Epilepsy in Cambodia-treatment aspects and policy implications: a population-based representative survey

A cluster-randomized trial comparing home-based primary health care and usual clinic care for epilepsy in a resource-limited country

OBJECTIVE

To ascertain whether home-based care with community and primary healthcare workers' support improves adherence to antiseizure medications, seizure control, and quality of life over routine clinic-based care in community samples of people with epilepsy in a resource-poor country.

METHODS

Participants included consenting individuals with active epilepsy identified in a population survey in impoverished communities. The intervention included antiseizure medication provision, adherence reinforcement and epilepsy self- and stigma management guidance provided by a primary health care-equivalent worker. We compared the intervention group to a routine clinic-based care group in a cluster-randomized trial lasting 24 months. The primary outcome was antiseizure medication adherence, appraised from monthly pill counts. Seizure outcomes were assessed by monthly seizure aggregates and time to first seizure and impact by the Personal Impact of Epilepsy scale.

RESULTS

Enrolment began on September 25, 2017 and was complete by July 24, 2018. Twenty-four clusters, each comprising ten people with epilepsy, were randomized to either home- or clinic-care. Home-care recipients were more likely to have used up their monthly-dispensed epilepsy medicine stock (regression coefficient: 0.585; 95% confidence intervals, 0.289-0.881; P = 0.001) and had fewer seizures (regression coefficient: -2.060; 95%CI, -3.335 to -0.785; P = 0.002). More people from clinic-care (n = 44; 37%) than home-care (n = 23; 19%) exited the trial (P = 0.003). The time to first seizure, adverse effects and the personal impact of epilepsy were similar in the two arms.

SIGNIFICANCE

Home care for epilepsy compared to clinic care in resource-limited communities improves medication adherence and seizure outcomes and reduces the secondary epilepsy treatment gap.

Availability, affordability, and quality of essential anti-seizure medication in Cambodia

Objective

Epilepsy is a major neurological disorder that requires long‐term medical treatment. Once epilepsy is diagnosed, people with epilepsy face many difficulties in accessing treatment (treatment gap). Our objective was to assess the situation regarding the availability, price, affordability, and quality of anti‐seizure medication (ASM), which are major determinants of access to treatment.

Method

A cross‐sectional study was performed in provincial/district hospitals and private pharmacies in urban and rural areas in Cambodia. Data on ASM availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest‐paid government employee must work to purchase a monthly treatment. Samples of ASM were collected, and the quality of ASM was assessed through Medicine Quality Assessment Reporting Guidelines.

Results

Out of 138 outlets visited, only 72 outlets (52.2% [95% CI 43.5‐60.7]) had at least one ASM available. Phenobarbital 100 mg was the most available (35.5%), followed by carbamazepine 200 mg (21.7%), phenobarbital 50 mg (11.6%), sodium valproate 500 mg (9.4%), and phenytoin 100 mg (9.4%). In provincial/district hospitals, ASM was provided free of charge. In private pharmacies, affordability for phenobarbital 50 mg and 100 mg was the best, with 0.6 and 0.5 days, respectively, compared to phenytoin 100 mg (1.8 days), and other ASM. No counterfeit ASM was found in this study. Phenytoin sample presented the worst quality (33.0%) compared to carbamazepine (27.8%), and other ASM.

Significance

A lack of access to affordable and effective ASM due to low availability and poor quality of ASM was identified. Our research highlights the need for future policy efforts to ensure the quality of ASM and improve their availability. This can be achieved by involving the calculation of their annual needs for these drugs and increasing the national production of ASM.

Models of community-based primary care for epilepsy in low- and middle-income countries

OBJECTIVE

To review systematically community-based primary care interventions for epilepsy in low- and middle-income countries to rationalize approaches and outcome measures in relation to epilepsy care in these countries.

METHODS

A systematic search of PubMed, EMBASE, Global Index Medicus, CINAHL, and Web of Science was undertaken to identify trials and implementation of provision of antiseizure medications, adherence reinforcement, and/or health care provider or community education in community-based samples of epilepsy. Data on populations addressed, interventions, and outcomes were extracted from eligible articles.

RESULTS

The 24 reports identified comprise mostly care programs addressing active convulsive epilepsy. Phenobarbital has been used most frequently, although other conventional antiseizure medications (ASMs) have also been used, but none of the newer. Tolerability rates in these studies are high, but overall attrition is considerable. Other approaches include updating primary health care providers, reinforcing treatment adherence in clinics, and raising community awareness. In these programs, the coverage of existing treatment gap in the community, epilepsy-related mortality, and comorbidity burden are only fleetingly addressed. None, however, explicitly describe sustainability plans.

CONCLUSIONS

Cost-free provision, mostly of phenobarbital, has resulted in short-term seizure freedom in roughly half of the people with epilepsy in low- and middle-income countries. Future programs should include a range of ASMs. These should cover apart from seizure control and treatment adherence, primary health care provider education, community awareness, and referral protocols for specialist care. Programs should incorporate impact assessment at the local level. Sustainability in the long term as much as resilience and scalability should be addressed in future initiatives.

A home-based, primary-care model for epilepsy care in India: Basis and design

OBJECTIVES

A cluster-randomized trial of home-based care using primary-care resources for people with epilepsy has been set up to optimize epilepsy care in resource-limited communities in low- and middle-income countries. The primary aim is to determine whether treatment adherence to antiepileptic drugs is better with home-based care or with routine clinic-based care. The secondary aims are to compare the effects of the two care pathways on seizure control and quality of life.

METHODS

The home-based intervention comprises epilepsy medication provision, adherence reinforcement, and epilepsy self-management and stigma management guidance provided by an auxiliary nurse-midwife equivalent. The experimental group will be compared to a routine clinic-based care group using a cluster-randomized design in which the unit of analysis is a cluster of 10 people with epilepsy residing in an area cared for by a single accredited government grass-roots health care worker. The primary outcome is treatment adherence as measured by monthly tablet counts supplemented by two self-completed questionnaires. The secondary outcomes include monthly seizure frequency, time to first seizure (in days) after enrollment, proportion of patients experiencing seizure freedom for the duration of the study, and quality of life measured by the "Personal Impact of Epilepsy Scale," all assessed by an independent study nurse.

RESULTS

The screening phase and neurologic evaluations and randomizations have been recently completed and follow-up is underway.

SIGNIFICANCE

The results of the trial are likely to have substantial bearing on the development of governmental policies and strategies to provide coverage and care for patients with epilepsy in resource-limited countries.

EFHC1 variants in juvenile myoclonic epilepsy: reanalysis according to NHGRI and ACMG guidelines for assigning disease causality

PURPOSE

EFHC1 variants are the most common mutations in inherited myoclonic and grand mal clonic-tonic-clonic (CTC) convulsions of juvenile myoclonic epilepsy (JME). We reanalyzed 54 EFHC1 variants associated with epilepsy from 17 cohorts based on National Human Genome Research Institute (NHGRI) and American College of Medical Genetics and Genomics (ACMG) guidelines for interpretation of sequence variants.

METHODS

We calculated Bayesian LOD scores for variants in coinheritance, unconditional exact tests and odds ratios (OR) in case-control associations, allele frequencies in genome databases, and predictions for conservation/pathogenicity. We reviewed whether variants damage EFHC1 functions, whether efhc1^-/- KO mice recapitulate CTC convulsions and "microdysgenesis" neuropathology, and whether supernumerary synaptic and dendritic phenotypes can be rescued in the fly model when EFHC1 is overexpressed. We rated strengths of evidence and applied ACMG combinatorial criteria for classifying variants.

RESULTS

Nine variants were classified as "pathogenic," 14 as "likely pathogenic," 9 as "benign," and 2 as "likely benign." Twenty variants of unknown significance had an insufficient number of ancestry-matched controls, but ORs exceeded 5 when compared with racial/ethnic-matched Exome Aggregation Consortium (ExAC) controls.

CONCLUSIONS

NHGRI gene-level evidence and variant-level evidence establish EFHC1 as the first non-ion channel microtubule-associated protein whose mutations disturb R-type VDCC and TRPM2 calcium currents in overgrown synapses and dendrites within abnormally migrated dislocated neurons, thus explaining CTC convulsions and "microdysgenesis" neuropathology of JME.Genet Med 19 2, 144-156.

Leukocyte Infiltration Triggers Seizure Recurrence in a Rat Model of Temporal Lobe Epilepsy

Epilepsy, which affects about 1 % of the population worldwide, leads to poor prognosis and increased morbidity. However, effective drugs providing satisfactory control on seizure relapse were rare, which encouraged more etiological studies. Whether inflammation is one of key events underlying seizure is in debate. In order to explore the role of inflammatory in the pathogenesis and development of epilepsy, we conducted intra-caudal vein injection of leukocytes to aggravated brain inflammatory process in kainic acid-induced seizure model in this study. The results showed that intravenous administration of activated leukocytes increased the frequency and reduced the latent phase of seizure recurrences in rat models of epileptic seizure, during which leukocyte inflammation, brain-blood barrier damage, and neuron injury were also significantly aggravated, indicating that leukocyte infiltration might facilitate seizure recurrence through aggravating brain inflammation, brain-blood barrier damage, and neuron injury.

Examining the relationship between fatigue and cognition after stroke: A systematic review

Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.

Mental health services in Cambodia, challenges and opportunities in a post-conflict setting

Cambodia had suffered enormously due to war and internecine conflict during the latter half of the twentieth century, more so during the Vietnam War. Total collapse of education and health systems during the Pol Pot era continues to be a challenge for developing the necessary infrastructure and human resources to provide basic minimum mental health care which is compounded by the prevailing cultural belief and stigma over mental, neurological and substance abuse disorders (MNSDs). The mental health research and services in Cambodia had been predominantly 'trauma focused', a legacy of war, and there is a need to move toward epidemiologically sound public health oriented mental health policy and service development. Integrating mental health program with primary health care services with specifically stated minimum package of activities at primary level and complementary package of activities at secondary level is an opportunity to meet the needs and rights of persons with mental, neurological and substance abuse disorders (PWMNSDs) in Cambodia, provided there is mental health leadership, government commitment and political will.

Some cross-talks between immune cells and epilepsy should not be forgotten

Recent studies have reported that immune cells were not always found in brain specimens from epileptic patients, then should we stop investigating the relationship between these cells and epilepsy? The answer is no! In addition to immunocyte infiltration in brain parenchyma, a flurry of papers have demonstrated that there were significant alterations in peripheral blood cells (PBCs) immediately after seizure onset, especially changes in some specific transporters of neurotransmitters expressed on the membrane of immunocyte. These transporters may regulate neuronal excitability in mature neurons. Besides, many researchers did find activated leukocytes adhered to the endothelium of blood brain barrier or infiltrated into the brain parenchyma in several types of epilepsy both in human and animal studies; moreover, it is worth noting that different immune cells play different roles in epilepsy development, which was indicated by in vitro and in vivo evidence. This review is going to summarize available evidence supporting changes in PBCs after seizures, and will also focus on some specific effects of immune cells on epilepsy development.