Melissa A. Elafros

Early recurrence of atrial arrhythmias following pulmonary vein antral isolation: Timing and frequency of early recurrences predicts long-term ablation success

BACKGROUND Early recurrence of atrial arrhythmia (ERAA) is common after atrial fibrillation (AF) ablation and is associated with long-term recurrence. However, the association between timing or frequency of ERAA and long-term ablation success remains unclear. OBJECTIVE We aimed to examine whether timing or frequency of ERAA after pulmonary vein antral isolation (PVAI) affects long-term ablation success. METHODS Three hundred AF patients (100 paroxysmal, 100 persistent, 100 long-standing persistent; mean age 59.5 ± 9.6 years, 79% male) undergoing PVAI were included. All patients underwent 30-day monitoring with mobile continuous outpatient telemetry after PVAI and were followed for >1 year. ERAA was defined as AF or organized atrial tachycardia (OAT) in the first 6 weeks, and was categorized as early (weeks 1-2), intermediate (weeks 3-4), or late (weeks 5-6). Long-term ablation success was defined as the absence of AF/OAT lasting >30 seconds off antiarrhythmic drugs 1 year after a single ablation (excluding first 6 weeks). RESULTS ERAA occurred in 169 patients (53%); of those, 79 (46.7%) had single ERAA and 90 (53.3%) had multiple ERAAs. ERAA occurred less commonly with paroxysmal versus persistent or long-standing persistent AF (46% vs 57% and 66%; P = .017). ERAA was associated with worse ablation success at 1 year (38.1% vs 79.5% [no ERAA]; P < .001). Multiple (vs single) ERAA more strongly predicted long-term ablation failure (OR: 4.5; 95% CI [2.3-8.8]). CONCLUSIONS ERAA after PVAI is associated with decreased long-term ablation success. Patients experiencing multiple ERAA events are at greatest risk for long-term arrhythmia recurrence and represent a subgroup in whom early reablation may be considered.

Peer support groups as an intervention to decrease epilepsy-associated stigma.

Eighty percent of people with epilepsy (PWE) reside in low-income countries where stigma contributes substantially to social and medical morbidity. Peer support groups (PSGs) are thought to be beneficial for people with stigmatized conditions, but little data exist regarding PSG effectiveness. We facilitated monthly PSG meetings for men, women, and youth from three Zambian clinics for one year. Pre- and post-intervention assessments measured internalized stigma, psychiatric morbidity, medication adherence, socioeconomic status, and community disclosure. Of 103 participants (39 men, 30 women, and 34 youth), 80 PWE (78%) attended ≥ 6 meetings. There were no significant demographic differences between PWE who attended ≥ 6 meetings and those who attended <6 meetings. Among youth attending ≥ 6 meetings, internalized stigma decreased (p<0.02). Among adults, there was a non-significant stigma decrease. No differences were detected in medication use, medication adherence, or psychiatric morbidity. Peer support groups effectively reduce stigma for youth and may offer a low-cost approach to addressing epilepsy-associated stigma in resource-poor settings.

Stigma and psychiatric morbidity among mothers of children with epilepsy in Zambia

BACKGROUND Epilepsy-associated stigma contributes substantially to the social, medical, and economic burden of disease for people with epilepsy (PWE), but little is known about its impact on caregivers of PWE. METHODS To better understand stigma experienced by caregivers of PWE, factors that influence caregiver stigma, and the effect of stigma on a caregivers psychologic well being, we interviewed 100 caregivers of children with epilepsy in Zambia. Questions assessed maternal knowledge, attitudes, and practices related to epilepsy, maternal stigma, mothers proxy report of child stigma, and maternal psychiatric morbidity. RESULTS Of 100 mothers, 39 (39%) indicated that their child was stigmatized because of his or her epilepsy. Maternal proxy report of child stigma was highly correlated with maternal stigma (OR: 5.4, p=0.04), seizure frequency (p=0.03) and seizure severity (p=0.01). One in five of 100 mothers (20%) reported feeling stigmatized because of their childs epilepsy. Higher maternal stigma was associated with lower familial and community support (ORs: 65.2 and 34.7, respectively; both p<0.0001) as well as higher psychiatric morbidity (OR: 1.2; p=0.002). Formal education and epilepsy knowledge were associated with decreased maternal stigma (ORs: 0.8 and 0.7, respectively; both p<0.001). CONCLUSIONS One in five mothers of PWE feel stigmatized because of their childs epilepsy. As maternal stigma is associated with psychiatric morbidity, educating caregivers about epilepsy and screening for anxiety and depression are warranted.

Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Background—Transformation from persistent to paroxysmal atrial fibrillation (AF) after ablation suggests modification of the underlying substrate. We examined the nature of initial arrhythmia recurrence in patients with nonparoxysmal AF undergoing antral pulmonary vein isolation and nonpulmonary vein trigger ablation and correlated recurrence type with long-term ablation efficacy after the last procedure. Methods and Results—Three hundred and seventeen consecutive patients with persistent (n=200) and long-standing persistent (n=117) AF undergoing first ablation were included. AF recurrence was defined as early (⩽6 weeks) or late (>6 weeks after ablation) and paroxysmal (either spontaneous conversion or treated with cardioversion ⩽7 days) or persistent (lasting >7 days). During median follow-up of 29.8 (interquartile range: 14.8–49.9) months, 221 patients had ≥1 recurrence. Initial recurrence was paroxysmal in 169 patients (76%) and persistent in 52 patients (24%). Patients experiencing paroxysmal (versus persistent) initial recurrence were more likely to achieve long-term freedom off antiarrhythmic drugs (hazard ratio, 2.2; 95% confidence interval, 1.5–3.2; P<0.0001), freedom on/off antiarrhythmic drugs (hazard ratio, 2.5; 95% confidence interval, 1.6–3.8; P<0.0001), and arrhythmia control (hazard ratio, 5.2; 95% confidence interval, 2.9–9.2; P<0.0001) after last ablation. Conclusions—In patients with persistent and long-standing persistent AF, limited ablation targeting pulmonary veins and documented nonpulmonary vein triggers improves the maintenance of sinus rhythm and reverses disease progression. Transformation to paroxysmal AF after initial ablation may be a step toward long-term freedom from recurrent arrhythmia.

Comparison of Left Atrial Bipolar Voltage and Scar Using Multielectrode Fast Automated Mapping versus Point‐by‐Point Contact Electroanatomic Mapping in Patients With Atrial Fibrillation Undergoing Repeat Ablation

Bipolar voltage criteria to delineate left atrial (LA) scar have been derived using point‐by‐point (PBP) contact electroanatomical mapping. It remains unclear how PBP‐derived LA scar correlates with multielectrode fast automated mapping (ME‐FAM) derived scar. We aimed to correlate scar and bipolar voltages from LA maps created using PBP versus ME‐FAM.

Medication side effects among people with epilepsy taking phenobarbital in Zambia

Phenobarbital remains one of the most widely used antiepileptic drugs worldwide, yet there are limited data regarding side effects associated with its use in routine clinical care settings in low-income countries. Available data suggests that phenobarbital is as effective as other first-line drugs for treating tonic-clonic seizures, but side effect reports differ widely between high and low-income settings. A better understanding of phenobarbital side effect profile and severity in low-income settings is warranted given its role in efforts to decrease the epilepsy treatment gap. We used the Liverpool adverse events profile (LEAP) to assess side effects in consecutive patients with epilepsy on phenobarbital seeking care in rural Zambia. Data regarding age, gender, medication dose, and medication adherence were also collected. T-tests and Spearmans correlation coefficient were used to assess predictors of LEAP score and medication adherence. Thirty-five patients receiving a mean dose of 2.1mg/kg/day (SD: 2.78 mg/kg/day) of phenobarbital were assessed. All participants reported at least one side effect in the previous four weeks with a median of 6 symptoms (IQR: 4-8) and a mean side effects score of 28/76 (SD: 5.38). Over half reported sleepiness and dizziness. Memory problems and depression were also common (both 46%). Total LAEP score was not associated with age (p=0.88), gender (p=0.17), or phenobarbital dose (p=0.13). Medication adherence was not associated with side effects total score (p=0.56). Rural Zambian adults taking phenobarbital at doses recommended by the World Health Organization report a significant number of side effects. The most common side effects reported were similar to those reported in high-income countries. The significant burden of phenobarbital-associated side effects in this African cohort is in contrast to data from non-randomized clinical trials in China that reported phenobarbital to be well-tolerated with few side effects. Additional investigations regarding phenobarbital side effects during routine care in low income settings is warranted.

Reexamining epilepsy-associated stigma: validation of the Stigma Scale of Epilepsy in Zambia

AbstractPurposeEpilepsy-associated stigma is an important patient-centered outcome, yet quantification remains challenging. Jacoby’s 3-item Stigma Scale is commonly used to assess felt stigma among people with epilepsy (PWE) yet has ceiling effects. The Stigma Scale of Epilepsy (SSE) is a 24-item instrument that measures felt stigma among PWE and stigmatizing attitudes among others. If cross-culturally valid, the SSE may elucidate stigma determinants and provide an outcome measure for interventions. MethodsWe assessed the properties of the SSE in 102 Zambian PWE using exploratory and confirmatory item response theories and compared the latent traits assessed by the SSE to those assessed by Jacoby’s Stigma Scale. Differential item functioning based on forced disclosure of epilepsy was examined.ResultsThe SSE yielded two latent traits—the first reflected difficulties faced by PWE; the second reflected emotions associated with epilepsy. Jacoby’s Stigma Scale was associated only with the first latent trait. Forced disclosure was associated with “worry” and “pity” that were associated with the second latent trait.ConclusionsIn Zambian PWE, the SSE captured two latent traits. One trait represents feelings associated with epilepsy, which is theorized as a substantial yet unmeasured part of stigma. The SSE performs well across cultures and may more comprehensively assess felt stigma than other instruments. Further validation is required to determine whether the SSE adequately assesses stigmatizing attitudes among people without epilepsy.

Acute EEG findings in HIV-infected Zambian adults with new-onset seizure

Objective: To describe acute EEG findings in HIV-infected adults with new-onset seizure, assess baseline clinical characteristics associated with EEG abnormalities, and evaluate the relationship between EEG abnormalities and recurrent seizure. Methods: Eighty-one HIV-infected adults with new-onset seizure had EEG recordings during their index admission. Baseline characteristics assessed included HIV stage, seizure semiology, serum and CSF studies, neuroimaging, cognitive function based on the Zambian Mini-Mental State Examination and International HIV Dementia Scale, and psychiatric symptoms using the Shona Symptom Questionnaire. We evaluated the relationship between baseline characteristics and EEG abnormalities. Patients were followed for seizure recurrence, and the association between acute EEG abnormalities and seizure recurrence was assessed. Death was a secondary outcome. Results: Fifty-five patients had abnormal EEGs (68%): 18 (22%) had interictal spikes (12) or a recorded seizure (6). Among baseline clinical characteristics, more advanced HIV disease (p = 0.039) and any imaging abnormality (p = 0.027) were associated with abnormal EEGs. Cortical (p = 0.008) and white matter (p = 0.004) abnormalities were associated with slow posterior dominant rhythm. Patients were followed for a median of 303 days (interquartile range 103–560). Twenty-four (30%) died and 23 (28%) had recurrent seizures. EEG abnormalities were not associated with recurrent seizure. There was a nonsignificant association between seizures recorded during EEG and death (67% vs 26%, p = 0.051). Conclusions: EEG abnormalities are common in this population, particularly in patients with imaging abnormalities and advanced HIV. Acute EEG abnormalities were not associated with recurrent seizure, but high mortality rates during follow-up limited this analysis.

HIV and new onset seizures: slipping through the cracks in HIV care and treatment

The aim of the study was to describe patient characteristics and outcomes among HIV‐positive adults presenting to a Zambian tertiary care hospital with new‐onset seizures.

Neuroimaging abnormalities and seizure recurrence in a prospective cohort study of Zambians with human immunodeficiency virus and first seizure

In HIV-positive individuals with first seizure, we describe neuroimaging findings, detail clinical and demographic risk factors for imaging abnormalities, and evaluate the relationship between imaging abnormalities and seizure recurrence to determine if imaging abnormalities predict recurrent seizures. Among 43 participants (mean 37.4 years, 56% were male), 16 (37%) were on antiretroviral drugs, 32 (79%) had advanced HIV disease, and (28) 66% had multiple seizures and/or status epilepticus at enrollment. Among those with cerebrospinal fluid studies, 14/31 (44%) had opportunistic infections (OIs). During follow-up, 9 (21%) died and 15 (35%) experienced recurrent seizures. Edema was associated with OIs (odds ratio: 8.79; confidence interval: 1.03-236) and subcortical atrophy with poorer scores on the International HIV Dementia Scale) (5.2 vs. 9.3; P=0.002). Imaging abnormalities were not associated with seizure recurrence or death (P>0.05). Seizure recurrence occurred in at least a third and over 20% died during follow-up. Imaging was not predictive of recurrent seizure or death, but imaging abnormalities may offer additional diagnostic insights in terms of OI risk and cognitive impairment.