Challenges of status epilepticus management in a resource-limited setting: A review.

Status epilepticus (SE) is a life-threatening neurological condition with significant mortality. Rapid management is essential to minimize the mortality and disability of SE. Two recent trials provided evidence to guide SE management in early and established stages. The Rapid Anticonvulsant Medication Prior To Arrival Trial (RAMPART, 2011) showed that intramuscular midazolam is a better alternative for early convulsive SE in prehospital settings. The Established Status Epilepticus Treatment Trial (ESETT, 2020) supported the use of sodium valproate and levetiracetam as second-line treatment for its efficacy and shorter administration time. However, there are challenges to revising the status epilepticus management in resource-limited settings, in pre-hospital, first- and second-line treatment, as well as management of refractory and super-refractory SE. These challenges included restrictions or lack of training in the administration of benzodiazepine in the prehospital setting, limited availability and accessibility of newer antiseizure medications (ASMs) in emergency departments and smaller hospitals, and low clinicians' awareness of the latest evidence. A collaborative effort to educate, improve awareness, and make certain ASMs more readily available is recommended to achieve a better clinical outcome in SE.

The Impact of Post-COVID-19 Conditions on Sleep and Quality of Life in Indonesia: A Nationwide Cross-Sectional Study.

Background: Sleep disturbances are included in the six most commonly cited complaints in post-COVID-19 conditions. In order to find the optimal management approach and enhance Quality of Life (QoL), we intend to explore sleep disturbances that occur in post-COVID-19 conditions. Methods: This was a cross-sectional study conducted with interviews and questionnaires using the Pittsburgh Sleep Quality Index (PSQI) for assessing sleep quality, Insomnia Severity Index (ISI) for assessing insomnia, Epworth Sleepiness Scale (ESS) for assessing Excessive Daytime Sleepiness (EDS), STOP-BANG questionnaire for assessing Obstructive Sleep Apnea (OSA), and Short Form 36 (SF-36) for assessing QoL. We recruited respondents from several cities in Indonesia and performed an analysis to find the relationship between sleep disturbance and its association with QoL. Results: This study involved 757 respondents. They were predominantly female, with a median age of 39 years, no comorbidities, and had exhibited mild COVID-19 severity. Subjects with post-COVID-19 conditions experienced insomnia, poor sleep quality, normal sleepiness, and low risk of OSA. Sleep quality caused role limitations due to decreased physical and mental health. Insomnia caused role limitations due to emotional and social functioning problems. Meanwhile, OSA only affected physical functioning. Conclusion: Numerous aspects of patients' QoL are affected by sleep disturbance in post-COVID-19 conditions. A comprehensive approach and coordinated care pathways must be effectively managed to improve QoL among individuals experiencing sleep disturbance.

Cost-effectiveness analysis of HLA-B*15:02 screening before treatment of epilepsy in Indonesia.

INTRODUCTION: Adverse skin reactions due to drugs such as Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) occur in 3% of people receiving anti epileptic drugs (AED). Although SJS/TEN has a low incidence, the mortality and morbidity rates are high. Indonesia has not adopted HLA-B*1502 screening prior to administration of carbamazepine (CBZ), although previous studies found a relationship between HLA-B*1502 and SJS/TEN. METHODS: A hybrid decision tree and Markov model was developed to evaluate three strategies for treating newly diagnosed focal epilepsy: CBZ direct therapy, levetiracetam (LEV) direct therapy, and therapy based on HLA-B*15:02 test results. From a societal perspective, base case and sensitivity analyses were carried out over a lifetime. RESULTS: Direct administration of CBZ appears to have a slightly lower average cost than the HLA-B*15:02 allele screening strategy. The increase in quality-adjusted life year (QALY) in HLA-B*15:02 screening before treatment related to the cost difference reached 0.519 with an incremental cost-effectiveness ratio (ICER) of around USD 984 per unit of QALY acquisition. Direct treatment of LEV increased treatment costs by almost USD 2000 on average compared to the standard CBZ strategy. The increase in QALY is 0.834 in direct levetiracetam treatment, with an ICER of around USD 2230 for each QALY processing. CONCLUSION: Calculation of the cost-effectiveness of lifetime epilepsy therapy in this study found that the initial screening strategy with the HLA-B*15:02 test was the most cost-effective.

Affordability of newer antiseizure medications in Asian resource-limited countries.

OBJECTIVE: One of the objectives of the Intersectoral Global Action Plan on epilepsy and other neurological disorders for 2022 to 2031 is to ensure at least 80% of people with epilepsy (PWE) will have access to appropriate, affordable, and safe antiseizure medications (ASMs) by 2031. However, ASM affordability is a significant issue in low- and middle-income countries, preventing PWE from accessing optimal treatment. This study aimed to determine the affordability of the newer (second and third generation) ASMs in resource-limited countries in Asia. METHODS: We conducted a cross-sectional survey by contacting country representatives in lower-middle-income countries (LMICs) in Asia, including Indonesia, Lao People's Democratic Republic (PDR), Myanmar, Philippines, Vietnam, India, Bangladesh, and Pakistan, and the upper-middle-income country Malaysia, from March 2022 to April 2022. The affordability of each ASM was calculated by dividing the 30-day ASM cost by the daily wage of the lowest paid unskilled laborers. Treatment costing 1 day's wage or less for a 30-day supply of chronic disease is considered affordable. RESULTS: Eight LMICs and one upper-middle-income country were included in this study. Lao PDR had no newer ASM, and Vietnam had only three newer ASMs. The most frequently available ASMs were levetiracetam, topiramate, and lamotrigine, and the least frequently available was lacosamide. The majority of the newer ASMs were unaffordable, with the median number of days' wages for a 30-day supply ranging from 5.6 to 14.8 days. SIGNIFICANCE: All new generation ASMs, whether original or generic brands, were unaffordable in most Asian LMICs.

Multidrug Resistance-1 C3435T Polymorphism and Carbamazepine Plasma Level in Indonesian Temporal Lobe Epilepsy Patients.

BACKGROUND: Temporal lobe epilepsy (TLE) has the highest probability of becoming resistant. One of the causes was Polymorphism in multidrug resistant-1 (MDR1) C3435T. In Dr. Cipto Mangunkusumo Hospital, potential drug-resistant epilepsy prevalence was 84.51%; 66.6% of them used carbamazepine (CBZ) as antiseizure medication. This comparative cross-sectional study aimed to investigate MDR1 C3435T polymorphism and CBZ plasma level (plCBZ) in Indonesian TLE patients. METHODS: TLE patient was selected consecutively; divided into drug-responsive (DRV) and drugresistant (DRE) groups. Healthy subjects were included as a control for the gene polymorphism comparison. MDR1 was identified using the restriction fragment length polymorphism PCR technique; C allele at 159 and 57bp while T allele at 216bp. High-performance liquid chromatography was used to determine plCBZ. RESULTS: There were 86 subjects; 61 in the study group and 25 controls. The genotype distribution between them was 0.58 vs 0.42, x2=0.54, p=0.000. In the study group, CBZ within therapeutic doses (dCBZ) had outreached the therapeutic plCBZ and found similar in all genotypes. DRE criteria were found in 37 subjects. Distribution of C and T in DRV was 0.63 vs 0.37, x2=10.4; and DRE 0.55 vs 0.45 x2=6.17 (p=0.019). In Tukey's multiple comparison post hoc test, CT in DRV had significantly lower dCBZ (330,36 ± 174,91 mg) and plCBZ (7.15 ± 2.64 mcg/mL) compared to all genotypes in DRE. Whereas mean dCBZ was around 800mg and plCBZ outreached the toxic level; TT was the highest. CONCLUSION: The genotype MDR1 distribution was similar in the normal population and DRE. Therapeutic plCBZ was achieved using the low dose. CT genotype responds to lower dCBZ, while TT genotype outreached the highest toxic plCBZ.

Belly Dancer's Dyskinesia Responsive to Oral Medication Treatment.

Belly dancer's dyskinesia is a rare disease characterized mostly by the uncontrolled and rhythmic movements of the abdominal wall. No exact etiology has been identified yet and the treatment is mostly symptomatic. From most available case reports, oral medication therapy often provides disappointing result in term of reducing the symptom. Here, we report a patient who has satisfactory improvement after treated with oral medication only.

Indonesian Public Attitudes Toward Epilepsy (PATE) scale: Translation and psychometric evaluation.

INTRODUCTION: Epilepsy stigma has been associated with poor quality of life among people with epilepsy (PWE). It is important to understand the variation and degree of epilepsy stigma in one of the most populous and culturally diverse nations in the world, Indonesia. Hence, this study aimed to test the validity and reliability of the Indonesian version of the Public Attitudes Toward Epilepsy (PATE) scale. METHOD: The translation was performed according to standard principles and tested in 200 native Indonesian speakers who were aged above 18-year-old for psychometric validation. RESULTS: The items in each domain had similar means and standard deviations (equal item variance), means ranging from 2.17 to 2.86 in general domain and 2.75 to 3.56 in personal domain and, standard deviations ranging from 0.87 to 1.05 and 0.88 to 1.01 in general and personal domain, respectively. Item-domain correlations were more than 0.5 for all items, and they correlate higher within their own domain compare with the other domain (convergent and divergent validity). Multitrait analysis showed similar variance, floor, and ceiling patterns to a great extent compared with the initial study. The Indonesian PATE scale also showed mostly similar correlation with demographic characteristics except monthly income. Principle axis analysis revealed strong factor loading (>0.3) in their hypothesized domain, except item 14. The Cronbach's α values for general and personal domains were 0.836 and 0.765, which were within the accepted range of 0.7 to 0.9. CONCLUSION: The Indonesian PATE scale is a validated and reliable translation for measuring public attitudes toward epilepsy.

Early detection of peripheral neuropathy using stimulated skin wrinkling test in human immunodeficiency virus infected patients: A cross-sectional study.

Peripheral neuropathy is a common condition of human immunodeficiency virus (HIV)-infected patients, which often remains undetected. We assessed the performance of stimulated skin wrinkling-eutectic mixture of local anesthetic (SSW-EMLA) test compared with brief peripheral neuropathy screening (BPNS) to detect HIV neuropathy.This is a cross-sectional study conducted in HIV-positive patients. A modified skin wrinkling grading was used to assess SSW-EMLA effect. BPNS-detectable neuropathy was assessed by a combination of neuropathy severity scoring scale (subjective) and objective method of sensory and tendon reflex examination. The SSW-EMLA test accuracy with reference to BPNS was assessed using sensitivity and specificity and predictive values.In a total of 99 HIV patients, 61.6% were males and the majority age group were between 30 and 40 years (52%). The neuropathy detection was SSW-EMLA test 36.4% versus BPNS 15.2% (P = .04). The sensitivity of SSW-EMLA test was 60.0% [95% confidence interval (95% CI) 34.5-81.7], specificity 67% (95% CI 63.3-3-71.7), and overall accuracy of 66.7% (95% CI 58.9-73.2).The SSW-EMLA test detected many more peripheral neuropathy cases than BPNS in HIV patients and has potential as an alternative test for screening for HIV neuropathy in resource-constraint hospitals in Indonesia.