Search

BackgroundThere is no consensus on the treatment for spinal injuries resulting in thoracolumbar fractures without neurological impairment. Many trauma centers are opting for open surgery rather than a neurointerventional approach combining posterior percutaneous short fixation (PPSF) plus balloon kyphoplasty (BK).ObjectiveTo assess the safety and efficacy of PPSF+BK and to estimate the expected improvement by clarifying the factors that influence improvement.MethodsWe retrospectively reviewed patients who underwent PPSF+BK for the treatment of single traumatic thoracolumbar fractures from 2007 to 2019. Kyphosis, loss of vertebral body height (VBH), clinical and functional outcomes including visual analog scale and Oswestry disability index were assessed. We examined the overall effects in all patients by constructing a linear statistical model, and then examined whether efficacy was dependent on the characteristics of the patients or the fractures.ResultsA total of 102 patients were included. No patient experienced neurological worsening or wound infections. The average rates of change were 74.4% (95% CI 72.6% to 76.1%) for kyphosis and 85.5% (95% CI 84.4% to 86.6%) for VBH (both pConclusionsThis is the largest series reported to date and confirms and validates this surgical treatment. All patients exhibited improved kyphosis and restoration of VBH. We advise opting for this technique rather than open surgery.

Background and aim Traditional practices are deeply rooted in Lao people’s perceptions and beliefs about health and illness. The objective of the study was to understand the perceptions of healthcare professionals and traditional healers regarding the management of epilepsy in Laos, and their reciprocal views. Experimental procedure An observational study was carried out in two areas of Laos from February to May 2017. Semi directive questionnaires were used to collect quantitative and qualitative data. Semiotic square was carried out to highlight relationships between attitudes of traditional healers and healthcare professionals. For quantitative approach, the proportions were reported, and the test used was Fisher’s test for nominal variables. The mean and standard deviation expressed the continuous variables and the Student’s t-test was used. Results and conclusion Epilepsy was cited by 90.9% of traditional healers as a convulsive disease with saliva or urine, and herbal medicines were predominantly used (86.4%) to treat it. Few healthcare professionals (26.5%) pointed out that they knew remedies to treat epilepsy other than antiepileptic drugs (AEDs), and 76.5% of healthcare professionals mentioned that epilepsy was a disease which only AEDs could treat. On the other hand, 54.5% of traditional healers confirmed a traditional remedy could cure completely epilepsy through long-term use. Ninety percent of traditional healers said the collaboration with healthcare professionals was a good idea and 44.1% of the healthcare professionals group said was complicated. The combination of these medicines for the management of epilepsy needs to be adapted to Lao’s medical context., Graphical abstract Image 1, Highlights of the findings and novelties • Understanding the perceptions and reciprocal views of care providers. • Study the combination of traditional and conventional medicine for epilepsy. • Public health policies: integration of traditional medicine in the care of patients.

Resume Introduction La Tip-Apex Distance (TAD) est le seul facteur predictif d’echec mecanique des osteosyntheses des fractures trochanteriennes. L’objectif principal de notre etude etait d’evaluer la concordance entre l’estimation visuelle peroperatoire de la TAD et son controle postoperatoire sur des cliches numerises. Notre hypothese etait que cette concordance etait bonne. Materiel et methode Les patients presentant une fracture trochanterienne isolee ont ete inclus dans notre etude. Des cliches peroperatoires etaient imprimes avec calcul manuel de la TAD. Les patients etaient revus a 6 semaines, 3 et 6 mois pour un controle radio-clinique avec calcul numerique de la TAD. Nous avons recueilli le type de fracture (classification AO), le degre d’osteoporose (index radiographique de Singh), l’experience du chirurgien, l’âge et le score ASA. Resultats Quatre-vingt-dix-huit patients ont ete inclus dont 70 avec un suivi de 6 mois et des resultats radiographiques postoperatoires interpretables. L’âge moyen etait de 87 ans, avec 77,14 % de femmes et un score ASA moyen de 3. Le coefficient de concordance entre la TAD per et postoperatoire etait de 0,7202 (IC 95 % = 0,4905–0,9499). Le taux de deplacements secondaires etait de 3,28 %. L’analyse univariee a mis en evidence l’absence d’association statistiquement significative entre la presence d’une TAD peroperatoire > 25 mm et le type de fracture (p = 0,7290), le degre d’osteoporose (p = 0,5701) et l’experience du chirurgien (p = 1). Discussion/Conclusions La concordance entre l’estimation visuelle peroperatoire de la TAD et sa mesure postoperatoire numerisee est forte. Les fractures instables, sur os osteoporotiques, operees par des jeunes chirurgiens ne sont pas des facteurs de risque de TAD peroperatoire > 25 mm. Il est important de realiser un travail pedagogique aupres des jeunes chirurgiens pour qu’ils connaissent le concept de TAD ainsi que la technique d’estimation visuelle peroperatoire puisque celle-ci permet de positionner la vis cephalique de facon fiable lors des osteosyntheses des fractures trochanteriennes. Niveau de preuve II.

Introduction The tip-apex distance (TAD) is the only predictor for mechanical failure after internal fixation of trochanteric fractures. The main objective of our study was to assess whether the intraoperative visual estimation of the TAD concurred with the measurement taken on postoperative digital X-rays. We hypothesized that there was a good concordance between these 2 different methods of measurement. Materials and methods Patients with an isolated trochanteric fracture were included in our study. A hardcopy of the intraoperative X-rays were printed, and the TAD was calculated manually. Radiological and clinical follow-ups were scheduled at 6 weeks, 3 months and 6 months during which numerical measurements of the TAD were taken. We also recorded the fracture type (AO/OTA classification), degree of osteoporosis (Singh index), surgeon experience, age and ASA score. Results A total of 98 patients were included in our study. Of these, 70 had a 6-month follow-up and interpretable postoperative X-rays. The mean age was 87 years, with 77.14% women and a mean ASA score of 3. The coefficient of concordance between the intra and postoperative TAD was 0.7202 (95% CI = 0.4905–0.9499). The secondary displacement rate was 3.28%. The univariate analysis showed no statistically significant association between an intraoperative TAD > 25 mm and fracture type (p = 0.7290), degree of osteoporosis (p = 0.5701) and surgeon experience (p = 1). Discussion/Conclusions There was a high degree of concordance between intraoperative visual estimation of the TAD and its measurement on postoperative digital X-rays. The treatment of unstable fractures in osteoporotic bone by junior surgeons was not a risk factor for intraoperative TAD > 25 mm. It is therefore important to educate young surgeons on the concept of TAD and its intraoperative visual estimation technique as it ensures that the cephalic screw is positioned properly during the fixation of trochanteric fractures. Level of Evidence II.

Relevance More than 70 million people suffer epilepsy worldwide. Low availability of anti-epileptic drugs, side-effects and drug-resistant epilepsy affect the quality of life of persons with epilepsy in countries with a poorly developed health system. Herbal medicine is frequently used for this neurological condition. Objectives The main objective was to provide a detailed analysis of Herbal Medicine used for neurological conditions related with epilepsy in Asia, Africa and Latin America. More broadly, this study aims to highlight species with assessed efficacy (cross-cultural use, pharmacological effects on models of epileptic seizures) and safety (toxicological data in laboratory) information, in order to point out species of interest for further studies. A critical assessment of models used in pharmacological evaluations was done. Materials and methods The systematic search for Herbal Medicine treatments for epilepsy was performed considering all the articles published until February 2017 through three scientific databases. It was made with MeSH terms and free text defining the epilepsy seizures and plant species. We included studies carried out in Asia, Africa and Latin America. All articles reporting the use of Herbal Medicine to treat epilepsy seizures and/or their pharmacological evaluation were retained for further analysis. Results The search yielded 1886 articles, from 30 countries. Hundred and six articles published between 1982 and 2017 were included, corresponding to a total of 497 use reports for 351 plant species belonging to 106 families. Three hundred and seventy seven use reports corresponding to 264 species in ethnopharmacological surveys and 120 evaluation reports corresponding to 107 species were noted. Twenty-nine reports, for 29 species, combined both ethnopharmacological and pharmacological evaluation. Fifty eight studies originated from Africa, 35 studies from Asia and 18 from Latin America. Highest use report was noted for rhizomes of Acorus calamus L. (12 use report in 1 country) and leaves of Bacopa monnieri (L.) Wettst. (8 use report in 2 countries). Therefore these species display the highest use convergence. Regarding pharmacological evaluation most studied species were: Leonotis leonurus (L.) R.Br. (4 evaluation reports in 1 country), Uncaria rhynchophylla (Miq.) Miq. ex Havil. (3 evaluation reports in 2 countries) and Calotropis gigantea (L.) Dryand. (3 evaluation reports in 1 country). In vivo models of chronic epilepsy were more relevant than in vitro models or chemical models inducing acute seizures for pharmacological assessment. Conclusion Species with the highest use report were not those with pharmacological evaluation. It will be pertinent to assess the pharmacological effects and safety of medicinal plants used mostly by traditional healers on predictive models of seizures.

Optical diagnosis is necessary when selecting the resection modality for large superficial colorectal lesions. The COlorectal NEoplasia Endoscopic Classification to Choose the Treatment (CONECCT) encompasses overt (irregular pit or vascular pattern) and covert (macroscopic features) signs of carcinoma in an all-in-one classification using validated criteria. The CONECCT IIC subtype corresponds to adenomas with a high risk of superficial carcinoma that should be resected en bloc with free margins.This prospective multicentre study investigated the diagnostic accuracy of the CONECCT classification for predicting submucosal invasion in colorectal lesions20 mm. Optical diagnosis before en bloc resection by endoscopic submucosal dissection (ESD) was compared with the final histological diagnosis. Diagnostic accuracy for the CONECCT IIC subtype was compared with literature-validated features of concern considered to be risk factors for submucosal invasion (non-granular large spreading tumour [NG LST], macronodule1 cm, SANO IIIA area, and Paris 0-IIC area).Six hundred 63 lesions removed by ESD were assessed. The en bloc, R0, and curative resection rates were respectively 96%, 85%, and 81%. The CONECCT classification had a sensitivity (Se) of 100%, specificity (Sp) of 26.2%, positive predictive value of 11.6%, and negative predictive value (NPV) of 100% for predicting at least submucosal adenocarcinoma. The sensitivity of CONECCT IIC (100%) to predict submucosal cancer was superior to all other criteria evaluated. COlorectal NEoplasia Endoscopic Classification to Choose the Treatment IIC lesions constituted 11.5% of all submucosal carcinomas.The CONECCT classification, which combines covert and overt signs of carcinoma, identifies with very perfect sensitivity (Se 100%, NPV 100%) the 30% of low-risk adenomas in large laterally spreading lesions treatable by piecemeal endoscopic mucosal resection or ESD according to expertise without undertreatment. However, the low specificity of CONECCT leads to a large number of potentially not indicated ESDs for suspected high-risk lesions.

Introduction: Epilepsy affects >50 million people worldwide, with 80% of them living in low- and middle-income countries (LMICs). Studies with a standardized methodology are required to obtain comparable data on epilepsy and implement health policies in order to reduce the treatment gap and improve the diagnosis and management of epilepsy. In 2000, following the guidelines of the International League Against Epilepsy (ILAE), the “questionnaire for investigation of epilepsy in tropical countries” (IENT questionnaire) was developed to promote epidemiological surveys on epilepsy using a standard methodology. This study aims to describe how, when, where, and why the IENT questionnaire has been used through epidemiological studies on epilepsy over the last 2 decades and to acquire users’ opinions about the tool. Methods: Studies that used the IENT questionnaire were searched through international and local bibliographic databases, including the gray literature. An online survey was carried out, including a snowball effect. Original research studies were included. Characteristics of the studies and populations and general information on the instrument and its use were collected. Results: Eighty-two documents were selected referring to 61 studies that were mostly carried out on the African continent ( n = 54). Most of them aimed to determine the prevalence ( n = 31) and associated factors ( n = 28) of epilepsy in LMICs. Among the 61 studies, 35 were population-based, and 30 included both adults and children. A methodological heterogeneity was found between studies, and in cases where the IENT questionnaire alone did not ensure complete data collection, other tools were used concomitantly ( n = 40). Discussion/Conclusion: Over the last 2 decades, the IENT questionnaire has been continuously used in different LMICs. This result favors its promotion and updating, with the inclusion of new topics related to epilepsy (e.g., comorbidities, quality of life, and stigma), current ILAE guidelines, and digital versions.

OBJECTIVES To compare a standard protocol using chest computed tomography (CT) to a non-irradiant protocol involving a low-cost portable 3D scanner and magnetic resonance imaging (MRI) for all pectus deformities based on the Haller index (HI). METHODS From April 2019 to March 2020, all children treated for pectus excavatum or carinatum at our institution were evaluated by chest CT, 3D scanning (iPad with Structure Sensor and Captevia—Rodin4D) and MRI. The main objectives were to compare the HI determined by CT or MRI to a derived index evaluated with 3D scanning, the external Haller index (EHI). The secondary objectives were to assess the inter-rater variability and the concordance between CT and MRI for the HI and the correction index. RESULTS Eleven patients were evaluated. We identified a strong correlation between the HI with MRI and the EHI (Pearson correlation coefficient = 0.900; P CONCLUSIONS Non-irradiant pectus deformity assessment is possible in clinical practice, replacing CT with MRI and 3D scanning as a possible readily-accessible monitoring tool.

International audience; Psychiatric and neurological disorders are now considered among the first contributors to the globalburden of disease. In low‑ and middle‑income countries (LMICs), insufficient specialized humanresources, inadequate training of primary care workers, traditional beliefs, stigmatization, anddiscrimination are the most common barriers to access to care. Availability and cost of medicinesare also common problems. Although in many cases effective treatments exist, 76%–85% of patientswith mental disorders or epilepsy living in LMICs are not treated. Over the last 8 years, throughthe Interactive Meetings Promoting Access to Care and Treatment (IMPACT) forum, the Instituteof Epidemiology and Tropical Neurology UMR 1094 INSERM, the World Association of Social Psychiatry, and Sanofi Global Health Programs have convened every year a group of approximately forty people from about twenty countries (not only from Africa, Asia, and Latin America, but also from Europe), and from various backgrounds (public, private, associative, and academic sectors), who are all involved in developing access to care for people living with mental disorders or epilepsy in LMICs. The meeting held in Versailles, France, on September 13 and 14, 2018, focused on “Scaling Up Interventions for Better Access to Mental Health and Epilepsy Care.” Through didactic presentations based on the World Health ganization‑ExpandNet “Nine steps for developing a scaling‑up strategy” guide, as well as case studies and workshops around three pilot projectsimplemented in Cambodia, Guatemala, and Madagascar, this forum provided participants with an opportunity to gain in knowledge and understanding of scaling‑up theories and to apply these to practical cases.

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.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.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.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.

International audience; Methodologies of population-based studies on neurological diseases in low-and middle-income countries (LMICs) have not been standardized. The objective of this paper is to provide an overview of the numerous challenges occurring in this context and propose a standard framework for population- based studies in LMICs. We relied on our expertise on few diseases, epilepsy and neurodegenerative disorders.The proposed framework is the result of extensive field experience in tropical LMICs. It ensures that important steps are not forgotten when setting up a study plan. It must remain flexible and be adapted to each situation, to the disease studied, in particular its prevalence, but also to the geography of the study area and the availability of survey technologies

International audience; IntroductionLes données épidémiologiques sur les troubles psychiques, les troubles neurocognitifs et l’épilepsie mettent en évidence des maladies ubiquitaires, présentes dans toutes cultures et latitudes, avec des prévalences élevées, notamment dans les pays en développement.ObjectifsL’objectif principal était d’évaluer les connaissances, attitudes et pratiques (CAP) concernant les troubles psychiques, les troubles neurocognitifs et l’épilepsie auprès de futurs médecins, pharmaciens et infirmiers dans plusieurs pays à faible et moyen revenus.Patients et méthodesIl s’agit d’une étude descriptive transversale multicentrique en cours de réalisation dans 12 pays. Nous avons utilisé l’initiative STROBE pour développer la méthodologie d’étude. Le recrutement est exhaustif pour les étudiants qui répondent aux critères d’inclusion. Les investigateurs collectent les réponses auprès des étudiants par le biais d’un auto questionnaire lié à un système de gestion de base de données relationnelle et réalisent une conférence apportant des éléments sur le contexte de la recherche épidémiologique.RésultatsL’étude pilote menée au Gabon a inclus 75 étudiants (45 étudiants en médecine, 2 étudiants en pharmacie et 28 étudiants en soins infirmiers). Un score moyen de 15,37 ± 1,69 points sur 20 points a été retrouvé. Le score de connaissances était plus faible que le score d’attitudes et pratiques (p < 0,001). Les questions avec un pourcentage faible de bonnes réponses portaient sur la définition, le diagnostic des maladies ainsi que les effets indésirables des traitements.DiscussionLe niveau de connaissances, attitudes et pratiques des étudiants en santé était correct au Gabon. Le taux faible de participation observé doit nous amener à porter une attention particulière à la méthodologie de recrutement des étudiants dans l’étude.ConclusionIl est nécessaire de poursuivre cette étude pour évaluer les CAP dans les autres pays.

Background Onchocerciasis is a serious problem in tropical areas. The role of the parasite as a factor associated with neurological diseases needs to be addressed because it might involve a reduction of the risk via elimination strategies. We performed a systematic scoping review to identify available studies on this association and put into perspective the different methodological approaches for interpreting the evidence. Methodology A literature search was conducted using MEDLINE (Pubmed) through October 1, 2020. We included all the studies evaluating the association between onchocerciasis and four neurological diseases (epilepsy, nodding syndrome, Nakalanga syndrome, and encephalitis) in tropical countries. A descriptive and critical summary of the results was conducted to provide an overview of the findings. Results Overall, 161 articles were identified in the literature search. After full-length examination, we included twelve articles for epilepsy and three for nodding syndrome. Two meta-analyses of case-control studies found a modest strength of the association between O. volvulus and epilepsy. Recent meta-analyses and original studies support a significant association. Epidemiological studies suggest an association between onchocerciasis and nodding syndrome, however, the level of evidence from case-control studies was relatively low. No measure of association was reported for Nakalanga syndrome. There was no specific study on the association between O. volvulus and encephalitis. Conclusion The association between onchocerciasis and epilepsy seems increasingly likely. However, there are still many unanswered questions about the different clinical presentations of this epilepsy. Strong international collaboration is essential to improve our understanding of risk factors and physiopathological mechanisms of these intriguing conditions.

Relevance A low level of knowledge about epilepsy among health workers, a context of stigmatizing sociocultural beliefs, and a low availability of antiepileptic drugs in Lao People's Democratic Republic (PDR) are major gaps in the medical management of people with epilepsy in this country. Objectives The principal objective of the study was to identify the associated factors of adherence to community healthcare structures in Lao PDR. Specific objectives were to evaluate patients' adherence status, practices and knowledge about epilepsy and its care, and factors influencing decision-making on therapeutic interventions. Materials and methods The study was an observational cross-sectional survey about knowledge, attitudes, and practices, handled from February to May 2016. Eighty-seven people with epilepsy were identified in two areas in the periphery of Vientiane Capital through an active screening in villages and homes. Semidirective questionnaires were conducted to collect quantitative and qualitative data. Quantitative analysis included a comparison of adherent vs. nonadherent people with epilepsy, using Chi-square or Fisher's test. Advanced qualitative lexical analysis was carried out on the open-ended questions. Results Sixty-two people with epilepsy were included and the adherence rate to community care was 67.7%. The only sociodemographic variable that differed significantly between adherent and nonadherent members was the income level (p = 0.015): the wealthiest class of people with epilepsy did not adhere to community healthcare. Eleven percent of people with epilepsy thought that epilepsy was contagious, 80.6% that medication may reduce epilepsy seizure rates, and 33.9% that it was possible to cure epilepsy permanently. Physicians informed about the disease in 69.0% of adherent people with epilepsy and in 40.0% of nonadherent ones (p = 0.029), whereas villagers were involved in 29.0% and 50.0% of cases, respectively. There was a significant difference between the two groups for the prescribed antiepileptic drugs (p = 0.012): phenobarbital covered 73.8% of adherent people with epilepsy but only 40% of nonadherent ones. Half of nonadherent people with epilepsy went regularly to a central hospital in the Vientiane Capital, 15.0% went to Thailand, and 10.0% practiced self-medication in occasional mobilities. Conclusion A wider range of antiepileptic drugs at a reduced cost and the promotion of adherence to community healthcare would allow a better management of people with epilepsy in Lao PDR.

Objective The main objective of this study was to evaluate the knowledge, attitudes, and practices (KAP) of health sciences students regarding epilepsy at the end of their curriculum in Benin. Methods We conducted a cross-sectional survey among medical, pharmacy, nursing, and midwife students in their last year of health sciences training in the University of Abomey-Calavi in Benin. Students completed a self-administered questionnaire, containing items addressing demographics, epilepsy treatment, diagnosis, clinical practice, and social tolerance regarding a person with epilepsy (PWE). Results The response rate to our survey was 87.7% (n = 164). The sample consisted of 64 medical students, 22 pharmacy students, 43 nursing students, and 35 midwife students. They were divided into 95 female subjects and 69 males; sex ratio was 0.7. The mean age of participants was 23.6 ± 1.8 years. The mean scores for epilepsy knowledge, practices, and attitudes were respectively 7.6 ± 1.7 out of a maximum score of 11, 3.9 ± 1.8 out of 8, and 9.6 ± 0.8 out of 10. The KAP overall score was 21.1 ± 3.4 out of a maximum score of 29.0. The variables associated with the overall KAP score were training school, gender, having heard about epilepsy before health sciences studies (p = 0.017), and having a relative with epilepsy (p = 0.001). Male students and medical school students had significantly better overall KAP score than female students or the other training schools respectively (p Significance These findings support the need to improve the health sciences students' knowledge of epilepsy, in particular, during their training.

International audience; ObjectiveEpilepsy is a major public health issue in low‐ and middle‐income countries, where the availability and accessibility of quality treatment remain important issues, the severity of which may be aggravated by poor quality antiepileptic drugs (AEDs). The primary objective of this study was to measure the quality of AEDs in rural and urban areas in 3 African countries. MethodsThis cross‐sectional study was carried out in Gabon, Kenya, and Madagascar. Both official and unofficial supply chains in urban and rural areas were investigated. Samples of oral AEDs were collected in areas where a patient could buy or obtain them. Pharmacological analytical procedures and Medicine Quality Assessment Reporting Guidelines were used to assess quality. ResultsIn total, 102 batches, representing 3782 units of AEDs, were sampled. Overall, 32.3% of the tablets were of poor quality, but no significant difference was observed across sites: 26.5% in Gabon, 37.0% in Kenya, and 34.1% in Madagascar (P = .7). The highest proportions of substandard medications were found in the carbamazepine (38.7%; 95% confidence interval [CI] 21.8‐57.8) and phenytoin (83.3%; 95% CI 35.8‐99.5) batches, which were mainly flawed by their failure to dissolve. Sodium valproate was the AED with the poorest quality (32.1%; 95% CI 15.8‐42.3). The phenobarbital (94.1%; 95% CI 80.3‐99.2) and diazepam (100.0%) batches were of better quality. The prevalence of substandard quality medications increased in samples supplied by public facilities (odds ratio [OR] 9.9; 95% CI 1.2‐84.1; P < .04) and manufacturers located in China (OR 119.8; 95% CI 8.7‐1651.9; P < .001). The prevalence of AEDs of bad quality increased when they were stored improperly (OR 5.4; 95% CI 1.2‐24.1; P < .03). SignificanceNo counterfeiting was observed. However, inadequate AED storage conditions are likely to lead to ineffective and possibly dangerous AEDs, even when good‐quality AEDs are initially imported.

Objective To assess the current status of initiatives carried out in developing countries to improve therapeutic management of people with epilepsy. Methods A literature review was performed in 2015 to identify and analyze interventional programs carried out in countries with low- and middle-income economies. Electronic databases were reviewed with no time restriction. Each intervention was categorized according to the level of evidence achieved (A: blind randomized controlled trial, B: randomized controlled trial, C1: randomized trial, C2: controlled trial, D: prospective cohort, E: retrospective evaluation). Results A total of 46 intervention projects were identified, 13 with no quantitative assessment. The 31 remaining projects were carried out in 18 countries, 52% (16) in Africa, 42% (13) in Asia, and 6% (2) in Latin America. Among those, 13% (4) were level B, 3% (1) C1, 6% (2) C2, 74% (23) D, and 3% (1) were level E. The effectiveness of the intervention, assessed by the efficacy of antiepileptic drugs, was the primary objective in 81% (25). People with epilepsy were on average seizure-free in 44.6% ± 14.4% of cases at one year, ranging from 25.0% to 78.4%. At two years, on average 50.9% ± 29.7% are seizure-free, ranging from 4.6 to 92.7%. The median compliance was 79.3% with a minimum of 21.6% and a maximum of 100.0%. Discussion No blind randomized controlled trial has been used to assess the efficacy of a program to improve access to antiepileptic drugs (AEDs) in developing countries, and the level of evidence was globally low. Phenobarbital remains the AED predominantly used in programs. Adherence to treatment management has been pointed out to be a key element in the success of a program, sometimes not sufficiently considered. Monthly supply of AEDs, at specific and community level, reducing the costs and time spent traveling, appeared to be the most effective strategies. Homogenization and standardization of evaluation practices of programs to improve the management of epilepsy in resource-limited settings would lead to comparison and meta-analysis which would ultimately improve strategies of support for not only epilepsy but also other noncommunicable diseases in developing countries.

Ethnopharmacological relevance Epilepsy affects 150,000 people in Peru, with a prevalence of 16.6/1000 and a treatment gap of 75%. Herbal medicine (HM) is widely used in this country. Aim of the study We aimed to assess the use of plants in a rural community in northern Peru as part of therapeutic strategies for people with epilepsy (PWE). Materials and methods The study was a cross-sectional observational and descriptive study. The inclusion criteria for people with epilepsy were 2 years of age and over, having lived in the study area for at least 3 months and a confirmed diagnosis of epilepsy by a neurologist. The information was gathered through structured interviews using a survey questionnaire. Botanical species used by people with epilepsy or traditional healers were collected and identified. Results Out of the 228 people with epilepsy included, 60.0% had used herbal remedies and 54.8% both herbal medicine and anti-epileptic drugs. The traditional healer was the first practitioner consulted by 45.2% of people with epilepsy. Sixty-six species have been mentioned by the people with epilepsy and traditional healers on the treatment of epilepsy. Carbamazepine was the most prescribed anti-epileptic drug with 33.2% of prescriptions. Conclusions This study was the first to measure a percentage of use of herbal medicine for epilepsy in Peru. It would be interesting to conduct a pharmacological evaluation of the most commonly used species on epileptic models to validate and secure their use.

Background The prevalence of epilepsy is high in Madagascar (23.5/1000), as is the treatment gap (estimated at 92 %). The health system of the country is underfunded; some AEDs are used, and the national drug policy does not encourage price regulation or the administration of generic agents. We conducted a cross-sectional study to assess the availability and cost of solid oral AED formulations in Antananarivo, capital of Madagascar. Data were gathered from all officially registered pharmacies (according to the drug agency list, updated in 2015) by means of telephone interviews lasting no more than 10 min and conducted by a native Malagasy speaker. With regard to other sources (hospitals, illicit sales) data were obtained at specific visits. The study received ethical approval from the Madagascar Ministry of Health. Findings A total of 91 of 100 pharmacies (the nine not included were because of an inoperative phone number), two of three public hospitals, and two illegal outlets were investigated. Sodium valproate was available in 84.6 % of the pharmacies, while carbamazepine and phenobarbital were available in 68.1 % and 36.3 % of the pharmacies, respectively, but phenytoin was not available in any supply chain. There were more originator brands than generic formulations, with a higher cost (range 20.3–81.1 %, median 40.7 %) compared to the equivalent generic. The public system had only a very limited choice of AED, but offered the lowest costs. Illicit sources were more expensive by 54.3 % for carbamazepine and 62.5 % for phenobarbital. Concerning the annual cost of treatment, the average percentage of the gross national income per capita based on the purchasing power parity was 29.8 %/19.0 % (brand/generic) for sodium valproate, 16.4 %/7.3 % (brand/generic) for carbamazepine, 8.9 %/5.1 % (brand/generic) for phenobarbital. Conclusions The main sources of AEDs were private pharmacies, but the stocks held were low. The financial burden was still important in the capital of Madagascar, mainly the consequence of a highly developed private sector at the expense of the public sector. Although sodium valproate remains the most expensive solution, it still remains the most available instead of phenobarbital. The most striking feature of this study concerns the cost of AEDs in the informal sector, mostly used because they are deemed to provide less costly drugs, the opposite was observed there. The assessment of the cost and availability of medicines was easily and quickly implemented. It provided a relevant focus of the situation in areas difficult to investigate, in terms of road network and geographical situation.