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In the much older population (≥80 years), the management of cardiovascular diseases requires specific research to avoid a plain transposition of medical practice from younger populations. Whether statins are useful in primary prevention in this population is not clear. The 3 intricate issues requiring attention are (1) the impact of hypercholesterolemia on mortality and major adverse cardiovascular events in subjects80 years, (2) the efficacy of statins to prevent cardiovascular events at this age, and (3) the safety and tolerance of statins in this population. Three systematic reviews were performed using a search on EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases including publication until January 2021. Among the 7,617 references identified, 29 were finally retained. Regarding the first objective (16 studies, 121,250 participants), 7 studies (10,241 participants) did not find total cholesterol and low-density lipoprotein levels associated with an increased rate of major cardiovascular events in octogenarians. A total of 6 studies (14,493 participants) found increased levels associated with events, whereas 3 studies (96,516 participants) found the opposite, with increased risk of major adverse cardiovascular events with lower levels of cholesterol. In 8 studies (436,005 participants) addressing the efficacy of statins, most did not indicate a significant decrease in the rate of major cardiovascular events in these subjects. Finally, regarding tolerance (9 studies, 217,088 participants), the most important side effects in this population were muscular, hepatic, and gastrointestinal disorders. These events were more frequent than in the younger population. In conclusion, in the absence of convincing evidence, the benefit of statins in primary prevention for much older patients is not certain. Their prescription in this setting should only be considered case by case, taking into consideration physiological status, co-morbidities, level of risk, and expected life expectancy. Specific trials are mandatory.

Introduction Elderly patients with haematological malignancies are a population at risk of iatrogenic for whom these activities could optimize therapeutic management. However, the limitation of human resources requires optimization of the process in order to improve the efficiency of pharmaceutical activities. The objective was to build a decision tree to optimize the pharmaceutical consultation in these population within a multidisciplinary team in haematology. Method Pharmaceutical consultations were proposed to elderly subjects with haematological malignancies followed up in a haematology day hospitalization at the University Hospital of Limoges. Risk factors for prescribing risky drugs in this population were determined by logistic regression models. A decision tree was constructed based on these results and by agreement between pharmacist, geriatrician and hematologist. Results Female gender (aOR[CI95%] = 1.71 [1.14–2.57]), polypharmacy (aOR[CI95%] = 1.89 [1.14–3.13]), hyper-polypharmacy (aOR[CI95%] = 5.73 [3.03–10.84]) and moderate cholinergic load (aOR[CI95%] = 2.15 [1.04–4.45]) were risk factors for the prescription of inappropriate medicine. Female gender (aOR[CI95%] = 1.55 [1.02–2.35]) and hyper-polypharmacy (aOR[CI95%] = 6.19 [1–1.28]) were risk factors for prescribing anticholinergic drugs or anticoagulants; in contrast, frailty status was a protective factor for prescribing anticholinergics (aOR[CI95%] = 0.51 [0.33–0.81]). Prioritization of pharmaceutical consultations is based on frailty status, prescription of a target drug and polypharmacy. Discussion Pharmaceutical consultations during the day hospitalization of elderly subjects with hematological diseases allow to propose therapeutic optimizations. The prioritization proposed in our study would increase the efficiency of pharmaceutical activities in order to improve quality and safety throughout the care pathway of these patients.

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.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.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.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.

International audience; Objective: Epilepsy is a major neurological disorder that requires long-term medical treatment. Once epilepsy is diagnosed, people with epilepsy face many difficulties in accessing treatment (treatment gap). Our objective was to assess the situation regarding the availability, price, affordability, and quality of anti-seizure medication (ASM), which are major determinants of access to treatment. Method: A cross-sectional study was performed in provincial/district hospitals and private pharmacies in urban and rural areas in Cambodia. Data on ASM availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest-paid government employee must work to purchase a monthly treatment. Samples of ASM were collected, and the quality of ASM was assessed through Medicine Quality Assessment Reporting Guidelines. Results: Out of 138 outlets visited, only 72 outlets (52.2% [95% CI 43.5-60.7]) had at least one ASM available. Phenobarbital 100 mg was the most available (35.5%), followed by carbamazepine 200 mg (21.7%), phenobarbital 50 mg (11.6%), sodium valproate 500 mg (9.4%), and phenytoin 100 mg (9.4%). In provincial/district hospitals, ASM was provided free of charge. In private pharmacies, affordability for phenobarbital 50 mg and 100 mg was the best, with 0.6 and 0.5 days, respectively, compared to phenytoin 100 mg (1.8 days), and other ASM. No counterfeit ASM was found in this study. Phenytoin sample presented the worst quality (33.0%) compared to carbamazepine (27.8%), and other ASM. Significance: A lack of access to affordable and effective ASM due to low availability and poor quality of ASM was identified. Our research highlights the need for future policy efforts to ensure the quality of ASM and improve their availability. This can be achieved by involving the calculation of their annual needs for these drugs and increasing the national production of ASM.

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.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.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).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.

To evaluate the effect of clinical pharmacy interventions on the unplanned rehospitalizations rates of elderly people admitted for fall to the elderly emergency medicine (EEM) unit in a teaching hospital. DESIGN AND MEASURES This was a longitudinal, comparative pilot study. Patients aged at least 75 who were admitted to the EEM unit for a fall and who had at least two chronic diseases and who were being treated with two or more medications were included from February 1, 2018 to June 30, 2018 and followed by 90 days. The main outcomes were the unplanned rehospitalizations rate at Limoges Teaching Hospital within the 90 days (primary outcome), 30 days and 72 hrs. The estimated cost-saving was also assessed. RESULTS We included 252 patients. The mean age was 88.4 ± 5.8 years and the average baseline number of medications was 8.3 ± 3.4. In total, 158 pharmaceutical interventions were performed, reflecting an acceptance rate of 94.9%. We found a significant reduction of the rate of unplanned rehospitalizations at 90-day (OR = 0.45 (0.26-0.79) p = 0.005). These results were still consistent at 30-day (p = 0.035) and 72 hours (p = 0.041). We found a cost-saving of 37,770 euros related to 21 avoided rehospitalizations. CONCLUSIONS Our results highly emphasize the positive effects of clinical pharmacy services on the prevention of unplanned rehospitalizations of old adults admitted for fall.

International audience; Objective: To assess the availability of health workers and medications for clinical management of amyotrophic lateral sclerosis (ALS) in African hospital centers. Availability and affordability analyses of disease-modifying treatments were performed. Methods: A multicenter observational study involving African hospitals was conducted. A standard questionnaire was developed based on the European Federation of the Neurological Societies (EFNS) guidelines. We collected data on multidisciplinary care and availability of medicines. The availability and affordability were evaluated according to the WHO guidelines. Results: Nine hospital centers from eight African countries participated. We observed a low degree of implementation of multidisciplinary care in ALS management. Riluzole was only available in centers from South Africa, Senegal, Tunisia, and Togo. This treatment was unaffordable and the adjusted price was highly variable among countries. The cost of riluzole was partly or fully covered by patients, which implies a substantial economic burden. Conclusion: Our findings strengthen the need to promote multidisciplinary care in the clinical management of ALS in Africa. Disease-modifying medication should be both available and affordable. Local and international collaboration is needed to improve ALS health care access in Africa.

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.

International audience; Au début des années 1990, l’épidémiologie descriptive de l’épilepsie tropicale a préalablement visé la détermination d’indicateurs de prévalence, plus rarement d’incidence et encore plus rarement en proposant une bonne représentativité nationale ou macro-régionale. Dans un second temps, durant la décennie 2000, la recherche des facteurs expliquant les spécificités tropicales a dominé, tant du point de vue des dimensions culturelles pour expliquer un stigma élevé, de la disponibilité et l’accessibilité aux médicaments, que sur les facteurs associés (notamment les parasitoses à tropisme neurologique) expliquant des valeurs d’épidémiologie quantitative plus élevées que celles connues au nord. Depuis 2010, après une large campagne de sensibilisation mondiale sur un déficit de traitement supérieur à 75 %, les recherches interventionnelles et/ou les initiatives se sont multipliées à la recherche d’un modèle de soin efficient adapté à ces pays aux revenus faible et intermédiaire, afin de bénéficier au plus grand nombre. En 2019, l’Organisation Mondiale de la Santé (OMS), la Ligue Internationale contre l’Épilepsie (ILAE) et le Bureau International pour l’Épilepsie (IBE) ont publié conjointement un rapport intitulé « Épilepsie : un impératif de santé publique ». Les thématiques mises en avant afin de sensibiliser (à nouveau) la communauté internationale sont le principe de fardeau (sanitaire, psychologique et psychiatrique, social comme économique), le stigma et la discrimination (en parlant notamment de violation des droits de l’homme), le déficit de traitement (toujours supérieur à 70 %), la prévention (au moins 25 % des cas seraient évitables) et la nécessité de voir émerger des politiques de santé publique intégrant l’épilepsie. Cette communication ambitionne, après un rapide panorama chronologique des principales connaissances acquises depuis le début des années 2000, de mettre en perspective l’actualité des principales recherches contemporaines (conduites au cours des 5 dernières années) avec les défis que le rapport OMS, de l’ILAE et de l’IBE nous propose de relever.

International audience; ObjectiveEpilepsy is a chronic condition treatable by cost‐effective antiepileptic drugs (AEDs), but limited access to treatment was documented. The availability and affordability of good quality of AEDs play a significant role in access to good health care. This study aimed to assess the availability, affordability, and quality of long‐term AEDs in Lao PDR.MethodA cross‐sectional study was performed in both public and private drug supply chains in urban and rural areas in Lao PDR. Data on AEDs availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest‐paid government employee must work to purchase a monthly treatment. Samples of AEDs were collected, and the quality of AEDs was assessed through Medicine Quality Assessment Reporting Guidelines.ResultsOut of 237 outlets visited, only 50 outlets (21.1% [95% CI 16.1‐26.8]) had at least one AED available. The availability was significantly different between urban (24.9%) and rural areas (10.0%), P = .017. Phenobarbital 100 mg was the most available (14.3%); followed by sodium valproate 200 mg (9.7%), phenytoin 100 mg (9.7%), and carbamazepine 200 mg (8.9%). In provincial/district hospitals and health centers, AEDs were provided free of charge. In other healthcare facilities, phenytoin 100 mg and phenobarbital 100 mg showed the best affordability (1.0 and 1.2 day wages, respectively) compared to carbamazepine 200 mg (2.3 days) and other AEDs. No sample was identified as counterfeit, but 15.0% [95% CI 7.1‐26.6] of samples were classified as of poor quality. SignificanceWe quantified and qualified the various factors contributing to the high treatment gap in Lao PDR, adding to diagnostic issues (not assessed here). Availability remains very low and phenobarbital which is the most available and affordable AED was the worst in terms of quality. A drug policy addressing epilepsy treatment gap would reduce these barriers.

Oral therapies have highly modified cancer patient management and changed hospital practises. We introduce a specific Oral Therapy Centre and retrospectively review information prospectively recorded by co-ordination nurses (CNs) (the DICTO programme). We describe the roles played by CNs in the management of oral cancer therapies at Limoges Dupuytren Hospital between May 2015 and June 2018. All cancers, irrespective of stage or whether oral general chemotherapy or targeted therapy was prescribed, are included. We followed up 287 patients of median age 67 years (range 26–89 years). Of these, 76% had metastases and 44% were on first-line therapy. The vast majority (88%) of their first CN contacts occurred just after physician consultation and lasted an average of 60 min. As part of follow-up, the CNs made 2719 calls (average 10 min) to patients to educate them and to verify compliance and drug tolerance. They also received 833 calls from patients (70%) or their relatives or health professionals (30%) seeking advice on management of side effects. In addition to the initial appointments, 1069 non-scheduled follow-up visits were made to assess side effects (49.2%). The CNs devoted 5 h to each patient over 3 months of treatment (i.e. 25 min/day) and, also organised scheduled hospitalisations in the department of oncology for 51% of patients. We show the interest and real-life work in a specific oral therapy centre within oncology department with the role of CNs to facilitate the global health care of the patients. Electronic supplementary material The online version of this article (10.1007/s12032-020-01393-7) contains supplementary material, which is available to authorized users.

International audience; Background: Epilepsy is among the more stigmatising diseases, leading to a negative impact on the quality of life (QoL) of people with epilepsy (PWE). Assessment of the QoL and stigma in PWE reflects the outcome of their disease, and the findings can be used to improve the management of epilepsy. To fill a gap in the literature, our primary aim is to evaluate the QoL and stigma in Lebanese PWE, and our secondary aim is to identify factors affecting these parameters.Material and methods: A cross-sectional study was conducted for 1 year in Greater Beirut. PWE were interviewed by using a standardised questionnaire. QoL was evaluated by the QoL in Epilepsy Inventory-10 (QOLIE-10), and the stigma was evaluated by the Jacoby scale. Multivariate analyses were used to identify the factors associated with QoL and stigma.Results: The sample was 404 PWE. More than half of the PWE (61.4 %) had a better QoL than the other PWE (mean QOLIE-10 score of 26.9 ± 11.3), and 47.8 % of PWE felt stigmatised. Linear regression showed that presence of psychiatric comorbidities (p = 0.03), stigma (p < 0.001), experiencing side effects (p = 0.001), polytherapy (p = 0.002), living in a northern area (p = 0.003), and older age (p = 0.004) were the major factorsassociated with a poor QoL. Logistic regression showed that a low level of QoL (p = 0.005) and experiencing side effects (p = 0.045) were associated with a high level of stigma.Conclusions: An appropriate treatment based on a monotherapy can reduce the risk of side effects, improving QoL of PWE, and decreasing stigma. Furthermore, the management of depression by specialists is an essential step to improve the QoL of Lebanese PWE. Education programmes and information on epilepsy and treatment also play a major role in reducing stigma.

Resume Introduction Notre objectif etait de mettre en place une validation pharmaceutique des prescriptions dans un service d’urgences adultes pour ameliorer la securisation de la prise en charge medicamenteuse des patients dans un service a haut risque iatrogene. Materiel et methodes Validation des ordonnances des patients avec un traitement chronique par un interne en pharmacie (sous la responsabilite d’un pharmacien senior) suivant la methodologie de la Societe francaise de pharmacie clinique (SFPC). Cela entre 8 h 30 et 12 h 30, apres participation au staff du service. A chaque probleme identifie, des interventions pharmaceutiques (IP) etaient proposees au medecin en charge du patient. Resultats Quatre cent quatre-vingt-un prescriptions ont ete validees entre le 02/11/2015 et le 15/04/2016 dont 15,2 % avec des problemes et ayant fait l’objet d’IP. Les contre-indications, les surdosages et les administrations non appropriees representaient 78 % des problemes. On retrouvait 82,2 % d’IP acceptees ayant entraine une modification de prescription. Discussion/conclusion Le taux d’IP etait eleve et justifiait le maintien d’une presence pharmaceutique dans ce service pour ameliorer la qualite de la prise en charge medicamenteuse et lutter contre l’iatrogenie medicamenteuse.

Summary Background The aim of this study was to develop a prescription validation procedure in an emergency department (ED) in order to improve drug safety for patients in a setting with a high prevalence of iatrogenic risk. Material and methods A pharmacy resident performed pharmaceutical analyses of prescriptions written in the ED in the morning (8:30–12:30). Working under the responsibility of a senior pharmacist, the resident had access to patient charts and attended ED staff meetings. Pharmaceutical interventions were proposed to the attending physician if the prescription deviated from good practices according to the prescription validation methodology of the French society of clinical pharmacy (SFPC). Results Four hundred and eighty-one prescriptions were analyzed from November 11, 2015 through April 15, 2016. Pharmaceutical interventions were proposed for 73 prescriptions (15.2%) because of drug errors. Contraindications, overdosing, and inappropriate administration routes accounted for 78% of these errors. Discussion/Conclusion The rate of pharmaceutical intervention was high, providing evidence of the need for prescription validation in this kind of medical ward in order to improve the quality of drug management and avoid iatrogenic risks.

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

Epilepsy is the most common neurological disorder encountered in primary care in Southeast Asia. People with epilepsy require long-term therapy management. Nonadherence to antiepileptic drugs (AEDs) has been identified as a major factor in suboptimal control of epilepsy. Pharmacies offer patients a first-line point of contact with the healthcare system. Many pharmacies operate with limited or nonqualified human resources that can lead to insufficient knowledge, inappropriate supply of medicines, and insufficient counseling.The aim of this study was to evaluate the qualification and knowledge concerning epilepsy and AEDs among pharmacy-dispensing workers who sell drugs to people with epilepsy.A cross-sectional qualitative study was conducted in public and private pharmacies, in both urban and rural areas of Cambodia and Lao People's Democratic Republic (Lao PDR). The knowledge was collected through a questionnaire.A total of 180 respondents from 123 outlets in the two countries were included in this study. A proportion of 40.8% (31) of respondents in Cambodia and 38.5% (40) in Lao PDR were pharmacists, followed by sellers who did not received any healthcare training with a proportion of 18.4% (14) in Cambodia compared to 20.2% (21) in Lao PDR. Head trauma was cited as the main cause of epilepsy by 72.4% (55) in Cambodia and 27.2% (28) in Lao PDR (p 0.001). Epilepsy was considered as a contagious disease by 6.6% (5) of respondents in Cambodia compared to 18.4% (19) in Lao PDR (p = 0.03). Eighty-seven percent (66) of respondents in Cambodia knew at least one long-term AED versus 67.3% (70) in Lao PDR (p = 0.003). Phenobarbital was mentioned in more than 90.0% of cases in both countries. In overall, 15.4% (21) thought that if seizures are controlled for some months, people with epilepsy could stop taking their AEDs. Only one respondent from Lao PDR was aware of drug-drug interaction between AEDs and oral contraception.An educational intervention should be implemented to improve the knowledge of epilepsy and AEDs for pharmacy-dispensing workers. This could include advice for all pharmacy-dispensing workers in order to improve AED management and follow-up of therapeutic adherence.

International audience

Background Epilepsy is a common worldwide neurological disorder. For people with epilepsy (PWE), adherence and attitudes towards medication is a crucial step to improve efficacy of prescribed treatment and to prevent seizures. Objectives The first aim of this study was to evaluate attitudes towards antiepileptic medications in Lebanese population. Secondary aims were to assess factors affecting attitudes and associated with epilepsy control. Material and methods A cross-sectional study was conducted in outpatient neurology clinics located in Beirut-Lebanon. Data were collected using a structured questionnaire. Self-report of medication taking behaviors were assessed using the abbreviated (4 items) Morisky Medication Adherence Scale (MMAS-4). Epilepsy was considered as controlled if the patient had no seizures in the last 6 months. Results Among 250 PWE recruited in this study, male-to-female ratio was 0.87 (116/134), and 50.8% were married. Mean duration of epilepsy was 13.7 ± 12.8 years. Valproate was the most common antiepileptic drug (AED) used followed by levetiracetam and carbamazepine. About 60.8% of the population presented partial epilepsy. Uncontrolled epilepsy was present in more than half of participants (55.2%), with only 32.4% had positive attitudes to their medication. Positive attitudes towards antiepileptic increased in people who found that their treatment was efficacious (odds ratio (OR) = 4.9; 95% confidence interval (CI): 1.2–20.0; p = 0.03), who had controlled epilepsy (OR = 3.4; 95%CI 1.6–7.1; p = 0.001), and who were diagnosed as PWE between the age of 12–20 years (OR = 3.1; 95%CI 1.1–8.4; p = 0.03). Oppositely, these attitudes decreased in participants who felt their treatment as an economic burden (OR = 0.2; 95%CI 0.1–0.4; p ≪ 0.001), and in people with depression (OR = 0.4; 95%CI 0.2–0.9; p = 0.04). Controlled epilepsy was higher in people who contacted a neurologist if seizure occurred, in people with positive attitudes, and after a long duration of disease, but it decreased if patient did not follow neurologist's instructions in fasting period. Conclusions Lebanese PWE were less likely to have positive attitudes towards medication, which may lead to poor epilepsy control. Depression and economic burden were the major factors that decreased these attitudes. Identifying factors affecting attitudes to medication and leading to controlled epilepsy may help clinicians to elaborate educational programs to optimize medication adherence.

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.

International audience; To the EditorWe thank Job and Wiwanitkit [1] for their interest in our paper [2]. Indeed, we proposed, at the end of this review, to standardize the evaluationpractices of management programs because our review showed that the methodology was very variable and impaired the comparisons.This will consist in using valid designs of evaluation, similar indicators, etc., in order to adequately compare the studies and the programs intheir outcomes and to combine the different studies in meta-analyses.In fact, we did not propose to standardize the management itself, and we agree with Job and Wiwanitkit that this could be a bigproblem in practice and has to be concordant with social conditions. However, as researchers in public health, we have to try to fix generalguidelines that could improve conditions of people with epilepsy in all deprived settings. The standardization of the evaluation would help inthis purpose.

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.

Epilepsy affects about 70 million people worldwide, nearly 90% of whom live in developing countries. Epilepsy is surrounded by myths and stigma in these countries. Discrimination and social stigmatization are difficult obstacles for patients to overcome. Knowledge, attitudes and practices towards epilepsy are often inadequate, even sometimes totally false and then dangerous., The goal was to present the situation and analyse the determinants of using antiepileptic drugs in developing countries., The treatment gap exceeds 75% in most low-income countries, and could be even higher in rural areas. Reasons for that are low accessibility, availability, and/or affordability, lack of trained medical personnel and the associated beliefs and stigma. The interactions between drugs or due to other factors, such as malnutrition, are frequent. A long-lasting treatment is not usual for populations in developing countries due to cultural beliefs. The traditional healers are the first ones consulted in such a context, then delaying the entry in the "modern" medical care system., Information and education campaigns are mandatory among the general population and among the medical and paramedical staff to make progress on the management of epilepsy in developing countries.

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.

International audience; PURPOSE:To determine the accessibility of treatment and the quality of antiepileptic drugs (AEDs) in the Haute Matsiatra district of Madagascar.METHODS:Cross-sectional descriptive study and interviews. Samples of 10 units of each available AED were collected, and the active ingredient was quantified by reversed-phase high-performance liquid chromatography (RP-HPLC) with photodiode-array UV detection. The quality of an AED was considered satisfactory if the quantity of active ingredient in each tablet was in the range ±15% of the average value according to the European Pharmacopeia (6th edition, 2008).RESULTS:The area was well served with health infrastructure but rescue facilities were poorly distributed. Available AEDs were all first-generation, and 73% were generic formulations. People with epilepsy (PWE) surveyed consulted traditional healers and most were treated with plants. PWE did not consider themselves sick but believed they were "possessed"; they consulted a doctor only immediately after a seizure, following the advice of traditional healers. The most prescribed AED was phenobarbital, costing between 0.03 and 0.12 US Dollar (US$) per 100mg. The purchase of full treatment was difficult for 77% of PWE and as a result, 39% took nothing. The quality of AEDs were considered unsatisfactory in 2.8% of cases.CONCLUSION:The AEDs collected in Haute Matsiatra were globally of good quality. The main limiting elements were a lack of knowledge among PWE that epilepsy is a disease, and the cost of traditional treatments.

Hyperphosphatemic familial tumoral calcinosis (HFTC) and hyperphosphatemia hyperostosis syndrome (HHS) are rare diseases characterized by hyperphosphatemia and ectopic calcifications or recurrent episodes of diaphysitis. In the setting of metabolic or inflammatory diseases, recent data suggest that systemic administration of sodium thiosulfate (STS) could be effective in the treatment of ectopic calcifications but may also be poorly tolerated (digestive symptoms, metabolic acidosis). Our group developed a topical formulation of STS to treat ectopic calcifications locally, therefore limiting patient exposure to the drug and its adverse effects.We aimed at describing efficacy and tolerance for a topical formulation of STS in treated patients.We performed a retrospective study wherein clinical, radiological, and biological data before and after the application of the topical STS treatment were collected and analyzed.Three patients admitted to 3 different hospitals with an ectopic calcification secondary to HFTC or HHS were treated with topical STS.The topical STS was applied daily by the patients.A significant clinical and radiological decrease of ectopic calcifications was observed after at least 5 months of treatment. The STS treatment was well tolerated and no clinical or biological side effects were observed.Topical STS appears to be a promising treatment for ectopic calcifications secondary to HFTC or HHS.

International audience

International audience; The EpiNet project has been established to facilitate investigator-initiated clinical research in epilepsy, to undertake epidemiological studies, and to simultaneously improve the care of patients who have records created within the EpiNet database. The EpiNet database has recently been adapted to collect detailed information regarding status epilepticus. An incidence study is now underway in Auckland, New Zealand in which the incidence of status epilepticus in the greater Auckland area (population: 1.5 million) will be calculated. The form that has been developed for this study can be used in the future to collect information for randomized controlled trials in status epilepticus. This article is part of a Special Issue entitled "Status Epilepticus".

International audience; Epilepsy is a chronic neurological disease affecting more than 69 million people worldwide, nearly 90% of them in low and middle-income countries (LMICs). In those countries, only four major antiepileptic drugs are commonly used: phenobarbital, carbamazepine, sodium valproate and phenytoin. There are also problems with the accessibility, availability and quality of drugs. The main objective was to review the literature concerning "long" sustained-release formulations of AEDs that have the potential to reduce the number of administrations and help overcome problems of compliance, accessibility and the treatment gap. The main endpoint was a releasing of the active ingredient over more than 24h. We also assessed the feasibility and acceptability in resource-limited settings. Two drugs were found in unconventional release formulations: carbamazepine and sodium valproate; but they were not "long" sustained release because they required administration once a day. Several techniques were available, including: esterification, transdermal devices, liposomes and polymeric devices preformed or formed in situ. In situ methods for the preparation of injectable biodegradable microparticles or implants for controlled delivery seemed best suited to the objective. Furthermore, they appear to fulfil the requirements of feasibility and cost. Sodium valproate appeared as well to be a relevant candidate for a "long" sustained release formulation that would improve access to medicines for people with epilepsy in resource-limited settings. .

International audience