Neurology in the developing world

Old problems, new solutions: harnessing technology and innovation in Parkinson's disease-evidence and experiences from Thailand

The prevalence of Parkinson's disease (PD) is increasing rapidly worldwide, but there are notable inequalities in its distribution and in the availability of healthcare resources across different world regions. Low- and middle-income countries (LMICs), including Thailand, bear the highest burden of PD so there is an urgent need to develop effective solutions that can overcome the many regional challenges associated with delivering high-quality, and equitable care to a diverse population with limited resources. This article describes the evolution of healthcare delivery for PD in Thailand, as a case example of a LMIC. The discussions reflect the author's presentation at the Yoshikuni Mizuno Lectureship Award given during the 8th Asian and Oceanian Parkinson's Disease and Movement Disorders Congress in March 2023 for which he was the 2023 recipient. The specific challenges faced in Thailand are reviewed along with new solutions that have been implemented to improve the knowledge and skills of healthcare professionals nationally, the delivery of care, and the outcomes for PD patients. Technology and innovation have played an important role in this process with many new tools and devices being implemented in clinical practice. Without any realistic prospect of a curative therapy in the near future that could halt the current PD pandemic, it will be necessary to focus on preventative lifestyle strategies that can help reduce the risk of developing PD such as good nutrition (EAT), exercise (MOVE), good sleep hygiene (SLEEP), and minimizing environmental risks (PROTECT), which should be initiated and continued (REPEAT) as early as possible.

Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review

BACKGROUND

There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains.

METHODS

We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity.

RESULTS

From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia.

CONCLUSIONS

This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.

Screening of Parkinson's Disease Using Geometric Features Extracted from Spiral Drawings

Conventional means of Parkinson’s Disease (PD) screening rely on qualitative tests typically administered by trained neurologists. Tablet technologies that enable data collection during handwriting and drawing tasks may provide low-cost, portable, and instantaneous quantitative methods for high-throughput PD screening. However, past efforts to use data from tablet-based drawing processes to distinguish between PD and control populations have demonstrated only moderate classification ability. Focusing on digitized drawings of Archimedean spirals, the present study utilized data from the open-access ParkinsonHW dataset to improve existing PD drawing diagnostic pipelines. Random forest classifiers were constructed using previously documented features and highly-predictive, newly-proposed features that leverage the many unique mathematical characteristics of the Archimedean spiral. This approach yielded an AUC of 0.999 on the particular dataset we tested on, and more importantly identified interpretable features with good promise for generalization across diverse patient cohorts. It demonstrated the potency of mathematical relationships inherent to the drawing shape and the usefulness of sparse feature sets and simple models, which further enhance interpretability, in the face of limited sample size. The results of this study also inform suggestions for future drawing task design and data analytics (feature extraction, shape selection, task diversity, drawing templates, and data sharing).

Innovative Use of Google Cardboard in Clinical Examination of Patients of Vertigo

Background:

Vertigo is 1 of the most prominent and frequent neurological symptom. It is estimated that about 30% of all people need medical care once in their life due to this index symptom. The neurological expertise required is usually scarce in underprivileged areas. One has to look for spontaneous nystagmus, and perform Dix–Hallpike maneuver and Head Impulse test specifically to differentiate central from peripheral vertigo. The nystagmus, that is spontaneous, involuntary to-and-fro movement of the eyeball which aids in the diagnosis, can be better elicited by Frenzel glasses, Munich glasses. These devices consist of the combination of magnifying glasses and a lighting system to detect eye movements better than routine examination.

Objective:

To test usefulness of modified Google cardboard as Frenzel glasses in poor resource setting.

Study design:

A modified Google cardboard was used in 52 consecutive cases of vertigo and compared with examination with naked eye. The device consists of 2 magnifying lenses, 1 for each eye with power of +24 dioptres.

Observation:

The tool was found to be better for identifying spontaneous nystagmus, in Dix–Hallpike maneuver and during head impulse test as compared with the naked eye owing to the property of magnification and inhibition of fixation. Being a cheaper alternative and handy, it could be carried by every doctor in any setting.

A systematic review and mixed treatment comparison of monotherapy in early Parkinson's disease: implications for Latin America

Parkinson's disease (PD) is the second most common neurodegenerative disease. There are no clinical trials comparing all available pharmacological therapies for the treatment of early PD. The objective of this review is to indirectly analyze the efficacy of antiparkinson drugs currently available in Latin America. A systematic review was performed exploring only placebo-controlled randomized trials comparing antiparkinson monotherapy (levodopa, pramipexole, rasagiline, or selegiline) in patients with PD on Hoehn and Yahr stages I through III published from January 1994 to May 2014. The primary outcome was the mean change in the Unified PD Rating Scale (UPDRS) I, II and III. A mixed treatment comparison analysis (indirect comparisons) through a random-effects model was performed. Levodopa demonstrated the highest effects in terms of UPDRS score improvement both from baseline and when compared to other treatments. Levodopa showed a 60.1% probability of granting the greatest reduction in UPDRS I, II and III.

Neuroactive compounds obtained from arthropod venoms as new therapeutic platforms for the treatment of neurological disorders

The impact of neurological disorders in society is growing with alarming estimations for an incidence increase in the next decades. These disorders are generally chronic and can affect individuals early during productive life, imposing real limitations on the performance of their social roles. Patients can have their independence, autonomy, freedom, self-image, and self-confidence affected. In spite of their availability, drugs for the treatment of these disorders are commonly associated with side effects, which can vary in frequency and severity. Currently, no effective cure is known. Nowadays, the biopharmaceutical research community widely recognizes arthropod venoms as a rich source of bioactive compounds, providing a plethora of possibilities for the discovery of new neuroactive compounds, opening up novel and attractive opportunities in this field. Several identified molecules with a neuropharmacological profile can act in the central nervous system on different neuronal targets, rendering them useful tools for the study of neurological disorders. In this context, this review aims to describe the current main compounds extracted from arthropod venoms for the treatment of five major existing neurological disorders: stroke, Alzheimer’s disease, epilepsy, Parkinson’s disease, and pathological anxiety.

Acute dizziness in rural practice: Proposal of a diagnostic procedure

Acute dizziness is a frequent index symptom in the emergency department as well as in the rural practice office. Most acute dizziness, however, is not dangerous, but some types are highly dangerous. Clinical routine acute dizziness can be separated into frequent benign syndromes including benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Meniθre's disease or vestibular migraine, and what is here referred to as the “white shark” of dizziness, i.e. a stroke in the posterior circulation or more rarely a tumor in the posterior fossa. A practical concept is presented to clarify most frequent acute dizziness syndromes using clinical and low budget methods.