Delivery of care for migraine in the Asian Oceanian region: A cross-sectional study.

OBJECTIVE: To determine the current availability of care for headaches, in particular migraine in the Asian Oceanian region. METHOD: A questionnaire-based, cross-sectional study from August 2020 to February 2021, surveyed country representatives from the member countries of the Asian Oceanian Association of Neurology. The items of the survey were influenced by the findings and recommendations of the 2011 Atlas of Headache by Lifting the Burden and the World Health Organization. RESULTS: Respondents from all of the 21 member countries of the Asian Oceanian Association of Neurology and 3 other Asian countries participated in this survey. All countries have an established neurological association except for Brunei where there are only 6 neurologists. Thirteen countries (54%) have a dedicated council for headaches. The majority have no subspecialty training program for headaches (75%). Prevalence studies are available in 14 countries while 10 out of the 24 have clinical practice guidelines. Among the 6 countries who offer subspecialty training for headache, only 3 countries cater foreign neurologists. Most of the countries have a wide selection of non-specific migraine drugs. All countries except for Mongolia have at least 1 triptan but non-oral forms for triptans are only available in 8 countries. Monoclonal antibody for migraine prophylaxis is available in 12 out of 24 countries (50%). The majority of respondents agree that migraine is under-diagnosed and under-treated by non-neurologists and that more time should be allotted for lectures dedicated to primary headaches in medical schools. CONCLUSION: The survey showed the scarcity of clinical guidelines, subspecialty training, dedicated headache clinics, and patient advocacy organization for the care of headache patients in the participating countries. Acute and prophylactic medications approved for migraine are available in most countries but approved non-pharmacologic devices are lacking. The recommendations in the 2011 Atlas of Headache Disorders are still to be achieved.

Randomised, controlled trial of erenumab for the prevention of episodic migraine in patients from Asia, the Middle East, and Latin America: The EMPOwER study.

OBJECTIVE: EMPOwER, a double-blind, randomised, phase 3 study, evaluated the efficacy and safety of erenumab in adults with episodic migraine from Asia, the Middle East, and Latin America. METHODS: Randomised patients (N = 900) received monthly subcutaneous injections of placebo, erenumab 70 mg, or 140 mg (3:3:2) for 3 months. Primary endpoint was change from baseline in monthly migraine days at Month 3. Other endpoints included achievement of ≥50%, ≥75%, and 100% reduction in monthly migraine days, change in monthly acute migraine-specific medication treatment days, patient-reported outcomes, and safety assessment. RESULTS: At baseline, mean (standard deviation) age was 37.5 (9.9) years, 81.9% were women, and monthly migraine days was 8.2 (2.8). At Month 3, change from baseline in monthly migraine days (primary endpoint) was -3.1, -4.2, and -4.8 days for placebo, erenumab 70 mg, and erenumab 140 mg, respectively, with a statistically significant difference for erenumab versus placebo (P = 0.002 [70 mg], P < 0.001 [140 mg]). Both erenumab doses were also significantly superior to placebo on all secondary endpoints, including the proportion of patients achieving ≥50% reduction from baseline in monthly migraine days, change from baseline in monthly acute migraine-specific medication treatment days and change from baseline in the Headache Impact Test-6™ scores. The safety profile of erenumab was comparable with placebo; no new safety signals were observed. CONCLUSIONS: This study of erenumab in patients with episodic migraine from Asia, the Middle East, and Latin America met all primary and secondary endpoints. A consistent numerical benefit was observed with erenumab 140 mg versus erenumab 70 mg across all efficacy endpoints. These findings extend evidence of erenumab's efficacy and safety to patients under-represented in previous trials.ClinicalTrials.gov identifier: NCT03333109.

Global Survey of the Frequency of Atrial Fibrillation-Associated Stroke: Embolic Stroke of Undetermined Source Global Registry.

BACKGROUND AND PURPOSE: Atrial fibrillation (AF) is increasingly recognized as the single most important cause of disabling ischemic stroke in the elderly. We undertook an international survey to characterize the frequency of AF-associated stroke, methods of AF detection, and patient features. METHODS: Consecutive patients hospitalized for ischemic stroke in 2013 to 2014 were surveyed from 19 stroke research centers in 19 different countries. Data were analyzed by global regions and World Bank income levels. RESULTS: Of 2144 patients with ischemic stroke, 590 (28%; 95% confidence interval, 25.6-29.5) had AF-associated stroke, with highest frequencies in North America (35%) and Europe (33%) and lowest in Latin America (17%). Most had a history of AF before stroke (15%) or newly detected AF on electrocardiography (10%); only 2% of patients with ischemic stroke had unsuspected AF detected by poststroke cardiac rhythm monitoring. The mean age and 30-day mortality rate of patients with AF-associated stroke (75 years; SD, 11.5 years; 10%; 95% confidence interval, 7.6-12.6, respectively) were substantially higher than those of patients without AF (64 years; SD, 15.58 years; 4%; 95% confidence interval, 3.3-5.4; P<0.001 for both comparisons). There was a strong positive correlation between the mean age and the frequency of AF (r=0.76; P=0.0002). CONCLUSIONS: This cross-sectional global sample of patients with recent ischemic stroke shows a substantial frequency of AF-associated stroke throughout the world in proportion to the mean age of the stroke population. Most AF is identified by history or electrocardiography; the yield of conventional short-duration cardiac rhythm monitoring is relatively low. Patients with AF-associated stroke were typically elderly (>75 years old) and more often women.

Knowledge, attitude, and practices of Filipino adult neurologists on obstructive sleep apnea among stroke patients.

Objectives: This study aimed to describe the knowledge, attitudes, and practices of Filipino adult neurologists in the recognition and treatment of obstructive sleep apnea (OSA) among patients presenting with acute stroke. Methodology: A prospective cross-sectional study was conducted using a web-based survey from April to June 2022 among active locally-practicing adult neurology fellows of the Philippine Neurological Association. The 18-item knowledge statements from the validated "Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) Questionnaire was used as survey instrument. There were also eight additional items assessing knowledge, six items assessing attitudes, and ten items assessing practices that were included. Results: A total of 119 neurologists participated in the survey. Two-thirds of the respondents were females, and 70 % were between 31 and 40 years old. Majority of the respondents are General Neurologists (57.1 %) followed by Neurophysiologists (10 %) and Stroke Specialists (10 %). Forty-seven percent of neurologists got more than or equal to 75 % of the knowledge statements included in the OSAKA questionnaire correctly. Less than half of the respondents correctly answered the questions on (1) uvulopalatopharyngoplasty as curative for majority of patients with OSA (32.8 %), (2) continuous positive airway pressure (CPAP) therapy can cause nasal congestion (42.9 %), (3) laser-assisted uvuloplasty as treatment for severe OSA (16.8 %), and (4) less than 5 apneas is normal in adults (48.7 %). Majority (>80 %) of the respondents were able to correctly answer the statements relating OSA and stroke. Almost all agreed that OSA as a clinical disorder (95 %) is important and that acute stroke patients with possible OSA needs to be identified (94.1 %) and further evaluated (96.6 %). On the other hand, less than half of the respondents feel confident in: identifying patients at-risk for OSA (47.9 %), ability to manage acute stroke patients with OSA (34.5 %), and ability to manage acute stroke patients with OSA on CPAP therapy (21 %). Most neurologists would sometimes screen OSA among their patients with acute stroke (55.5 %). Most respondents would only educate their patients on OSA sometimes (43.7 %). With regards to the diagnosis (42 %), risk factors (42 %), and treatment options for OSA (40.3 %), most would discuss them with their patients. Conclusion: Less than half of neurologists were able to get at least 75 % of the knowledge questions. Majority had difficulty with statements pertaining to surgery as cure for OSA, CPAP therapy causing nasal congestion, and OSA severity classification. Almost all has a positive attitude towards the importance of OSA diagnosis and management; however, there is low confidence among them with regards to their practice in identification and handling of these patients.

Vitamin B for treating peripheral neuropathy.

BACKGROUND: Vitamin B is frequently used for treating peripheral neuropathy but its efficacy is not clear. OBJECTIVES: The objective of this review was to assess the effects of vitamin B for treating generalised peripheral neuropathy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (searched August 2005), MEDLINE (January 1966 to September 2005), EMBASE (January 1980 to September 2005), Philippine databases (searched September 2005) and reference lists of articles. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials where vitamin B was compared with placebo or another treatment in generalised peripheral neuropathy. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS: Thirteen studies involving 741 participants with alcoholic or diabetic neuropathy were included. In the comparison of vitamin B with placebo, two small trials showed no significant short-term benefit in pain intensity while one of the trials showed a small significant benefit in vibration detection from oral benfotiamine, a derivative of thiamine. In the larger of two trials comparing different doses of vitamin B complex, there was some evidence that higher doses resulted in a significant short-term reduction in pain and improvement in paraesthesiae, in a composite outcome combining pain, temperature and vibration, and in a composite outcome combining pain, numbness and paraesthesiae. There was some evidence that vitamin B is less efficacious than alpha-lipoic acid, cilostazol or cytidine triphosphate in the short-term improvement of clinical and nerve conduction study outcomes but the trials were small. There were few minor adverse effects reported. AUTHORS' CONCLUSIONS: There are only limited data in randomised trials testing the efficacy of vitamin B for treating peripheral neuropathy and the evidence is insufficient to determine whether vitamin B is beneficial or harmful. One small trial in alcoholic peripheral neuropathy reported slightly greater improvement in vibration perception threshold with oral benfotiamine for eight weeks than placebo. In another small study, a higher dose of oral vitamin B complex for four weeks was more efficacious than a lower dose in reducing symptoms and signs. Vitamin B administered by various routes for two to eight weeks was less efficacious than alpha-lipoic acid, cilostazol or cytidine triphosphate in short-term improvement of clinical and nerve conduction study outcomes. Vitamin B is generally well-tolerated.

The professional practice and training of neurology in the Asian and Oceanian Region: A cross-sectional survey by the Asian and Oceanian Association of Neurology (AOAN).

OBJECTIVE: To survey AOAN member countries regarding their organizational structure, postgraduate neurology training program, and resources for neurological care provision. METHODOLOGY: A cross-sectional survey using a 36-item questionnaire was conducted among country representatives to AOAN from August 2015 to August 2016. RESULTS: A total of 18/20 AOAN member countries participated in the survey. All the countries have organized association with regular meetings, election of officers and neurology training program. In 9/18 countries, professionals other than neurologists were eligible for affiliation. In 11/18 countries, prior Internal medicine training (or equivalent postgraduate housemanship) is prerequisite to neurology program. Recertification examination is not a practice, but submission of CME is required in 7/18 countries to maintain membership. 12/18 countries publish peer-reviewed journals with at least 1 issue per year. Subspecialty training is offered in 14/18 countries. The ratio of neurologist to population ranges from 1:14,000 to as low as 1:32 million with 9/18 having <1 neurologist per 100,000 population. 6/18 countries have at least 1 specialized center solely for neurological diseases. In government-funded hospitals, the lag time to be seen by a neurologist and/or obtain neuroimaging scan ranges from 1day to 3months. All except one country have several medical- and lay- advocacy or support groups for different neurological conditions. IMPLICATIONS: The data generated can be used for benchmarking to improve neurological care, training, collaborative work and research in the field of neurosciences among the AOAN member countries. The paper presented several strategies used by the different organizations to increase their number of neurologists and improve the quality of training. Sharing of best practices, academic networking, exchange programs and use of telemedicine have been suggested.

Clinical Profile and Outcome of Postthymectomy versus Non-Thymectomy Myasthenia Gravis Patients in the Philippine General Hospital: A 6-Year Retrospective Study.

BACKGROUND: Myasthenia gravis is an autoimmune neuromuscular disorder characterized by the production of abnormal autoantibodies directed against the receptors present in the neuromuscular junction. It has been the standard practice to offer thymectomy in all generalized myasthenia gravis patients despite the lack of robust evidence. OBJECTIVES: The objectives of this study are to describe the clinical profile and differentiate the clinical outcomes of thymectomy versus non-thymectomy and thymomatous versus non-thymomatous myasthenia gravis patients in the Philippine General Hospital. METHODOLOGY: Between 2009 and 2014, a total of 69 postthymectomy and 16 non-thymectomy patient records were successfully retrieved. The demographic characteristics, surgical approach, and histopathologic results were obtained. The clinical outcome after 6 months or 1 year-follow-up was also determined and grouped according to the following: (1) complete remission, (2) pharmacological remission, (3) no clinical change, (4) worsening symptoms, and (5) mortality. RESULTS: Majority of the patients were females (68.0%) with a mean age of 39.8 years and a mean duration of myasthenic symptoms of 21 months. Using the Myasthenia Gravis Foundation of America classification, 54.1% of patients fell under Class II and 48.2% of them presented with generalized weakness. In this study, 60.8% of postthymectomy myasthenia gravis patients had either complete remission or pharmacologic remission compared with 12.5% among non-thymectomy patients (p-value <0.001). No significant difference in the clinical outcome was found between thymomatous and non-thymomatous myasthenia gravis after thymectomy (p-value = 0.29). CONCLUSION: This study showed that both thymomatous and non-thymomatous myasthenia gravis patients who underwent thymectomy had a higher incidence of complete stable remission and pharmacologic remission as compared with myasthenia gravis patients who did not undergo thymectomy.

Current patterns in the management of adult stroke by Filipino neurologists: A nationwide cross-sectional survey among fellows of the Philippine Neurological Association

BACKGROUND: Despite the availability of clinical guidelines for stroke, variation exists in the management patterns of stroke among neurologists.OBJECTIVE: To determine the current practice patterns of Filipino adult neurologists in stroke and their adherence to the current clinical guidelines of the Stroke Society of the Philippines (SSP).METHODS: Cross-sectional survey using a 3-page, 17-item questionnaire reviewed by the Stroke Council of the Philippine Neurological Association (PNA).RESULTS AND OBSERVATIONS: From November 2013 to July 2014, 136 of 277 (49%) locally practicing board certified adult neurologists of the PNA were surveyed. Some important findings from the survey include: (1) 70% of respondents underestimated the benefit of warfarin in stroke prevention in nonvalvular atrial fibrillation (NVAF); (2) for acute ischemic stroke, although the recommended systolic blood pressure (SBP) threshold is >220 mm Hg, 43% would initiate antihypertensive therapy at SBP >180 mm Hg; (3) for acute primary intracerebral hemorrhage (ICH), 42% would start antihypertensives at SBP >140 mm Hg; (4) despite the absence of guidelines recommending the use of neuroprotectant drugs for acute stroke, 75% and 56% of neurologists have prescribed it to >80% of their patients with infarcts and ICH respectively; (5) 46% of neurologists have not experienced giving thrombolytic therapy to any of their patients with acute ischemic stroke; (6) among patients with clinically stable hemorrhagic strokes, 77% of neurologists would give antithrombotics, while 28% of them would start it 30 days after the onset of stroke; (7) only 21% of respondents have ordered carotid studies as part of their work up in >80% of their patients with ischemic strokes; and (8) 64% of respondents have requested carotid revascularization procedures for patients with significant carotid stenosis, and about 38% of these patients underwent the procedure.CONCLUSION: The management patterns in stroke remain varied among Filipino neurologists, although the patterns show increasing adherence toward guideline recommendations. The following practices are noted: underestimation of the benefits of oral anticoagulation for stroke prevention among patients with NVAF; use of pharmacologic control of blood pressure below the recommended threshold for acute ischemic stroke; widespread use of neuroprotectant drugs despite lack of definite evidence for its use; low utilization of carotid studies in the work-up of patients with ischemic stroke and the low rate of revascularization procedures in confirmed cases of carotid stenosis; and a relative increase in experience with thrombolysis.

Hemichorea and myoclonus in Filipino patients with cerebral toxoplasmosis: A report of two cases

BACKGROUND: This paper synthesizes two unique cases of an adult Filipino patient presenting with involuntary unilateral extremity movements which upon further workup revealed cerebral toxoplasmosis as their primary etiology, further revealing their immunocompromised states. To our best knowledge there is limited available data on cerebral toxoplasmosis in our local setting. RATIONALE AND OBJECTIVES: The Filipino population is not spared from the pervasive global upsurge of AIDS cases as well as HIV-related infections. The aim of this report is to document the clinical features and diagnostics of two patients with cerebral toxoplasmosis presenting with unilateral involuntary extremity movements to heighten the level of awareness of Filipino physicians on the need to further explore possible etiologies of common neurological signs and symptoms as well as document additional cases of HIV-related infection in our country. CASE DESCRIPTION: The first case is a 30 year old male with no comorbidities who presented with fever and sudden onset of choreoathetoid movements of the left extremities. MRI revealed a rim enhancing nodule in the left supraorbital frontal lobe and in the middle cerebral peduncle. The second case is a 40 year old male, known hypertensive, initially diagnosed to have pulmonary tuberculosis, who presented with sudden onset of focal left arm myoclonic jerks. MRI revealed a rim enhancing cortical nodule on the right precentral gyrus. Both lesions were consistent with characteristics of toxoplasmosis. Both patients also showed positive serological titers for toxoplasmosis and had low CD4 T-cell count on flow cytometry. Both patients were treated with high dose trimethoprim-sulfamethoxazole and were further worked up for HIV-related infections. CONCLUSION: Majority of Filipino patients are still not provided with the opportunity to be diagnosed and treated for HIV-related infections, with one reason being the low index of suspicion for such cases. There is still limited amount of data available locally regarding patients presenting with Cerebral Toxoplasmosis, and that common neurological signs and symptoms as presented in this report should provide the much needed enlightenment in a physician's clinical eye to entertain such etiologies.

Safety, tolerability and recovery assessment of using sulodexide in acute ischemic stroke (STRAUSS): A pilot study

Sulodexide was evaluated in an investigator-initiated, multi-center, randomized, controlled, open-labeled study to determine its safety and tolerability profile, and effect on the neurological recovery and functional outcome of patients with acute ischemic stroke. Sixty-five (65) patients were randomized to Standard care group and 46 to Standard care plus Sulodexide Treatment group. Sulodexide was observed to be safe and well-tolerated among patients included in this study. Although not statistically significant, Modified Rankin Scale Responder Analysis consistently showed higher proportions of functionally improved patients in the Sulodexide group than in the Standard Care group on treatment days 10, 30, and 90 respectively.