The burden of inpatient neurologic disease in two Ethiopian hospitals

Neurology Training and Medical Education in Resource-Limited Settings: Building and Growing the First Neurology Residency Program in East Africa

The burden of neurological disease disproportionately affects low- and middle-income countries, where the lowest number of neurologists are located. Building local training opportunities in resource-limited settings is a foundational step to enhancing the neurological workforce and improving access to neurological care in these regions. In this article, we describe the development and growth of the first neurology residency program in East Africa, which was established in 2006 at Zewditu Memorial Hospital and the Tikur Anbessa Specialized Hospital, Addis Ababa University, Ethiopia. We highlight the impact of the program on clinical care, research, collaborations between neurologists across Ethiopia, and ways to build educational opportunities and mentorship while faced with limited resources. The main challenges in starting the residency program included lack of faculty with neurological expertise, lack of a precedent for subspecialty training in our setting, as well as limited resources and space. The formation of sustainable international collaborations with clinicians at established institutions in high-income countries and neurological societies has been a major source of support in developing the initial infrastructure, curriculum and educational content, knowledge assessments, and mentored research projects. Local partnerships with related medical specialties, including internal medicine, critical care, neurological surgery, and psychiatry, were also instrumental in creating training opportunities. As the program continues to evolve, many challenges remain, including limited diagnostics, lack of access to advanced treatment modalities, lack of fellowship training opportunities in various neurological subspecialties, and insufficient training and experience in scientific writing. Despite these challenges, the residency program has persevered and its creation resulted in many positive changes: since its inception in 2006, we graduated 80 neurologists and the number of practicing neurologists in Ethiopia has increased from 5 to 78, our institution has evolved into a national referral center for neurology, graduates have published 61 articles in the past 3 years and contributed to international neurology research, and alumni of the program have grown the Association of Ethiopian Neurologists. Future directions include development of fellowship opportunities, creation of international rotations, and implementation of teleneurology to further strengthen neurological care across Ethiopia.

The Interplay Between Neuroinfections, the Immune System and Neurological Disorders: A Focus on Africa

Neurological disorders related to neuroinfections are highly prevalent in Sub-Saharan Africa (SSA), constituting a major cause of disability and economic burden for patients and society. These include epilepsy, dementia, motor neuron diseases, headache disorders, sleep disorders, and peripheral neuropathy. The highest prevalence of human immunodeficiency virus (HIV) is in SSA. Consequently, there is a high prevalence of neurological disorders associated with HIV infection such as HIV-associated neurocognitive disorders, motor disorders, chronic headaches, and peripheral neuropathy in the region. The pathogenesis of these neurological disorders involves the direct role of the virus, some antiretroviral treatments, and the dysregulated immune system. Furthermore, the high prevalence of epilepsy in SSA (mainly due to perinatal causes) is exacerbated by infections such as toxoplasmosis, neurocysticercosis, onchocerciasis, malaria, bacterial meningitis, tuberculosis, and the immune reactions they elicit. Sleep disorders are another common problem in the region and have been associated with infectious diseases such as human African trypanosomiasis and HIV and involve the activation of the immune system. While most headache disorders are due to benign primary headaches, some secondary headaches are caused by infections (meningitis, encephalitis, brain abscess). HIV and neurosyphilis, both common in SSA, can trigger long-standing immune activation in the central nervous system (CNS) potentially resulting in dementia. Despite the progress achieved in preventing diseases from the poliovirus and retroviruses, these microbes may cause motor neuron diseases in SSA. The immune mechanisms involved in these neurological disorders include increased cytokine levels, immune cells infiltration into the CNS, and autoantibodies. This review focuses on the major neurological disorders relevant to Africa and neuroinfections highly prevalent in SSA, describes the interplay between neuroinfections, immune system, neuroinflammation, and neurological disorders, and how understanding this can be exploited for the development of novel diagnostics and therapeutics for improved patient care.

High frequency of Taenia solium antigen positivity in patients admitted for neurological disorders in the Rural Hospital of Mosango, Democratic Republic of Congo

Background

The epidemiology of human cysticercosis and neurocysticercosis, caused by the larval stage of the pork tapeworm Taenia solium, is not well known in the Democratic Republic of Congo (DRC). Within a multicenter etiological and diagnostic study conducted by the NIDIAG consortium (“Better Diagnosis for Neglected Infections”) and investigating several challenging syndromes, we consecutively evaluated from 2012 to 2015 all patients older than 5 years presenting with neurological disorders (neurology cohort) and with fever > 7 days (persistent fever cohort) at the rural hospital of Mosango, province of Kwilu, DRC. In both cohorts, etiological diagnosis relied on a systematic set of reference laboratory assays and on pre-established clinical case definitions. No neuroimaging was available in the study hospital. In this study, we determined the frequency of T. solium infection in both cohorts and explored in the neurology cohort its association with specific neurological presentations and final etiological diagnoses.

Methods

We conducted a post-hoc descriptive and analytic study on cysticercosis in the neurology and persistent fever cohorts, based on the presence in serum samples of circulating T. solium antigen using the B158/B60 enzyme-linked immunosorbent assay (ELISA) and of cysticercosis IgG using the LDBIO Cysticercosis Western Blot IgG assay.

Results

For the neurology cohort, 340 samples (of 351 enrolled patients) were available for analysis (males: 46.8%; mean age: 38.9 years). T. solium antigen positivity was found in 43 participants (12.6%; 95% confidence interval [CI] 9.3–16.7%), including 9 of 60 (15%) patients with epilepsy. Among the 148 samples available from the persistent fever cohort (males: 39.9%; mean age: 19.9 years), 7 were positive in the T. solium antigen ELISA (4.7%; 95% CI 1.9–9.5%; P = 0.009 when compared to the neurology cohort). No significant association was found within the neurology cohort between positivity and clinical presentation or final diagnoses. Of note, the IgG antibody-detecting assay was found positive in only four (1.3%) of the participants of the neurology cohort and in none of the persistent fever cohort.

Conclusions

T. solium antigen positivity was found in at least 10% of patients admitted with neurological disorders in the Kwilu province, DRC, with no specific pattern of presentation. Further neuroimaging studies should be used to confirm whether neurocysticercosis is prevalent in this region.

Evaluation of a screening tool for the identification of neurological disorders in rural Uganda

BACKGROUND

Neurological disorders are common in sub-Saharan African, but accurate neuroepidemiologic data are lacking from the region. We assessed a neuroepidemiological screening tool in a rural Ugandan cohort with high HIV prevalence.

METHODS

Participants were recruited from the Rakai Neurology Study in rural Rakai District, Uganda. A nurse administered the tool and a sociodemographic survey. 100 participants returned for validation examinations by a neurologist (validation cohort). The diagnostic utility and validity of the instrument were calculated and characteristics of those with and without neurological disorders compared.

RESULTS

The tool was administered to 392 participants, 48% female, 33% people with HIV, average age 35.1 ± 8.5 years. 33% of the study cohort screened positive for neurologic disorders. These participants were older [mean (SD): 38.3 (9.7) vs. 33.5 (7.1) years, p < 0.001], had a lower Karnofsky score [89.8 (8.4) vs. 93.9 (7.5), p < 0.001] and had a lower body mass index [21.8 (3.3) vs. 22.8 (3.7), p = 0.007] than those who screened negative. Amongst the validation cohort, 54% had a neurological abnormality of which 46% were symptomatic. The tool was 57% sensitive and 74% specific for detecting any neurological abnormality and 80% sensitive and 69% specific for symptomatic abnormalities.

CONCLUSIONS

We found a lower sensitivity and similar specificity for the screening tool compared with two previous studies. The lower validity in this study was likely due in part to the high percentage of asymptomatic neurological abnormalities detected. This screening tool will require further refinement and cultural contextualization before it can be widely implemented across new populations.

Prevalence of and characteristics associated with in-hospital mortality in a Ugandan neurology ward

Background

While the burden of neurologic illness in developing countries is increasing, less is known about mortality among patients admitted to sub-Saharan African hospitals with neurologic disease. We sought to characterize the rate and patient-level predictors of in-hospital mortality in a Ugandan Neurology ward.cc.

Methods

Data was prospectively collected on 335 patients admitted to the Neurology ward of Mulago Hospital, Kampala, Uganda. Kaplan-Meier survival curves and multivariate COX proportional hazard modeling were used to assess survival.

Results

Within our sample (n = 307), 35.8% received no diagnosis at time of hospital admission. Stroke (27.3%), head trauma (19.6%), and malaria (16.0%) were the most common diagnoses. Among the 56 (18.5%) patients who died during the index hospitalization, the most common diagnosis at admission and at death was stroke. Adjusted regression analysis showed that patients without a diagnosis at time of death (HR = 7.01 [2.42–20.35], p < .001) and those with diagnoses of infections (HR = 5.21 [2.16–12.58], p = <.001), stroke (HR = 2.69 [1.20–6.04], p = .017), or head trauma (HR = 3.39, [1.27–9.07], p = 0.15) had worse survival.

Conclusions

In-hospital mortality affected nearly 20% of the cohort, with worse survival among those without a diagnosis and with infections, stroke, head trauma. Future work should identify reasons for increased mortality among these high-risk groups and implement targeted interventions.

Neurological disorders in a consultant hospital in Northern Tanzania. A cohort study

OBJECTIVES

To determine the sociodemographic characteristics, clinical findings and outcome by HIV status in a series of adult patients presenting with neurological disorders (NDs) and admitted to a consultant hospital in Northern Tanzania.

METHODS

A cohort study took place over a 6-month period from Oct 2007 to March 2008 and included all adult patients with a neurological disorder admitted to the medical wards.

RESULTS

A total of 1790 patients were admitted during this period, of whom 337 (18.8%) were diagnosed with a neurological disorder and formed the study group. Of these 337, 69 (20.5%) were HIV-positive. Among the 69 HIV positives, 25% were previously known to be HIV seropositive of whom 82% were on antiretroviral (ARV) medication. Seropositive patients were more likely than seronegative patients to be younger, better educated, have a business occupation, present clinically with confusion, headache and aphasia and have meningitis/CNS infection or a space occupying lesion. Seropositive patients were more likely to present with a Glasgow Coma Score (GCS) of 9-12/15 (33.3% v 17.2%). Seropositive patients had a median CD4 T-lymphocyte count of 47cells/L and were more likely to be anaemic and have an elevated ESR. CT of the head was carried out on 132/337 (39%) patients. The overall findings were infarction 37%, hemorrhage 19%, tumors 15% and abscesses 9%. Brain abscess was more likely in seropositive patients and hemorrhage in seronegatives. The outcome at discharge for all patients was: death 27.6%, disability 54% and no disability 18.4% with death (39.1%) being more likely in seropositive patients. Patients presenting with coma (GCS <9/15) were more likely to die whilst those with stroke, para/quadriplegia and space occupying lesions (SOLs) were more likely to be discharged with disability. Case fatality rate was highest for tetanus 71.4%, meningitis 57.1%, cerebral malaria 42.9% and CNS infections 37.1%. Seropositive patients presenting with meningitis and other CNS infections were more likely to die than seronegatives.

CONCLUSION

This study reports NDs occurring in one fifth of adult medical admissions with stroke and infections as the leading causes. The prevalence of HIV infection in NDs was 20%. The HIV positive cohort was characterized by advanced immunosuppression, CNS infections and high mortality.

Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.

Electrodiagnostic consultations in Zambia: Referral characteristics and neuromuscular disorders

INTRODUCTION

Research on neuromuscular disorders in sub-Saharan Africa is scarce. We aimed to delineate referral characteristics and the neuromuscular disorders observed among electrodiagnostic (EDX) consultations in a tertiary care setting in Zambia.

METHODS

EDX records were reviewed for all specialist-performed studies after the establishment of the laboratory. The frequency of demographic, medical characteristics, and final EDX impressions are presented.

RESULTS

Among 108 referrals, 52% were male, 84% were adults (mean age 44 years). Referrals were predominantly outpatients (85%) and sent by neurologists (68%). HIV infection was common (12%). Diabetes was rare (3%). Overall, 77% of studies were abnormal. Polyneuropathy was the most common abnormal EDX finding, followed by motor neuron disease.

DISCUSSION

A diverse range of neuromuscular diseases was evaluated among EDX referrals in Zambia. Though labor and expertise intensive, access to EDX consultation can enhance clinical care and facilitate research and surveillance of neuromuscular disorders in the region.

Spectrum of Disease and Prescription Pattern for Outpatients with Neurological Disorders: An Empirical Pilot Study in Bangladesh

BACKGROUND

Neurological disorders represent one of the most prominent causes of morbidity and mortality that adversely affect the lifestyle of patients and a major percentage of these diseases exists in developing countries.

PURPOSE

The objective of this study was to examine the prevalence and prescription pattern for outpatients with neurological disorders in Bangladesh.

METHODS

The study was conducted on 1,684 patients in 6 hospitals (National Institute of Neurosciences and Hospital, Dhaka Medical College and Hospital, Bangabandhu Sheikh Mujib Medical University, Shaheed Suhrawardy Medical College, Sir Salimullah Medical College, and Apollo Hospitals Dhaka) of the Dhaka City from March 2014 to June 2015. Data were collected through a predesigned questionnaire from the patients that contain information about gender, age, marital status, occupation, residential status, affected disease, self-medicated medicines, and prescribed medicines.

RESULTS

Out of 1,684 patients, 28.38% patients were aged 51-60 years and male, 57.19% predominance. The study exposed headache and migraine for 29.75% patients, followed by stroke for 23.93% patients and seizure for 7.07% patients. Genetic reason for the neurological disorders was seen only among 12.35% patients. In this study, 16.98% patients had been affected by neurological disorders for more than 2 years and 19% of patients for less than 6 months. Most extensively prescribed medicines were multivitamins and multiminerals used by 17.89% of patients followed by nonsteroidal anti-inflammatory drugs and other analgesic by 14.84%; afterwards antiulcerants were used by 12.62%, subsequently anticoagulants were used by 11.61% followed by antihyperlipidemic medicines by 10.26% and antiepileptic drugs by 8.08% of patients. The crucial reasons for the selection of prescribed medicines were the confidence that patients had with the physician's prescribed medicines, which was shown for 40.97% patients and knowledge of the medicines was reported for 35.04% patients. The period of prescribed medicine usage was 1-3 months for 39.73% patients and 3-6 months for 29.16% patients. The patient's compliance for prescribed medicines was satisfactory for 34.56% patients, good for 28.15% patients, and side effects were reported for 23.22% patients.

CONCLUSION

In Bangladesh, it is not surprising to note that neurological diseases are more prevalent than other different diseases among different age groups and genders. Headache and migraine, stroke and seizure are most frequently encountered neurological disorders here. Treatment procedure of these disorders is not quite suitable due to the anomalies of health care management systems. Appropriate management of the health care system, especially the placement of hospital and community pharmacy can overcome the existing inconsistencies as well as increase the knowledge, awareness, and perception of the patients about health and neurological disorders.

Clinical Spectrum, Etiology, and Outcome of Neurological Disorders in the Rural Hospital of Mosango, the Democratic Republic of Congo

There is little published information on the epidemiology of neurological disorders in rural Central Africa, although the burden is considered to be substantial. This study aimed to investigate the pattern, etiology, and outcome of neurological disorders in children > 5 years and adults admitted to the rural hospital of Mosango, province of Kwilu, Democratic Republic of Congo, with a focus on severe and treatable infections of the central nervous system (CNS). From September 2012 to January 2015, 351 consecutive patients hospitalized for recent and/or ongoing neurological disorder were prospectively evaluated by a neurologist, subjected to a set of reference diagnostic tests in blood or cerebrospinal fluid, and followed-up for 3–6 months after discharge. No neuroimaging was available. Severe headache (199, 56.7%), gait/walking disorders (97, 27.6%), epileptic seizure (87, 24.8%), and focal neurological deficit (86, 24.5%) were the predominant presentations, often in combination. Infections of the CNS were documented in 63 (17.9%) patients and mainly included bacterial meningitis and unspecified meningoencephalitis (33, 9.4%), second-stage human African trypanosomiasis (10, 2.8%), and human immunodeficiency virus (HIV)-related neurological disorders (10, 2.8%). Other focal/systemic infections with neurological manifestations were diagnosed in an additional 60 (17.1%) cases. The leading noncommunicable conditions were epilepsy (61, 17.3%), psychiatric disorders (56, 16.0%), and cerebrovascular accident (23, 6.6%). Overall fatality rate was 8.2% (29/351), but up to 23.8% for CNS infections. Sequelae were observed in 76 (21.6%) patients. Clinical presentations and etiologies of neurological disorders were very diverse in this rural Central African setting and caused considerable mortality and morbidity.

Frequency, associated features, and burden of neurological disorders in older adult inpatients in Brazil: a retrospective cross-sectional study

Background

The burden of neurological disorders (NDs) in older adult inpatients is often underestimated. We studied diagnostic frequency and comorbidity of NDs among inpatients aged ≥60 years. We compared rates of hospital mortality, length of stay (LOS), and readmission with younger patient counterparts (aged 18–59 years) and older adult non-neurological patients.

Methods

This was a retrospective cross-sectional study of inpatients in a tertiary care center in Brazil. We compiled data for all patients admitted between 1 January 2009 and 31 December 2010, and selected those aged ≥18 years for inclusion in the study. We collected data for inpatients under care of a clinical neurologist who were discharged with primary diagnoses of NDs or underlying acute clinical disorders, and data for complications in clinical or surgical inpatients. Patients who remained hospitalized for more than 9 days were categorized as having long LOS.

Results

Older adult inpatients with NDs (n = 798) represented 56% of all neurological inpatients aged ≥18 years (n = 1430), and 14% of all geriatric inpatients (n = 5587). The mean age of older adult inpatients was 75 ± 9.1 years. Women represented 55% of participants. The most common NDs were cerebrovascular diseases (51%), although multimorbidity was observed. Hospital mortality rate was 18% (95% confidence interval [CI], 15–21) and readmission rate was 31% (95% CI, 28–35), with 40% of patients readmitted 1.8 ± 1.5 times. The long LOS rate was 51% and the median LOS was 9 days (interquartile interval, 1–20 days). In younger inpatients mortality rate was 1.4%, readmission rate was 34%, and long LOS rate was 14%. In older adult non-neurological inpatients, mortality rate was 22%, readmission rate was 49%, and long LOS rate was 30%.

Conclusions

Older adult neurological inpatients had the highest long LOS rate of all patient groups, and a higher mortality rate than neurological patients aged 18–59 years. Readmissions were high in all groups studied, particularly among older adult non-neurological inpatients. Improved structures and concerted efforts are required in hospitals in Brazil to reduce burden of NDs in older adult patients.

Standard operating procedures improve acute neurologic care in a sub-Saharan African setting

Objective:

Quality of neurologic emergency management in an under-resourced country may be improved by standard operating procedures (SOPs).

Methods:

Neurologic SOPs were implemented in a large urban (Banjul) and a small rural (Brikama) hospital in the Gambia. As quality indicators of neurologic emergency management, performance of key procedures was assessed at baseline and in the first and second implementation years.

Results:

At Banjul, 100 patients of the first-year intervention group exhibited higher rates of general procedures of emergency management than 105 control patients, such as neurologic examination (99.0% vs 91.4%; p < 0.05) and assessments of respiratory rate (98.0% vs 81.9%, p < 0.001), temperature (60.0% vs 36.2%; p < 0.001), and glucose levels (73.0% vs 58.1%; p < 0.05), in addition to written directives by physicians (96.0% vs 88.6%, p < 0.05), whereas assessments of other vital signs remained unchanged. In stroke patients, rates of stroke-related procedures increased: early CT scanning (24.3% vs 9.9%; p < 0.05), blood count (73.0% vs 49.3%; p < 0.01), renal and liver function tests (50.0% vs 5.6%, p < 0.001), aspirin prophylaxis (47.3% vs 9.9%; p < 0.001), and physiotherapy (41.9% vs 4.2%; p < 0.001). Most effects persisted until the second-year evaluation. SOP implementation was similarly feasible and beneficial at the Brikama hospital. However, outcomes did not significantly differ in the hospitals.

Conclusions:

Implementing SOPs is a realistic, low-cost option for improving process quality of neurologic emergency management in under-resourced settings.

Classification of evidence:

This study provides Class IV evidence that, for patients with suspected neurologic emergencies in sub-Saharan Africa, neurologic SOPs increase the rate of performance of guideline-recommended procedures.

The Burden of Movement Disorders in Cameroon: A Rural and Urban-Based Inpatient/Outpatient Study

Background

Because of rapid demographic changes, the prevalence of movement disorders (MDs) is expected to increase in Africa. The objective of this study was to estimate the prevalence of MDs in an inpatient/outpatient-based study of rural and urban health care centers in Cameroon.

Methods

In this retrospective medical chart review, the inpatient/outpatients settings covered an urban population (3,000,000) and a rural population (380,276). Neurological diseases were classified according to the International Statistical Classification of Diseases-Related Health Problems, 10th revision (ICD-10). Crude prevalence was calculated per 100 with 95% confidence intervals (CIs).

Results

Of 20,131 medical charts reviewed (13% from the rural area), 4187 patients (20.8%) with neurological complaints were identified. MDs were diagnosed exclusively from urban centers in 134 patients (3.2%): the mean patient age was 48.6 ± 18.6 years, and 54.7% were women. The most prevalent MDs were hyperkinetic movements (tremor, myoclonus, and drug-induced MDs [ICD-10 code G25]; prevalence, 1.19%; 95% CI, 1.192-1.194%), Parkinson's disease (ICD-10 code G20; prevalence, 0.78%; 95% CI, 0.785-0.787%), dystonia (ICD-10 code G24; prevalence, 0.61%; 95% CI, 0.612-0.613%), secondary parkinsonism (ICD-10 code G21; prevalence, 0.56%; 95% CI, 0.564-0.565%), Huntington's disease (ICD-10 code G10; prevalence, 0.09%; 95% CI, 0.091-0.092%), and ataxia (ICD-10 code R29; prevalence, 0.04%; 95% CI, 0.0451-0.0456).

Conclusion

Although the burden of MDs is expected to increase, MDs are likely underdiagnosed in rural areas. High-quality movement disorder training is essential to tackle this need.

Profile of neurological disorders in an adult neurology clinic in Kumasi, Ghana

BACKGROUND

Although the burden of neurological disorders is highest among populations in developing countries there is a dearth of data on the clinical spectrum of these disorders.

OBJECTIVE

To profile the frequency of neurologic disorders and basic demographic data in an adult neurology out-patient service commissioned in 2011 in Kumasi, Ghana.

METHODS

The study was conducted at the neurology clinic of the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Over a three year period, all medical records of patients enrolled at the out-patient neurology clinic was reviewed by a neurologist and neurological diagnoses classified according to ICD-10.

RESULTS

1812 adults enrolled for care in the neurology out-patient service between 2011 and 2013. This comprised of 882 males and 930 females (male: female ratio of 1.0: 1.1) with an overall median age of 54 (IQR, 39-69) years. The commonest primary neurological disorders seen were strokes, epilepsy and seizure disorders, and movement disorders at frequencies of 57.1%, 19.8%, and 8.2% respectively.

CONCLUSIONS

Cerebrovascular diseases, epilepsy and movement disorders were among the commonest neurological disorders and the major contributors to neurologic morbidity among Ghanaians in an urban neurology clinic.

The spectrum of neurological presentations in an outpatient clinic of rural Zimbabwe

BACKGROUND

Previous studies to estimate burden of neurological disorders in Africa are limited to inpatients in urban hospitals. The spectrum of neurological conditions in rural Africa remains unclear.

OBJECTIVE

To determine the spectrum of neurological presentations in an outpatient setting in rural Zimbabwe.

METHODS

Clinical data was collected from outpatient records at Karanda Mission Hospital, a rural community hospital in Northern Zimbabwe from February 2013 to February 2014. Each patient visit was entered in an outpatient record book by a registered nurse or a nurse trainee. Demographic details such as age, sex, weight and address of the patient, and clinical details such as diagnosis on discharge and medications prescribed were recorded in the record book following assessment by a physician or nurse practitioner. Each visit corresponded to a separate entry in the study.

RESULTS

We recorded a total of 19,206 visits in the outpatient registry. The average age was 46.41 years (standard deviation=21.46), and there were more visits from women (57.81%). 11.63% (2233) of all visits had a neurological diagnosis at discharge. The most common neurological diagnoses were epilepsy/seizures (24.38%), followed by neuropathies (13.63%), headaches (11.4%) and strokes (4.6%).

CONCLUSIONS

One in ten cases in an outpatient setting in rural Zimbabwe were neurologically related. Further studies are required to determine the public health burden of neurological disorders in rural Africa. The development and funding of educational initiatives in resource-limited areas is needed to improve neurological diagnosis and care.

The pattern of neurological diseases in elderly people in outpatient consultations in Sub-Saharan Africa

BACKGROUND

Neurological diseases are frequent in older adults, affecting between 5% and 55% of people age 55 and older. They are associated with a high risk for adverse health outcomes, including mortality, disability, institutionalization and hospitalization. Little is known about the epidemiology and clinical pattern of neurological disorders of the elderly in developing countries. Although many studies have demonstrated the areas where the burden of neurological diseases lies, elderly patients in Sub-Saharan Africa have received little attention. We performed this descriptive study to understand the burden of disease faced by Cameroonian neurologists and geriatricians.

METHODS

The records of all out-patient neurological consultations from May 2005 to December 2011 were collected at the Clinique Bastos, the sole clinic with adult neurological consultations during the study period in Yaoundé, the political capital of Cameroon. All medical records were reviewed by a neurologist and neurological diagnoses were classified according to ICD-10.

RESULTS

Among a total of 912 patients, 187 (20.5%) were aged 60 and older. According to the ICD-10 classification, episodic and paroxysmal disorders were present in 18.7% of patients, extrapyramidal and movement disorders in 14.6%, and nerve, nerve root and plexus disorders in 13.3%. The most common neurological diseases of the elderly in this study were lumbar arthrosis (14%), dementia (Alzheimer's type, vascular) (12.4%), Parkinson's disease (10.2%), and polyneuropathy (9.1%).

CONCLUSION

Degenerative diseases like dementia and Parkinson's disease as well as strokes and headaches are frequently encountered neurological diseases in elderly patients in Sub-Saharan Africa. It is important that standard treatment regimes, often Ministry of Public Health based, are adhered to these diseases.

Diagnostic work-up of neurological syndromes in a rural African setting: knowledge, attitudes and practices of health care providers

Background

Neurological disorders of infectious origin are common in rural sub-Saharan Africa and usually have serious consequences. Unfortunately, these syndromes are often poorly documented for lack of diagnostic tools. Clinical management of these diseases is a major challenge in under-equipped rural health centers and hospitals. We documented health care provider knowledge, attitudes and practices related to this syndrome in two rural health zones in Bandundu Province, Democratic Republic of Congo.

Methods

We used a qualitative research approach combining observation, in-depth interviews and focus group discussions. We observed 20 patient-provider contacts related to a neurological syndrome, conducted 12 individual interviews and 4 focus group discussions with care providers. All interviews were audiotaped and the transcripts were analyzed with the software ATLAS.ti.

Results

Care providers in this region usually limit their diagnostic work-up to clinical examination primarily because of the financial hurdles in this entirely out-of-pocket payment system. The patients prefer to purchase drugs rather than diagnostic tests. Moreover the general lack of diagnostic tools and the representation of the clinician as a “diviner” do not enhance any use of laboratory or other diagnostic methods.

Conclusion

Innovation in diagnostic technology for neurological disorders is badly needed in Central-Africa, but its uptake in clinical practice will only be a success if tools are simple, affordable and embedded in a patient-centered approach.

Rapid diagnostic tests for neurological infections in central Africa

Infections are a leading cause of life-threatening neuropathology worldwide. In central African countries affected by endemic diseases such as human African trypanosomiasis, tuberculosis, HIV/AIDS, and schistosomiasis, delayed diagnosis and treatment often lead to avoidable death or severe sequelae. Confirmatory microbiological and parasitological tests are essential because clinical features of most neurological infections are not specific, brain imaging is seldom feasible, and treatment regimens are often prolonged or toxic. Recognition of this diagnostic bottleneck has yielded major investment in application of advances in biotechnology to clinical microbiology in the past decade. We review the neurological pathogens for which rapid diagnostic tests are most urgently needed in central Africa, detail the state of development of putative rapid diagnostic tests for each, and describe key technical and operational challenges to their development and implementation. Promising field-suitable rapid diagnostic tests exist for the diagnosis of human African trypanosomiasis and cryptococcal meningoencephalitis. For other infections-eg, syphilis and schistosomiasis-highly accurate field-validated rapid diagnostic tests are available, but their role in diagnosis of disease with neurological involvement is still unclear. For others-eg, tuberculosis-advances in research have not yet yielded validated tests for diagnosis of neurological disease.

The spectrum of neurological disorders presenting at a neurology clinic in Yaoundé, Cameroon

Introduction

The burden of these neurological diseases is higher in developing countries. However, there is a paucity and scarcity of literature on neurological diseases in sub-Saharan Africa. This study was therefore undertaken to determine the pattern of neurological diseases in this setting and then, compare to those elsewhere in the African continent and also serve as a baseline for planning and care for neurological disorders in Cameroon.

Methods

The study was conducted at the Clinique Bastos, in Yaoundé, city capital of Cameroon, centre region. Over a period of six years, all medical records were reviewed by a neurologist and neurological diagnoses classified according to ICD-10.

Results

Out of 4526 admissions 912 patients (20.15%) were given a neurological diagnosis. The most frequent neurological disorders were headache (31.9%), epilepsy (9.86%), intervertebral disc disorder (7.67%), followed by lumbar and cervical arthrosis, polyneuropathy, stroke, Parkinson disease and dementia. According to ICD-10 classification, Episodic and paroxysmal disorders (headaches, epilepsy, cerebrovascular, sleep disorders) were observed on 424 (46.48%) patients; followed by nerve, nerve root and plexus disorders in 115 (12.6%) patients.

Conclusion

The above data emphasizes that neurological disease contributes substantially to morbidity in an urban African hospital. Headaches, epilepsy and intervertebral disc disorders are major causes of morbidity.

Validity of a screening instrument for neurologic disability in resource-poor African communities

BACKGROUND

There have been no recent population-based studies on all-cause adult neurological morbidity in sub-Saharan Africa. We have developed a screening survey to improve the feasibility in performing these studies.

METHODS

Our screening instrument contains both history questions and examination items. We pilot tested this instrument in the Hai District, Tanzania, and Butajira, Ethiopia using trained individuals from the local communities. To measure sensitivity, we applied the instrument blindly to 25 previously-identified subjects with Parkinson's disease, stroke or epilepsy. To measure specificity, we examined 42 randomly selected previously screened subjects. We also compared the validity of the entire instrument to the history-only section.

RESULTS

There were 669 adult subjects screened in both communities (150 screen-positives, and 519 screen-negatives). The sensitivity of the instrument was 100% (95% CI 84.2-100%) and the specificity was 82.4% (95% CI 66.1-92.0%). However, when restricting the instrument to the history-only section, the sensitivity remained unchanged, but the specificity became 91.2% (95% CI 76.3-97.7%; p=0.48).

CONCLUSIONS

We have created a valid tool to screen adults for neurologic morbidity in resource-poor communities. The use of the history-only section of the tool is adequate as a screen and will improve feasibility.

The spectrum of neurological disorders in a Zambian tertiary care hospital

OBJECTIVES

To define the spectrum of inpatient and outpatient neurological illness in a Zambian tertiary care facility where HIV is endemic.

METHODS

A retrospective period prevalence study of patients seen by the consulting neurologist between 1/2/06-12/20/06 at the University of Zambia's University Teaching Hospital (UTH).

RESULTS

443 inpatients and 368 outpatients were seen during this period. Overall, 160 (19.7%) patients underwent HIV testing: 125 (15.4%) HIV(+) and 35 (4.3%) HIV(-). The other 651 (80.3%) patients were untested. The most common inpatient neurological diseases among HIV(+) patients were infectious diseases 26 (38.8%), neuropathy/radiculopathy 10 (10.4%), cerebrovascular disease 6 (9.0%), and myelopathy 5 (7.5%). The most common inpatient neurological diseases in the general population were cerebrovascular disease 62 (16.5%), infectious diseases 47 (12.5%), neuropathy/radiculopathy 37 (9.8%), and seizures/epilepsy 27 (7.2%). In the outpatient population, the most common neurological illnesses in HIV(+) patients were neuropathy/radiculopathy 18 (31.0%), cerebrovascular disease 8 (13.8%), dementia/neurodegenerative 8 (13.8%), and encephalopathy 7 (12.1%). Outpatients in the general population most commonly had headaches/cephalgias 60 (19.4%), movement disorders 47 (15.2%), neuropathy/radiculopathy 43 (13.8%), and seizures/epilepsy 39 (12.6%).

CONCLUSIONS

HIV-infected individuals are a sizeable group among neurology patients in Zambia, and they are affected by a different disease spectrum than the general population. Infectious diseases make up the largest percentage of inpatient neurological illness. Non-infectious causes are responsible for the majority of outpatient neurological cases. Emphasis should be placed on treatment of both infectious and non-infectious neurological illnesses. The most common outpatient neurological conditions are symptomatically treatable with routinely available medications.

Neurological disorders in rural Africa: a systematic approach

Empirical knowledge suggests that neurological disorders are common in sub-Saharan Africa. The aims of our study were to assess the hospital-based prevalence of neurological disorders in a rural African setting and to suggest a systematic approach to disease classification. Of 8676 admissions (over a period of eight months) 740 patients (8.5%) were given a neurological diagnosis; cases were grouped according to diagnostic certainty. We suggest three major categories for neurological disorders (group 1 = no diagnostic uncertainties; group 2 = minor diagnostic uncertainties; group 3 = major diagnostic uncertainties) with clinical implications.