Transcript Stages of epileptology treatment

Antiepilepsy Service in Kazakhstan and Role of
"SVSNevro" Public Union – Movement of Physicians
and Patients Against Epilepsy.
• Savinov Sergey Viktorovich – Chairman of the Board of
"SVSNevro" Public Union (Movement of Physicians and
Patients Against Epilepsy www.svsnevro.kz), Director of V.M.
Savinov SVS Laboratory for Epilepsy, Seizure Disorders and
Family Monitoring (www.svs.kz), Director of the Project
"Postgraduate Education Division for Neurophysiology and
Epileptology" (www.eeg.kz), Member of Kazakhstan
Association of Children's Neurologists, Member of the Board
of Kazakhstan Association of Neurophysiologists and
Epileptologists (www.nsi.kz), Chief Editor of Kazakhstan
Medical Internet Portal "SVS Medical" (www.svsmedical.kz).
1
Eight years ago, before the V.M. Savinov SVS Clinics
was established, epileptology practically has not been
developed in the country
• Over recent years Kazakhstan has made great
advances in controlling epilepsy.
As is known, 0.5 to 2% of the populations suffer
under this disease in various countries. So, if to take
average statistics, in our country there are at least
160,000 patients with epilepsy.
•
• Although, according to the Ministry of Public Health
of Kazakhstan this figure is much lower, just 31,000!
2
Epileptology in Kazakhstan
• As of today, thanks to methodical efforts of many
structures, including SVSNevro" Public Union,
V.M. Savinov SVS Laboratory for Epilepsy and
Seizure Disorders, Departments of Children's and
Adult Neurology under Almaty State Medical
Refresher Institute, Neurology Departments of
Medical Universities and Institutes of the
Republic of Kazakhstan, Kazakhstan Association of
Neurophysiologists and Epileptologists as well as
Kazakhstan Neurosurgeons Association have
practically completed the structuring of the
antiepileptic service in compliance with the ILAE
requirements.
•
3
Stage-by-stage approach to treat
patients with epilepsy
• It means that there is the stage-bystage approach comprising of four
basic stages.
•
• Also, Public Unions and Associations
supporting both patients and
physicians
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Stage 1
Primary general medical selection
Stage 2
Special neurology-related
selection and examination
protocol preparation
Stage 3
Special epileptologyrelated treatment
Dedicated imaging rooms
and centers provided with
diagnostic equipment
Stage 4
Special preand surgical epileptologyrelated treatment
5
Stages of epileptology treatment
• First stage involves a primary identification of a
disease to be performed by district neurologists who
have undertaken refresher courses organized by
Departments of Children's and Adult Neurology and
pediatricians, therapists, ambulance physicians and
other medical officers.
•
• At first stage, patients suspected of paroxysmal
states and epilepsy are identified. Persons identified
so pass to second stage.
6
Stages of epileptology treatment
• Second stage is represented by special assistance provided by
both national and private institutions.
•
• The objective at this stage is to complete a patient's
examination protocol, to checkup using the high-tech devices,
to make a primary diagnosis and to put on treatment. All
major towns and regional centers have departments of
children's neurology provided with bed spaces for patients
with seizures and epilepsy, which make up on average up to
10% of the total neurology profile capacity.
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Second stage of epileptology
treatment
• Besides, the Republican Aksai Clinic exists to
treat sufferers coming from all regions of the
Republic. The video EEG-monitoring system is
slated for 2012 to be installed there.
• All in-patient hospitals, beds are equipped
with EEG devices to carry out routine
electroencephalography.
8
Equipment Status
• The video EEG-monitoring
stations operate in the
psychoneurology ward at the
Mother and Child Center in
Astana, in children's municipal
hospital № 2 in Almaty and the
Kostanai railway hospital.
9
Equipment Status
• Also, the video EEG-monitoring facilities have
already been installed in clinics and policlinics of
Almaty, Astana, Karaganda, Taldykurgan, Talgar,
Kaskelen, Petropavlovsk, Issyk, Kapchagai and other
places, where some stations function without any
allocated hospital stock. During next year the same
systems will be mounted in Aktau, Aktobe, Taraz
and Pavlodar. Almost all these cities are provided
with MRT machines, and Astana has the Positron
Emission Apparatus as well.
10
Stage Three. Specialized Medical Care
• Stage Three is a specialized expert epileptology-related
care. The objective of this stage is to specify diagnoses
made at first two stages, differential diagnostics of
difficult and disputable cases, concrete types of
examinations (transport, stress and the like). Moreover,
objectives of stage-three clinics include the
determination of pharmacoresistent cases and
preparation of patients for a fourth, surgical stage. I.e.
Stage Three is in-deep specialized care to be provided
by highly-proficient personnel represented by
epileptologists, while using sophisticated devices.
•
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Community of private and state-run
epileptology structures
• For instance, in Almaty (V.M. Savinov SVS
Clinic), Karaganda (Hippocrates Clinic),
Shymkent (Sunkar Clinic), Astana and
Kokshetau (Clinic headed by Doctor Elubayeva
A.M.) function complete-profile private
epileptology centers fitted with video EEG
monitors, continuous Holter monitoring unit,
MRT and KT equipment, and devices to define
a concentration of drugs in blood.
12
Stage Three
• In Astana, at the Mother and Child Center also
equipped with the video EEG monitor, Dsc Mrs.
Dzhaksybayeva A.H. has started treating
children with epileptic encephalopathy.
•
• Besides, in a number of cities separate video
EEG monitoring offices exist: in Almaty - 3,
Petropavlovsk - 1, Astana - 1. In 2012, 5 private
EEG monitoring offices are scheduled to be
installed in various cities.
13
Therapeutic Epileptology
Development
• Construction and equipping of two
epileptology departments started in Almaty.
As a sample we introduce a clinic, which has
become a founder of the systematic and
scientific approach to epileptology in
Kazakhstan. To-date, nearly all day-and-night
clinics and centers apply the SVS Clinic
experience.
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V.M. Savinov SVS Laboratory of
Epilepsy and Seizure Disorders
(Almaty, Tulebayev Street, 38,
www.svs.kz).
• The SVS Laboratory performed 21,000
video EEG monitoring sessions over April
2004 to April 2012! As well as Holter EEG and
stress EEG monitoring.
•
• Main units and procurement.
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Video - EEG and Holter EEG Monitoring Department.
• Goals and Objectives:
•
• To specify diagnoses made at Stage
Two,
• Diagnostics of problematic patients,
• To ascertain "Pharmacoresistent
Epilepsy" diagnosis,
• To correct treatment of patients after
Stage Two,
• To warrant treatment and to develop
protocols
• To manage patients from Stage Four.
16
Video - EEG and Holter EEG Monitoring Department of SVS
Clinic
• Expert examination as to look into the
opportunity to cancel treatment.
• Continuous, up to one month, EEG
monitoring; preparation of patients for
surgery treatment.
• Equipment: Four wards with video EEG
monitoring and polysomnography.
• Two wards of ambulance – Holter EEG
monitoring c/w video control.
• Examinations are carried out by
physicians majoring in neurology,
epileptology and neurophysiology only.
17
Stress EEG – ECG Monitoring Department.
• Areas:
• Stress loads for differential
diagnostics of syncopal states and
epilepsy paroxysms.
• Transport and situation EEG expertise.
• Identification of tolerance to loads
and sensibility to the concentration of
antiepileptic drugs in blood during
stresses and loads.
• Performance of loading tests to
identify latent epileptic activity before
canceling anticonvulsant therapy.
18
Stress EEG – ECG Monitoring
Departmen.
• Equipment: Bicycle ergometry
apparatuses in combination
with video EEG monitoring
and ambulance – Holter EEG
monitoring devices.
•
• Loading tests are performed
by two teams: one of
neurology epileptologists,
second of cardiologist and
therapists.
19
Drug Monitoring
• In the course 7 years of the work the laboratory
involved in determination of a drug (concentration)
level in blood has carried out over 40,000 studies!
20 articles have been written, and 1 dissertation has
•
•
•
•
•
been defended.
Laboratory determines:
Level of anticonvulsant drugs
Level of cardiac glycoside
Level of psychotropic drugs and anti-depressants
In addition, the laboratory runs general clinic and
immunology tests
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Department of Coma Monitoring and
Brain Death Identification
• Department of coma monitoring and brain terminal
condition identification
•
• From 2008 onwards, the SVS Laboratory is engaged
in neurophysiology monitoring of patients in
terminal conditions and comas.
• In 2011, after Kazakhstan has ratified the
Transplantlogy Law, the SVS Laboratory joined the
Republican Brain Death Expert Commission working
at the Syzganov Surgery Institute.
21
Follow-Up Study Department for children
afflicted by CNS in neonatal period
• As epilepsy early identification is a prerequisite
to rehabilitate patients with epilepsy, in 2009 a
follow-up study department for children
afflicted by CNS in neonatal period was set up.
•
• Along with the SVS Laboratory, this department
comprises of Pediatry Institute (Almaty) and
Almaty Municipal Perinatal Center.
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Follow-Up Study Department for Children Afflicted by
CNS in Neonatal Period
• The department carries out neuro-physiology and
neuro-visualization examinations of children
afflicted by CNS in a neonatal period, and when
paroxysmal states or EEG changes are identified it
differentiates them and patronage further.
•
• This department pursues the differentiated
approach to patients during treatment, while not
applying drugs and methods contraindicated in
convulsions and epilepsy.
23
Follow-Up Study Department for Children Afflicted by
CNS in Neonatal Period
• The department is
headed by Akchurina
Yana Evgenyevna,
leading specialist of SVS
Laboratory (picture
above: with Ponyatishenyi
A.E., Assistant Professor
from St. Petersburg)
•
• And curated by
Degtyareva M.G., Doctor
of Medical Sciences,
Professor of Neonatology
Chair under Russia State
Medical University
(Russia, Moscow) (picture
below)
24
Appreciation by Professor Zenkov L.R.
•
In its anniversary year of 2009 the SVS
Laboratory invited Mr. Zenkov Leonid
Rostislavovich, who is one of epileptology
and neurophysiology patriarchs in the CIS
and Europe, to assess activity of the
personnel and the laboratory as a whole.
Mr. Zenkov L.P. during his stay with our clinic
left two records. First one in his book reads
"To Dear Sergey Viktorovich, the winning
follower from the conquered tutor with
deepest respect from the author! 25.05.09",
and second in the official expert review log
is "To highly-regarded Savinov Sergey
Viktorovich and all his fellows with grateful
acknowledgment of making my dream – one
of best clinical neurophysiology and
epileptology laboratories - come true. My
admirations touched with envy and
congratulations. 25.05.09. Zenkov L.P."
We Cherish the Memory of the
Master and Great Scientist!
• We regret to say
that on 26
February 2012
the great
scientist and
doer Zenkov
Leonid
Rostislavovich
passed away.
But his
comments will
always call us for
new victories!
26
Stage Four. Surgical Epileptology
• On account of works of
Akshulakov Serik
Kuandykovich, the
outstanding surgeon and
organizer, since 2008
surgical epileptology
develops rapidly in
Kazakhstan. The state-ofthe-art Neurosurgery
Institute in Astana opened a
surgical epileptology
department, the fourth
stage to treat epilepsy!
27
Stage Four. Surgical Epileptology
• Over the past period the Neurosurgery Institute has
purchased equipment to perform continuous EEG monitoring
with both scalp electrodes and intracranial application of
electrodes to bare brain.
• Staff of the surgical epileptology and neurophysiology
department was trained at clinics of Russia, Germany, the USA
and Israel. Prominent neurosurgery epileptologists from
Russia, Germany and Israel held international master classes
for them.
•
• and
10 operations to remove the epileptic
focus were success.
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"SVS Nevro" Public Union – Movement of
Physicians and Patients Against Epilepsy.
www.svsnevro.kz
• As there is a need to register and unify patients,
and to disseminate authentic information on
epilepsy diagnostics and treatment, we created
an organization uniting patients and physicians,
which is the "SVS Nevro" Public Union. Today, it
numbers over 7 thousand members who are
patients and physicians. The Public Union has its
representations practically in each town of
Kazakhstan.
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Structure of "SVSNevro" Public Union
BOARD
Fraction of Medical Kazakhstan
Officers
Association of
www.svsnevro.kz
Neurophysiology
Epileptologists
www.nsi.kz
Fraction of Patients
www.svsnevro.kz
V.M. Savinov SVS
Laboratory for Epilepsy
and Seizure Disorders
www.svs.kz
Technical Support
Service
Hi – Tech Global
www.hitech.kz
Information Service of
Kazakhstan Medical Portal
"SVS Medical"
Postgraduate Education
Division for
Neurophysiology and
Epileptology
www.eeg.kz
Clinics and unions in
Epileptology School
Shymkent, Karaganda, for of Patients and
Astana, Bishkek, Aktau,
Their Relatives
Kostanai, etc.
www. svsmedical.kz
Kazakhstan Association of Neurophysiology
Epileptologists
• Due to tremendous upgrowth of neurophysiology
and epileptology under management by SVSNevro
Public Union, Kazakhstan Association of
Neurophysiology Epileptologists was formed. The
goal of this organization is to prevent chaotic and
non-professional development of neurophysiology
and epileptology in Kazakhstan. The Association
comprehensively integrates with international
associations of neurophysiologists and
epileptologists.
31
Expert Board of Kazakhstan Association of
Neurophysiology Epileptologists
• The Expert Board has become one of
structures of the Association from the
moment of its creation. The Board members
are both local specialists and known foreign
professors and assistant professors.
•
• When any disputable moments arise we go to
the Board to seek advices to resolve
situations.
32
Expert Board of Kazakhstan Association of
Neurophysiology Epileptologists
• This year the Expert Board was joined by leading
psychiatrists, professors from Almaty State Medical
Refresher Institute, Asfendiyarov University, Astana
Medical Institution and key specialists from all
regions. The Expert Board is headed by Elubayeva
Altynai Mukashevna, chief freelance epileptologist of
Kazakhstan.
•
• The Association has its own web-site www.nsi.kz,
which we use to communicate and coordinate our
activities throughout the country and abroad.
33
Extended Councils
• One of innovative
methodologies applied to treat
patients and retrain physicians
are extended councils
introduced in 2009 to support
the work of the Public Union.
•
• The extended republican council
is held once a month via Internet
tele-bridges and covers cities
and towns of Kazakhstan.
Councils are designed to
consider complex and disputable
cases that are used by the Expert
Board for its day-to-day activity.
34
Tele-Medicine International Consultations
.
• Besides, once a month we
conduct Global Online TeleMedicine Internet
Consultations with top
neurologists. During such
consultations also our
members who stay in other
cities and even nations join
them, and thus sometimes
the consultations overflow
into master-classes and
mini-seminars.
35
Online Consultation with Professor Mukhin K.Y.
(Moscow)
• Owing to such
consultations, patients
residing in Kazakhstan
may get consulted by
foreign specialists, and
findings of their
examinations are
completely analyzed by
them online.
36
Succession of Third and Forth Stages
• Mechanisms of extended councils and telebridges are used to select patients to the
forth, surgical stage of epilepsy treatment as
well as when patients pass from the forth
stage to the therapeutic follow-up care. In
doing so, the therapy succession is
maintained, and patients may freely travel
across the country, but within of eyeshot of
their doctors in charge or physicians who
attend them in any settlement of Kazakhstan.
37
Postgraduate Education Division
www.eeg.kz
• Three years ago we founded
Postgraduate Education Division for
Neurophysiology and Epileptology that
every year arranges for video EEG,
EMG/IP monitoring and epileptology
courses. Some cycles go with the
participation of leading specialists from
Russia, Germany, Italy, Israel and other
states.
38
Medical Internet Portal "SVS Medical"
(www.svsmedical.kz).
• The structure of this
Internet portal includes
tens of web-sites
covering activity of
neurology departments,
epileptology events,
web-sites of patients
suffering seizure
disorders and web-sites
for EEG and
neurophysiology
specialists.
39
Медицинский Интернет Портал SVS
Medical (www.svsmedical.kz )
• On the basis of the said above,
the epilepsy identification rates
and correct diagnostics have
improved several times. So,
according to these facts we can
say that Kazakhstan ranks
among nations with improved
antiepileptic care to
communities within the CIS
territory.
However, alongside with
achievements concerns exist as
well.
40
Epileptology Develops
• On the basis of the said above, the epilepsy
identification rates and correct diagnostics
have improved several times. So, according to
these facts we can say that Kazakhstan ranks
among nations with improved antiepileptic
care to communities within the CIS territory.
However, alongside with achievements
concerns exist as well.
41
Negative Moments in Epileptology
• The foremost is that anyone who feels like it takes on
to treat epilepsy! It was not until 29 December 2011
that our country introduced a position of a non-staff
chief epileptologist! And almost all epileptologists of
our Union undertook advance training abroad. But,
doors of many offices in Kazakhstan bear a plate
"epileptologist"! Very often so-called epileptologists
have not even taken neurology training!
The same situation is with EEG and EMG specialists
as well.
42
Negative Moments in Epileptology
• Examinations are carried out not by neurology
neurophysiologists, but by functional
diagnostics physicians. Uncertainties and
numerous reforms in postgraduate education
resulted in that adult neurologists treat
children with epilepsy.
The lack of a single coordination regulatory
authority renders therapy isolated and
disconnected.
43
Late identification is a consequence of low
qualification of neurophysiologists
• According to our data, that is why merely 1,200
patients with epilepsy out of 6,400 were
identified during the first year!
•
• Where 5,100 patients were prescribed and
passed routine EEG! And after it neither has
shown signs nor a low-qualified functionalist has
identified "distention of cortical sulci" a
neurologist diagnosticates a hypertension
syndrome.
44
Causes of poor epilepsy identification
• But it has long been known that usual routine EEG is
informative only in 10% of cases! That is what on this
subject told one of recognized doctors:
•
• Routine intercritical electroencephalography is one
of the most frequently misused methods of
researches in clinical medicine, and undoubtedly is
responsible for huge human sufferings (D. Chadwick)
• (cited by Zenkov L.P. in his monograph "Clinical
Epileptology", Issue 2, 2010)
45
Free Provision With Medications
• The Policy of the Government of Kazakhstan, the
Public Union, municipal and regional health care
departments provide that 80 % of medications for
epilepsy treatment are on the free register.
•
• But, because local hospitals practically do not
maintain statistics, and patients not always are
assisted by a district physician, annually hundreds of
patients do not get this help! And the Government is
unaware of a true number of persons in need of
drugs.
46
Try not to shift from one medicine to
another without clear justification!
• The drug market has no idea about the
availability of all medicines on the free provision
list. As a result, a patient is sometimes shifted
from one drug to another, which gives rise to
aggravated seizures. Very often the transition
from one drug to another even from the same
pharmaceutical line leads to deterioration of a
state.
47
Patient is not adapted socially
• Another thing that is contrary to our patients is the
lack of a legislative background to define rights of
patients, and as a consequence, no social adaptation
of patients with epilepsy is ensured. There are no
special temporary stay centers, dedicated
kindergartens and schools. Patients with convulsions
are not taken to usual institutions! There are cases
when seizures are arrested, the disability
commissions reduces a level of disability or rejects it
at all.
48
We can overcome everything when
together !
• These main and many other factors prevent
faster and efficient development of
epileptology in Kazakhstan.
•
• Nevertheless I am confident that we together
can solve these concerns! Because we live in a
great country, and common accord is a
mainstay of our society!
49
Representatives of our team with Professor
Karlov V.A.
• Let me remind once
again that all
achievements I listed
have been attained in
the course of the last 8
years! And its bigger
part is a merit of the
V.M. Savinov SVS
Epilepsy Laboratory and
"SVS Nevro"Public
Union - Movement of
Physicians and Patients
Against Epilepsy.
50
One Soldier Does Not Make A
Battle
• Dear Fellows!
• Thank you for your attention.
• I wish to recite a poem of the proletarian poet
Mayakovskiy
51
We can overcome everything when
together !
•
•
•
•
•
•
It is bad to be alone
One cannot conquer alone
He who is powerful is a master to him
And even the weak, if they are two!
The today's congress already proves
that we are not alone!
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