Effects of an intervention program to improve mental health and epilepsy care in Madagascar.

BACKGROUND: Despite the high prevalence of mental disorders and epilepsy in low- and middle-income countries, nearly 80% of patients are not treated. In Madagascar, initiatives to improve access to epilepsy and mental health care, including public awareness and training of general practitioners (GPs), were carried out between 2013 and 2018. Our study's main objective was to assess the effectiveness of these initiatives, two to five years post-intervention. METHODS: This quasi-experimental study (intervention vs. control areas) included five surveys assessing: general population's Knowledge Attitudes and Practices (KAP), GPs' KAP , number of epilepsy and mental health consultations at different levels of the healthcare system, diagnostic accuracy, and treatments' availability. OUTCOMES: In the general population, KAP scores were higher in intervention areas for epilepsy (11.4/20 vs. 10.3/20; p = 0.003). For mental disorders, regardless of the area, KAP scores were low, especially for schizophrenia (1.1/20 and 0.1/20). Among GPs, KAP scores were higher in intervention areas for schizophrenia (6.0/10 vs. 4.5/10; p = 0.008) and epilepsy (6.9/10 vs. 6.2/10; p = 0.044). Overall, there was a greater proportion of mental health and epilepsy consultations in intervention areas (4.5% vs 2.3%). Although low, concordance between GPs' and psychiatrists' diagnoses was higher in intervention areas. There was a greater variety of anti-epileptic and psychotropic medications available in intervention areas. INTERPRETATION: This research has helped to better understand the effectiveness of initiatives implemented in Madagascar to improve epilepsy and mental health care and to identify barriers which will need to be addressed. FUNDING: Sanofi Global Health, as part of the Fight Against STigma Program.

Knowledge, attitudes and practices of general practitioners on peripheral neuropathies in Benin in 2021.

PURPOSE: First healthcare actors in neurological diseases management, General Practitioners (GPs) still limited in the assessment of Peripheral Neuropathies (PN). This study assesses the knowledge, attitudes, practices (KAP) of GPs on PN in Benin in 2021 and identifying associated factors to low KAP. MATERIALS AND METHODS: It was a cross-sectional study conducted from 20 November 2020 to 30 June 2021 which included GPs registered in the National Order of Physicians in Benin and interns in last year of medical studies (MS). An overall KAP score of 24 points was derived. KAP levels were low (score < 17), medium (17 to 19) and high (score ≥ 20). Multivariable regression models were performed to identify factors associated with low KAP. RESULTS: 645/1,066 participants (60.5%) were included in the study with median age 28 years [Interquartile range IQR: 26-30 years], and 442 (68.5%) were male. The KAP level was low in 70.1%. 16.7% had a low knowledge of polyneuropathy manifestations, 35% perceived PN as an incurable disease. Lack of knowledge on PN before MS (adjusted Odds-ratio aOR = 1.6 [95% confidence interval CI: 1.1-2.3]), and no postgraduate training on PN (aOR = 1.8 [95% CI: 1.--3.0]) were associated with low overall KAP level. Working in rural area (aOR = 0.4 [95%CI: 0.2-0.7]), and being an intern (aOR = 0.6 [95%CI: 0.4-0.9]) were associated with better overall KAP level. CONCLUSION: This study highlights the need for better training with strong emphasis on PN during the MS and the organization of postgraduate training for GPs; the cornerstone for improving the management of PN in Benin.

Mapping, Associated Factors, and Pathophysiology of Nodding Syndrome in Africa: A Systematic Review.

INTRODUCTION: Nodding syndrome (NS) remains a poorly understood disorder. For a long time, it has been thought to be restricted to East Africa; however, cases in Central Africa have been increasing over time. The objective of this systematic review (SR) was to provide a summary of the state of knowledge on NS to date. METHODS: All original articles published on NS up to November 2021 were searched in four major databases and in the gray literature. Commentaries, editorials, book chapters, books, conference paper, qualitative studies that mentioned NS cases were also included. Data retrieved included study location (with GPS coordinates searched), year of study and publication, population characteristics, definition and diagnosis of NS, associated factors, and treatment if applicable. A meta-analysis of associated factors was performed where possible, and results were presented as odds ratios (ORs) and visualized as forest plots. Geographic information systems were used for cartographic representations. The quality of the articles included was assessed. RESULTS: Of the 876 articles initially identified, 67 (corresponding to 59 studies) were included in the SR. NS is only present in Central and East Africa. Interestingly, there were reports of NS in Central Africa prior to 2010, earlier than previously thought. The way NS diagnosis was established varies according to studies, and the 2012 WHO classification was used in only 60% of the studies. Approximately 11% of the articles did not meet the quality requirements set for this review. In our meta-analysis, the main factor associated with NS was onchocerciasis (OR = 8.8 [4.8, 15.9]). However, the pathophysiology of the disease remains poorly understood. The lack of common anti-epileptic drugs is a significant barrier to the management of head nodding and associated epileptic seizures. DISCUSSION/CONCLUSION: The lack of an operational definition of NS is an obstacle to its diagnosis and, thus, to its appropriate treatment. Indeed, diagnostic difficulties might have led to false positives and false negatives which could have altered the picture of NS presented in this article. Treatment should take into account nutritional and psychological factors, as well as associated infections. Some risk factors deserve further investigation; therefore, we suggest a multicentric study with an etiological focus using a more operational definition of NS.

Nutritional status and associated factors among the elderly in Guinea: a first national cross-sectional study.

Aging of the Guinean population is a public health concern for the coming years, and the nutritional status of older people is virtually unknown. We also know that this population is growing and that undernutrition and obesity can affect the health of older adults. This study aimed to assess the nutritional status of older people in the general population of Guinea and its associated factors. A representative cross-sectional survey was conducted using sociodemographic, clinical, and anthropometric data (weight and height). Oral status was assessed by using the University of Nebraska Oral Status Scale. Visual acuity was assessed using the Monoyer scale. The standardized prevalence ratio (SPR) of the nutritional status was calculated for each region. The sample included 1698 subjects with a mean BMI of 22.6 ± 4.3 kg/m2. A total of 50.3% had impaired oral status and 20.3% had moderately to severely impaired visual acuity. The prevalence of undernutrition was 14.4% and of obesity 5.7%. Differences in the prevalence of nutritional status were found between regions, with an SPR > 1 for undernutrition in the Labé region (SPR 1.9, 95% CI = 1.5-2.5) and for obesity in the Conakry and Kindia regions (SPR of 2.90, 95% CI = 2.0-4.05 and 2.32, 95% CI = 1.5-3.3, respectively). In Guinea, The prevalence of nutritional disorders was approximately 20%. Screening and management of the health and nutritional status of older adults should be a national priority, and management should be adapted to each region of the country.

Barriers to accessing multiple sclerosis disease-modifying therapies in the Middle East and North Africa region: A regional survey-based study.

BACKGROUND: Multiple sclerosis (MS) management varies markedly between different countries of the Middle East and North Africa (MENA) region based on the availability and accessibility of disease-modifying therapies (DMTs). OBJECTIVE: To evaluate the accessibility to DMTs in each MENA country, identify barriers to treatment and make recommendations for improved access to DMTs across the region. METHODS: This is a descriptive, survey-based study whereby we extracted data collected, between October 2019 and April 2020, for countries in the MENA region by the Multiple Sclerosis International Federation (MSIF) through their Atlas of MS survey. RESULTS: 16 out of 19 countries in the MENA region were included in this study. Sudan and Syria did not have any originator DMTs approved. Interferons were the most widely low-efficacy originator approved DMTs. Three countries did not have any high efficacy DMTs approved. Moreover, follow-on DMTs were approved in half (50%) of the countries. Cost of treatment was the most important barrier, reported in nearly half (47%) of the MENA countries. CONCLUSION: Although most MENA countries have access to DMTs, more than half of countries report problems with treatment continuation, highlighting the need for a targeted regional strategy to address the variations in access to MS treatments.

Early predictors of remission in children and adolescents with new-onset epilepsy: A prospective study.

PURPOSE: This study aims to identify predictive factors of a two-year remission (2YR) in a cohort of children and adolescents with new-onset seizures based on baseline clinical characteristics, initial EEG and brain MRI findings. METHODS: A prospective cohort of 688 patients with new onset seizures, initiated on treatment with antiseizure medication was evaluated. 2YR was defined as achieving at least two years of seizure freedom during the follow-up period. Multivariable analysis was performed and recursive partition analysis was utilized to develop a decision tree. RESULTS: The median age at seizure onset was 6.7 years, and the median follow-up was 7.4 years. 548 (79.7%) patients achieved a 2YR during the follow up period. Multivariable analysis found that presence and degree of intellectual and developmental delay (IDD), epileptogenic lesion on brain MRI and a higher number of pretreatment seizures were significantly associated with a lower probability of achieving a 2YR. Recursive partition analysis showed that the absence of IDD was the most important predictor of remission. An epileptogenic lesion was a significant predictor of non-remission only in patients without evidence of IDD, and a high number of pretreatment seizures was a predictive factor in children without IDD and in the absence of an epileptogenic lesion. CONCLUSION: Our results indicate that it is possible to identify patients at risk of not achieving a 2YR based on variables obtained at the initial evaluation. This could allow for a timely selection of patients who require close follow-up, consideration for neurosurgical intervention, or investigational treatments trials.

Elevated plasma interleukin-8 as a risk factor for mortality in children presenting with cerebral malaria.

BACKGROUND: Cerebral malaria (CM) is a neuropathology which remains one of the deadliest forms of malaria among African children. The kinetics of the pathophysiological mechanisms leading to neuroinflammation and the death or survival of patients during CM are still poorly understood. The increasing production of cytokines, chemokines and other actors of the inflammatory and oxidative response by various local actors in response to neuroinflammation plays a major role during CM, participating in both the amplification of the neuroinflammation phenomenon and its resolution. In this study, we aimed to identify risk factors for CM death among specific variables of inflammatory and oxidative responses to improve our understanding of CM pathogenesis. METHODS: Children presenting with CM (n = 70) due to P. falciparum infection were included in southern Benin and divided according to the clinical outcome into 50 children who survived and 20 who died. Clinical examination was complemented by fundoscopic examination and extensive blood biochemical analysis associated with molecular diagnosis by multiplex PCR targeting 14 pathogens in the patients' cerebrospinal fluid to rule out coinfections. Luminex technology and enzyme immunoassay kits were used to measure 17 plasma and 7 urinary biomarker levels, respectively. Data were analysed by univariate analysis using the nonparametric Mann‒Whitney U test and Pearson's Chi2 test. Adjusted and multivariate analyses were conducted separately for plasma and urinary biomarkers to identify CM mortality risk factors. RESULTS: Univariate analysis revealed higher plasma levels of tumour necrosis factor (TNF), interleukin-1beta (IL-1ß), IL-10, IL-8, C-X-C motif chemokine ligand 9 (CXCL9), granzyme B, and angiopoietin-2 and lower urinary levels of prostanglandine E2 metabolite (PGEM) in children who died compared to those who survived CM (Mann-Whitney U-test, P-values between 0.03 and < 0.0001). The multivariate logistic analysis highlighted elevated plasma levels of IL-8 as the main risk factor for death during CM (adjusted odd ratio = 14.2, P-value = 0.002). Values obtained during follow-up at D3 and D30 revealed immune factors associated with disease resolution, including plasma CXCL5, C-C motif chemokine ligand 17 (CCL17), CCL22, and urinary 15-F2t-isoprostane. CONCLUSIONS: The main risk factor of death during CM was thus elevated plasma levels of IL-8 at inclusion. Follow-up of patients until D30 revealed marker profiles of disease aggravation and resolution for markers implicated in neutrophil activation, endothelium activation and damage, inflammatory and oxidative response. These results provide important insight into our understanding of CM pathogenesis and clinical outcome and may have important therapeutic implications.

Prevalence and associated factors with peripheral neuropathies in the general population in the rural area of Adjohoun in Benin.

BACKGROUND: Peripheral neuropathies (PN) are a group of neurological conditions related to damage to the peripheral nervous system. Due to their wide diversity, few studies in sub-Saharan Africa have explored their epidemiology in general population. Our objective was to study the prevalence and associated factors with PN in general population in Adjohoun in Benin. METHODS: A cross-sectional study has been conducted from February to March 2019 and included people aged ≥ 18 years old living in Adjohoun, Benin. Following a screening phase for PN (using World Health Organization questionnaire for major neurological diseases), a neurologist made a diagnosis after in-depth clinical examinations completed in some cases by electroneuromyography. The EFNS (European Federation of Neurological Societies) 2010 criteria was used for chronic inflammatory demyelinating polyneuropathy diagnosis. Data such as age, occupation, consanguinity, alcohol consumption, diabetes, hypertension were collected. Association between independent variables and PN were investigated using multivariable logistic regression models. RESULTS: In total, 1 655 participants were included, mean age 41.4 ± 16.7 years; 64.8 % are female. The overall prevalence of PN was 6.9 % (95 %CI: 5.7 %-8.2 %). The main types of PN were: polyneuropathies 4.8 % (95 %CI: 3.8 %-5.9 %); polyradiculoneuropathies 1.6 % (95 %CI: 1.0 %-2.2 %). Factors independently associated with PN were age ≥ 40 years (adjusted Odds Ratio aOR = 19.6; 95 %CI: 8.2-46.3), diabetes (aOR = 1.8; 95 %CI: 1.08-2.99) and hypertension (aOR = 1.6; 95 %CI: 1.02-2.5). CONCLUSION: The prevalence of PN was high in the rural commune of Adjohoun in Benin. Actions on its modifiable associated factors such as diabetes and hypertension could help reduce the proportion of PN and their potential harmful consequences.

Knowledge of epilepsy, quality of life, and psychiatric comorbidities in Lebanese adults with epilepsy.

INTRODUCTION: People with epilepsy (PWE) face a variety of psychosocial challenges. A lack of knowledge of epilepsy, a high level of depression and anxiety and a low quality of life (QoL) are among the major problems that affect most PWE. The objective of this study was to examine the association of sociodemographic characteristics, clinical factors and knowledge of epilepsy with the level of QoL, and the presence of psychiatric comorbidities. METHOD: A cross-sectional study was conducted in Lebanon. The PWE were recruited from neurologists' clinics in Beirut and its suburbs. A questionnaire translated into Arabic was used and composed of four parts: sociodemographic factors, clinical characteristics, psychosocial characteristics (QoL, psychiatric disorders), and knowledge epilepsy scale. Backward logistic regression models were developed, the associations were estimated by odds ratio (OR), and the level of significance was set at p ≤ 0.05. RESULTS: Four hundred and four PWE were recruited in this study. About a half of PWE had controlled epilepsy (46.3 %) and 40.3 % had epilepsy for less than 5 years. The QoL was low for 38.6 % of PWE and 30.2 % had psychiatric comorbidities. More than half of PWE had a good level of knowledge (71.5 %). Controlled epilepsy (OR = 1.8; 95 %CI: 1.2-2.9), and good knowledge about epilepsy (OR = 5.5; 95 %CI: 3.4-9.1) were associated with better QoL. Patients on polytherapy with anti-seizure drugs (OR = 0.6; 95 %CI: 0.4-0.9), experienced side effects of anti-seizure drugs (OR = 0.6; 95 %CI: 0.4-0.9) and with psychiatric comorbidities (OR = 0.6; 95 %CI: 0.3-0.9) had a lower QoL. A high number of nonpsychiatric comorbidities (OR = 2.5; 95 %CI: 2.0-3.1) and a polytherapy increased the risk of having psychiatric comorbidities (OR = 1.8; 95 %CI: 1.1-2.8). CONCLUSIONS: Good knowledge of epilepsy and the absence of psychiatric comorbidities are important predictors of good QoL in Lebanese PWE. Educational programs are needed to reduce misconceptions about epilepsy and improve mental health of PWE.

Spatio-temporal clustering of amyotrophic lateral sclerosis in France: A population-based study.

OBJECTIVE: To assess spatial aggregates of amyotrophic lateral sclerosis (ALS) incident cases, using a solid geo-epidemiological statistical method, in France. METHODS: This population-based study (2003-2011) investigated 47.1 million person-years of follow-up (PYFU). Case ascertainment of incident ALS cases was based on multiple sources (ALS referral centers, hospital centres and health insurance data). Neurologists confirmed all ALS diagnoses. Exhaustiveness was estimated through capture-recapture. Aggregates were investigated in four steps: (a) geographical modelling (standardized incidence ratio (SIR) calculation), (b) analysis of the spatial distribution of incidence (Phothoff-Winttinghill's test, Global Moran's Index, Kulldorf's spatial scan statistic, Local Moran's Index), (c) classification of the level of certainty of spatial aggregates (i.e. definite cluster; probable over-incidence area; possible over-incidence area) and (d) evaluation of the robustness of the results. RESULTS: The standardized incidence of ALS was 2.46/100,000 PYFU (95% CI 2.31-2.63, European population as reference) based on 1199 incident cases. We identified 13 areas of spatial aggregates: one cluster (stable in robustness analysis), five probable over-incidence areas (2 stable in robustness analysis) and seven possible over-incidence areas (including 4 stable areas in robustness analysis). A cluster was identified in the Rhône-Alpes region: 100 observed vs 54.07 expected cases for 2,411,514 PYFU, SIR: 1.85 (95% CI 1.50-2.25). CONCLUSION: We report here one of the largest investigations of incidence and spatial aggregation of ALS ever performed in a western country. Using a solid methodology framework for case ascertainment and cluster analysis, we identified 13 areas that warrant further investigation.

Non-traumatic coma in young children in Benin: are viral and bacterial infections gaining ground on cerebral malaria?

BACKGROUND: While malaria morbidity and mortality have declined since 2000, viral central nervous system infections appear to be an important, underestimated cause of coma in malaria-endemic Eastern Africa. We aimed to describe the etiology of non-traumatic comas in young children in Benin, as well as their management and early outcomes, and to identify factors associated with death. METHODS: From March to November 2018, we enrolled all HIV-negative children aged between 2 and 6 years, with a Blantyre Coma Score ≤ 2, in this prospective observational study. Children were screened for malaria severity signs and assessed using a systematic diagnostic protocol, including blood cultures, malaria diagnostics, and cerebrospinal fluid analysis using multiplex PCR. To determine factors associated with death, univariate and multivariate analyses were performed. RESULTS: From 3244 admissions, 84 children were included: malaria was diagnosed in 78, eight of whom had a viral or bacterial co-infection. Six children had a non-malarial infection or no identified cause. The mortality rate was 29.8% (25/84), with 20 children dying in the first 24 h. Co-infected children appeared to have a poorer prognosis. Of the 76 children who consulted a healthcare professional before admission, only 5 were prescribed adequate antimalarial oral therapy. Predictors of early death were jaundice or increased bilirubin [odd ratio (OR)= 8.6; 95% confidential interval (CI): 2.03-36.1] and lactate > 5 mmol/L (OR = 5.1; 95% CI: 1.49-17.30). Antibiotic use before admission (OR = 0.1; 95% CI: 0.02-0.85) and vaccination against yellow fever (OR = 0.2, 95% CI: 0.05-0.79) protected against mortality. CONCLUSIONS: Infections were found in all children who died, and cerebral malaria was by far the most common cause of non-traumatic coma. Missed opportunities to receive early effective antimalarial treatment were common. Other central nervous system infections must be considered in their management. Some factors that proved to be protective against early death were unexpected.

Amyotrophic lateral sclerosis mortality rates in Latin America and the Caribbean: a meta-analysis.

Background: Recent studies have described a low occurrence of Amyotrophic Lateral Sclerosis (ALS) in Latin America. Significant differences in ALS risk have been reported among ethnic populations in the region. We conducted a meta-analysis using population-based data to describe ALS mortality rates in Latin America. We explored sources of heterogeneity among key covariates.Methods: National mortality registries from Latin American countries were searched to identify ALS deaths according to the International Classification of Diseases (ICD-9: code 335.2 and ICD-10: code G12.2). Crude and standardized mortality rates were calculated. A random-effect meta-analysis was conducted to estimate pooled mortality rates. Subgroup analysis was performed as a means of investigating heterogeneity.Results: Overall, 28,548 ALS deaths and 819 million person-years of follow-up (PYFU) from ten Latin American countries were considered. Standardized mortality varied among countries. The highest mortality rates were observed in Uruguay and Costa Rica at 1.3 and 1.2 per 100,000 PYFU, respectively. The pooled crude mortality rate was 0.38 (95%CI: 0.28-0.53) and the pooled standardized mortality was 0.62 (95%CI: 0.49-0.77) per 100,000 PYFU. Heterogeneity was high (I2: 99.9%, Cochran's Q p < 0.001). Subgroup analysis showed a higher mortality rate among countries with a higher proportion of Caucasian populations and higher income levels.Conclusion: There is a lower ALS occurrence in Latin America compared to Europe and North America. This meta-analysis supports the hypothesis of a higher ALS risk among the Caucasian population. Further studies are needed to investigate the role of ancestral origins in ALS, taking socioeconomic status into consideration.

Instruments for investigation of epilepsy in low- and middle-income countries: A systematic review.

OBJECTIVE: Systematic reviews were conducted on the existence of screening tools for epilepsy, quality of life or comorbidities tools, but not specifically in low- and middle-income countries. This study aimed to identify the different tools developed and validated in low- and middle-income countries for the investigation of epilepsy. This to facilitate research in these regions and to identify needs in areas where few instruments are available. METHODS: This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Embase, MedLine, Google Scholar, Web of Science, SciELO, Neurology Asia, African Journal of Neurological Sciences and Institute of Epidemiology and Tropical Neurology bibliographic databases were investigated. Articles were included according to the following criteria: (1) to be validation studies on tool for investigating epilepsy, (2) to be conducted in a low- or middle-income country, (3) to be published between 1980 and 2021, and (4) to be written in English, French, Spanish or Portuguese. The characteristics of the tools and validation methods were collected. The frequency of use of the tools was estimated. RESULTS: Ninety-three articles were retained, corresponding to 91 tools from 44 countries. The main tools targeted quality of life (n = 30), comorbidities (n = 19) and screening (n = 13). Instruments were mainly developed and validated in Asia (n = 43), then in Central and South America (n = 24). The IENT (Institute of Epidemiology and Tropical Neurology) questionnaire was developed in several tropical countries (Africa, South East Asia and Latin America). The development and validation methods were heterogeneous from one tool to another and some tools (e.g., QOLIE-31, NDDI-E, PATE, etc.) were culturally adapted. CONCLUSION: This review identifies geographic specificity regarding the creation, validation and use of tools for investigating epilepsy available in low- and middle-income countries. It will help investigators in the choice of tools in their future epidemiological studies on epilepsy in this context.

Management of epilepsy in Lebanon: Medication reviews and drug-related problems.

PURPOSE: The goal of epilepsy treatment is to control seizures without drug related problems (DRPs). The evaluation of anti-seizure drugs (ASD) strategies and identification of DRPs are rarely studied. This study aimed primarily to evaluate the choice of ASD according to international guidelines and secondarily to identify and describe anti-seizure drug-related problems. METHODS: A cross-sectional study was conducted during 1 year among Lebanese adults with epilepsy attending neurology clinics. The choice of ASD was compared to National Institute for Health and Care Excellence guidelines. Drug-drug interactions were evaluated by the Lexicomp database, and the DRP classification was performed using the Pharmaceutical Care Network Europe classification. RESULTS: A total of 404 patients with epilepsy were included. The prescription for an ASD was in accordance with the indication set in guidelines in 75.0% of population, and 1078 DRPs were identified. The main DRPs detected were adverse drug reactions (51.0%), inappropriate combinations of drugs (50.0%), and suboptimal drug regimens (46.3%). Single and divorced patients, who living in Mount Lebanon, and who took the old with the new generation had a less risk to have an inadequate prescription to guidelines. However, female gender, controlled epilepsy, multiple ASDs, and living in a rural region increased DRPs. CONCLUSIONS: This study showed that quarter of the population used ASDs contraindicated according to international guidelines. Since DRPs were related to the number and type of ASD prescribed, it is important to assess the case of each patient by a clinical pharmacist to prevent drug-drug interactions and iatrogenic issues.

Empowering health workers and leveraging digital technology to improve access to mental health and epilepsy care: A longitudinal quasi-experimental study in Hlaing Thar Yar Township.

Background: Despite an estimated 8% prevalence of mental disorders in Myanmar, the treatment gap is high, up to 90%. This project aimed to assess the effects of a series of activities implemented by the Myanmar Medical Association over a 2-year period in Hlaing Thar Yar Township involving community health workers (CHWs) and general practitioners (GPs) on the identification, diagnosis and management of people with psychotic disorders, depression and epilepsy. Methods: Seventy-six CHWs were trained to raise awareness, identify people with mental disorders and refer them to GPs. Fifty GPs were upskilled to diagnose and manage patients. Prevalence, treatment gap and general population's Knowledge-Attitudes-Practices (KAP) were evaluated through door-to-door surveys, whilst CHWs' and GPs' KAP were measured pre-, and post-training as well as post-intervention. Patient identification, diagnosis and management were analysed through data collected by CHWs and GPs via smartphones and tablets. Findings: At baseline, the average treatment gap was 79·7%. During the 2 year-intervention, 1,378 suspected cases were referred by CHWs to GPs and 1,186 (86%) of them saw a GP. Among the 1,088 patients (92%) diagnosed, the concordance between GPs' diagnosis and CHWs' screening was 75·6%. For CHWs, knowledge improved post-training (16·9 vs. 15·3; p = 0·0010), whilst attitudes and practices improved post-intervention (17·1 vs. 15·7; p = 0·010 and 19·4 vs. 11·2; p < 0·0001 respectively). GPs' global KAP score improved post-training (14·6 vs. 12·8; p = 0·0010), and remained stable post-intervention. General population's KAP score improved between baseline and end-line (8·3 vs. 12·7; p < 0·0001). Interpretation: This project suggests that a 2-year intervention including the training of frontline health workers and raising awareness among the population can have positive outcomes and lead to a greater number of people with mental disorders being diagnosed and managed. Funding: This project was implemented as part of a partnership involving the Myanmar Medical Association, the Myanmar Mental Health Society, the World Association of Social Psychiatry, the Université Numérique Francophone Mondiale and Sanofi Global Health. It was funded by Sanofi Global Health, within the framework of the Fight Against STigma (FAST) Program.

Epidemiological and genetic features of amyotrophic lateral sclerosis in Latin America and the Caribbean: a systematic review.

Introduction: Heterogeneity of amyotrophic lateral sclerosis (ALS) has been suggested in terms of epidemiology, phenotypes and genetics between geographic areas and populations. However, there is limited information in Latin America. We conducted a systematic review that aimed to describe the epidemiology, frequency of genetic mutations, clinical characteristics and survival of ALS patients in this region. Methods: We reviewed Medline, Scopus, Scielo and LILACS databases up to April 2020. The search terms "Amyotrophic Lateral Sclerosis" or "Motor Neuron Disease" were used in combination with the list of Latin American countries from the United Nations. All observational studies were included. A methodological overview was performed using the principles of descriptive epidemiology. Results: Overall, 1364 publications were identified and 36 studies were selected, covering 13 Latin American countries. According to the original reports, ALS occurrence varied among countries with a standardized incidence ranging from 0.3 per 100,000 person-years follow up (PYFU) in Ecuador to 3.6 per 100,000 PYFU in Uruguay. A low proportion of the C9orf72 repeat expansion was reported in Cuba and Brazil. We identified age at onset between 50 and 60 years. Survival time was higher than 40 months in half of the studies. Data from multiethnic populations reported a higher risk of developing ALS in Caucasians compared to admixed and Black populations. Conclusion: This review provides a perspective of ALS variability across Latin America and highlights specific differences when comparing to Europe and North America. However, we cannot draw firm conclusions because of different methodological concerns within the studies.

Epidemiology of Primary Brain Tumors in the Province of Catania during the 2003-2016 Period.

INTRODUCTION: Primary brain tumors (PBTs) account for approximately 2% of all cancers and are associated with significant morbidity and mortality. However, only few epidemiological studies focus on PBTs in Italy. The aim of this study was to evaluate incidence, temporal trend, and survival rate of all PBTs in the province of Catania during the study period. METHODS: All patients diagnosed with PBTs in the province of Catania during the 2003-2016 were identified through the local cancer registry. All cases were classified by histology according to 2007 WHO classification of central nervous system tumors, using the International Classification of Diseases for Oncology, 3rd edition codes. The incidence rate (IR) was calculated for all PBTs and by gender, histology, age-groups, and behavior. Trend analysis was performed using a piecewise log-linear model. RESULTS: A total of 3,819 cases were identified with a female/male ratio of 1.45. The IR for all PBTs was 25.3/100,000 person-years (95% confidence interval 24.5-26.1). Most PBTs were nonmalignant (59.5%, IR = 15.0) with a female predominance. Conversely, malignant tumors (32.4%, IR = 8.2) were more common among men, with a female/male ratio of 0.9. The most frequently reported histology was meningioma (39.0%, IR = 9.8), followed by glioblastoma (11.6%, IR = 2.9). A peak of incidence was found in the 75-84 years age-group, with an IR of 77.6/100,000 person-years. Overall, no increase in incidence was observed along the study period. CONCLUSIONS: The IR of PBTs in the province of Catania is close to incidence reported worldwide. Further studies on risk factors are necessary.

Can a brief training intervention on schizophrenia and depression improve knowledge, attitudes and practices of primary healthcare workers? The experience in Armenia.

BACKGROUND: Although the World Health Organization has called for mental health services to be integrated into primary care, mental health remains in most countries, and especially in low- and middle-income countries, one of the most neglected topics in the training curriculum of frontline health workers. As a result, primary healthcare professionals leave medical and nursing schools with insufficient knowledge, and often with negative attitudes towards mental disorders. AIM: We investigated the effect of a brief training intervention on schizophrenia and depression conducted among general practitioners and nurses in Armenia. METHODS: Training interventions were one-day, face-to-face, interactive workshops, including didactic presentations and discussions of case studies. We used a quasi-experimental design of the before/after type, to compare data on knowledge, attitudes and practices collected before and after the training sessions. RESULTS: Mean scores for knowledge, attitudes and practices increased significantly (p < 0.001) among both nurses and GPs for both schizophrenia (111 GPs and 167 nurses) and depression (459 GPs and 197 nurses). CONCLUSIONS: Our experience suggests that a brief training intervention can result in significant improvements in knowledge, attitudes and practices among primary healthcare workers and could help improve mental health services.

Effects of an educational comic book on epilepsy-related knowledge, attitudes and practices among schoolchildren in Madagascar.

INTRODUCTION: Epilepsy is a chronic disease of the brain that affects approximately 50 million people globally, with over 80 % of them living in low- and middle-income countries (LMICs). In Madagascar, as in most LMICs, one of the main obstacles to treatment is the stigma and discrimination experienced by patients. Beliefs and prejudices regarding this disease are common, especially among children. "Ao Tsara" is an educational comic book regarding epilepsy, which has been translated in Malagasy from a French version, and which objective is to raise awareness and fight epilepsy related stigma and discrimination. Comic books have indeed been used successfully to raise awareness and change behaviors in several areas of public health. METHODS: We conducted a study to evaluate the effect of a single reading of this comic book on epilepsy related knowledge, attitudes and practices (KAP) in schoolchildren in Madagascar. This quasi-experimental study compared data collected before and immediately after reading "Ao Tsara". It was conducted both in a school in an urban area and in a school in a rural area. RESULTS: We recruited 244 children with a mean age of 11.4 (±1.5) in this study. We noted a significant improvement in the global KAP score after reading the comic book, overall as well as both in the urban school and the rural school. Out of a maximum score of twenty, the global KAP score increased from 9.4 to 11.2 (p < 0.001). Although the increase in knowledge was reasonable (from 10.2 to 12.9, p < 0.001) and the corresponding subscore after reading the comic book was at a satisfactory level, that was not the case for attitudes & practices, where the sub-score despite a significant increase remained low (from 8.7 to 9.5 out of a maximum score of twenty, p < 0.001). The comic book was much appreciated by the children with more than 50.0 % giving it the top rating, and 66.4 % stating they had learned a lot from it. CONCLUSION: A single reading of the comic book has demonstrated a positive effect on the knowledge, attitudes and practices of primary school children in Madagascar. This educational tool, which was much enjoyed by the children, could be of great value to raise awareness about epilepsy in Madagascar. By targeting a slightly older age group and adjusting the reading approach, the outcomes could be optimized especially in terms of attitudes and practices.

Mental health capacity building in Mali by training rural general practitioners and raising community awareness.

INTRODUCTION: despite the high prevalence and significant burden of mental disorders, they remain grossly under-diagnosed and undertreated. In low-income countries, such as Mali, integrating mental health services into primary care is the most viable way of closing the treatment gap. This program aimed to provide a mental health training intervention to rural general practitioners (GPs), to organize community awareness activities, and to evaluate the impact on mental health knowledge and through the number of new patients diagnosed with mental disorders and managed by these general practitioners. METHODS: a pre-test/post-test design and the monthly monitoring of the number of new patients diagnosed with mental disorders by the trained GPs were used to evaluate the effect of the training interventions (two face-to-face group training workshops followed by individual follow-up supervisions) and of the community awareness activities. RESULTS: the mean knowledge score of the 19 GPs who completed the initial 12-day group training raised from 24.6/100 at baseline, to 61.5/100 after training (p<0.001), a 150% increase. Among them, sixteen completed the second 6-day group training with a mean score increasing from 50.2/100 to 70.1/100 (p<0.001), a 39.6% improvement. Between July 2018 and June 2020, 2,396 new patients were diagnosed with a mental disorder by the 19 GPs who took part in the program. CONCLUSION: despite limited data regarding the effect of the community awareness component at this stage, the findings from this study suggest that the training intervention improved GPs' knowledge and skills, resulting in a significant number of new patients being identified and managed.