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Disconcerting data from analysis of the Women’s Interagency HIV Study database
Gretchen L. Birbeck, MD, MPH, Without Borders Editor, Rochester, NY
In this issue of Neurology, Rubin and colleagues report disconcerting data from their analysis of the Women’s Interagency HIV Study database. In longitudinal assessments of cognitive and motor function in women with and without HIV infection, even among women with continuous viral suppression HIV-associated differences were evident. Perhaps even more disturbingly, in some domains women with continuous suppression performed more poorly than those with HIV who were not suppressed.
This cohort data is from 2009-2013 so many of the participants would have an antiretroviral therapy initiated only after some significant period of viral suppression and possibly with a very low CD4 nadir—both recognized as underlying risk factors for adverse neurologic outcomes in HIV. One can hope that with earlier treatment initiation long term cognitive outcomes in women with HIV will cease to differ from their HIV uninfected counterparts. Nonetheless, the women with continuous viral suppression had longer antiretroviral therapy duration and greater use of efavirenz and this report may offer some fuel to the fire of concerns regarding the neurotoxicity of antiretrovirals, particularly efavirenz.1 The strongest HIV-related predictor of neurocognitive performance remains the proportion of time with undetectable viral load. Within the context of HIV as a chronic condition, balancing the toxicity and neurologic protective aspects of antiretroviral use appears to be one of the bigger challenges that lies ahead.

1. Ma Q, Vaida F, Wong J, et al. Long-term efavirenz use is associated with worse neurocognitive functioning in HIV-infected patients. J Neurovirol 2016;22:170-178.

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Sickle cell and neurologic complications
Gretchen L. Birbeck, MD, MPH, Without Borders Editor, Rochester, NY
A newly published systematic review and meta-analysis in Neurology looks at the complications of sickle cell disease in Africa. In an accompanying editorial, Dr. Ralph Green and I consider the unmet challenges of these neurologic complications. As we note in the editorial, “Sometimes an important scientific report is more notable for what it cannot tell us than for what it can”.


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Inflammation, anxiety and depression
Gretchen L. Birbeck, MD, MPH, Without Borders Editor, Rochester, NY
Rossi and colleagues have published an interesting report on CNS inflammation in multiple sclerosis as it relates to anxiety and depression that may be more relevant to resource-limited tropical settings than one might imagine. Their paper makes an important contribution to the growing body of clinical data supporting the importance of CNS inflammation-induced anxiety and depression in persons with neurologic disorders. The potential for these psychiatric symptoms to serve as a possible warning sign of ongoing CNS inflammation warrants further study and the range of conditions for which this might be relevant is extensive.
In 2006 during the antiretroviral therapy (ART) roll out in rural Zambia, we undertook a study of the neurologic and psychiatric status of people initiating ART and patient outcomes at 1 year1. Mortality was 20% at a median of 80 days (IQR 44-139) after treatment initiation. After adjusting for World Health Organization HIV Disease Stage, the only predictor of mortality was the Shona Symptom Score, an instrument developed in Zimbabwe to quantify anxiety and depression symptoms. More recently, we evaluated predictors of mortality among people with HIV and new onset seizure. After advanced imaging, EEG and extensive cerebrospinal fluid (CSF) studies to identify opportunistic infections2, the highest mortality was seen among those patients in who we could find no cause for the underlying seizure. Clearly CSF studies of CNS inflammation in this population, and likely others, are needed.
1. Birbeck GL, Kvalsund MP, Byers PA, et al. Neuropsychiatric and socioeconomic status impact antiretroviral adherence and mortality in rural Zambia. Am J Trop Med Hyg 2011;85:782-789.
2. Siddiqi OK, Elafros MA, Bositis CM, et al. New-onset seizure in HIV-infected adult Zambians: A search for causes and consequences. Neurology 2017;88:477-482.
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As Summer Peaks, the US House of Representative Appropriations Committee Proposes Budget that Keeps Fogarty International Center Intact
Gretchen L. Birbeck, MD, MPH, Without Borders Editor, Rochester, NY
Most in the ‘global know’ were dumbfounded in March when both President Trump’s “skinny” budget and the subsequent detailed one explicitly targeted the Fogarty International Center (FIC) for closure.1 Happy news arrived earlier this month when the appropriations committee for the House of Representatives approved a bill that did not close Fogarty but in fact allocated FIC a 1.5% increase ($73.4 million total budget).2 Despite its teeny, tiny budget (described by some as amounting to “less than pencil dust” in the overall NIH budget, Fogarty’s work yields serious benefits to U.S citizens and the global community alike including Fogarty’s leadership in the Brain Disorders programme which has played such a central role in the globalization of US Neurology.3 A disclosure—as an investigator funded through the Brain Disorders program and a Fogarty International Center Advisory Board member, I am seriously conflicted here. So don’t take my word for it—you can read any number of Op Eds and commentaries testifying to the critical nature of the FIC.1, 4-6 The Senate appropriations committee take this up in September. We certainly live in interesting times. Stay tuned.


1. McNeil DG. Muffling an early warning system. New York Times 2017 March 21, 2017;Sect. 4.
2. US House of Representatives proposal preserves Fogarty, boosts NIH by $1B. In: NIH Fogerty International Center [online]. Available at: www.fic.nih.gov/News/GlobalHealthMatters/july-august-2017/Pages/house-ap.... Accessed August 14, 2017.
3. Birbeck GL, Meyer AC, Ogunniyi A. Nervous system disorders across the life course in resource-limited settings. Nature 2015;527:S167-171.
4. Drain PK, Subbaraman R, Heimburger DC. Preserving the Fogarty International Center - Benefits for Americans and the World. N Engl J Med 2017;377:9-11.
5. Green A. US stands to lose as much as Africa if Fogarty closes. University World News 2017 16June17.
6. Karim SSA, Karim QA, Abimiku A, et al. Closing the NIH Fogarty Center threatens US and global health. Lancet 2017;390:451.


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  • HIV-associated motor neuron disease HERV-K activation and response to antiretroviral therapy In this small case series Bowen and colleagues report activation of human endogenous retrovirus-K (HERV-K) in people with HIV who developed motor neuron disease that subsequently improved with antiretroviral therapy. For neurologists caring for HIV patients in HIV endemic areas, this may be the silver lining on a heavy cloud. ​
    Lauren N. Bowen, MD, Richa Tyagi, MS, Wenxue Li, PhD, Tariq Alfahad, MD, Bryan Smith, MD, Mary Wright, MD, MPH, Elyse J. Singer, MD and Avindra Nath, MD  Published September 24, 2016
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Call to action to stop mob murders of people with epilepsy in Malawi - On 17 October 2017, Abdul Matola, a 19-year-old from Malawi, was burned to death because of a belief that his epilepsy symptoms were indicative of vampirism. Without immediate epilepsy education for the community, more young lives may be lost. We encourage you to support the petition set by the Federation of Disability Organisations in Malawi (FEDOMA) and the National Epilepsy Association of Malawi (NEAM) that calls upon the government of Malawi to urgently develop and implement a national plan for epilepsy management. See the petition here.

The September issue of the American Academy of Neurology's Global Health Section has posted: 
This issue includes information on the Foundation for African Medicine & Education (FAME), Iceland's health care system, experiences in an observership at the Neuroscience Center of All India Institute of Medical Sciences, and The International AIDS Society Conference on HIV Science in Paris.

US Immigration Policy Update - An update to the original letter of January 2017 has been published on the American Academy of Neurology website, regarding a recent decision by the Supreme Court and announcements by the U.S. Department of Homeland Security.

Neurology®: Clinical Practice has just launched their next Practice Current survey on a very globally relevant topic—How do you treat epilepsy in pregnancy? Given the broad range of approaches to managing this problem in diverse settings with varying resources, this survey promises to provide interesting insights. If you care for epilepsy patients, please consider completing the survey to add your own perspective.

Check out Dr. Omar Siddiqi’s most recent blog on his work in Zambia. Read about “The Broken File” effect. Quite an insightful commentary on what we need to do to improve patient care wherever we work.


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32nd International Epilepsy Congress Report

Naluca Mwendaweli, BSc.HB, MB.ChB (UNZA), Senior Resident Medical Doctor, Ministry of Health, Chikankata Southern Province, Zambia.  

The International Epilepsy Congress (IEC) is a biennial event recognized by many epilepsy specialists around the globe. Delegates have the chance to come together with fellow researchers, clinicians, health care practitioners, care givers and patients. This year, the 32nd IEC was held in Barcelona Spain, from 2nd to 6th September at the prestigious Palau de Congressos de Catalunya. This congress was jointly organized by the International League against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). The scientific program had a presidential symposium, a wide range of main sessions and parallel sessions, video sessions, teaching sessions, debates, as well as EEG Technicians course. 

Over a thousand abstracts were presented as posters in 20 categories, and as a first time-attendee and poster presenter, I was amazed at how much research work is being carried out in the field of epilepsy. And for a person who is from a resource-limited setting, I was struck by how much technology exists in the developed world for diagnosing and treating epilepsy, especially in the area of genetics. 

The presidential symposium covered the new classification of seizures and epilepsy. The 2017 ILAE classification has seizure types that are focal, generalized onset or unknown onset. Epilepsy types include focal, generalized, combined generalized and focal, and unknown. The terms: complex partial, simple partial, partial, psychic, secondarily generalized tonic-clonic and dyscognitive are no longer in use. There are no approved ILAE epilepsy syndromes. 

The video sessions focused on the practical implementation of the new classification. 

The scientific program also had the Ask the Experts interactive sessions that took place over three days, covering topics such as classification, women’s issues, and managing difficult cases of epilepsy in childhood. There was a session on stress being a key factor in epilepsy and co-morbidities, and the evolving interactions of stress, anxiety and depression in epilepsy. Mood disorders are a risk factor for developing epilepsy and vice-versa. We also had a session on the role of diets in the management of epilepsy, mainly the effectiveness of the ketogenic diet. The ketogenic diet is based on a diet that is high in fat, adequate in protein and low in carbohydrate and is a proven medical therapy for epilepsy. The diet uses fat as an alternative fuel source for the body, producing ketones. These ketones and the associated biochemical changes in the brain can have an anti-convulsive effect. This is an area that I think has not been fully explored in Zambia but would also pose some challenges in rural areas. 

The IBE/ILAE congress awards were presented to honor individuals who have made significant contributions, over a long period of time and at international level, in the field of epilepsy. The lifetime achievement award, the highest award bestowed by IBE/ILAE, was presented to Professor Charlotte Dravet, who is especially known for the epilepsy syndrome that bears her name (Dravet syndrome). 

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Neurology Podcasts

March 27, 2017: Dr. Kiran T. Thakur interviews Dr. Tarun Dua, Medical Officer at the World Health Organization working on the Program for Neurological Diseases and Neuroscience, Management of Mental and Brain Disorders in the Department of Mental Health and Substance Abuse, Geneva, Switzerland Find it here.

February 6, 2017: Dr. Omar Siddiqi interviews Dr. Victor Valcour, Associate Professor of Geriatric Medicine and Neurology at the UCSF Memory and Aging Center and Deputy Director of the Global Brain Health Institute. Find it here.

Without Borders Podcast Archive

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Dr. Stephen Donahue interviews Dr. Aaron Berkowitz

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