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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 5-18

Telecollaboration: Telementorship for epilepsy surgery services in resource: Challenged lower-middle-income countries environs – A model and proof of concept


1 Department of Neurosurgery; R. Madhavan Nair Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 R. Madhavan Nair Centre for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
3 Global Centre for Excellence in Neurosciences, Aster Hospital, Bengaluru, Karnataka, India
4 Epilepsy Centre, Institute of Neurology, National Hospital of Sri Lanka, Colombo, Sri Lanka
5 Department of Neurosurgery, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
6 Department of Neurosurgery, Narayana Medical College, Nellore, Andhra Pradesh, India
7 Department of Neuroimaging and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
8 Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Submission12-May-2022
Date of Decision18-May-2022
Date of Acceptance20-May-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Prof. George Chandy Vilanilam
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_105_22

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  Abstract 

Background and Aim: Although 80% of people with epilepsy live in low and lower-middle-income countries (LMIC), epilepsy surgery (ES) has reached very few of its potential beneficiaries in these nations. This imbalance could be overcome by telecollaboration ES, aided by the burgeoning digital penetration in LMIC. We aimed to propose a telecollaboration-mentorship model for resource-limited LMIC environs to initiate, sustain, and expand ES centers. We also aimed to assess the model's feasibility and provide a proof of concept. Materials and Methods: Five mentee centers (level 3 epilepsy centers) across three LMIC under the mentorship of a tertiary comprehensive epilepsy care center (level 4) were part of the telecollaboration-mentorship model. This model was used for surgical candidacy selection, intraoperative surgical support, and postoperative outcome assessment at the mentee centers, using both asynchronous and synchronous telecollaboration exchanges. Results: Nineteen patients across five centers and three LMIC underwent ES as part of the telecollaboration-mentorship program from 2018 to 2021. Sixty-eight telemedicine exchanges (average 3.5/patient), 42 asynchronous (email, text message, multimedia message), and 26 synchronous (phone call, video call, video conference) were made in the preoperative, intraoperative, and postoperative period. Worthwhile seizure outcome (Engel Class I, II) was achieved in 17 patients (89.4%) at a mean duration of follow-up of 13.5 months (standard deviation 10.9). Conclusion: The telecollaboration-mentorship model is a feasible, sustainable scalable, and replicable mechanism to expand the outreach of surgical care in epilepsy, especially in resource-constrained LMIC environs. It holds the potential to overcome the “ES divide” between LMIC and high-income countries and reduce the surgical treatment gap with acceptable surgical outcomes.

Keywords: Epilepsy surgery, lower-midd le-income countries, telecollaboration, telementorship


How to cite this article:
Vilanilam GC, Abraham M, Radhakrishnan A, Keni RR, Senanayake S, Attanayake D, Muhammed Rumi JU, Sai Kiran N A, Varma RG, Chowdhury FH, Menon R, Thomas B, Venkat EH. Telecollaboration: Telementorship for epilepsy surgery services in resource: Challenged lower-middle-income countries environs – A model and proof of concept. Arch Med Health Sci 2022;10:5-18

How to cite this URL:
Vilanilam GC, Abraham M, Radhakrishnan A, Keni RR, Senanayake S, Attanayake D, Muhammed Rumi JU, Sai Kiran N A, Varma RG, Chowdhury FH, Menon R, Thomas B, Venkat EH. Telecollaboration: Telementorship for epilepsy surgery services in resource: Challenged lower-middle-income countries environs – A model and proof of concept. Arch Med Health Sci [serial online] 2022 [cited 2022 Dec 7];10:5-18. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/5/347949


  Introduction Top


“Distance can't stop what is meant to be”

Anonymous

Economic disparities and geographic distances create huge global challenges in healthcare access and availability.[1] The health-care incongruencies across nations, further impair ideal “standards of care” with reference to the management of chronic ailments like epilepsy.[2] The global penetration of digital communication technology has helped limit this healthcare divide. With 59%–62% of the world's population having access to the internet, there is a tremendous potential for telemedicine services to enhance access and availability in health care.[3] The ubiquitous usage of smartphones with affordable internet services has revolutionized the health-care ecosystem. The care of people with epilepsy too has benefitted immensely from the breakthroughs in modern digital communication.[4]

It is estimated that 50 million people suffer from epilepsy worldwide and 20% and 40% of them have drug-resistant epilepsy (DRE). The incidence of epilepsy is about 139/100,000 people in lower-middle-income countries (LMIC) and 48.9 in high-income countries (HIC). About 80% of people with epilepsy in the world live in low and LMIC.[5],[6]

A gross imbalance exists in the availability of epilepsy surgery (ES) services with its availability restricted to about 13%–21% of LMIC and nearly 66% of HIC.[6] The concept of surgically remediable epilepsy advocates early surgical referrals for conditions with known pathophysiologies, good surgical outcomes, and drug-resistant natural histories. The burden of potential recipients of ES is also proportionately higher in LMIC.[7] Efforts to reduce the surgical treatment time gap have not been successful in LMIC due to several limiting factors. Limitations in infrastructure, trained personnel, access to care, economic constraints, etc., have all contributed to a culture of late surgical referrals in LMIC. The problem of surgical refractoriness due to secondary epileptogenesis and recrudescent epileptic networks further compromises good seizure outcome and results in delayed ES.[8],[9],[10],[11],[12]

The International League Against Epilepsy (ILAE) task forces and the National Association of Epilepsy Centres (NAEC) have structured the levels of care in epilepsy treatment by creating a hierarchy of centers based on resources and expertise available.[13],[14] This helps to create efficient referral patterns and optimize treatment outcomes. However, in LMIC, an ideal hierarchical system for epilepsy care is difficult to set up. Nevertheless, the internet revolution in LMIC holds the potential to collaborate with international experts and faculty mentors to establish close to ideal standards of epilepsy care which are close to the prescribed norms.

We aimed to close the gaps in surgical care of epilepsy in LMIC using newer communication avenues aided by the expanding internet services in these resource-challenged environs. Collaborations between LMIC and HIC centers to set up epilepsy care have been reported earlier (Morocco-France, United States-Uganda, Columbia-Switzerland). These collaborations however have not solely relied on the power of telemedicine.[6] The role of telemedicine in mentor–mentee collaborations in ES has not been described and evaluated effectively. Several LMICs have experienced and trained personnel along with adequate facilities. However, the lack of a suitable mentorship support to guide the services, fall back upon in case of adverse outcomes and to expand the spectrum of care, restrict growth to its full potential.

Where distance is a critical factor, telemedicine has the potential to provide equal access to healthcare, improve patient outcomes and reduce costs.[15],[16],[17],[18],[19],[20],[21],[22] Modes of telecommunications used for collaboration-mentorship exchanges between health-care professionals can be classified based on the following:

  1. Mode (text: Short messaging service, chat platform, E-mails, fax; video, using mobile devices, personal computers; audio: Phone, audio applications)
  2. Time (real-time/synchronous: By video, audio, text, video conferencing and asynchronous, E-mails).


The easy availability and affordability of text/multimedia messaging applications (WhatsApp, Telegram), video calling applications (Google Duo), large data transfer applications (Anydesk, We transfer), videoconferencing digital platforms (Zoom, Google meet), etc., have made telecollaborations-mentorship within the reach of health-care professionals across LMIC. This has made possible virtual patient management epilepsy care discussions and intra-operative real-time virtual mentorship, thereby breaking down geographical barriers.[15],[16]

We aimed to develop and evaluate a telecollaboration-mentorship model for LMIC. The cornerstone of this model would be a strong collaborative teaching-training network of shared decision-making aided by contemporary communication technology. Expanding the outreach of ES, betterment of outcomes, and limiting the surgical referral time gap were the secondary gains intended


  Materials and Methods Top


We proposed a telecollaboration-mentorship model for LMIC with a mentor (level 4) Centre and 5 other mentee centers. The Mentor Centre (R Madhavan Nair Comprehensive Epilepsy Care Centre, Sree Chitra Tirunal Institute Trivandrum, India) a tertiary level 4 epilepsy care center was the apex of the telecollaboration-mentorship network model.[23],[24],[25],[26],[27] Five mentee centers (level 3 epilepsy centers) across 3 LMIC-Sri Lanka, Bangladesh, and India were identified and prepared for telecollaboration-telementorship in ES.

Definitions

The following definitions were used for the purpose of the study.

Epilepsy (International League Against Epilepsy, 2014)[5]

At least 2 unprovoked seizures more than 24 h apart, one unprovoked seizure with at least a 60% risk of further seizures, or diagnosis of an epilepsy syndrome.

Drug-resistant epilepsy (International League Against Epilepsy, 2010)[9]

Failure of adequate trials of two tolerated, appropriately chosen, and used antiepileptic drug schedules (whether as monotherapies or in combination) to achieve sustained seizure freedom.

Epilepsy surgery[27]

Surgery was undertaken primarily with the intent to control drug-resistant seizures rather than for resecting an underlying brain lesion.

Surgically remediable epilepsy[10]

Conditions with relatively well-known pathophysiologies and natural histories with seizures that are typically medically refractory and can be cured by surgery.

Level 3 and level 4 ES centers were described as per the guidelines of the NAEC (Labiner et al., 2010).[13]

Identification of the research question

The two research questions for providing a proof-of-concept of the telecollaboration-telementorship model for ES in LMIC were,

  1. Can telecolloborations and telementorship aid the initiation, sustenance, and growth of ES in resource-constrained LMIC environs?
  2. What are the limitations in telementorship-telecollaborations in identifying ES candidacy?


Study design

A telecollaboration-mentorship model was developed between the mentor center (Centre M) (R. Madhavan Nair comprehensive epilepsy care center, Sree Chitra Tirunal Institute Trivandrum, India) and the five mentee centers in three LMIC countries-National Hospital, Colombo, Sri Lanka (Centre S), National Institute of Neurosciences and Hospital, Dhaka, Bangladesh (Centre B) and three Centers in India-Narayana Institute, Nellore (Centre I-1), Aster hospital Calicut (Centre I-2) and Aster hospital Kolhapur (Centre I-3) [Figure 1]. The patients recruited for ES were operated at the mentee centers during the period from 2018 to 2021.
Figure 1: Geographical schema of telecollaboration network. (a) -Asia/World map schema, (b) South Asia map schema. Mentor centre at Trivandrum India and 5 mentee centres 1–5, 1 - Dhaka, Bangladesh, 2 - Colombo, Srilanka, 3 - Nellore, Andhra Pradesh, India, 4 - Calicut, India, 5 - Kolhapur, India

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Profile of centers

The NAEC guidelines (Labiner et al., 2010) were used to stratify the levels of care in this telecollaboration mentor-mentee model.[13]

The apex mentor center has been a tertiary level-4 high-volume Epilepsy Centre Since 1995 offering the entire spectrum of ES procedures with fellowship training programs in ES. The mentee centers in Sri Lanka, Bangladesh, and India were identified based on the requisite standards of facilities and personnel prescribed for level 3 training centers.

Experience and training of personnel

The mentor center team (AR, MA, GV, RM, BT) formed the core team consisting of experienced epileptologists, epilepsy surgeons, neuroradiologists, and other multidisciplinary experts. The mentor team members have been part of a comprehensive epilepsy care team involved in 100–125 epilepsy surgical procedures every year and have successfully completed over 2000 epilepsy surgeries.

The mentee center team members, the epileptologists, epilepsy surgeons, and neurotechnologists underwent prior training in ES evaluation and care at the mentor center or other level 4 centers. These included a postdoctoral ES fellowship program (1 year) (RRK) or a short period of skilled observership training at the mentor center (SS, DA, JUMR) or another level 4 epilepsy center (NASK, RGV). The mentor team also conducted ES training workshops at some of the mentee centers in Sri Lanka and India to further enhance the expertise of the mentee center personnel. The mentee team included an epileptologist-neurosurgeon (SS, DA, Sri Lanka), two neurosurgeons (JUMR, FHC, Bangladesh), epileptologist-neurosurgeon at centers I-1 (RRK, NASK), I-2 (RRK, RGV), and I-3 (RRK, RGV), respectively.

Telecollaboration-mentorship model

DRE patients under the care of the mentee centers (S, B, I-1, I-2, or I-3) were included to evaluate the proof of concept of this model. The workflow of the model is illustrated in [Figure 2]. The telecollaboration/mentorship model was used for the preoperative workup (surgical candidacy and resection planning), in the perioperative period/during surgery and/or in the postoperative care.
Figure 2: Workflow schema: Telecollaboration-telementorship in ES. ES: Epilepsy surgery, EEG: Electroencephalogram, MRI: Magnetic resonance imaging, PET/SPECT: Positron emission tomography/Single photon emission computed tomography, DRE: drug-resistant epilepsy

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Telecollaboration exchanges

Clinical data with a history of seizure semiology, examination findings, and investigations (video electroencephalogram [EEG], magnetic resonance [MR], and positron emission tomography [PET]/single-photon emission computed tomography [SPECT] images, other ancillary investigations) were part of the telecollaboration exchanges. These were established using broadband internet services (wired/wireless) or/and telecommunication phone network.

Six mechanisms of telecommunication for telecollaboration-mentorship were used as follows (3 asynchronous and 3 synchronous mechanisms).

A. Asynchronous (A) - Exchange of clinical information independent of time as any of the following:

  • Text message (A-T)
  • Multimedia message/File transfer (A-M) (WhatsApp, AnyDesk, We Transfer)
  • Email (A-E).


B. Synchronous (S) - The transmitter and receiver are present in the same time and/or space (real-time) during transfer of clinical information permitting a two-way communication, as any of the following:

  • Videoconference (S-C) (Zoom/Google meet)-Two or more participants
  • Phone call (audio only) (S-P)
  • Videophone call (S-V) using WhatsApp, Google Duo.


The outcome of telecollaboration consults.

After the presurgical telecollaboration-mentorship consult, a decision on further treatment plan was made. This could be categorized as one of the following:

  1. The surgical candidacy plan remained unchanged (as decided earlier by the mentee center team)
  2. The resection plan was modified
  3. Planned for a level 4 center referral or unsuitable for surgical candidacy.


Treatment protocols at the mentee centers

Presurgical workup

The ILAE definition of DRE was used for initiating a presurgical workup.[5] The protocol included a detailed clinical history with seizure semiology and examination, long-term video-EEG monitoring, and 1.5 T MR imaging (MRI). Standard 10–20 system of electrode placement was used. Antiepileptic drugs in all patients except those with daily or frequent seizures were tapered. Barbiturates and benzodiazepines were tapered after other medications.

The electro-clinico-radiological characteristics were discussed by the team at the mentee centers to arrive at surgical candidacy selection and resection plan.

Concurring presurgical decision making by telecollaboration

Clinical data with a history of seizure semiology, examination findings, and investigations (video EEG, MR and PET/SPECT images, and other ancillary investigations) were further evaluated by the mentor center team by synchronous or asynchronous telecollaboration exchanges. Teleconference patient management meets were used for the difficult cases. The broad principles for surgical candidacy decision-making and establishing electro-clinico-radiological concordance were followed. The interictal epileptiform discharges (IEDs) in the long-term EEG were classified as concordant, if 75% of the IEDs corresponded to the presumed site of seizure origin (based on seizure semiology, MRI abnormality, and discordant (contralateral, bilateral independent, multifocal, or generalized). The scalp recorded ictal EEG activity was categorized as localized to the presumed lobe of seizure origin, lateralized to the presumed hemisphere of seizure origin, and diffuse (uncertain hemispheric origin).

Surgical strategy

Based on the clinico-electrical-radiological localization of the “epileptogenic zone” finalized further by telecollaboration exchanges, the surgical strategy for surgical resection at the mentee centers was one of the followings:

  1. Lesionectomy – Resection involving a focal radiological/morphological abnormality/lesion


  2. Example: Temporal focal cortical dysplasia (FCD).

  3. Extended lesionectomy – Resection involving a focal radiological/morphological abnormality/lesion with surrounding lesions (FCD, gliosis) having epileptogenic potential


  4. Example: Resection of a ganglioglioma with surrounding FCD (ILAE Type III B).

  5. Unilobar resection – Resection confined to a single lobe


  6. Example: Temporal lobectomy with amygdalohippocampectomy for hippocampal sclerosis.

  7. Multilobar resection; Resection of 2 or more lobes


  8. Example: Posterior quadrantic resection (temporo-parieto-occipital).

  9. Vagus nerve stimulation (VNS)-for primary generalized seizures with no resectable focus, done with a palliative intent.


Intraoperative electrocorticography (Acute ECoG) was done when available with 20 contact grid electrode. Tailored limited extensions of the resection limits were done in noneloquent locations for focal cortical dysplasias only.

Pathological examination

The histopathological examination was done at the mentee centers (Sri Lanka, Bangladesh) by neuropathologists. At the centers in India, the histopathological examination was done at another level 4 epilepsy center (other than the mentor center) by an expert neuropathology team.

Four-micrometer-thick histologic sections were generated from 10% formalin-fixed, paraffin-embedded tissue and stained with hematoxylin and eosin (H and E) by a trained neuropathologist. Special stains such as Cresyl violet, Bodian, and Luxol fast blue-hematoxylin eosin and immunohistochemical stains such as Neurofilament protein, synaptophysin, epithelial membrane antigen, glial fibrillary acid protein, Neu N, chromogranin were used as and when indicated. The WHO classification of central nervous system tumors (Louis et al., 2016) and the ILAE classification of cortical dysplasia (Blümcke et al., 2011) were followed.[10],[11]

Postoperative assessment

Telecollaboration was used in decisions about tapering anticonvulsants, managing surgical adverse events, and revaluation of “failed surgery.” Regular clinical follow-up was planned at 3, 6, and 12 months after surgery and at yearly intervals thereafter. Seizure outcome (Engel score), late sequelae/adverse events, and quality of life parameters were assessed. Decisions to taper anticonvulsants were highly individualized and based on seizure outcome benefits, additional unresected epileptogenic lesions, adequacy of resection, and background EEG epileptiform activity.

Ethical considerations

Patient identification details were not included/encrypted in the telecollaboration exchanges. The mentor center had no access to the patient identification details. Informed consent for clinical decision-making telecollaborations with the mentor level 4 epilepsy care center, was obtained from the patients and their caregivers. Administrative and ethical committee approvals were obtained for the clinical telecollaboration at the mentee centers.


  Results Top


The multi-center prospective study for telecollaboration-mentorship in ES involved five centers across three LMIC-India, Sri Lanka, and Bangladesh. Nineteen patients (6 males, 13 females) who underwent ES at the mentee centers were included in the study (10 patients from 3 centers in India, 4 patients from Sri Lanka, and 5 from Bangladesh. A detailed profile of the clinical history, seizure semiology, investigations, surgical planning, telecollaboration exchanges, treatment plan after telecollaboration, surgical resection executed, seizure outcome, surgical adverse events, and follow-up is tabulated in [Table 1]. A comparison of the different aspects of care across the mentee centers has included in [Table 2].
Table 1: Clinical profile of telecollaboration epilepsy surgery patient

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Table 2: Summary of telecollaboration-telementorship epilepsy surgery across 3 lower-middle income countries

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Demographic profile

The mean age of patients in the study group was 25.68 years (Range 8–42, standard deviation [SD] 9.54). One pediatric patient (8-year-old) who underwent temporal lobe resection was part of the group. There were more female patients[13] as compared to males.[6]

Epilepsy characteristics

Temporal lobe epilepsy was commoner (10/19) and extratemporal (7/19). Two patients had primary generalized diffuse ictal onset. The mean seizure frequency per month in the operated cohort was 29.4 (Range 4–90, SD 26.6). The mean duration of epilepsy was 15.3 years in the surgically treated group (Range 6–28, SD 5.43).

Telecollaboration exchanges

The total number of telecollaboration exchanges was 68 with 40 in the preoperative/planning stage, 7 in the intraoperative stage and 21 in the postoperative period respectively. There was an average of 3.5 exchanges per patient. The bar graph representing the volumes, nature, and stages of telecollaboration consults is depicted in [Figure 3]. A total of 68 telecollboration exchanges-42 asynchronous exchanges (7 text messages, 13 multimedia messages, 22 emails) and 26 synchronous exchanges (8 telephone calls, 6 video conferences, 12 video calls), respectively, were done as part of the study [Figure 3].
Figure 3: Spectrum of telecollaboration mentorship exchanges. S: Synchronous, A: Asynchronous

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Outcome of telecollaboration

In 13 patients, the surgical plan remained unchanged after the telecollaboration exchange and review. In six patients, the surgical plan was modified. Five patients were found unsuitable for surgical candidacy and referred to a level 4 center.

Surgical spectrum and pathological profile

The surgical spectrum included 10 temporal resections, 6 extra temporal, 1 multilobar resection, and 2 VNS. Hippocampal sclerosis was the most common pathology in 6 out of 19 patients. Focal cortical dysplasia was noted in four patients. No patient had a dual pathology.

Seizure outcome and adverse events

Engel Class I seizure outcome was noted in 10 patients (52.6%) and Engel Class II in seven (36.8%) patients, respectively. Two patients had poor outcomes (Engel Class III). Minor adverse events were noted in 4 patients. These included transient visual field defects and postoperative depression which eventually improved. No permanent morbidity or fixed neurological deficits were noted.

Based on the proof-of-concept experience generated by this model, a proposed schema of telecollaboration-mentorship for LMIC is proposed in [Figure 4].
Figure 4: Telecollaboration in ES for LMICs-A proposed systems model. ES: Epilepsy surgery, LMIC: Lower-middle income countries, DRE: drug-resistant epilepsy, EEG: Electroencephalogram, MRI: Magnetic resonance imaging, PET/SPECT: Positron emission tomography/Single photon emission computed tomography

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  Discussion Top


Chronic ailments like epilepsy pose formidable patient-care challenges in remote and resource-restricted environs.[4],[21],[22] ES in these environs, which calls for further facilities and expertise, makes the challenge even more daunting. Telecommunication breakthroughs offer a ray of hope to overcome these limitations. The penetrance of affordable and effective high-speed internet has revolutionized diagnosis, treatment, and care of patients in remote locations.[28],[29],[30],[31],[32],[33] Distances and resource limitations are not considered a barrier anymore as communication technology strives to close in the “resource gap” and the “skill gap” between HIC and LMIC.

Our telementorship-collaboration model aims to effectively use indigenous facilities and expertise at LMIC level 3 epilepsy centers to raise the bar of ES. The effective use of telecollaboration to bolster locally available expertise is a novel step forward. We evaluated the effectiveness of this model through the following five questions,

Is it necessary?

The World Bank classifies LMIC based on per capita gross national income in the range of 1046–4095 US dollars.[1] While 80% of people with epilepsy reside in low-income and LMIC, only about 13%–22% of these countries have ES services.[2],[6] About 66%–70% of HIC have ES facilities and the surgical referral time gaps are also lesser than in LMIC. The epilepsy burden in LMIC is about four times that in HIC with surgical candidature figures also proportionately higher. Epidemiological estimates suggest that out only one of 1000 patients who deserve ES in LMIC, receives it. In South Asia, it is estimated that currently, over 2 million people may benefit from ES.[2] The economic burden of epilepsy due to the indirect costs of a lost livelihood also adds to the burden in LMIC. Limitations in facilities and skilled personnel are the key factors inhibiting the growth of ES in LMIC.[2],[6]

Levels of care in epilepsy have been proposed by Labiner et al. and a similar concept has been proposed for pediatric epilepsy centers by Gaillard et al.[13],[14] This hierarchical epilepsy care system may be difficult to strictly implement in LMIC. Nevertheless, a careful identification of surgical candidacy in LMIC as proposed by Asadi Pooya et al. would help LMIC set up successful ES programs with collaborations with level 4 centers.[7] Telecollaborations help to establish communications between the team members very effectively as shown by our experience.

Is it feasible?

In several LMIC, there are sufficient skilled personnel and efficient facilities available to establish ES programs.[6] However, a very narrow gap in skills and experience often limits the development of ES. A lack of awareness about the good outcomes and a tendency to maintain the “status quo” in medical management of epilepsy, further impair the growth of ES. As shown by our experience, telementoring holds the immense potential to fill this skill and experience gap. The easy and affordable availability of high-speed Internet in 65% of urban LMIC, adds to the spectrum of telementorship possibilities.[3] The wide variety of currently available free software such as Skype (Microsoft Co), Facebook Messenger (Facebook Inc.), Viber (Rakuten Group Inc.), and WhatsApp (Facebook Inc.), and smartphones have made physician–physician communications across geographical barriers very efficient.[16],[17],[18],[19]

Telementoring (surgeon-surgeon) helps to overcome the disparity of access to surgical care, and ensure rapid knowledge and skill transfer of innovative surgical techniques. It fosters a culture of autonomy and expands the spectrum of surgical possibilities. Real-time synchronous telementorship helps to tide over efficiently the difficult moments in the surgical operation. Huang et al. report that telementorship has comparable results as on-site mentorship.[19] Hands-on training programs and workshops add further to the strength of the telementorship collaboration. Teleproctorship to assess the strengths and limitations of the mentee surgeon help to ensure a gradual, safe, and effective progress in telementorship.[18]

Several authors report successful telemedicine (patient–physician) in epilepsy care and several other specialties.[34] Thus, telementorship helps to fine-tune surgical decision making, skill expansion, and also audit the outcomes of ES. Most importantly it brings efficient and affordable care to patients needing ES well within their home countries.

Is it reproducible?

The focal point of this model is a strong team collaboration between the mentor and mentee centers. Prior training in the work-up for ES and surgical technique of the mentee center team members are crucial, as demonstrated by our model. Careful case selection clearly realizing the strengths and limitations of the mentee team is necessary. A prior close professional collaboration by visits to the mentor and mentee centers by the personnel and other training initiatives, help forge a close teaching-learning-treating bond. Several ES collaborations between HIC and LMIC centers have been reported earlier. However, telecollaboration experiences have not been reported in ES. Thus, the model is easy to replicate with locally available resources, communication technology, and expertise, further reinforced by telecollaboration-mentorship.

Is it advantageous over existing mechanisms?

There has been no formal ES program at the mentee centers in Sri Lanka and Bangladesh till this telecollaboration possibility was explored. Despite the availability of local expertise in LMIC epilepsy centres, a real-time, individual patient-based decision-making mentorship support was lacking. This telementorship model helped to bridge this gap to initiate, sustain and enhance ES programs in these nations.

Widjaja et al. in a large review of ES outcomes in the general population noted that the hemispheric surgery was reported to have the highest seizure freedom rate (74.7%), followed by temporal lobe ES (73.3%) and extratemporal lobe ES (60.2%).[35] Adverse events ranged from 6% to 10% in most series. Our results which are comparable to many large series showed a worthwhile seizure outcome (Engel Class I, II) in 89% of patients which was made possible by careful case selection and telementorship. The two cases of failed surgery were found to be “temporal plus” epilepsy and await further evaluation.

Is there scope for improvisation?

The key objectives of telecollaboration are to foster rapid knowledge and skill transfer while upholding autonomy.[30],[31],[32] The ultimate aims would be to reduce the need for telecollaboration and the mentee centers becoming completely autonomous. Enhancing the surgical spectrum of these centers to include hemispheric disconnections, multilobar resections, and invasive EEG-based resections would be the next step forward. Conferring further surgical privileges based on performance has to be carefully done by the mentor center. Involving specialized neuropathologists, neuropsychologists, occupational therapists, etc., would further extend the efficiency of this model. After a successful evaluation of the proof-of-concept of this model, we propose more telecollaborations between HIC-LMIC and LMIC-LMIC centers. As there are several comparable resource-related factors in LMIC-LMIC, collaborations, these may have some advantages. With more penetrance of communication technology, newer avenues for ES to reach the masses in LMIC such as telecollaborations, need to be enhanced.

Strengths and Limitations of the study

Telecollaboration-mentorship to establish ES centers have not been reported earlier, despite reports on several inter-institutional collaborations.[6],[34] Not using telecollaborations for pathological diagnosis of the surgical specimen is a limitation of the study. A more robust outcome audit and comparison with the cases done at the mentor center would help define standards of ideal care. Though patient identification details have been confidential, a stronger patient privacy encryption is desired. An audit of cost savings by the mentee centers and time invested by the mentor center for telecollaborations, needs a future assessment.


  Conclusion Top


The surgical treatment gap between HIC and LMIC in the availability of ES can be overcome by telecollaboration-mentorship programs. We provide a feasible, sustainable scalable, and reproducible model to expand the outreach of ES in LMIC. The proof-of-concept demonstrates that the model could help enhance surgical candidacy selection and the expand the surgical spectrum, thereby creating and sustaining new ES centers in LMIC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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