Mass General Team Works to Find Cost-Effective Ways to Improve Global Neurological Care

By Alyssa Gocinski
Research Institute Intern

In addition to seeing neurology patients here at Massachusetts General Hospital, Farrah J. Mateen, MD, PhD, (below, second from left) is committed to finding innovative solutions to neurological health challenges in resource-limited settings worldwide.

In a recent interview, Mateen explained that many of the countries that she works with lack practicing neurologists and do not have the resources to provide a Western standard of medical care, so innovative solutions must be found that blend affordability and accessibility. Mobile technology and out-of-the-box thinking play a key role in her
work.

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In the Bhutan, for example, Mateen has been testing a smartphone-based EEG cap that can be used to provide a remote diagnosis of epilepsy. This study, called The Bhutan Epilepsy Project, may revolutionize neurological care in one of the last countries in the
world with a 90% rural population.

In Africa, Mateen has launched two more creatively designed research projects that seek to improve care for patients with neurological issues. 

HIV and stroke in Tanzania

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Mateen’s first project consists of obtaining preliminary data for a clinical trial investigating the potential of fluoxetine, more commonly known as Prozac, as a drug for stroke recovery in patients living with HIV in Tanzania.

Funded by the Harvard Center for AIDS Research (CFAR), the study is being conducted at the Muhimbili National Hospital.

“HIV is a large scale pandemic problem. What has become especially important nowadays is people surviving with HIV. It used to be a life or death matter, and it still is,” Mateen explained.

“But now the recognition is on comorbidity, or chronic diseases that can be accelerated or have early onset in people living with HIV. There’s a large number of people in Sub-Saharan Africa who still have HIV as part of their picture.”

People with HIV tend to have strokes more often and earlier in life due to the impact of the disease on the immune system, the side effects of HIV antivirals, and common co-infections. Mateen says the Muhimbili National Hospital generally sees three new stroke patients per day, and about a third of those patients have HIV.

In the US, stroke patients are given clot busters immediately after onset to help restore blood flow to the brain. But patients in Africa don’t have access to these expensive drugs, which contributes to what Mateen estimates is the continent’s close to 50% stroke mortality rate.

Mateen says it can also be difficult for those living in Africa to obtain medical attention in a timely manner, since many patients live in remote villages and getting to a medical clinic quickly when a stroke hits is nearly impossible.

So when patients finally reach the hospital days after their stroke, doctors don’t have many options to assist with repairing brain function.

“You can do some bits of preventative treatment so they don’t get a clot in their legs from lying down, but there’s not a lot you can offer them for the pathophysiology of stroke,” she said. “So we’ve been trying to figure out what are other repairing drugs?”

The answer may be fluoxetine, more commonly known by the brand name Prozac. Mateen says there has been evidence that the antidepressant can act as a repairing drug for stroke in the longer term by stimulating neuroplasticity, or the potential the brain has to create new neural pathways. However, the drug has not been universally accepted as a treatment for stroke.

“Many doctors here in the United States will give fluoxetine right after stroke, but not everyone,” she said. “Two people who are both knowledgeable and have read the same papers will come to different conclusions [regarding its effectiveness]. So there’s still a need to know on this side of the earth, but even more so in a resource-limited setting, where no such research has been done.”

In order to determine whether fluoxetine can be the solution for HIV-positive stroke patients in Africa, Mateen aims to first recruit 160 adults with stroke into a baseline study with 60-day follow-ups to observe motor recovery.

Comparing the progress of HIV-positive and HIV-negative patients, she’ll also gather data on how common post-stroke depression and mortality is before introducing fluoxetine in the following round.

Mateen also notes the possibility of creating a pediatric clinical trial, since many more children have strokes in Africa than they do in the US. “There’s a lot of opportunity to do some of this work really well, and we’re just trying to set some of it up,” she said.

However, no clinical trial is without difficulties. Because it is unknown if the brain will have beneficial effects from fluoxetine if the treatment is started more than a month after the stroke, Mateen stresses the importance of getting treatment to patients in a timely manner. She said she’ll also have to factor in the continent’s high post-stroke mortality rates.

Neurocognitive assessment in Asian and African schoolchildren

Mateen’s second project aims to determine the cognitive development status of children in Africa and Asia by using optical coherence tomography (OCT)—a non-invasive technique that creates 3D images of tissue by measuring how light scatters when it makes contact with the eye.

In this project, the OCT scan will focus on the retina and eye curve—parts of the eye that are embryologically part of the brain—to obtain information about the brain itself.

Neurocognitive assessments in the U.S. typically rely on magnetic resonance imaging (MRI) scans and items such as tricycles and playing cards to test cognitive skill, but Mateen says many of these tests don’t translate to children in Africa.

“One of the other things that’s really missing from global health and neurology is that we don’t really have a good way to look at neurodevelopment in kids,” she said. “American tests are helpful for our population, but what do you do for populations that don’t speak English and don’t have access to the same toys?”

Using OCT scanning combined with common growth metrics and cognitive scoring,
Mateen hopes to see if it is possible to establish a uniform standard of cognitive status throughout Africa and Asia; or if there are geographical differences that make it difficult to use the same metrics for different patient populations.

She’ll also take in factors like the HIV status of the parents and preterm birth to see whether they worsen the cognitive ability of affected children in Africa.

With about 120 children between the ages of three and nine already recruited from Kenya, Mateen intends to conduct similar screenings in Bhutan and East Timor afterwards. One challenge that she faces is explaining the importance of cognitive testing and treatment to
primarily rural communities. The process can be time-consuming.

“These are very rural populations, and cognitive testing doesn’t hold the same value to them,” she said. “We’ve had some convincing to do that this is a worthwhile thing to participate in.”

The OCT scan itself is painless and noninvasive, and Mateen hopes doctors will be able to use this quick procedure to accurately determine which children need MRI scans and early intervention based on cognitive status. “You can’t afford to do this for everyone, but how do you separate out who needs better care?”

Mateen’s exploratory work is supported by the Bill & Melinda Gates Foundation, and the bulky $30,000 OCT scanner machine is on loan from Optovue Inc. in California. Smaller handheld OCT machines do exist, but Mateen says the data quality is better with this larger version.

Through her ongoing work in developing countries, Mateen hopes to find practical solutions to serious public health issues that can be easily implemented given resource limitations and cultural sensitivities. “I think the trick is not just to have the answer, but to make the answer user-friendly.”

Get more information and stay updated on Mateen’s projects here.

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