Frank Aiwansoba Imarhiagbe

Serum uric acid and acute stroke outcome in Nigerian Africans

Background : Serum uric acid (SUA) has long been recognized as a potent antioxidant in plasma and increasingly its prognostic value and therapeutic role in acute stroke has been proven in different population groups. Aim: To assess the role of admission SUA in acute stroke outcome in a Nigerian population. Setting: A tertiary neurologic care center in Nigeria. Design: Prospective observational study. Materials and Methods: Total 240 acute stroke patients aged 30-91 years with first-ever stroke had their blood samples taken consecutively for SUA and blood sugar within 48 hours of onset of stroke symptoms. All were followed-up for outcome within 42 days from the date of admission. Outcome was either discharged to follow-up and still in care or in-hospital death. Stroke subtypes were defined by cranial computed tomography (CT) scan; stroke severity was assessed by the admission Glasgow coma scale (GCS). Statistics: Age, sex, SUA, blood sugar and GCS were compared between the stroke outcome groups. SUA and stroke outcome was tested on simple logistic regression after adjustment for age above 60 years and elevated blood sugar above 200 mg/dl. The contribution of SUA, blood sugar, age, stroke subtype and GCS to time of all cause in-hospital mortality was tested on Cox regression. Results: 1) Mean SUA, age and blood sugar were higher and mean GCS was lower in the deceased group (P < 0.001, 0.001, 0.001 and 0.001). 2) SUA predicted poorer outcome of acute stroke after adjustment for age above 60 years and blood glucose level above 200 mg/dl (P = 0.045, n = 96). 3) SUA, blood glucose and age predicted time to in-hospital mortality (P < 0.001, 0.047, <0.001). Conclusion: SUA predicts poorer outcome and time to all cause in-hospital mortality in acute stroke and may also become a reliable surrogate of acute stroke outcome in Africans as shown in other populations.

Hypertriglyceridemia in Antiretroviral Therapy

Elevated serum triglycerides, total cholesterol, very low-density lipoprotein (VLDL) cholesterol, and low-density lipoprotein (LDL) cholesterol have been reported in the literature from areas where experience with antiretroviral drugs has amassed. Up until recently the use of antiretroviral drugs in Nigeria on a wide scale was a rarity owing largely to prohibitive cost, and so experience with its use was limited. Here we report 3 cases out of 11 followed up on antiretroviral drugs for a period of 6 months (June to November 2002) who had a steady rise in serum triglyceride level, as part of the initial 25 trial patients on free antiretroviral drugs supplied by the Nigerian federal government as a pilot study – an accelerated clinical trial of a combination of stavudine/lamivudine/nevirapine in the treatment of people living with HIV-AIDS in Nigeria – at the University of Benin teaching hospital, one of the designated centers for the treatment of HIV/AIDS. (Published: 12 September 2005) doi:10.1186/1758-2652-7-3-65 Full text: BioMed Central: http://www.biomedcentral.com/1758-2652/content/7/3/65 PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740787/

Cognitive function in patients with newly diagnosed HIV infection in a tertiary health facility in south – west Nigeria: Assessment using computer-assisted neuropsychological test battery

Introduction Cognitive dysfunction is common among patients with human immunodeficiency virus (HIV) infection however there are few reports from sub-Saharan Africa. Methods We studied fifty seropositive patients with human immunodeficiency virus (HIV) infection along with fifty matched seronegative control. Medical history taking and general physical and neurological examinations were done for all study participants. Laboratory evaluations and chest X-ray were done for all the patients. The cognitive function was done with the aid of ‘Fepsy’ automated test battery for all the study participants. The data was analyzed with statistical package for social sciences software version 21.0 (SPSS Chicago IL). Result About 70% of the HIV patients were in advanced disease stage. The auditory and visual reaction times, binary choice reaction times, and computerized visual scanning task time were more prolonged in the HIV group (p < 0.05). There were also increased memory accuracy and binary choice task accuracy in the HIV group (p < 0.05). However the vigilance task performance was similar between the two groups (p > 0.05). Among the patients with HIV infection, the presence of anemia and central nervous system toxoplasmosis infection was associated with prolonged auditory and visual reaction times. Conclusion There was a high rate of cognitive dysfunction in patients with HIV infection in this study.

Intellectual Impairment in Patients with Newly Diagnosed HIV Infection in Southwestern Nigeria

Neurocognitive impairment is a detrimental complication of HIV infection. Here, we characterized the intellectual performance of patients with newly diagnosed HIV infection in southwestern Nigeria. We conducted a prospective study at Owo Federal Medical Center by using the adapted Wechsler Adult Intelligence Scale (WAIS). The raw scores were converted to standardized scores (z-scores) and correlated with clinical and laboratory findings. Fifty-eight HIV positive patients were recruited; 72% were in WHO stages 3 and 4. We detected a high rate of intellectual impairment in HIV positive patients and controls (63.8% and 10%, resp.; P < 0.001). HIV positive patients performed worse throughout the subtests of both verbal and performance intelligence quotients. Presence of opportunistic infections was associated with worse performance in the similarities and digit symbol tests and performance and full scale scores. Lower body weight correlated with poor performance in different WAIS subtests. The high rate of advanced disease stage warrants measures aimed at earlier diagnosis and treatment. Assessment of neurocognitive performance at diagnosis may offer the opportunity to improve functioning in daily life and counteract disease progression.

Should non acute and recurrent headaches have neuroimaging before review by a Neurologist?--a review in a Southern Nigerian Tertiary Hospital.

BACKGROUND Headache is a common complaint in general practice and it is known that most headaches are primary and that the yield of neuroimaging like cranial computed tomography (CT) in headache is generally low. In this study, we were able to demonstrate that the yield of neuroimaging in non-acute and recurrent headache could be higher if cases are reviewed first by a specialist Neurologist before cranial CT. METHOD Seventy-four cases that were referred to the specialist neurology clinic with complaints of chronic and recurrent headaches without focal neurological deficit that had CT scan were reviewed consecutively using the short form of the International Classification of Headache Disorders second edition (ICHD 2) criteria after their demographics of age, sex were captured, to find out the proportion and characteristics of study cases that had identifiable cranial lesions on cranial CT scan. All cases were reviewed by a specialist Neurologist before CT scan and all CT films were reviewed by a specialist Radiologist. Age, sex and the distribution of CT findings were described from a frequency table and mean age of study cases with and without identifiable lesions on CT were compared with t-test for any significant difference and the effect of gender on the presence of identifiable lesions was tested with chi square and the agreement between clinical and CT diagnoses were tested on kappa statistics. RESULTS (1) Mean age of cases was 37.55 (22.06) years. (2) No significant effect of gender was found on intracranial lesions (P = 0.345). (3) Intracranial lesions were found in 47.3% of cases and the mean age was higher compared to cases with normal findings on cranial CT (P = 0.019). (4) Clinical and CT diagnoses agreed in 56.2% of the cases (P = 0.000). CONCLUSION The high yield of intracranial lesions may be accounted for by the method of selection of cases for cranial CT.

Cognitive functions in newly diagnosed patients with HIV infection in a tertiary health facility: Assessment using community screening interview for dementia

Introduction Neurocognitive dysfunction is a detrimental complication of HIV infection. In this study we attempt to characterize the pattern of cognitive dysfunction in a sample of Nigerian patients with newly diagnosed HIV infection. Methods We conducted a prospective study in which 50 patients with newly diagnosed HIV infection were studied along with 50 normal control subjects. The participants were evaluated with the medical history, general, physical and neurological examination. Laboratory evaluation and chest X-Ray were done for all patients. The Community Screening Interview for Dementia (CSID) questionnaire was administered to all the study participants. Results About 70% of the patients were in advanced disease stage. The mean age (SD) of the patients and controls in years were 36.44 ± 8.22 and 35.40 ± 11.53 respectively. More than half (56%) of the patients had secondary level of education (12 years of education). About 20% of the patients had severe neurocognitive impairment while 48% had minor neurocognitive disorder. The patients with HIV infection performed poorly in the domains of language, memory, orientation, attention/calculation and praxis relative to controls (p < 0.05).There were no significant effect of gender, age, sex and level of education on cognitive functions in the patients (p > 0.05) but the presence of opportunistic infections had negative impact on the performances on orientation and total CSID scores in the patients with HIV infection (p < 0.05). Conclusion Patients with newly diagnosed HIV infection have poor cognitive functions when compared to normal controls and some presence of opportunistic infections in the patient is a significant risk factor for cognitive impairment.

Burden of informal caregivers of stroke survivors: Validation of the Zarit burden interview in an African population

Background: Informal care giving can be burdensome particularly where the option of institutionalized informal care scarcely exist. Objective: To look at the burden of informal caregivers of stroke survivors using the Zarit burden interview (ZBI). Method: 64 stroke survivors were assessed for demographics of age, gender, duration of follow-up since discharged from in-patient care, modified Rankin score at the time of discharge and at the time of evaluation for this study and the most important informal care giver at home was also assessed for whether care giving was telling on their health or life in any negative way. All the caregivers were subsequently assessed with the ZBI. Results: Mean age of most important informal care givers was 40.67 ± 14.27 years and the sex distribution was 33(51.6%) female and 29(45.4%) males. 21(32.8%) reported that caregiving was a health burden. Mean ZBI scores were significantly higher (30.19 ± 14.81 vs 20.30 ± 12.96, P < 0.01) in those that reported that caregiving was telling on their health. ZBI overall rating of burden of caregiving was also significantly associated with whether caregiving was telling on the health of caregiver (P = 0.01) and also symmetrically agreed with whether the burden of caregiving was telling on health (k = 0.33, P< 0.01). The sensitivity and specificity of ZBI were 70% and 68.4% respectively on ROC statistics (AUC = 0.67, P = 0.017). Conclusion: Reported burden of informal caregiving of about 33% is in our opinion huge. The moderate sensitivity and specificity of the ZBI means it could be safely used in the population studied.

Adult stroke registry in West Africa: Profile of 334 in-patients in the University of Benin Teaching Hospital, Benin City, Nigeria

Background: Profiling of stroke types in sub-Saharan Africa until recently has been done in part with the clinical diagnosis, where neuroimaging is not affordable or accessible. Objective: To profile all first-ever stroke using cranial computed tomography (CT) scan. Methods: Three hundred and thirty-four first-ever stroke had demographic data as well as the duration of admission or time to event (outcome), stroke type and severity, volume of hemorrhage in cases of parenchymal hemorrhage captured from the stroke unit register. Operationally outcome was defined as discharge to follow-up or discharge against medical advice (DAMA) or all-cause in-hospital mortality, stroke type was defined by cranial CT as cerebral infarct or intracerebral hemorrhage (ICH) or subarachnoid hemorrhage. Stroke severity was defined by the Canadian Neurological Scale (CNS) and the National Institutes of Health Stroke Score (NIHSS). Data were analyzed as appropriate. Results: Mean age was 62.63 ± 14.90 years, comprising 190 (56.9%) males and 144 (43.1%) females. Mean duration of admission was 12.91 ± 11.38 days. Totally, 251 had cerebral infarct (75.15%), 81 (24.25%) had ICH, 2 (0.60%) had subarachnoid hemorrhage. A total of 177 (51.19%) were discharged to follow-up, 15 (4.50%) were DAMA with acute case fatality of 148 (44.31%). Mean CNS score was 2.85 ± 2.57 and mean NIHSS was 17.29 ± 5.15. Age, time to outcome and NIHSS were the predictors of outcome (survival or discharged to follow-up and all-cause mortality) (odds ratio [OR] =1.043, P = 0.016, OR = 0.923, P = 0.001, OR = 2.467, P < 0.001 respectively) and NIHSS was the only predictor of survival (hazard ratio = 0.872, P < 0.001). Conclusion: This neuroimaging profiling of acute stroke type and outcome is expected to be an improvement over reviews based largely on the presumptive diagnosis.

Headache associated with sexual activity: From the benign to the life threatening

Background: Neurologic syndromes like headache may on occasion complicate sexual activity. Though largely benign, the headache may seldom be a symptom of an underlying sinister and life threatening neurologic disorder such as aneurysmal subarachnoid heamorrhage. Method: Relevant published materials on the subject of headache associated with sexual intercourse and their cross references from Pubmed Medline, Cochrane Library, International Headache society, EMBASE and other relevant bibliographic repositories were ferreted since 1980 till date. Result: HAS is mainly a diagnosis of exclusion. The secondary or malignant form has a course that is dictated by its underlying cause. HAS in the primary or benign form is amenable to treatment with drugs including indomethacin, propranolol and calcium channel blockers (nimodipine, verapamil and diltiazem) with excellent prognosis. Conclusion: Early evaluation for underlying cause of HAS and institution of appropriate treatment is recommended.

Post-stroke depression in a sub-Saharan Africans: Validation of the Japanese Stroke Scale for Depression

Background: Japanese Stroke Scale for Depression (JSS-D) is not a validated instrument for post stroke depression (PSD) in sub-Saharan Africans. Methods: Ninety-two subjects on follow-up in a stroke clinic were consecutively assessed for demographic and clinical variables, and all were subsequently assessed for depression with the JSS-D. Functional ability was assessed with Rankin score and good functional recovery was defined as Rankin score of ≤2. Stroke type was determined using cranial computed tomography or magnetic resonance imaging as cerebral infarct or intracerebral hemorrhage. Data was compared between subjects with and without PSD. Symmetric agreement between JSS-D and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria for depression was compared on Cohens kappa statistics and the sensitivity, specificity of JSS-D was tested on a receiver operated characteristics (ROC) curve. Results: PSD occurred in 17 (18.5%) of study subjects. Mean age was not significantly different between PSD and no PSD, P = 0.226, but there was a difference in the sex distribution (P = 0.034) with a male sex preponderance for both groups. Rankin score was higher in PSD and significantly different both at discharge and the time of evaluation (P = 0.019 and 0.003). JSS-D agreed with DSM IV criteria for mild depression significantly on Cohens kappa statistics, kappa = 0.69, P < 0.0001. The sensitivity and specificity of JSS-D on ROC curve were 94.1% and 97.2% respectively at a JSS-D cut-off value of 2.37, area under the curve = 0.99, P = < 0.0001. Conclusion: JSS-D could be used for PSD with acceptable sensitivity and specificity in sub-Saharan Africans.