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ObjectiveTo determine the effectiveness of a 6-month, interactive, multimodal, Web-based EEG teaching program (EEGonline) in improving EEG analysis and interpretation skills for neurologists, neurology residents, and technologists, particularly in resource-limited settings.MethodsBetween June 2017 and November 2018, 179 learners originating from 20 African countries, Europe, and the United States were registered on the EEGonline course. Of these, 128 learners (91% African) participated in the study. Pre- and postcourse multiple choice question (MCQ) test results and EEGonline user logs were analyzed. Differences in pre- and posttest performance were correlated with quantified exposure to various EEGonline learning modalities. Participants' impressions of EEGonline efficacy and usefulness were assessed through pre- and postcourse satisfaction surveys.ResultsNinety-one participants attempted both pre- and postcourse tests (71% response rate). Mean scores improved from 46.7% ± 17.6% to 64.1% ± 18%, respectively (p < 0.001, Cohen d 0.974). The largest improvement was in correct identification of normal features (43.2%–59.1%; p < 0.001, Cohen d 0.664) and artifacts (43.3%–61.6%; p < 0.001, Cohen d 0.836). Improvement in knowledge was associated with improved subjective confidence in EEG analysis. Overall confidence among postcourse survey respondents improved significantly from 35.9% to 81.9% (p < 0.001). Lecture notes, self-assessment quizzes, and discussion forums were the most utilized learning modalities. The majority of survey respondents (97.2%) concluded that EEGonline was a useful learning tool and 93% recommended that similar courses should be included in EEG training curricula.ConclusionsThis study demonstrated that a multimodal, online EEG teaching tool was effective in improving EEG analysis and interpretation skills and may be useful in resource-poor settings.

A 52-year-old previously healthy man was hospitalized with a 6-day history of progressive gait instability rendering him unable to walk. He reported no respiratory symptoms or fever. He was a smoker (5–10 pack-years) and consumed an undisclosed amount of alcohol over weekends for some years. At presentation, he was tachypneic (20 bpm) and pyrexial (37.7°C) but alert and oriented. He exhibited cerebellar signs, including multidirectional gaze-evoked nystagmus, dysarthria, and truncal and appendicular ataxia. His examination was otherwise normal.

Background: Epilepsy is a common neurological disorder, associated with serious cognitive, physical, and psychosocial burdens. Mesial temporal lobe epilepsy (mTLE) is the commonest form of focal epilepsy. The aim of this study was to establish the incidence of patients with electroencephalographic epileptiform discharges consistent with mTLE attending a tertiary hospital in South Africa, and determine whether these patients may be candidates for anterior temporal lobectomy. Methods: This was a cross-sectional observational study of all patients receiving scalp electroencephalograms (EEG) performed at the Groote Schuur Hospital Neurophysiology laboratory during the period January 1, 2017–December 31, 2019. Where magnetic resonance imaging (MRI) brain scans had been performed, these were assessed for corroborative evidence of mTLE. Results: Over the 3-year period, 4 342 EEGs were assessed. A total of 411 (11%) showed epileptiform discharges consistent with all epilepsy types. Of these, 327 (69%) were of focal onset and 108 (33% of all focal onset epilepsies) were consistent with mTLE. Of the patients with electroencephalographic features of mTLE, only 27 (25%) had had MRI brain scans performed according to an epilepsy surgery protocol. None of these patients had been considered for surgery. Conclusion: Surgery, especially anterior temporal lobectomy, is widely acknowledged to be an efficacious and cost-effective intervention in patients with drug-resistant mTLE. The findings of our study suggest that patients with mTLE in our setting are under-investigated for potential surgery; and that it is under-utilized. These findings are in line with similar studies in both well-resourced and resource-constrained countries. Our study also highlights the utility of EEG as a practical screening tool to identify potential surgical candidates, as well as the establishment of an EEG and MRI database to assist in recognizing these patients.

Summary Background The Thymectomy Trial in Non-Thymomatous Myasthenia Gravis Patients Receiving Prednisone (MGTX) showed that thymectomy combined with prednisone was superior to prednisone alone in improving clinical status as measured by the Quantitative Myasthenia Gravis (QMG) score in patients with generalised non-thymomatous myasthenia gravis at 3 years. We investigated the long-term effects of thymectomy up to 5 years on clinical status, medication requirements, and adverse events. Methods We did a rater-blinded 2-year extension study at 36 centres in 15 countries for all patients who completed the randomised controlled MGTX and were willing to participate. MGTX patients were aged 18 to 65 years at enrolment, had generalised non-thymomatous myasthenia gravis of less than 5 years' duration, had acetylcholine receptor antibody titres of 1·00 nmol/L or higher (or concentrations of 0·50–0·99 nmol/L if diagnosis was confirmed by positive edrophonium or abnormal repetitive nerve stimulation, or abnormal single fibre electromyography), had Myasthenia Gravis Foundation of America Clinical Classification Class II–IV disease, and were on optimal anticholinesterase therapy with or without oral corticosteroids. In MGTX, patients were randomly assigned (1:1) to either thymectomy plus prednisone or prednisone alone. All patients in both groups received oral prednisone at doses titrated up to 100 mg on alternate days until they achieved minimal manifestation status. The primary endpoints of the extension phase were the time-weighted means of the QMG score and alternate-day prednisone dose from month 0 to month 60. Analyses were by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00294658. It is closed to new participants, with follow-up completed. Findings Of the 111 patients who completed the 3-year MGTX, 68 (61%) entered the extension study between Sept 1, 2009, and Aug 26, 2015 (33 in the prednisone alone group and 35 in the prednisone plus thymectomy group). 50 (74%) patients completed the 60-month assessment, 24 in the prednisone alone group and 26 in the prednisone plus thymectomy group. At 5 years, patients in the thymectomy plus prednisone group had significantly lower time-weighted mean QMG scores (5·47 [SD 3·87] vs 9·34 [5·08]; p=0·0007) and mean alternate-day prednisone doses (24 mg [SD 21] vs 48 mg [29]; p=0·0002) than did those in the prednisone alone group. 14 (42%) of 33 patients in the prednisone group, and 12 (34%) of 35 in the thymectomy plus prednisone group, had at least one adverse event by month 60. No treatment-related deaths were reported during the extension phase. Interpretation At 5 years, thymectomy plus prednisone continues to confer benefits in patients with generalised non-thymomatous myasthenia gravis compared with prednisone alone. Although caution is appropriate when generalising our findings because of the small sample size of our study, they nevertheless provide further support for the benefits of thymectomy in patients with generalised non-thymomatous myasthenia gravis. Funding National Institutes of Health, National Institute of Neurological Disorders and Stroke.

A high proportion of HIV-positive patients in South Africa receive concomitant efavirenz (EFV) and isoniazid (INH) therapy. EFV is metabolised in the liver via CYP2B6, and genetic polymorphism of CYP2B6 is known to result in slowed metabolism of the drug. INH is also metabolised in the liver, causing inhibition of a pathway that plays an important role in slow EFV metabolisers. Concomitant INH use therefore affects plasma levels of EFV. EFV is well known to cause neuropsychiatric side-effects on initiation, and a recent adult case series described late-onset neurotoxicity in the form of subacute ataxia and encephalopathy in patients treated with EFV for a median of 2 years, in association with toxic plasma levels of the drug. We have seen an increase in cases of EFV toxicity presenting to our neurology referral unit. All cases have been in the context of recent initiation of concomitant INH. We therefore conducted a retrospective case record audit to describe these seven cases with the additional advantage of tertiary-level assessment. We outline the clinical features and investigation results, as well as outcomes after EFV was stopped. Our main objectives are to highlight the probable role of concomitant INH use in the development of this syndrome, and to suggest that only limited work-up may be warranted in suspected cases.