Cost-effectiveness of HARNESS-MRI protocol in focal drug-resistant epilepsy in a limited-resources country: An Egyptian study.

OBJECTIVES: The international league against epilepsy (ILAE) recommended the harmonized neuroimaging of epilepsy structural sequences (HARNESS-MRI) to improve the detection of epileptogenic lesions in patients with focal drug-resistant epilepsy (DRE). The application of this protocol is still limited in low-resource countries, mainly due to apparent high costs. We aimed to evaluate the cost-effectiveness of the HARNESS-MRI protocol in Egypt and highlighted our experience. METHODS: Patients diagnosed with focal DRE at Cairo University epilepsy clinic underwent both conventional MRI (c-MRI) and HARNESS-MRI. Electro-clinical data were collected and analyzed. After the radiologists' initial diagnosis, a multidisciplinary team re-evaluated the MRI. Lesion detection rate and cost for detecting an extra lesion by HARNESS-MRI protocol were calculated. RESULTS: The study included 230 patients with focal DRE (146, 62% males and 91, 38% females), with a mean age of 20.5 years. Epileptogenic lesions detected by c-MRI and HARNESS-MRI before and after the board meeting were 40, 106, and 131 lesions, respectively (P < 0.001). Sixty-nine percent of the lesions detected by HARNESS-MRI were missed on c-MRI; most commonly were mesial temporal sclerosis (MTS) and Malformations of cortical development (MCDs). Thirty-seven MTS and 32 MCDs were detected with HARNESS-MRI, compared to only 6 and 3, respectively, detected on c-MRI (P < 0.001). HARNESS-MR protocol is more cost-effective than c-MRI in detecting MRI lesions; it can save about 42$ for detecting an extra lesion in MRI. CONCLUSION: The HARNESS-MRI protocol was cost-effective and highly recommended even in limited-resource countries for patients with focal DRE.

Resective epilepsy surgery in a limited-resource settings: A cohort from a multi-disciplinary epilepsy team in a developing country.

Background: Multidisciplinary pre-surgical evaluation is vital for epilepsy surgery decision and outcomes. Resective epilepsy surgery with assisted monitoring is currently a standard treatment for focal drug resistant epilepsy (DRE). In resource-limited countries, lack of epilepsy surgery center is a huge challenge. We presented and illustrated how to create a multidisciplinary protocol with resource-limited settings in a developing country and epilepsy surgery outcome using brain mapping and monitoring techniques for ensuring satisfactory resection. Methods: We created multicentric incomplete but complementary units covering all epilepsy-related sub-specialties and covering a wide geographical area in our country. Then, we conducted a prospective and multicentric study with low resource settings on patients with focal DRE, who underwent resective epilepsy surgery and were followed up for at least 12 months and were evaluated for postoperative seizure outcome and complications if present. Preoperative comprehensive clinical, neurophysiological, neuropsychological, and radiological evaluations were performed by multidisciplinary epilepsy team. Intraoperative brain mapping including awake craniotomy and direct stimulation techniques, neurophysiological monitoring, and electrocorticography was carried out during surgical resection. Results: The study included 47 patients (18 females and 29 males) with mean age 20.4 ± 10.02 years. Twenty-two (46.8%) patients were temporal epilepsy while 25 (53.2%) were extra-temporal epilepsy. The epilepsy surgery outcome at the last follow up was Engel Class I (seizure free) in 35 (74.5%), Class II (almost seizure free) in 8 (17%), Class III (worthwhile improvement) in 3 (6.4%), and Class IV (no worthwhile improvement) in 1 patient (2.1%). Conclusion: With low resource settings and lack of single fully equipped epilepsy center, favorable outcomes after resective surgery in patients with focal DRE could be achieved using careful presurgical multidisciplinary selection, especially with using intraoperative brain mapping and electrocorticography techniques.

Dopamine agonist withdrawal syndrome associated factors: A retrospective chart review.

Dopamine agonist withdrawal syndrome (DAWS) has been introduced to describe the constellation of symptoms resulting from reduction or suspension of dopamine agonist medications. In patients with Parkinson's disease (PD) the impact of DAWS can be significant in terms of distress and disability. Unfortunately, no standard treatment exists other than reintroduce the dopamine agonist even in the presence of adverse effects. Therefore, identification of vulnerable patients would be beneficial. Previous studies have linked DAWS with impulse control disorder behavior (ICD), higher dopamine agonist doses, and milder motor impairment in PD patients. We conducted a retrospective chart review of PD patients treated with dopamine agonist. A total of 313 charts from January 2011 to December 2013 were reviewed, showing 126 patients who were discontinued from dopamine agonist. Twenty-one patients (16.8 %) fulfilled the diagnostic criteria for DAWS. Factors associated with the occurrence of DAWS were: (1) dose of dopamine agonist ≥150 mg expressed in levodopa equivalents daily dose (LEDD) (p = 0.018), (2) impulse control disorder as an adverse effect to dopamine agonist (p = 0.002), and (3) prior deep brain stimulation (DBS) (p = 0.049). The probability of developing DAWS in the presence of all 3 identified factors was 92 %; presence of 2 factors raised the probability up to 70 %; the presence of one factor increased the probability up to 30 %. In the absence of these 3 factors the probability of developing DAWS was 3 %. Prospective studies are warranted to confirm these findings.

Changes in migraine characteristics over 30 days of Ramadan fasting: A prospective study.

OBJECTIVE: To study Ramadan's effect on migraine from the start to the end of the month and the tolerability of patients with migraine to fasting. BACKGROUND: Fasting is a well-known trigger for migraine. Whether this effect on migraine is the same throughout the whole month, or whether it varies from the first to the last days of the month, has not been studied yet. METHODS: A prospective cohort observational study was carried out on persons with migraine who fasted from 24 April to 23 May during Ramadan 2020. Each patient was asked to fill out their headache diary starting from Shaaban (the month before Ramadan) to the end of Ramadan. The Ramadan diary was divided by 10 days each, by which the patient was asked to accurately describe their migraine attacks in terms of frequency, duration, and intensity by using the Visual Analog Scale. Migraine attacks during the first day of fasting were assessed separately. RESULTS: A total of 292 known persons with migraine from Egypt completed the study. Their median age was 33 years; 72/292 (24.7%) were male, and 220/292 (75.3%) were female. About 126/236 (53.4%) of the patients had migraine attacks on Ramadan's first day, most of them during fasting. The frequency of migraine attacks was significantly increased in Ramadan (median 4, interquartile range [IQR] 2-7) compared with Shaaban (median 3, IQR 1-6), p = 0.009. The number of attacks was significantly reduced in both the second (median 1, IQR 0-2.25) and the third 10 days of Ramadan (median 1, IQR 1-3) compared with the first 10 days (median 3, IQR 1-5) (p < 0.001 for each). CONCLUSION: Ramadan's potential exacerbating effect on the frequency of migraine attacks should be discussed with patients with migraine. This effect appears to be limited to the first 10 days of Ramadan and then subsides with successive days of fasting.

Impact of behavioral side effects on the management of Parkinson patients treated with dopamine agonists.

Dopamine agonists are one of the main stay of treatment option for Parkinson disease (PD). Side effects that develop from their use are generally categorized into behavioral and non-behavioral. Behavioral side effects include: impulse control behavior disorder (ICD), psychosis and cognitive impairment. Non-behavioral side effects include: nausea/vomiting, "sleep attacks", leg swelling, weight gain and orthostasis. The aim of this study is to evaluate the clinicians' response to PD patients who developed behavioral side effects from dopamine agonists, in comparison to those patients who developed only non-behavioral side effects. We performed a retrospective chart review of all patients diagnosed with PD over a two year period. Among 313 patients who were on a dopamine agonist, 156 reported side effects. Sixty-five patients reported behavioral (with or without non-behavioral) side effects, while 91 experienced only non-behavioral side effects. Forty-nine out of the 65 patients (75.3%) who experienced behavioral side effects had their dopamine agonist dose decreased compared to 53 out of 91patients (58.2%) who experienced only non-behavioral side effects (Chi square = 4.92, p < 0.05). Patients with behavioral side effects were 3 times more likely have their dose decreased (OR = 3.3; 95%CI = 1.442-7.551; P = 0.005). However, neither taper speed nor the occurrence of dopamine agonist withdrawal syndrome (DAWS) differed between the two groups. Amongst PD patients treated with dopamine agonists, the presence of behavioral side effects independently increased the chance of dopamine agonist dose reduction. Prospective studies are needed to confirm these findings.

Dopamine agonist withdrawal syndrome (DAWS) in a tertiary Parkinson disease treatment center.

INTRODUCTION: Dopamine agonists are a mainstay of treatment for patients with Parkinson disease (PD). However, side effects limit their use, often necessitating dose change. Upon withdrawal, patients may experience dopamine agonist withdrawal syndrome (DAWS). To date, there is no established protocol for the prevention or treatment of DAWS. METHODS: We performed a retrospective chart review of PD patients who were taking a dopamine agonist. RESULTS: In our large cohort of 313 PD patients who were on a dopamine agonist, we found that 39.5% (n=124) had a change in their dose of medication for various reasons, including 102 patients who experienced a side effect on a dopamine agonist. Twenty out of 102 patients (19.6%) developed symptoms consistent with DAWS, whereas 1 out of 22 patients (4.5%) who had medication dose changed due to any other reason (e.g. dyskinesias, DBS surgery, decreased by another provider, etc.) developed symptoms consistent with DAWS. Our DAWS population had a shorter duration of PD, less exposure to a dopamine agonist, and was on a lower dose compared to those patients who did not develop DAWS. Agitation was the most common DAWS symptom reported in our cohort. Interestingly, in terms of developing DAWS, the prevalence of DAWS (19.0% vs 16.5%; p=0.76) between partial versus total discontinuation was not significantly different whether the dopamine agonist dose was decreased (21 patients) or completely stopped (103 patients). CONCLUSION: Contrary to previous reports, we have found that other side effects besides impulse control behavioral disorders also increase risk for developing DAWS. Furthermore, the prevalence of DAWS did not differ between partial versus total discontinuation of the dopamine agonist.