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Panahi P, Mirzohreh ST, Zafardoust H, Khamnian Z, Alizadeh M. Navigating the waves: A systematic review of telemedicine interventions and health service access challenges in epilepsy during COVID-19. Epilepsy Behav 2024; 158:109934. [PMID: 39079379 DOI: 10.1016/j.yebeh.2024.109934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 05/13/2024] [Accepted: 06/30/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION The COVID-19 pandemic has dramatically reshaped the landscape of healthcare delivery, prompting a surge in the adoption of telemedicine as a means to ensure continuity of care. During the pandemic, patients with epilepsy experienced difficulties accessing healthcare and obtaining necessary medications, with a substantial percentage facing obstacles in acquiring anti-seizure medication and reaching healthcare professionals. Disruptions in the supply and distribution of medication, due to COVID-19-related actions, further caused more problems for people with epilepsy and their caregivers like increasing seizure frequency. The pandemic has also accelerated the adoption of telemedicine, with evidence suggesting its potential benefits in various medical fields. In this systematic review and meta-analysis, we aim to investigate the challenges faced by patients with epilepsy during the COVID-19 pandemic, including healthcare access and medication acquisition, as well as evaluate changes in seizure frequency. Additionally, we will synthesize existing evidence on the use of telemedicine to address the healthcare needs of these patients, exploring its advantages and limitations. METHODS This systematic review was prepared using PRISMA reporting guidelines. The databases searched were PubMed, Scopus, Web of Science, and Cochrane. Risk of Bias was assessed using Joanna Briggs Institute (JBI). Following rigorous application of eligibility criteria, relevant data, covering both telemedicine-related and health service access information, were methodically extracted and organized using Microsoft Excel spreadsheets. The analytical procedures were executed through the utilization of Comprehensive Meta-Analysis (CMA) software. RESULTS A total of 70 articles included in this review. Regarding difficulties in accessing healthcare, 34% of PWE and 41% of caregivers experienced cancelled, changed or postponed appointments. Following issues with obtaining medicine, 13% of patients and 16% of caregivers had difficulties in medicine availability and 11% of patients and 10% of caregivers in medicine accessibility. A very high rate of 90% satisfaction with telemedicine was reported by PWE. 17.6% of PWE experienced an escalation, 9% a decrease and 67% no changes in seizure frequency. CONCLUSION This review and meta-analysis revealed that telemedicine and virtual communications have been helpful but not sufficient for meeting healthcare needs for PWE during the COVID-19 pandemic. Additionally, there was a significant increase in seizure frequency among PWE who had difficulty obtaining medicine and access to healthcare.
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Affiliation(s)
| | | | | | - Zhila Khamnian
- Department of Community Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahasti Alizadeh
- Faculty of Medicine, Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Iran.
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Wanigasinghe J, Thisarani Weeraratne C, Niroshika Dolapihilla B, Mahen Elapatha D. Impact of COVID-19 pandemic on caregivers of persons with epilepsy - A systematic review. Epilepsy Behav 2023; 149:109516. [PMID: 37952417 DOI: 10.1016/j.yebeh.2023.109516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/26/2023] [Accepted: 11/02/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To describe the impact of COVID-19 pandemic on caregivers of persons with epilepsy. METHODS This systematic literature review was conducted according to the Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA) guidelines. The PECO (Patient, Exposure, Comparison, Outcome) framework criteria were as follows: caregivers of persons with epilepsy; exposed to the COVID-19 pandemic; and outcomes, evaluated under 4 domains- Difficulties faced by caregivers during the COVID-19 pandemic, physical, emotional and behavioural impacts, diagnosed health conditions, and impact on clinical management and follow-up). Literature was searched in PubMed, Google Scholar, CINAHL, Medline, and Cochrane Library Databases. Appraisal tool for Cross-Sectional Studies (AXIS) was used to assess the methodological quality of studies. RESULTS Data were extracted from 21 eligible articles from 199 and included 5810 caregivers of persons with epilepsy. In the domain of difficulties faced by caregivers during the COVID-19 pandemic, the most significant effect was related to difficulties in obtaining and affording anti-seizure medications. Appointment cancellations also affected most caregivers (4/7 studies). Seizure exacerbation was not a major concern to them. Anxiety, reported by most caregivers in 5/7 studies, depression in 2/5 studies, stress by majority of caregivers in 4/6 studies, and increased substance use in one study were other significant bad experiences. Social isolation increased for the majority in 2/7 studies. Financial difficulties were described in two studies. Under caregivers' health conditions, there was only one study to review. Emotional issues affected majority in 3/7 studies, physical issues in 2/4 studies, and worsened behavior in one. With regards to clinical management and follow-up, most caregivers (4/5 studies) adopted self-management strategies, but 3/8 studies reported difficulties in accessing medications and healthcare services. Additionally, 4/8 studies highlighted communication and coordination difficulties with healthcare providers. Caregivers' attitude towards telemedicine varied across studies. SIGNIFICANCE COVID-19 pandemic had a profound impact on caregivers of persons with epilepsy, affecting their emotional, physical, and behavioral health. It limited their access to healthcare and impacted financial stability. Caregivers of persons with epilepsy need comprehensive support and resources during crisis situations.
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Dal-Pai J, Dos Santos MP, Donida NDS, Cesarino MR, de Oliveira VHMS, Nunes ML. Health consequences and daily life modifications in children and adolescents with epilepsy during the COVID-19 pandemic - a systematic review: Running Title: Covid-19 Pandemic in Children/Adolescents with Epilepsy. Seizure 2023; 108:102-115. [PMID: 37146514 PMCID: PMC10140054 DOI: 10.1016/j.seizure.2023.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023] Open
Abstract
PURPOSE To describe the impact of the COVID-19 pandemic on the health care and daily life of children and adolescents with epilepsy. METHODS This systematic review followed the preferred reporting items guidelines and was registered on the PROSPERO platform (CRD42021255931). The PECO (Patient, Exposure, Comparison, Outcome) framework criteria were as follows: people with epilepsy (0-18 years old); exposed to the COVID-19 pandemic; and outcomes, including epilepsy type, time of clinical diagnosis, seizure exacerbation, treatment and medications, need for emergency because of seizures, sleep, behavior, comorbidities and/or concerns, social and/or economic impact, insurance status, electronic device use, telemedicine, and distance learning. Literature searches for cross-sectional and longitudinal studies were conducted on Embase and PubMed. The methodological quality of identified studies was assessed using the Newcastle‒Ottawa Scale (NOS). RESULTS Data were extracted from 23 eligible out of 597 identified articles and included 31,673 patients. The mean NOS scores for cross-sectional study design was 3.84/10, and for longitudinal, it was 3.5/8 stars. Seizure exacerbations were reported in three studies, difficulties with access to anti-seizure medications in two, changes in dosage in five, and visit postponed or cancelation in five studies. Problems with sleep were highlighted in three, issues related to distance learning in two, an increased time spent on electronic devices in three, and increased behavioral problems in eight studies. Telemedicine, when available, was described as useful and supporting patient's needs. CONCLUSION The pandemic affected the health care and lifestyle of young individuals with epilepsy. The main problems described revolved around seizure control, accessing anti-seizure medication, sleep and behavioral complains.
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Affiliation(s)
- Janise Dal-Pai
- Brain Institute of Rio Grande do Sul - Pontifical Catholic University of Rio Grande do Sul (InsCer / PUCRS), Porto Alegre, Brazil
| | - Michele Paula Dos Santos
- Extension and Management of Continuing Education Activities Program - Pontifical Catholic University of Rio Grande do Sul (PEGA / PUCRS), Porto Alegre, Brazil
| | - Natalie da Silveira Donida
- Extension and Management of Continuing Education Activities Program - Pontifical Catholic University of Rio Grande do Sul (PEGA / PUCRS), Porto Alegre, Brazil
| | - Matheus Ribeiro Cesarino
- Extension and Management of Continuing Education Activities Program - Pontifical Catholic University of Rio Grande do Sul (PEGA / PUCRS), Porto Alegre, Brazil
| | - Victor Hugo Midões Santana de Oliveira
- Extension and Management of Continuing Education Activities Program - Pontifical Catholic University of Rio Grande do Sul (PEGA / PUCRS), Porto Alegre, Brazil.
| | - Magda Lahorgue Nunes
- Professor of Neurology, School of Medicine - Pontifical Catholic University of Rio Grande do Sul (InsCer / PUCRS), Porto Alegre, Brazil.
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Hovanesian J, Singh IP, Bauskar A, Vantipalli S, Ozden RG, Goldstein MH. Identifying and addressing common contributors to nonadherence with ophthalmic medical therapy. Curr Opin Ophthalmol 2023; 34:S1-S13. [PMID: 36951648 DOI: 10.1097/icu.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
PURPOSE OF REVIEW To discuss common reasons for nonadherence and review existing and emerging options to reduce nonadherence with ocular medical therapy and optimize therapeutic outcomes. RECENT FINDINGS Nonadherence can arise from patient-related issues (e.g. physical, cognitive) and healthcare-related issues (e.g. cost, access to care). Multiple strategies have been developed and evaluated to overcome these barriers to adherence. Identifying nonadherence and its cause(s) facilitates the development of strategies to overcome it. SUMMARY Many common causes of nonadherence can be mitigated through a variety of strategies presented.
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Affiliation(s)
| | - I Paul Singh
- The Eye Centers of Racine and Kenosha, Racine, Wisconsin
| | - Aditi Bauskar
- Ocular Therapeutix, Inc., Bedford, Massachusetts USA
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Living with Epilepsy during COVID-19 pandemic restrictions: A Longitudinal Perspective. Epilepsy Behav 2023; 142:109146. [PMID: 37075509 PMCID: PMC9941304 DOI: 10.1016/j.yebeh.2023.109146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 02/25/2023]
Abstract
The purpose of our study was to explore how people with epilepsy fared during two of the most stringent 4-month society-wide COVID-19 related pandemic restrictions in Ireland, in 2020 and one year later in 2021. This was in the context of their seizure control, lifestyle factors and access to epilepsy-related healthcare services. A 14-part questionnaire was administered to adults with epilepsy during virtual specialist epilepsy clinics in a University Hospital in Dublin, Ireland at the end of the two lockdowns. People with epilepsy were questioned on their epilepsy control, lifestyle factors and quality of epilepsy-related medical care, compared to pre-COVID times. The study sample consisted of two separate cohorts of those diagnosed with epilepsy (100 (51.8%) in 2020, 93 (48.2%) in 2021, with similar baseline characteristics. There was no significant change in seizure control or lifestyle factors from 2020 to 2021, except for deterioration in anti-seizure medication (ASM) adherence in 2021 compared to 2020 (p = 0.028). There was no correlation between ASM adherence and other lifestyle factors. Over the two years, poor seizure control was significantly associated with poor sleep (p <0.001) and average seizure frequency in a month (p = 0.007). We concluded that there was no significant difference between seizure control or lifestyle factors between the two most stringent lockdowns in Ireland, in 2020 and in 2021. Furthermore, people with epilepsy reported that throughout the lockdowns access to services was well maintained, and they felt well supported by their services. Contrary to popular opinion that COVID lockdowns greatly affected patients with chronic diseases, we found that those with epilepsy attending our service remained largely stable, optimistic, and healthy during this time.
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Kelly D, Koay A, Mineva G, Volz M, McCool A, McLoughlin E, Ó Conluain R, Sharma M, Kerr A, Franklin BD, Grimes T. A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies. Public Health 2023; 214:50-60. [PMID: 36521272 DOI: 10.1016/j.puhe.2022.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/06/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Public health emergencies (PHE) can disrupt personal medication practices and increase the risk of medication-related harm and other negative medication-related outcomes. Our aim was to examine the extent and nature of published research on this topic to guide future research and practice. STUDY DESIGN Scoping review. METHODS Standard electronic databases were searched. PRISMA-ScR guidelines were followed. Extracted data were organised in response to review questions and narrative accounts developed. RESULTS A total of 129 studies were included, conducted across 32 countries, mostly in the USA (n = 42). Sixty-eight (53%) reported on infectious events, 49 (39%) climatological or ecological events and the remainder a mixture of terrorism, war or other disasters. The studies described several medication safety outcomes (medication-related harm, adherence, supply) and adaptive medication practices (self-altering prescribed medications, sharing medications and changing healthcare providers). Challenges to maintaining routine medication practices during a PHE included transport, finance, quarantine and knowledge-related issues. Twenty-eight studies (22%) examined health inequalities pertaining to adverse medication-related outcomes, with findings suggesting that gender, age, ethnicity, educational and socio-economic status may be related to inequalities. Research gaps identified included carers', children's and minority communities' experiences and intervention studies. CONCLUSIONS There is considerable evidence of disruptions to routine personal medication practices during PHEs and of medication-related harm and other negative outcomes. Maintaining medication supply for the management of chronic conditions is a universal problem across all emergency types. Research is needed to address these disruptions, particularly amongst people who experience health inequalities who may need additional support.
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Affiliation(s)
- Dervla Kelly
- School of Medicine, University of Limerick, Limerick, Ireland; Health Research Institute, University of Limerick, Limerick, Ireland
| | - Aaron Koay
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Gabriela Mineva
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Monika Volz
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Aoibhin McCool
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Eavan McLoughlin
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | | | - Manuj Sharma
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Aisling Kerr
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Bryony Dean Franklin
- Imperial College Healthcare NHS Trust, London, UK; NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, UK; UCL School of Pharmacy, London, UK
| | - Tamasine Grimes
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
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von Gaudecker JR, Clarke DF, Perkins S, Ali A, Sanjuan D, Vidaurre J. Epilepsy care delivery during COVID-19 in resource-limited countries: A survey in collaboration with International Epilepsy Equity Group. Epilepsy Behav 2023; 138:108998. [PMID: 36436359 PMCID: PMC9690616 DOI: 10.1016/j.yebeh.2022.108998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The impact of pandemic has had worse effects in countries with already stretched healthcare resources. study's The study aimed to explore changes in epilepsy care delivery in resource-limited countries during and since the acute phase of the COVID-19 pandemic. METHOD A cross-sectional survey was conducted in 22 countries among healthcare providers (HCPs) caring for persons with epilepsy (PWE), in collaboration with newly formed global collaborators, the International Epilepsy Equity Group. Findings were compared based on the World Bank Ranking (WBR) and HCPs' practice type. Data were analyzed using Chi-square tests (α = 0.05) and pairwise multiple comparisons with α = 0.017 (Bonferroni adjustment). Open-ended responses were analyzed using thematic analysis. FINDINGS A total of 241 HCPs participated in the study. Of these, 8.30%, 65.98%, and 21.99% were from high-income (HIC), upper-middle-income (UMIC), and lower-middle-income countries (LMICs), respectively. Among HCPs, 31.12% were adult specialists, and 43.98% were pediatric specialists. During the acute phase of the pandemic, HCPs reported that the major barrier for PWE was difficulty reaching physicians/healthcare providers. Except for difficulty reaching physicians/healthcare providers (WBR P = 0.01 HIC < LMIC), no other significant differences in barriers during the acute phase were observed. Since the acute phase of the pandemic, the major concern for PWE was fear of getting infected with the SARS-CoV-2 virus. Significant differences in concerns since the acute phase included lockdowns (WBR: P = 0.03 UMIC < LMIC), fiscal difficulties (WBR: P < 0.001 UMICs < LMICs, UMICs < HIC; practice type: P = 0.006 adult < others, pediatrics < others), clinic closure (WBR: P = 0.003 UMIC < HIC; practice type: P =< 0.001 adult < others, pediatric < others), and long waiting times (WBR: P = 0.005, LMIC < UMIC, LMIC < HIC; practice type: P = 0.006 pediatric < adults). Diagnostic services, including EEG, MRI, CT (practice type: P < 0.001, adult < others; pediatric < others), and lab work (WBR: P = 0.01 UMIC < HIC), were restricted. The telephone was the most reported teleconsultation method used. Except for SMS/texting (WBR P = 0.02 UMIC < LMIC), there were no significant differences in teleconsultation methods used. DISCUSSION There is a high probability that the initial wave and consequent reduction of in-person care, restriction of health services, and fiscal difficulties affecting all involved in care delivery, led to the disruption of epilepsy care. Additional support are needed in resource-limited countries to cope with future pandemics.
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Affiliation(s)
- Jane R von Gaudecker
- Indiana University School of Nursing, Indiana University, Indianapolis, IN 46202, USA.
| | - Dave F Clarke
- Neurology and Pediatrics, Dell Medical School, University of Texas at Austin, USA; Pediatric Epilepsy, Dell Children's Medical Center of Central Texas, USA.
| | - Susan Perkins
- Department of Biostatistics, Indiana University School of Medicine, Indiana University, Indianapolis, IN 46202, USA.
| | - Amza Ali
- Epilepsy Centre of Jamaica, Jamaica; The University of the West Indies, Jamaica.
| | - Daniel Sanjuan
- National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
| | - Jorge Vidaurre
- Nationwide Children's Hospital - The Ohio State University, Columbus, OH, USA.
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Russo G, Jesus TS, Deane K, Osman AY, McCoy D. Epidemics, Lockdown Measures and Vulnerable Populations: A Mixed-Methods Systematic Review of the Evidence of Impacts on Mother and Child Health in Low-and Lower-Middle-Income Countries. Int J Health Policy Manag 2022; 11:2003-2021. [PMID: 34894643 PMCID: PMC9808285 DOI: 10.34172/ijhpm.2021.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 11/06/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The aim of this research was to synthetise the existing evidence on the impact of epidemic-related lockdown measures on women and children's health in low- and lower-middle-income countries (LLMICs). METHODS A mixed-methods systematic review was conducted of qualitative, quantitative and mixed-methods evidence. Between 1st and 10th of November 2021, seven scientific databases were searched. The inclusion criteria were that the paper provided evidence on the impact of lockdown and related measures, focused on LLMICs, addressed impacts on women and child's health, addressed epidemics from 2000-2020, was peer-reviewed, provided original evidence, and was published in English. The Joanne Briggs Institute's critical appraisal tools were used to assess the quality of the studies, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. The evidence from the papers was grouped by type of lockdown measure and categories of impact, using a narrative data-based convergent synthesis design. RESULTS The review process identified 46 papers meeting the inclusion criteria from 17 countries that focussed on the coronavirus disease 2019 (COVID-19) and Ebola epidemics. The evidence on the decrease of utilisation of health services showed plummeting immunisation rates and faltering use of maternal and perinatal services, which was linked to a growth of premature deaths. Impacts on the mental health of children and women were convincingly established, with lockdowns associated with surges in depression, anxiety and low life satisfaction. Vulnerability may be compounded by lockdowns, as livelihoods were disrupted, and poverty levels increased. CONCLUSION Limitations included that searches were conducted in late-2020 as new research was being published, and that some evidence not published in English may have been excluded. Epidemic-related lockdown measures carry consequences for the health of women and children in lower-income settings. Governments will need to weigh the trade-offs of introducing such measures and consider policies to mitigate their impacts on the most vulnerable.
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Affiliation(s)
- Giuliano Russo
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Tiago Silva Jesus
- Global Health & Tropical Medicine, Instituto de Higiene e Medicina Tropical, Nova University of Lisbon, Lisbon, Portugal
| | - Kevin Deane
- Faculty of Arts & Social Sciences, School of Social Sciences & Global Studies, Open University, Milton Keynes, UK
| | | | - David McCoy
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Shah U, Rajeshree S, Ravat P, Kalika M, Mehta S, Sapre A, Ravat SH. Challenges for low middle-income people with epilepsy during the COVID-19 pandemic: Lessons learnt, call for action. Epilepsia Open 2022; 7:665-673. [PMID: 36005396 PMCID: PMC9538458 DOI: 10.1002/epi4.12646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/16/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The COVID-19 pandemic impacted the care of people with epilepsy (PWE). Several online surveys were conducted but there is limited data regarding the impact on low-income PWE from lower-middle income countries (LMICs) who have no access or ability to answer online surveys. The purpose of this interview was to understand the challenges faced by low-income PWE during the lockdown phase of the pandemic. METHOD PWE visiting the epilepsy specialty outpatient department of a tertiary referral government hospital to avail of subsidized services were interviewed. In the interview, they discussed challenges in obtaining medical care, the impact on wellbeing, employment, and vaccination status during the lockdown phase of the pandemic. RESULTS Out of the 214 PWE interviewed, 20.6% had increased seizure frequency, 28.9% did not have access to medication mainly due to travel restrictions, 30.5% reported lack of availability of medication and 50% were not able to afford the medication mainly due to loss of income. 51% were unable to have follow-up consultations. 36% reported worsening of mood and some reported impact on other aspects of wellbeing. The impact on wellbeing was significantly associated with an increase in seizure frequency (P < .05). The study revealed hesitation related to vaccines in the majority and expectations of financial support by the government and assistance for procuring medication. There was a lack of awareness about telemedicine services and the same was not adequately offered by government hospitals. SIGNIFICANCE The study underscores the need to learn lessons from the challenging experiences of low-income PWE and create an action plan for the future to address the issues of lack of affordability of medical care and access to telemedicine. It is critical that the care of the marginalized, underrepresented PWE from lower-middle income countries is not neglected during a pandemic.
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Affiliation(s)
- Urvashi Shah
- Department of NeurologySeth GSMC and KEM HospitalMumbaiIndia
| | | | - Parthvi Ravat
- Department of NeurologySeth GSMC and KEM HospitalMumbaiIndia
| | - Mayuri Kalika
- Department of NeurologySeth GSMC and KEM HospitalMumbaiIndia
| | - Saloni Mehta
- Department of NeurologySeth GSMC and KEM HospitalMumbaiIndia
| | - Antara Sapre
- Department of NeurologySeth GSMC and KEM HospitalMumbaiIndia
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Lavin B, Gray CL, Brodie M. Telemedicine and Epilepsy Care. Neurol Clin 2022; 40:717-727. [DOI: 10.1016/j.ncl.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Kuroda N, Gajera PK, Yu H, Kubota T. Seizure Control in Patients with Epilepsy during the COVID-19 Pandemic: A Systematic Review and Meta-analysis. Intern Med 2022; 61:2287-2293. [PMID: 35650127 PMCID: PMC9424088 DOI: 10.2169/internalmedicine.9321-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective To investigate seizure control in patients with epilepsy during the coronavirus disease 2019 (COVID-19) pandemic. Method A systematic review and meta-analysis was conducted, and the MEDLINE, EMBASE, CENTRAL, and ClinicalTrials.gov databases were comprehensively searched for relevant studies. Studies that reported seizure control in patients with epilepsy during the COVID-19 pandemic were included. Pooled proportions with 95% confidence intervals (CIs) of patients with epilepsy who experienced seizure worsening during the COVID-19 pandemic were assessed using a random-effects model. The quality of the assessment for each study, heterogeneity between the studies, and publication bias were also evaluated. Subgroup analyses were performed, excluding studies with reports of seizures worsening from caregivers. Results A total of 24 studies with 6,492 patients/caregivers were included in the meta-analysis. The pooled proportion of seizure worsening was 18.5% (95% CI: 13.9-23.6; I2=96%; p<0.01). The pooled proportion of seizure worsening in the subgroup analysis was 18.9% (95% CI: 13.5-25.0; I2=96%; p<0.01). Conclusion Although the heterogeneity was high, our results showed a relatively high incidence of seizure worsening during the COVID-19 pandemic. During the COVID-19 pandemic, physicians should be aware of the likelihood of worsening seizures in patients with epilepsy.
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Affiliation(s)
- Naoto Kuroda
- Department of Pediatrics, Wayne State University, USA
- Department of Epileptology, Tohoku University Graduate School of Medicine, Japan
| | | | - Hongxuyang Yu
- Department of Neurology, West Virginia University, USA
| | - Takafumi Kubota
- Department of Neurology, Tohoku University Graduate School of Medicine, Japan
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Monteiro S, Fournier M, Favrod J, Drainville AL, Plessis L, Freudiger S, Skuza K, Tripalo C, Franck N, Lebas MC, Deloyer J, Wilquin H, Golay P, Rexhaj S. Ability to Care for an Ill Loved One During the First COVID-19 Lockdown: Mediators of Informal Caregivers' Stress in Europe. Front Psychiatry 2022; 13:852712. [PMID: 35492725 PMCID: PMC9039127 DOI: 10.3389/fpsyt.2022.852712] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/08/2022] [Indexed: 12/04/2022] Open
Abstract
Informal caregivers are overlooked, healthcare actors. They are at particular risk of distress and suffer from poor mental health. This study aimed to investigate the perceived stress and modulating factors during the first COVID-19 lockdown in Europe, regardless of the illness that care recipients suffer from. Sociodemographic data, coping resources, and perceived stress level using the Perceived Stress Scale (PSS-10) questionnaire were assessed using a web-based survey in Switzerland, France, and Belgium with 232 informal caregivers. Mediation analyses were used to identify the factors that modulate stress. Higher perceived stress among informal caregivers was associated with a younger age for the care recipient, family relationship with the care recipient, cohabitation, and female sex of the informal caregiver. These associations were partially mediated by the fear of getting ill (age, cohabitation), the conviction that lockdowns had a negative impact on health (age, kinship), and the perceived deterioration of the care recipient's health (gender). The fear of losing the ability to cope with caregiving tasks due to an illness (COVID-19 and/or other) and the negative impact of the lockdown on care recipients' health, particularly on the mental health of young care recipients, increased the stress of informal caregivers. Our results emphasize the importance of informal caregiving support to prevent heightened stress in lockdown conditions, regardless of care recipient illness or kinship.
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Affiliation(s)
- Shadya Monteiro
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Margot Fournier
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Jérôme Favrod
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Anne-Laure Drainville
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Léa Plessis
- Aix Marseille Université, LPCPP, Aix-en-Provence, France
| | - Sylvie Freudiger
- AVASAD, Association Vaudoise d’Aide et de Soins à Domicile Route de Chavannes, Lausanne, Lausanne, Switzerland
| | - Krzysztof Skuza
- HESAV, School of Health Sciences, HES-SO University of Applied Sciences Western Switzerland, Switzerland
| | - Charlene Tripalo
- Service de Psychiatrie Générale, Psychiatry Department, CHUV, Lausanne, Switzerland
| | - Nicolas Franck
- Pôle Centre Rive Gauche et Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive, Centre Hospitalier Le Vinatier, UMR 5229, CNRS, Université Claude Bernard Lyon 1, Lyon, France
| | - Marie-Clotilde Lebas
- Département des Sciences de la Santé Publique et de la Motricité, Haute Ecole de la Province de Namur, Namur, Belgium
| | | | - Hélène Wilquin
- Aix Marseille Université, LPCPP, Aix-en-Provence, France
| | - Philippe Golay
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Shyhrete Rexhaj
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
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13
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Sookaromdee P, Wiwanitkit V. Care for dementia patients and caregivers and COVID-19 pandemic: Correspondence. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2022; 3:100138. [PMID: 35313601 PMCID: PMC8925088 DOI: 10.1016/j.cccb.2022.100138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/11/2022] [Accepted: 03/12/2022] [Indexed: 11/25/2022]
Abstract
•Correspondence on published article in the journal
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Affiliation(s)
| | - Viroj Wiwanitkit
- Dr DY Patil University, Pune, India
- Joseph Ayobabalola University, Ikeji-Arakeji, Nigeria
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14
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Nicoletti A, Todaro V, Cicero CE, Giuliano L, Zappia M, Cosmi F, Vilte E, Bartoloni A, Crespo Gómez EB. The impact of COVID-19 pandemic on frail health systems of low- and middle-income countries: The case of epilepsy in the rural areas of the Bolivian Chaco. Epilepsy Behav 2021; 118:107917. [PMID: 33735816 PMCID: PMC9760068 DOI: 10.1016/j.yebeh.2021.107917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The Coronavirus disease 2019 (COVID-19) has put some health systems under pressure, especially in low- and middle-income countries. We aimed at evaluating the impact of COVID-19 emergency on the management of people with epilepsy (PWE) living in the rural communities of the Gran Chaco area of the Plurinational State of Bolivia. MATERIALS AND METHODS We selected a sample of PWE living in the rural communities of the Bolivian Chaco. A standardized questionnaire was developed, consisting of six questions addressing drug availability, drug discontinuation, personnel responsible for drug retrieval during the lockdown, and the presence of seizures in the two months preceding the interview. Questionnaires were administered by community health workers of the rural health centers in September 2020. RESULTS Seventy PWE (38 men, 54.3%; mean age 26.9 ± 16.7) were interviewed. During the lockdown the large majority of them (n = 51, 73.9%) reported an irregular medication intake mainly due to the lack of antiseizure medications in the local health posts, leading to an increase in seizure frequency. CONCLUSION The COVID-19 pandemic has unmasked the frailty of the Bolivian health system, especially for the management of chronic diseases such as epilepsy in the rural communities.
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Affiliation(s)
- Alessandra Nicoletti
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Neuroscience Section, University of Catania, Catania, Italy.
| | - Valeria Todaro
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Neuroscience Section, University of Catania, Catania, Italy
| | - Calogero Edoardo Cicero
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Neuroscience Section, University of Catania, Catania, Italy
| | - Loretta Giuliano
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Neuroscience Section, University of Catania, Catania, Italy
| | - Mario Zappia
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Neuroscience Section, University of Catania, Catania, Italy
| | | | - Estela Vilte
- Center of Anthropological Researches of the Teko Guaraní, Gutierrez, Bolivia
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, Infectious and Tropical Diseases Unit, University of Florence, Florence, Italy
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15
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Koh MY, Lim KS, Fong SL, Khor SB, Tan CT. Impact of COVID-19 on quality of life in people with epilepsy, and a multinational comparison of clinical and psychological impacts. Epilepsy Behav 2021; 117:107849. [PMID: 33631434 PMCID: PMC8021335 DOI: 10.1016/j.yebeh.2021.107849] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to determine the relationship among the clinical, logistic, and psychological impacts of COVID-19 on people with epilepsy (PWE), and the impact of COVID-19 on the quality of life. METHOD This is a cross-sectional anonymized web-based study on PWE, using an online questionnaire to assess the clinical, logistic, and psychological impacts of COVID-19, including Hospital Anxiety Depression Scale (HADS) and Quality of Life in Epilepsy Inventory (QOLIE-31). RESULT 461 patients were recruited, with a mean age of 39.21 ± 15.88 years, majority female (50.1%), with focal epilepsy (54.0%), and experienced seizures at least once yearly (62.5%). There were 13.0% experienced seizure worsening during COVID-19 period, which were associated with baseline seizures frequency ≥ 1 per month (32.0% vs. 6.2%, p < 0.001), worries of seizure worsening (18.0% vs. 10.9%, p < 0.001), difficulty to go emergency unit (24.4% vs. 10.4%, p < 0.001), AEDs ran out of stock (23.2% vs. 11.6%, p < 0.05), self-adjustment of AED dosages (26.4% vs. 11.3%, p < 0.001), inadequate sleep (22.4% vs. 9.2%, p < 0.001), and stress (23.4% vs.10.1%, p < 0.01). Participants experiencing seizure worsening reported greater anxiety (8.10 ± 5.011 vs. 4.84 ± 3.989, p < 0.001) and depression (6.05 ± 3.868 vs. 3.86 ± 3.589, p < 0.001). Logistic regression showed baseline seizures frequency >1 per month (OR, 14.10) followed by anxiety (OR, 3.90), inadequate sleep (OR, 0.37), and treated in UMMC (OR, 0.31) as the predictors for seizure worsening during COVID-19 period. Poorer total QOLIE-31 score was noted in those with seizure worsening (48.01 ± 13.040 vs. 62.15 ± 15.222, p < 0.001). Stepwise regression highlighted depression as the main negative predictor for quality of life (β = -0.372, p < 0.001), followed by anxiety (β = -0.345, p < 0.001). CONCLUSION A significant number of PWE experienced seizure worsening during COVID-19 period, which was related to the clinical, logistic, and psychological factors. Quality of life was affected by the seizure worsening and the psychological stress.
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Affiliation(s)
| | - Kheng-Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Zhen J, Stefanolo JP, Temprano MDLP, Seiler CL, Caminero A, de-Madaria E, Huguet MM, Santiago V, Niveloni SI, Smecuol EG, Dominguez LU, Trucco E, Lopez V, Olano C, Mansueto P, Carroccio A, Green PH, Duerksen D, Day AS, Tye-Din JA, Bai JC, Ciacci C, Verdú EF, Lebwohl B, Pinto-Sanchez MI. Risk perception and knowledge of COVID-19 in patients with celiac disease. World J Gastroenterol 2021; 27:1213-1225. [PMID: 33828395 PMCID: PMC8006100 DOI: 10.3748/wjg.v27.i12.1213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/07/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We recently demonstrated that the odds of contracting coronavirus disease 2019 (COVID-19) in patients with celiac disease (CeD) is similar to that of the general population. However, how patients with CeD perceive their COVID-19 risk may differ from their actual risk. AIM To investigate risk perceptions of contracting COVID-19 in patients with CeD and determine the factors that may influence their perception. METHODS We distributed a survey throughout 10 countries between March and June 2020 and collected data on demographics, diet, COVID-19 testing, and risk perceptions of COVID-19 in patients with CeD. Participants were recruited through various celiac associations, clinic visits, and social media. Risk perception was assessed by asking individuals whether they believe patients with CeD are at an increased risk of contracting COVID-19 when compared to the general population. Logistic regression was used to determine the influencing factors associated with COVID-19 risk perception, such as age, sex, adherence to a gluten-free diet (GFD), and comorbidities such as cardiac conditions, respiratory conditions, and diabetes. Data was presented as adjusted odds ratios (aORs). RESULTS A total of 10737 participants with CeD completed the survey. From them, 6019 (56.1%) patients with CeD perceived they were at a higher risk or were unsure if they were at a higher risk of contracting COVID-19 compared to the non-CeD population. A greater proportion of patients with CeD perceived an increased risk of contracting COVID-19 when compared to infections in general due to their CeD (56.1% vs 26.7%, P < 0.0001). Consequently, 34.8% reported taking extra COVID-19 precautions as a result of their CeD. Members of celiac associations were less likely to perceive an increased risk of COVID-19 when compared to non-members (49.5% vs 57.4%, P < 0.0001). Older age (aOR: 0.99; 95%CI: 0.99 to 0.99, P < 0.001), male sex (aOR: 0.84; 95%CI: 0.76 to 0.93, P = 0.001), and strict adherence to a GFD (aOR: 0.89; 95%CI: 0.82 to 0.96, P = 0.007) were associated with a lower perception of COVID-19 risk and the presence of comorbidities was associated with a higher perception of COVID-19 risk (aOR: 1.38; 95%CI: 1.22 to 1.54, P < 0.001). CONCLUSION Overall, high levels of risk perceptions, such as those found in patients with CeD, may increase an individual's pandemic-related stress and contribute to negative mental health consequences. Therefore, it is encouraged that public health officials maintain consistent communication with the public and healthcare providers with the celiac community. Future studies specifically evaluating mental health in CeD could help determine the consequences of increased risk perceptions in this population.
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Affiliation(s)
- Jamie Zhen
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University Medical Center, Hamilton Health Sciences, Hamilton L8S4K1, ON, Canada
| | - Juan Pablo Stefanolo
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - María de la Paz Temprano
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Caroline L Seiler
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University Medical Center, Hamilton Health Sciences, Hamilton L8S4K1, ON, Canada
| | - Alberto Caminero
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University Medical Center, Hamilton Health Sciences, Hamilton L8S4K1, ON, Canada
| | - Enrique de-Madaria
- Department of Pancreatic Unit, Hospital General Universitario de Alicante, Alicante 03010, Spain
| | - Miguel Montoro Huguet
- Department of Medicine, Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza 50009, Spain
- Department of Medicine, Hospital Universitario San Jorge. Huesca, Zaragoza 50004, Spain
| | - Vivas Santiago
- Department of Gastroenterology, Univ Hosp Leon, Gastroenterol Unit, Altos de Nava S-N, Leon 24071, Spain
| | - Sonia Isabel Niveloni
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Edgardo Gustavo Smecuol
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Luis Uzcanga Dominguez
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico DF 14080, Mexico
| | - Elena Trucco
- Department of Medicine, Universidad de la Republic, Montevideo 11800, Uruguay
| | - Virginia Lopez
- Department of Medicine, Universidad de la Republic, Montevideo 11800, Uruguay
| | - Carolina Olano
- Department of Medicine, Universidad de la Republic, Montevideo 11800, Uruguay
| | - Pasquale Mansueto
- Department of Internal Medicine, PROMISE Department, University of Palermo, Palermo 90127, Italy
| | - Antonio Carroccio
- Department of Internal Medicine, V. Cervello Hospital, PROMISE Department, University of Palermo, Palermo 90127, Italy
| | - Peter H Green
- Celiac Disease Center, Columbia University Medical Center, Columbia Univ, Celiac Dis Ctr, Div Digest and Liver Dis, New York, NY 10032, United States
| | - Donald Duerksen
- Department of Medicine, St Boniface Gen Hosp, University of Manitoba, Winnipeg R2H 2A6, Canada
| | - Andrew S Day
- Department of Paediatrics, University of Otago Christchurch, Christchurch 8041, New Zealand
| | - Jason A Tye-Din
- Department of Gastroenterology, Royal Melbourne Hospital, Immunology Division, Walter and Eliza Hall Institute, Melbourne 3052, Australia
| | - Julio César Bai
- Department of Medicine, Dr. C. Bonorino Udaondo Gastroenterology Hospital, Buenos Aires 1264, Argentina
| | - Carolina Ciacci
- Department of Medicine, Surgery and Dentry, Scuola Medica Salernitana, University of Salerno, Celiac Center at the University Hospital San Giovanni di Dio e Ruggi di Aragona, Salerno 84131, Italy
| | - Elena F Verdú
- Department of Medicine, Farncombe Family Digestive Research Institute, McMaster University, Hamilton L8S4K1, ON, Canada
| | - Benjamin Lebwohl
- The Celiac Disease Center, Columbia University, New York, NY 10032, United States
| | - M Ines Pinto-Sanchez
- Department of Medicine, Farncombe Family Digestive Research Institute, McMaster University, Hamilton L8S4K1, ON, Canada
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Wanigasinghe J, Jayawickrama A, Hewawitharana G, Munasinghe J, Weeraratne CT, Ratnayake P, Wijesekara DS, Fernando S, Rupasinghe P. Experience during COVID-19 lockdown and self-managing strategies among caregivers of children with epilepsy: A study from low middle income country. Seizure 2020; 84:112-115. [PMID: 33321430 DOI: 10.1016/j.seizure.2020.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Abrupt halt of service provision due to pandemic state of COVID-19, significantly affected care of patients with chronic diseases like epilepsy; its impact being greater on caregivers of vulnerable groups such as children with epilepsy. We performed this study to describe difficulties posed by the lockdown to caregivers of children with epilepsy in a low-middle income country and describe their responses and self-management strategies to overcome difficulties and prepare for a recurrence. METHOD A cross-sectional all-island survey was carried out at paediatric neurology centers in Sri Lanka. Data was gathered via a face-to-face interview after the lockdown period. Parental stress level was evaluated using a self-rating Stress Assessment Questionnaire. RESULTS Caregivers of 140 children with epilepsy from seven centers served by paediatric neurologists were interviewed. Mean duration of epilepsy was 7.9 years(SD 4). Majority were on one (52.1 %) or two (20 %) anti-seizure medications regularly. The pandemic did not affect epilepsy control in majority (87.3 %), however, signficant proportion faced difficulties over regular reviews and presecription refills. Despite difficluties, 87.1 % of parents maintained dispensing anti-seizure medications to their child regularly. Caregivers demonstrated healthy self-management strategies such as awareness on medications and access methods to healthcare during lockdown and remained confident of accessability to services. Stress was experienced in < 5%. CONCLUSION Lockdown status for COVID-19 did not significantly affect the control of epilepsy in children though it posed difficulties for regular reviews and obtaining medications. Self-management strategies will help caregivers to adopt to new-normal status and potential future outbreaks.
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Affiliation(s)
| | - Ashan Jayawickrama
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Sri Lanka
| | | | - Jagath Munasinghe
- Sirimavo Bandaranayaike Specialized Children's Hospital, Peradeniya, Sri Lanka
| | | | | | - Dimuthu S Wijesekara
- Department of Paediatrics, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka
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