Epidemiology, clinical features and outcome of stroke in rural versus urban hospitals in Cameroon.

OBJECTIVES: Stroke is a major public health problem worldwide with disparities between urban and rural areas. The aim of this study was to compare the epidemiological, clinical features and outcomes of stroke between rural and urban hospitals in Cameroon. MATERIALS AND METHODS: We conducted a retrospective cohort study at the Douala General Hospital (urban) and Ad Lucem Hospital of Banka (rural) from January 1st, 2014, to December 31st, 2019. The medical records of all patients admitted for stroke, and meeting the inclusion criteria were reviewed. Diagnosis of stroke was based on brain imaging and/or the World Health Organization definition. Data were analyzed using SPSS version 20.0. RESULTS: Among the 15277 files reviewed, 752 were included with 623 cases (82.80%) in urban areas. The percentage of patients hospitalized for stroke were 9.06% and 2.85% in urban and rural hospitals respectively. The frequency of patients admitted for severe stroke (Glasgow coma scale ≤ 8) was higher in the rural hospital (p = 0.004). In-hospital mortality (p = 0.010), cumulative mortality at one-month (p = 0.018), poor functional recovery (p = 0.002), one-year stroke recurrence (p = 0.020) were significantly higher in rural setting. Undefined stroke was predictor of mortality in the rural hospital, while hemorrhagic stroke was predictor of mortality at one-month in the urban hospital. CONCLUSIONS: Stroke cases were significantly more severe with poor outcomes in the rural hospital. Efforts are needed to improve prevention, and access to stroke care for communities, especially in rural setting.

Diagnosis and treatment challenges of autism spectrum disorder at a reference hospital in Douala, Cameroon.

BACKGROUND: Autism spectrum disorder (ASD) is a neurodevelopmental disability associated with deficiency in social interaction, unusual development of social communication, and restricted or repetitive behaviors, interests and activities. This study aimed to describe management of pediatric ASD in Cameroon, a resource-constrained Central Africa country. METHODS: A retrospective study was conducted between December 2021 and May 2022 at the Pediatrics department of a reference hospital in the town of Douala. Data of interest of children with ASD were collected through eligible medical records and telephone discussions with their parents/guardians. RESULTS: Medical records of 145 children with ASD aged 2-15 years were included in the study, giving a hospital ASD prevalence of 3.7%. Time delay between parental concerns and hospital management was specified in 69 (47.58%) children, and among them 38 (55.07%) had a mean delay ± SD was less than five months. Children were mainly males (76%) and aged 4-5 years (37.93%), with mean age ± SD of 44.4 ± 22.2 months old. The main consultation reason was delayed language development (100%). Mean time delay between parental concerns and the first medical consultation was 18 months (range 1-60 month). Attention deficit hyperactivity disorder were found in 68.18% of children aged ≥ 6 years old. Neuropsychology (66.2%) was the most frequently used intervention. Some children were treated using traditional medicine. CONCLUSIONS: Management of pediatric ASD is strongly influenced by socioeconomic and cultural context. It is crucial to implement behavioral change campaigns in community, organize training sessions to medical staff on diagnosis and treatment of ASD, and provide specialized centers with skilled staff and equipped material.

The prognostic value of serum uric acid in the acute phase of hemorrhagic stroke patients in black Africans.

INTRODUCTION: Very few studies have been conducted to evaluate the prevalence of hyperuricemia and its impact on the prognosis amongst acute hemorrhagic stroke (AHS) patients. The objectives was to determine the prevalence of hyperuricemia in AHS patients and examined the association between hyperuricemia and stroke outcomes in the Douala General Hospital (DGH). METHODS: This was a hospital based prospective cohort which included AHS patients with baseline SUA levels and 3 months post stroke follow-up data. SUA values were divided into quintiles. Associations between hyperuricemia and stroke outcomes were analyzed using multiple logistic regression and survival analysis (cox regression and Kaplan Meier). RESULTS: A total of 221 AHS patients were reviewed with a mean age of 55.8±11.8 years. The prevalence of hyperuricemia among AHS patients was 34.4% with mean SUA level of 376.8±131.9 µmol/l. On multivariate analysis, hyperuricemia was not independently associated with early death [(OR = 1.072 (CI: 0.370-3.056; p = 0.897)] and poor functional outcome [(OR=2.487 (CI: 0.771-8.699; p = 0.154)] after hemorrhagic stroke. No significant increase in stroke deaths was observed across higher SUA quintiles amongst hemorrhagic stroke patients (p = 0.326). No statistically significant correlation was observed between SUA level and NIHSS (r = 0.063, p = 0.353) and between SUA level and mRS (r = 0.030, p = 0.662) in hemorrhagic stroke. CONCLUSION: About one third of patients present with hyperuricemia in the acute phase of hemorrhagic stroke. Hyperuricemia can act as risk factor for stroke because of its relationship with CVRFs but hyperuricemia has no impact on the severity and short-term outcome amongst black African hemorrhagic stroke patients.

Acute Stroke Patients with Newly Diagnosed Diabetes Mellitus Have Poorer Outcomes than Those with Previously Diagnosed Diabetes Mellitus.

BACKGROUND: Diabetes mellitus (DM) is associated with poor outcomes in acute stroke patients (ASPs). This study aims to determine the prevalence of NDDM in the ASPs and to compare the outcome in NDDM and previously diagnosed DM (PDDM) in Cameroon. METHODS AND MATERIALS: This was a hospital-based prospective cohort study that included ASPs with NDDM and PDDM. Outcome data were collected within 3 months of stroke onset. Chi-square and t tests were used for comparisons, whereas survival analysis was performed using Cox regression and Kaplan-Meier analysis. RESULTS: Of the 701 ASPs included, 24.8% had PDDM (n = 174) and 9.4% NDDM (n = 66). NDDM had a higher mortality rate on admission and 3 months after stroke (P < .05). PDDM were more likely to survive within 3 months after stroke onset (log-rank test P = .008). The risk of dying among NDDM was increased (adjusted hazard ratio = 1.809; 95% confidence interval: 1.1532.839; P = .010). NDDM were more likely to have higher mean National Institutes of Health Stroke Scale and modified Rankin score (P < .05) on admission. PDDM were more likely to develop urinary tract infections during hospitalization (P = .015). There was no significant difference between functional outcome on admission and 3 months after stroke (P > .05). CONCLUSION: NDDM are associated with increased mortality and are more likely to have poorer functional outcomes and more severe stroke than those with PDDM.

The Prognostic Value of Serum Uric Acid in the Acute Phase of Ischemic Stroke in Black Africans.

BACKGROUND: The association between hyperuricemia and stroke outcome still remains controversial worldwide. This study aims to determine the prevalence of hyperuricemia and its association with the outcome of patients with acute ischemic stroke in a tertiary care hospital. METHODS: This was a hospital-based prospective cohort study that included patients with ischemic stroke with baseline uric acid levels and 3-month post-stroke follow-up data. Associations between hyperuricemia and stroke outcomes were analyzed using multiple logistic regression, Kaplan-Meier, and Cox proportional hazards regression analysis. RESULTS: A total of 480 patients were reviewed with a mean age of 62.8 ± 13.3 years. The prevalence of hyperuricemia was 52.3% with mean uricemia of 71.1 ± 25.3 mg/dL. There was a significant association between hyperuricemia and mortality with unadjusted odds ratio (OR) = 4.120 [95% (confidence interval [CI]: 2.466-7.153); P = .001)], but on multivariate analysis, hyperuricemia was not an independent predictor of stroke mortality [OR = 1.270 (CI: .547-2.946); P = .578)]. An independent association between increasing uric acid levels and mortality was noted on Cox proportional hazards regression; adjusted hazard ratio (95% CI) of 3.395 (2.114-5.452), P value greater than .001. Stroke mortality significantly increased across higher uric acid quintiles in patients with acute stroke (P < .001). Hyperuricemia was an independent predictor of poor functional outcome within 3 months after stroke with adjusted OR (95% CI) of 2.820 (1.359-5.851); P = .005. CONCLUSIONS: Half of black African patients with ischemic stroke present with hyperuricemia, and hyperuricemia is a predictor of mortality and adverse functional outcomes. Further studies are therefore warranted to determine whether reducing hyperuricemia after stroke would be beneficial within our setting.

Gender-Related Differences and Short-Term Outcome of Stroke: Results from a Hospital-Based Registry in Sub-Saharan Africa.

BACKGROUND: Studies suggest that sex differences have an impact on patients with stroke, but existing data in Africa remain inconclusive about this inference. OBJECTIVES: To study sex differences in terms of the clinical profile and short-term outcome of stroke in the Douala General Hospital, Cameroon. METHODS: A hospital-based prospective cohort study was carried out in a tertiary care hospital over an 8-year period, which included all patients admitted for confirmed acute stroke. Information about the history of stroke with emphasis on clinical profile and outcome was collected. Descriptive statistics, t test, and chi square test were used for comparisons, while the Kaplan-Meier curve was used for survival rate analysis. RESULTS: Of the 818 patients included, 455 (55.6%) were male patients. When compared to males, female patients are more likely to experience a stroke at an older age (mean age 62.3 ± 14.1 vs. 58.4 ± 12.9 years, p < 0.001), to be unmarried, to remain unemployed, and to have higher rates of cardio-embolic stroke (p = 0.049), body mass index (p = 0.031), altered levels of consciousness at presentation (p = 0.005), higher mean HDL cholesterol levels (p = 0.001), and in-hospital complications (p = 0.011), especially urinary tract infections (p = 0.018). Males were more likely to have health insurance, to smoke, to consume alcohol (p < 0.001), and to have higher rates of dysarthria (p = 0.004), higher mean uric acid (p = 0.013), and creatinine (p < 0.001) concentrations. Ischemic and hemorrhagic strokes were more prevalent in men (p = 0.003). There are no sex differences in terms of stroke severity, length-of-hospital stay, case fatality, and functional outcome on admission. CONCLUSIONS: Sex differences exist in the clinical profile of stroke but not in the outcome. Knowledge of these differences could help influence stroke prevention, thereby improving stroke burden in Africa.

Sero-prevalence and Correlates of Hepatitis B and C Co-infection Among HIV-infected Individuals in Two Regional Hospitals in Cameroon.

BACKGROUND: Liver disease related to Hepatitis B (HBV) and C (HCV) infection has become a major cause of morbidity and mortality in HIV/AIDS patients. Data on the prevalence of HBV and HCV in Cameroon remains inconclusive. OBJECTIVE: We aimed to determine the sero-prevalence and correlates of Hepatitis markers in HIV/AIDS patients in two Regional Hospitals. METHODS: A cross-sectional study carried out from December 2014 to March 2015. HIV/AIDS patients aged 21 were included and above, receiving care at HIV treatment centres. Data was collected using a structured questionnaire. Blood samples were collected to screen for Hepatitis with HBsAg and anti HCV antibody rapid immunochromatographic test kits. Correlates of hepatitis were investigated by logistic regression. STATA was used for data analysis. RESULTS: We included 833 HIV/AIDS patients,78.8% (657) were female. Mean age was 44(SD 11) years. Prevalence of Hepatitis in general (total of two viral markers tested) was 8.9% (74/833), with 6.1% for HBsAg and 2.8% for Anti-HCV antibodies. From multivariate analysis, the likelihood of having hepatitis was independently increased by a history of surgical interventions [OR: 1.82(1.06-3.14)], and of sexually transmitted infections [OR: 2.20(1.04-4.67)]. CONCLUSION: Almost one in ten participants with HIV/AIDS attending the BRH and LRH tested positive for either HBsAg or anti HCV antibodies. Screening for HBV and HCV should therefore be integrated to the existing guidelines in Cameroon as it can influence management. More studies are needed to evaluate the extent of liver disease and magnitude of HIV suppression in hepatitis and HIV coinfection in this setting.

[Incidence of strokes in HIV-positive patients treated with long term antiretroviral treatment]. / Incidence des accidents vasculaires cérébraux chez les patients VIH positifs sous traitement antirétroviral au long court.

INTRODUCTION: With the introduction of triple therapy regimen in 1996, the morbidity and mortality associated with HIV infection decreased significantly. Concomitantly with this clinical success, several metabolic changes including diabetes, arterial hypertension, dyslipidemia and lipodystrophy were observed, being associated with the risk of stroke. This study aims to determine the incidence of strokes in HIV-positive patients treated with long term antiretroviral treatment. METHODS: This was a retrospective cohort study of HIV-positive adult patients receiving long term antiretroviral treatment for at least 12 months. It was conducted at the Approved Treatment Centres of Douala General Hospital (HGD); data collection spanned a 10-year period from May 2001 to April 2010. Patients were treated according to Cameroon national treatment guidelines. The Kaplan-Meyer method was used to determine the time of stroke onset. The Khi-2 test was used to investigate the association between two qualitative variables. The statistical significance level was set at 0.05. RESULTS: 407 patients were included in the study, 62.4% were female, the average age was 40.1 ± 9.9 years. The incidence of strokes was 1.7% over 72 months follow up with no significant difference between women and men (P = 0.76). The incidence rate was calculated to be 0.3 per 100 person years. 85.7% of cases had an ischemic stroke. The mean time from stroke onset was 33.4 months. Factors associated with stroke occurrence were: patients who underwent treatment at WHO Clinical Stage III and IV and with CD4 count> 100/mm3at the start of antiretroviral therapy. CONCLUSION: The incidence of stroke in HIV-positive patients treated with long term antiretroviral therapy is similar to that previously reported but these strokes occur at an early age and justify increased clinical monitoring. A prospective study involving a control population is needed.

Comparison of the clinical profile of Parkinson's disease between Spanish and Cameroonian cohorts.

BACKGROUND: There are limited data in terms of the clinical profile of Parkinson's disease in sub-Saharan African patients. OBJECTIVE: To compare the clinical profile and access to standard antiparkinsonian therapies of a Cameroonian cohort of patients with an age, sex, and disease duration-matched Spanish cohort (Longitudinal Study of Parkinson's disease, ELEP). METHODS: Observational, cross-sectional design. Demographic data were collected and the following ELEP assessments were applied: Scales for Outcomes in Parkinson's disease (SCOPA) Motor, Autonomic, Cognition, Sleep and Psychosocial; Hoehn and Yahr staging; modified Parkinson Psychosis Rating Scale; Cumulative Illness Rating Scale-Geriatrics; Hospital Anxiety and Depression Scale; pain and fatigue visual analog scales; Zarit, and EuroQoL. RESULTS: 74 patients with idiopathic Parkinson's disease were included (37 from each country) with a mean age of 64.4±10.5 years old, 70.3% males, and mean disease duration of 5.6±5.9 years. Compared to the Spanish cohort, Cameroonians were intermittently treated, less frequently received dopaminergic agonists (p<0.001), had a trend for taking lower doses of levodopa (p=0.06), and were more frequently on anticholinergics (p<0.0005). Cameroonians were more severely impaired in terms of motor (Hoehn Yahr stage, p=0.03; SCOPA-Motor, p<0.001), cognitive status (p<0.001), anxiety and depression (p<0.001), psychosis (p=0.008), somnolence, fatigue and pain (p<0.001, respectively), caregiver burden (p<0.0001), and quality of life (p=0.002). Instead, autonomic, comorbidity, and nocturnal sleep problems were similarly found. CONCLUSIONS: Limited and intermittent access to dopaminergic drugs has a negative impact on motor symptoms, nonmotor symptoms and quality of life in patients with Parkinson's disease and their caregivers.

Cryptococcal meningoencephalitis in human immunodeficiency virus/acquired immunodeficiency syndrome in douala, cameroon: a cross sectional study.

BACKGROUND: Cryptococcal meningoencephalitis (CM) kills about half a million human immunodeficiency virus (HIV) patients per year, mostly in Africa. AIM: The aim of this study was to determine the prevalence, clinical presentation and in-hospital outcome of CM among HIV-infected patients in Douala. MATERIALS AND METHODS: A cross-sectional clinical note review of 672 HIV-1 patients' files admitted from January 1 (st) 2004 to December 31 (st) 2009 at the Internal Medicine unit of the Douala General Hospital, Cameroon was performed. Only patients diagnosed of CM by microscopy of Indian ink stained cerebrospinal fluid (CSF) were studied. RESULTS: The prevalence of CM in the study was 11.2%. Mean age of patients was 36.9 ΁ 12.7 years. Median cluster of differentiation 4 (CD4) cell count was 23 cells/µL, (interquartile range [IQR]: 10-61) and 62.7% of CD4 cell counts were >50 cells/µL. The most prevalent symptom was headache in 97.3% of patients. In CSF, median proteins was 0.9 g/L (IQR: 0.6-1); median glucose 0.2 g/L (IQR: 0.1-0.3) and median leucocyte count 54 cells/µL (IQR: 34-76) mostly of mixed cellularity. The case fatality rate was 52% and low CD4 cell count was strongly associated with death, odd ratio 4.6 (95% confidence interval: 2.6-8.0, P > 0.001). CONCLUSION: The high case fatality of CM in Douala warrants adequate diagnostic measures and optimization of standardized treatment to reduce mortality.

Toxoplasma encephalitis in HIV/AIDS patients admitted to the Douala general hospital between 2004 and 2009: a cross sectional study.

BACKGROUND: It is estimated that about a third of the world's population is chronically infected with Toxoplasma gondii. Toxoplasma encephalitis (TE), which occurs as a reactivation of quiescent chronic infection, is one of the leading causes of central nervous system (CNS) infection in AIDS. Its diagnosis in most centres still remains difficult. We opted to describe the clinical and radiological features of TE as well as in-hospital outcome and its associated factors. METHODS: We carried out a cross sectional study on the clinical case notes of adult patients admitted and treated for TE at the Douala General Hospital, Cameroon between January 1st 2004 to December 31st 2009. RESULTS: Of 672 patients admitted during the study period, 14.4% (97/672) had TE. The mean age was 36.9 ± 14.1 years and the median CD4 cell count was 68/mm3 (IQR): 43 - 103). Headache and fever were the most common presenting symptoms in 92.8% (90/97) and 87.6% (85/97) of patients. Annular contrast enhanced lesions were the most common brain scan finding in 81.4% (79/97) of patients. In-hospital mortality was 29.9% (29/97). Altered sensorium, presence of focal signs, neck stiffness and low CD4 cell count were factors associated with mortality. Adjusting for low CD4 count, altered sensorium remained strongly associated with fatality, adjusted odd ratio (AOR) 3.5 (95% CI 1.2 - 10.5). CONCLUSION: Toxoplasma encephalitis is common among AIDS patients in Douala. Its high case fatality warrants adequate and compliant prophylactic therapy in severely immune depressed patients as well as early initiation of antiretroviral therapy in HIV-infected patients.

HIV-Associated Central Nervous System Disease in Patients Admitted at the Douala General Hospital between 2004 and 2009: A Retrospective Study.

Background. Studies on HIV-associated central nervous system (CNS) diseases in Cameroon are rare. The aim of this study was to describe the clinical presentation, identify aetiological factors, and determine predictors of mortality in HIV patients with CNS disease. Methods. From January 1, 2004 and December 31, 2009, we did at the Douala General Hospital a clinical case note review of 672 admitted adult (age ≥ 18 years) HIV-1 patients, and 44.6% (300/672) of whom were diagnosed and treated for HIV-associated CNS disease. Results. The mean age of the study population was 38.1 ± 13.5 years, and median CD4 count was 49 cells/mm(3) (interquartile range (QR): 17-90). The most common clinical presentations were headache (83%), focal signs (40.6%), and fever (37.7%). Toxoplasma encephalitis and cryptococcal meningitis were the leading aetiologies of HIV-associated CNS disease in 32.3% and 25% of patients, respectively. Overall mortality was 49%. Primary central nervous system lymphoma (PCNSL) and bacterial meningitis had the highest case fatality rates of 100% followed by tuberculous meningitis (79.8%). Low CD4 count was an independent predictor of fatality (AOR: 3.2, 95%CI: 2.0-5.2). Conclusions. HIV-associated CNS disease is common in Douala. CNS symptoms in HIV patients need urgent investigation because of their association with diseases of high case fatality.

HIV-associated sensory neuropathy in HIV-1 infected patients at the Douala General Hospital in Cameroon: a cross-sectional study.

BACKGROUND: Peripheral neuropathy (PN) which is the most common neurological complication of HIV infection is under recognised and undertreated especially in resource limited settings. This ailment which has a negative impact on the quality of life of HIV/AIDS patients exists in different clinical patterns of which HIV-associated Sensory neuropathy (HIV-SN) is the most common affecting up to two thirds of patients with advanced disease in some settings. In Cameroon where HIV is a major public health problem, the burden of HIV-SN has not yet been well defined. METHODS: Using the Brief Peripheral Neuropathy Screening (BPNS) tool validated by the AIDS Clinical Trial Group (ACTG) we carried out a cross sectional study to determine the prevalence of HIV-SN and its associated factors among HIV-1 patients at the Douala General Hospital between 1st July and 31st October 2011. HIV-SN was defined as the presence of neuropathic symptoms and at least an abnormal perception of vibrations of a 128Hz tuning fork on the great toe or abnormal ankle reflexes or both and expressed as a percentage of the study population. RESULTS: Out of 295 patients studied, 21% had HIV-SN. In HIV-SN patients the median duration of HIV infection was 79.8 months (IQR 46 - 107.5) and their median CD4 count 153cells/µL (IQR 80 - 280). Patient recall and clinical chart review showed that, 83.9% had neuropathic symptoms prior to HAART initiation and 16.1% after HAART initiation. Low CD4 count, history of alcohol intake and history of anti-tuberculosis treatment were strongly associated with HIV-SN (AOR 2.5, 2.8 and 2.9 respectively). CONCLUSIONS: HIV-SN is common among patients with advanced HIV infection in Cameroon. This simple diagnostic tool (BPNS) should therefore be routinely used to detect those with HIV-SN or at risk so as to minimise the negative impact it has on their quality of life.

Determinants of retention in care in an antiretroviral therapy (ART) program in urban Cameroon, 2003-2005.

BACKGROUND: Retention in long-term antiretroviral therapy (ART) program remains a major challenge for effective management of HIV infected people in sub-Saharan Africa. Highly Active Antiretroviral Therapy (ART) discontinuation raises concerns about drug resistance and could negate much of the benefit sought by ART programs. METHODS: Based on existing patient records, we assessed determinants of retention in HIV care among HIV patients enrolled in an urban ART at two urban hospitals in Cameroon. Extended Cox regression procedures were used to identify significant predictors of retention in HIV care. RESULTS: Of 455 patients, 314 (69%) were women, median (IQR) age and baseline CD4 cell count were respectively 36 years (30 - 43) and 110 cells/µL (39 - 177). Forty patients (9%) had active tuberculosis (TB) at enrollment. After a median (IQR) follow-up of 18 months (10-18), 346 (75%) were still in care, 8 (2%) were known dead, and 101 (22%) were lost to follow-up (LFU). Severe immunosuppression (CD4 cell count ≤ 50 cells/µL) at baseline (aHR 2.3; 95% CI 1.4 - 3.7) and active tuberculosis upon enrollment (aHR 1.8; 95% CI 1.0 - 3.6) were independent predictors of cohort losses to follow-up within the first 6 months after HAART initiation. CONCLUSION: These data suggest that three-quarter of HIV patients initiated on HAART remained in care and on HAART by 18 months; however, those with compromised immunologic status at treatment initiation, and those co-infected with TB were at increased risk for being lost to follow-up within the first 6 months on treatment.