measure the associations between explanatory variables with the outcome of depression. RESULT Of 140 PWE (age range: 16-66 years old; 64 female; 64% taking an antiseizure medication including 28% carbamazepine, 16% phenobarbital, and 14% valproic acid; duration of epilepsy: 11 years; 71% with one or more seizures in the past month; 17% never treated with an antiseizure medication; 90% with loss of consciousness during seizures; 10% without formal education; 31% with university level education; 62% using tap water; 48% with a serious seizure-related injury), the point prevalence of depression was 66% (95% confidence interval [CI]: 58%-74%): 43% of PWE had mild depression, 19% moderate, 4% moderate to severe, and 0.1% severe. In a multivariate analysis, the occurrence of a seizure in the past month (odds ratio: 3.03, 95% CI: 2.63-3.48, p = 0.01) was associated with depression, while gender, self-perceived stigma score, serious injuries, and the number of antiseizure medications taken were not statistically significantly associated (p > 0.05). Twenty-five percent of all participants endorsed thoughts of self-harm or suicidality. CONCLUSION Two-thirds of PWE in Guinea had depression in this single-institution convenience cohort. The presence of a seizure in the last month was the factor most associated with depression and is modifiable in many PWE. The high prevalance of depression suggests that screening and addressing depressive symptoms should be incorporated into routine epilepsy care in Guinea.
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Affiliation(s)
| | - Andre C. Vogel
- Department of Neurology, Massachusetts General Hospital, Boston, USA
| | | | | | | | | | | | | | | | | | - Farrah J. Mateen
- Harvard Medical School, Boston, USA,Department of Neurology, Massachusetts General Hospital, Boston, USA
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