Stroke care in Armenia: Recent developments.

Introduction: Armenia is an upper-middle-income country with a population of nearly 3 million. Stroke is one of its major public health problems and ranks as the sixth leading cause of death, with a mortality of 75.5 per 100,000. Methods and results: Until recently, modern stroke care was not available in Armenia. During the past 8 years substantial advances have been made in building medical infrastructure and delivering acute stroke care. This manuscript describes contributors to this progress, including extensive and long-term collaboration with international stroke experts, the development of hospital-based stroke teams, and a funding commitment for stroke care by the government. Conclusion: The results of acute stroke revascularization procedures during the past 3 years are reviewed and found to meet international standards. Future directions are discussed including the immediate need to expand acute stroke care to underserved parts of the country by adding primary and comprehensive stroke centers. An active educational program for nurses and physicians and the TeleStroke system development will help support this expansion.

Using a Facebook Virtual Examination Room to Enhance ROP Training in Armenia.

Purpose: Retinopathy of prematurity (ROP) is a leading cause of worldwide childhood blindness with increasing incidence in low and middle income countries (LMICs) due to advances in neonatal care. There are insufficient numbers of healthcare professionals specialized in ROP management and few local training opportunities in LMICs. Social media platforms provide a promising solution to enable interactive medical education across geographic and logistic barriers. As an adjunct to an ROP training program for ophthalmologists in Armenia, we implemented a Facebook Virtual Examination Room (VER) for case discussion with a global community of collaborators and preceptors. To evaluate training through VER, we operationalized engagement as a multilayer meta-construct that includes cognitive, behavioral, and social-emotional domains. Methods: A concurrent mixed methods approach was taken to collect and analyze data from comments and activities within VER. Quantitative data was analyzed for descriptive statistics on group utilization, participant activity, and clinical metrics. Qualitative data was analyzed by conducting thematic analysis involving initial and pattern coding. Results: Ten participants (7 trainees and 3 preceptors) interacted in the Facebook group across 153 unique cases, with 218 threads, 414 comments, and 216 likes. Of the 120 unique cases eligible for consensus evaluation, treatment was mentioned most frequently (87), followed by location (68), staging (65), and plus disease (31), with agreement ranging from 67% to 97%. Based on the qualitative analysis, the most common themes of discussion were clinical management, dilemma resolution, knowledge growth, and gratitude. Conclusion: A closed Facebook group for case-based discussions can be a useful adjunct to an existing ROP training program by engaging learners across social-emotional, behavioral, and cognitive domains. For international training partnerships, the financial and logistical advantages can be significant, though focus should remain on the primary curriculum and training modality.

Pattern and prevalence of eye disorders and diseases in school-aged children: findings from the Nationwide School Sight Sampling Survey in Armenia.

Objective: This study aims to identify the prevalence of eye disorders and their causes among secondary schoolchildren aged 6-15 years old in Armenia, based on analysis of the Nationwide School Sight Sampling Survey. Methods and Analysis: A two-stage proportionate stratified cluster sample was designed for the survey. 22 600 students were screened for visual acuity in schools; 5944 of them were selected for analysis as a nationally representative sample. Those with 20/40 or worse vision were referred to photoscreening and rapid ophthalmic assessment in schools and then were provided with vouchers for free comprehensive eye examination in eye clinics. Data were collected through data collection forms and analysed using SPSS V.23. Results: While majority of the children (85%) had normal vision, 15% had a visual acuity ≤20/40. The prevalence of vision impairment (VI) in at least one eye was 9.7% and blindness in at least one eye was 0.05%. The prevalence of abnormal vision and VI was higher among girls and older children. VI was more prevalent in urban areas. The most common diagnoses were myopia (60%), astigmatism (33.7%), hyperopia (29.5%) and strabismus (3.8%). Conclusion: Majority of the vision abnormalities and VI among schoolchildren are a result of refractive error and are treatable. Our results highlight the importance of regular eye examinations for schoolchildren to detect and prevent VI. Raising awareness among parents, school staff and children about eye health is vital.

Regional and national differences in stroke thrombolysis use and disparities in pricing, treatment availability, and coverage.

BACKGROUND: Major disparities have been reported in recombinant tissue plasminogen activator (rtPA) availability among countries of different socioeconomic status. AIMS: To characterize variability of rtPA price, its availability, and its association with and impact on each country's health expenditure (HE) resources. METHODS: We conducted a global survey to obtain information on rtPA price (50 mg vial, 2020 US Dollars) and availability. Country-specific data, including low, lower middle (LMIC), upper middle (UMIC), and high-income country (HIC) classifications, and gross domestic product (GDP) and HE, both nominally and adjusted for purchasing power parity (PPP), were obtained from World Bank Open Data. To assess the impact of rtPA cost, we computed the rtPA price as percentage of per capita GDP and HE and examined its association with the country income classification. RESULTS: rtPA is approved and available in 109 countries. We received surveys from 59 countries: 27 (46%) HIC, 20 (34%) UMIC, and 12 (20%) LMIC. Although HIC have significantly higher per capita GDP and HE compared to UMIC and LMIC (p < 0.0001), the median price of rtPA is non-significantly higher in LMICs (USD 755, interquartile range, IQR (575-1300)) compared to UMICs (USD 544, IQR (400-815)) and HICs (USD 600, IQR (526-1000)). In LMIC, rtPA cost accounts for 217.4% (IQR, 27.1-340.6%) of PPP-adjusted per capita HE, compared to 17.6% (IQR (11.2-28.7%), p < 0.0001) for HICs. CONCLUSION: We documented significant variability in rtPA availability and price among countries. Relative costs are higher in lower income countries, exceeding the available HE. Concerted efforts to improve rtPA affordability in low-income settings are necessary.

Sleep-related movement disorders in a population of patients with epilepsy: prevalence and impact of restless legs syndrome and sleep bruxism.

STUDY OBJECTIVES: Sleep disorders are frequent co-occurrences in patients with epilepsy (PWE), but sleep-disordered breathing and insomnia are better studied than others. Our aim was to study sleep-related movement disorders in epilepsy. METHODS: We interviewed 175 PWE (age range 18-71 years, mean 35.4 years, 47.4% female) and 130 controls (age range 18-72 years, mean 33.6 years, 47.7% females). Restless legs syndrome (RLS) and sleep bruxism (SB) were diagnosed by International RLS Study Group's diagnostic criteria and International Classification of Sleep Disorders, Third Edition criteria respectively. We also used Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS) and Berlin Questionnaire (BQ). RESULTS: Our findings suggest that RLS and SB are encountered more frequently in PWE than controls: 20.6% versus 6.1% for RLS, and 23.7% versus 5.4% for SB (P < .05). Insomnia was more prevalent in epilepsy (46.2% versus 24.6%, P < .05) while poor sleep hygiene occurred more frequently in controls (28.3% versus 53.8%), (P < .05). PWE had poorer sleep by PSQI 61.7% versus 41.5% (P < .05). Sleepiness (38.7% versus 39.2%) and snoring (42.8% versus 40.8%) were equally distributed in both groups, also ESS and BQ not showing significant differences (P > .05). CONCLUSIONS: Our study demonstrates that sleep disorders comprise important part of epilepsy comorbidity. We demonstrated that unselected PWE had higher prevalence of RLS. For the first time we show higher prevalence of sleep bruxism in epilepsy population. Also complaints of insomnia are seen more in PWE, while snoring and poor sleep hygiene not.

Pyridoxine-dependent epilepsy: an under-recognised cause of intractable seizures.

Pyridoxine-dependent epilepsy (PDE) is a rare autosomal recessive disorder causing intractable seizures in neonates and infants. PDE patients are typically resistant to anti-epileptic treatment but respond to the administration of pyridoxine. Different seizure types have been reported in PDE, and episodes of status epilepticus are common. Electroencephalographic or neuroimaging abnormalities are not pathognomonic for this disorder. Intellectual disability is frequent at the follow-up. Recently, elevated urinary α-aminoadipic semialdehyde has been shown to be a reliable biomarker of this disorder, and mutations in the ALDH7A1 gene, encoding α-aminoadipic semialdehyde dehydrogenase, have been demonstrated in the large majority of PDE patients. However, early consideration of a pyridoxine trial remains the most important issue in a neonate or in an infant with intractable early onset seizures.

Long-term follow-up in two siblings with pyridoxine-dependent seizures associated with a novel ALDH7A1 mutation.

Pyridoxine-dependent seizures (PDS) is a rare disorder characterized by seizures resistant to anticonvulsants but controlled by daily pharmacologic doses of pyridoxine. Mutations in the antiquitin (ALDH7A1) gene have recently reported to cause PDS in most of patients. We report the long-term follow-up in two PDS siblings carrying a novel ALDH7A1 mutation.

Galloway-Mowat syndrome: an early-onset progressive encephalopathy with intractable epilepsy associated to renal impairment. Two novel cases and review of literature.

Galloway-Mowat Syndrome (GMS) is an autosomal recessively inherited condition which manifests with severe encephalopathy, featuring microcephaly, developmental delay, and early-onset intractable epilepsy. Patients typically show also renal involvement from the onset. We report two siblings with GMS presenting with early-onset, intractable epilepsy and neurological deterioration, later followed by renal impairment. In both patients intractable epilepsy started during the first months of life and included a combination of spasms, focal and myoclonic/atonic seizures, along with psychomotor retardation and dysmorphic features. One of the patient died from fulminating renal failure at age 6 years. The other patient developed only isolated proteinuria from the age 3 years. Our cases differ from 'classic' GMS, as manifested the clinical and laboratory features of renal involvement only some years later the onset of epilepsy and neurological symptoms. Therefore, the diagnosis of GMS should be considered in infants with intractable epilepsy, encephalopathy, and multiple neurological deficits, also in absence of renal manifestations. The literature data about the electroclinical features of epilepsy in GMS are also reviewed.