Current clinical presentations of AIDS dementia in a tropical environment: study of 26 observations in the neurology department of the University Hospital of Conakry.

INTRODUCTION: In sub-Saharan Africa (SSA), the clinical and progressive diagnostic certainty of AIDS dementia is difficult to establish due to under-medicalization and delays in consultation and especially the diversity of etiologies of demented states. MATERIAL AND METHODS: We carried out a retrospective study of 196 patients hospitalized for dementia syndrome between 2016 and 2021 in the neurology department of the University Hospital of Conakry. The criteria labeled in this study are those retained by the DSM-IV and the classification of the American Academy of Neurology (AAN) developed in accordance with the WHO. RESULTS: HIV etiology was identified in patients aged 44-67 years (17 women and 19 men). The clinical picture was dominated by severe cognitive disorders, slowed ideation, memory disorders and reduced motor skills associated with personality changes. Neurological examination revealed dysphoric disorders in most patients, sphincter abnormalities in 13 cases and labio-lingual tremor in 11 cases. Diagnosis was based on positive serological tests for HIV1 antibodies (25 cases) and HIV2 antibodies (1 case) using the Elisa and Western blot techniques, and the presence of discretely hypercellular CSF. Magnetic resonance imaging contributed to the diagnosis, showing diffuse white matter abnormalities with hyper signals on T2-weighted or FLAIR sequences. CONCLUSION: This study shows a non-stereotype clinical picture of AIDS dementia requiring a differential diagnosis with other infectious dementias. These results are important for the therapeutic and prognostic discussion.

COVID-19 vaccine acceptance and hesitancy in N'Djamena, Chad: A cross-sectional study of patients, community members, and healthcare workers.

As of March 2022, the COVID-19 vaccination rate in Chad approximated 1%. There are no published reports of COVID-19 vaccine hesitancy or beliefs in Chad. We aimed to study COVID-19 vaccine acceptance and hesitancy among community members, patients, and health care workers in urban Chad. We recruited a prospective convenience sample of adult patients, community members, and healthcare workers from N'Djamena, Chad between August-October 2021. Participants completed a 15-minute, 25-question survey instrument exploring demographic, social, and clinical variables related to COVID-19 and an adapted WHO SAGE Vaccine Hesitancy Survey. Primary outcomes were vaccine acceptance and vaccine hesitancy. Regression models were fit to assess associations between Vaccine Hesitancy Scale (VHS) scores, ranging from 10 (least hesitant) to 50 (most hesitant) points, and pre-selected variables of interest. An inductive thematic analysis was used to analyze the qualitative vaccine hesitancy responses. Of 508 participants (32% female; mean age 32 years), 162 were patients, 153 were community members, and 193 were healthcare workers. COVID-19 vaccine acceptance was significantly higher among patients (67%) than community members (44%) or healthcare workers (47%), p < .001. The average VHS score was 29 points (patients = 27.0, community members = 28.9, healthcare workers = 29.4), and more than one-third of participants were classified as highly vaccine hesitant (score >30 points). Knowing someone who died from COVID-19, believing local healthcare workers support vaccination, trusting the government, having a higher socioeconomic status (i.e. having electricity), and reporting medical comorbidities were each associated with less vaccine hesitancy (all p < .05). The vaccine concerns most frequently endorsed were: vaccine side effects (48%), efficacy (38%), safety (34%), concerns about the pharmaceutical industry (27%), and lack of government trust (21%). Four main themes arose from qualitative vaccine hesitancy responses (n = 116): education, trust, clinical concerns, and misinformation and false beliefs. Overall, COVID-19 vaccine acceptance was low, including among health care workers, and reasons for vaccine hesitancy were broad. We detail the most commonly reported concerns of urban Chadians for receiving the COVID-19 vaccine; we also identify subgroups most likely to endorse vaccine hesitancy. These analyses may inform future vaccination outreach campaigns in N'Djamena.

Epilepsy stigma in the Republic of Guinea and its socioeconomic and clinical associations: A cross-sectional analysis.

OBJECTIVE: We aim to quantify the degree of epilepsy stigma perceived by people living with epilepsy (PLWE) in the Republic of Guinea (2019 gross national income per capita, 930 USD) and analyze the demographic, social, and clinical factors associated with epilepsy stigma in this setting. METHODS: A prospective convenience cohort of PLWE was recruited at the Ignace Deen Hospital in Conakry and evaluated by U.S. and Guinean neurology-trained physicians. A survey instrument exploring demographic, social, and clinical variables was designed and administered. The primary outcome measure was the Stigma Scale of Epilepsy (SSE), a 24-item scale with scores ranging from 0 (least stigma)-100 (most). Regression models were fit to assess associations between SSE score and pre-selected demographic, social, and clinical variables of interest. RESULTS: 249 PLWE (112 female; mean age 20.0 years; 22 % from rural locales; 14 % of participants >16 years old with no formal schooling; 11 % seizure-free for >=6 months) had an average SSE score of 46.1 (standard deviation = 14.5) points. Children had an average SSE score of 45.2, and adults had an average score of 47.0. There were no significant differences between self- and guardian-reported SSE scores (means = 45.8 and 46.5, respectively), p = .86. In univariate analyses, higher stigma scores were associated with more seizures (p = .005), more depressive symptoms (p = .01), and lower household wealth (p = .03). In a multivariable model including sex, educational level, household wealth, generalized tonic-clonic seizures, seizure frequency, and seizure-related burns, only higher seizure frequency (ß = -2.34, p = .03) and lower household wealth (ß = 4.05, p = .03) were significantly associated with higher SSE scores. CONCLUSION: In this Guinean cohort of people living with poorly-controlled epilepsy, there was a moderate degree of perceived stigma on average. Stigma was associated with higher seizure frequency and lower household wealth-both potentially modifiable factors.

Availability of Therapies and Services for Parkinson's Disease in Africa: A Continent-Wide Survey.

BACKGROUND: The growing burden of Parkinson's disease (PD) in Africa necessitates the identification of available therapies and services to improve patient care. OBJECTIVE: To investigate the availability, affordability, frequency of usage, and insurance coverage of PD therapies (pharmacological, surgical, physical, and speech therapies) and services including specialized clinics, specialists, and nurses across Africa. METHODS: A comprehensive web-based survey was constructed and distributed to neurologists/physicians with a special interest in PD across Africa. The survey instrument includes components that address availability, affordability, frequency of use, and insurance coverage of different therapies and services. RESULTS: Responses were received from 28 (of 43 contacted) countries. Levodopa-based oral preparations were always available in 13 countries (46.4%) with variable affordability and "partial or no" insurance coverage in 60% of countries. Bromocriptine was the most available (50%) and affordable ergot dopamine agonists (DA), whereas non-ergot DA was always available in only six countries (21.4%). Trihexyphenidyl was the most available and affordable anticholinergic drug (46.4%). Tricyclic antidepressants and selective serotonin reuptake inhibitors were available in most countries (89.3% and 85.7% respectively), with variable affordability. Quetiapine and clozapine were less available. Specialized clinics and nurses were available in 25% and 7.1% of countries surveyed, respectively. Other services were largely unavailable in the countries surveyed. CONCLUSION: PD-specific therapies and services are largely unavailable and unaffordable in most African countries. The data provide a platform for organizing strategies to initiate or scale up existing services and drive policies aimed at improving access to care and tailoring education programs in Africa. © 2021 International Parkinson and Movement Disorder Society.

Practical needs and considerations for refugees and other forcibly displaced persons with neurological disorders: Recommendations using a modified Delphi approach.

Background: There are >70 million forcibly displaced people worldwide, including refugees, internally displaced persons, and asylum seekers. While the health needs of forcibly displaced people have been characterized in the literature, more still needs to be done globally to translate this knowledge into effective policies and actions, particularly in neurology. Methods: In 2020, a global network of published experts on neurological disease and refugees was convened. Nine physician experts from nine countries (2 low, 1 lower-middle income, 5 upper-middle, 1 high income) with experience treating displaced people originating from 18 countries participated in three survey and two discussion rounds in accordance with the Delphi method. Results: A consensus list of priority interventions for treating neurological conditions in displaced people was created, agnostic to cost considerations, with the ten highest ranking tests or treatments ranked as: computerized tomography scans, magnetic resonance imaging scans, levetiracetam, acetylsalicylic acid, carbamazepine, paracetamol, sodium valproate, basic blood tests, steroids and anti-tuberculous medication. The most important contextual considerations (100% consensus) were all economic and political, including the economic status of the displaced person's country of origin, the host country, and the stage in the asylum seeking process. The annual cost to purchase the ten priority neurological interventions for the entire displaced population was estimated to be 220 million USD for medications and 4.2 billion USD for imaging and tests. Conclusions: A need for neuroimaging and anti-seizure medications for forcibly displaced people was emphasized. These recommendations could guide future research and investment in neurological care for forcibly displaced people.

Socioeconomic associations of poorly controlled epilepsy in the Republic of Guinea: cross-sectional study.

OBJECTIVE: To explore the socioeconomic factors associated with epilepsy in the Republic of Guinea. METHODS: People living with epilepsy (PLWE) were prospectively recruited at Ignace Deen Hospital, Conakry, in 2018. An instrument exploring household assets as a measure of wealth was designed and administered. Multivariate logistic regression models with fixed effects were fitted to assess the associations of sociodemographic and microeconomic factors with self-reported frequency of seizures in the prior month and regular intake of antiseizure medications (ASMs). Participants were stratified by age group: children (<13 years), adolescents (13-21) and adults (>21). RESULTS: A total of 285 participants (mean age 19.5 years; 129 females; 106 children, 72 adolescents, 107 adults, median household size 8) had an average of 4.2 seizures in the prior month. 64% were regularly taking ASMs. Direct costs of epilepsy were similar across income strata, averaging 60 USD/month in the lowest and 75 USD/month in the highest wealth quintiles (P = 0.42). The poorest PLWE were more likely to spend their money on traditional treatments (average 35USD/month) than on medical consultations (average 11 USD/month) (P = 0.01), whereas the wealthiest participants were not. Higher seizure frequency was associated with a lower household education level in adolescents and children (P = 0.028; P = 0.026) and with being male (P = 0.009) in children. Adolescents in higher-educated households were more likely to take ASMs (P = 0.004). Boys were more likely to regularly take ASMs than girls (P = 0.047). CONCLUSIONS: Targeted programming for children and adolescents in the households with the lowest education and for girls would help improve epilepsy care in Guinea.

OBJECTIF: Explorer les facteurs socioéconomiques associés à l'épilepsie en République de Guinée. MÉTHODES: Des personnes vivant avec l'épilepsie (PVE) ont été recrutées prospectivement à l'hôpital Ignace Deen, à Conakry, en 2018. Un outil explorant les actifs des ménages en tant que mesure de la richesse a été conçu et administré. Des modèles de régression logistique multivariée avec des effets fixes ont été ajustés pour évaluer les associations de facteurs sociodémographiques et microéconomiques avec la fréquence autodéclarée des crises au cours du mois précédent et la prise régulière de médicaments antiépileptiques (MAE). Les participants ont été stratifiés par groupe d'âge: enfants (<13 ans), adolescents (13-21) et adultes (> 21). RÉSULTATS: 285 participants (âge moyen 19,5 ans; 129 femmes; 106 enfants, 72 adolescents, 107 adultes, taille médiane du ménage 8) ont eu en moyenne 4,2 crises au cours du mois précédent. 64% prenaient régulièrement des MAE. Les coûts directs de l'épilepsie étaient similaires dans toutes les strates de revenus, atteignant en moyenne 60 USD/mois dans les quintiles de richesse les plus bas et 75 USD/mois dans les quintiles de richesse les plus élevés (p = 0,42). Les PVE les plus pauvres étaient plus susceptibles de dépenser leur argent pour des traitements traditionnels (35 USD/mois en moyenne) que pour des consultations médicales (11 USD/mois en moyenne) (p = 0,01), contrairement aux participants les plus riches. Une fréquence de crises plus élevée était associée à un niveau d'éducation du ménage plus faible chez les adolescents et les enfants (p = 0,028; p = 0,026) et au fait d'être de sexe masculin (p = 0,009) chez les enfants. Les adolescents des ménages avec un niveau d'éducation plus élevé étaient plus susceptibles de prendre des MAE (p = 0,004). Les garçons étaient plus susceptibles de prendre régulièrement des MAE que les filles (p = 0,047). CONCLUSIONS: Des programmes ciblés pour les enfants et les adolescents dans les ménages les moins scolarisés et pour les filles aideraient à améliorer les soins de l'épilepsie en Guinée.

School status and its associations among children with epilepsy in the Republic of Guinea.

BACKGROUND: In low-income countries (LICs), there are multiple barriers for children with epilepsy (CWE) to attend school. We examined potentially modifiable associations with poor school performance in CWE in the West African Republic of Guinea. METHODS: Children with epilepsy of school age were recruited using public announcements and a clinical register of people with epilepsy at the Ignace Deen Hospital in Conakry in 2018. A team of Guinean and U.S. neurologists and neurologists-in-training interviewed each CWE and parent for his/her epilepsy history, household finances, educational attainment level, and perceived stigma using the Stigma Scale of Epilepsy (SSE). Each child was also tested using the Wechsler Nonverbal Scale of Ability (WNV). Low school performance was defined as either not attending school or being held back a grade level at least once. Potential predictors of low school performance were analyzed. FINDINGS: Of 128 CWE (mean age: 11.6 years, 48.4% female), 11.7% (n = 15) never attended school, 23.3% (n = 30) dropped out, and 64.8% (n = 83) were currently enrolled. Of CWE attending school, 46.9% (n = 39) were held back a grade level. Overall, 54 children were defined as low performers (LPs) (42%). ;Greater than 100 lifetime seizures (odds ratio (OR) = 8.81; 95% confidence interval (CI) = 2.51, 37.4; p = 0.001) and lower total WNV score (OR = 0.954; 95% CI = 0.926, 0.977; p < 0.001) were significantly associated with poor school performance in separate models, when controlling for potential confounders. Given the strong relationship between seizure freedom and school performance, we estimated that 38 additional CWE (33.6%) could become high performers (HPs) if all CWE were adequately treated to achieve the lifetime seizure category of <10 seizures and could be cognitively intact again. Models examining SSE and household wealth quintile were not significantly associated with school performance. CONCLUSIONS: Higher lifetime seizures and lower WNV score were significantly associated with low school performance in CWE in Guinea. In spite of our conservative definition of high school performance (attending without failing) and risk of referral bias at an academic center where patients were allowed to self-refer, we demonstrate that seizure control in this setting could increase the number of CWE who could attend and stay in school.

Smartphone EEG and remote online interpretation for children with epilepsy in the Republic of Guinea: Quality, characteristics, and practice implications.

PURPOSE: Children with epilepsy in low-income countries often go undiagnosed and untreated. We examine a portable, low-cost smartphone-based EEG technology in a heterogeneous pediatric epilepsy cohort in the West African Republic of Guinea. METHODS: Children with epilepsy were recruited at the Ignace Deen Hospital in Conakry, 2017. Participants underwent sequential EEG recordings with an app-based EEG, the Smartphone Brain Scanner-2 (SBS2) and a standard Xltek EEG. Raw EEG data were transmitted via Bluetooth™ connection to an Android™ tablet and uploaded for remote EEG specialist review and reporting via a new, secure web-based reading platform, crowdEEG. The results were compared to same-visit Xltek 10-20 EEG recordings for identification of epileptiform and non-epileptiform abnormalities. RESULTS: 97 children meeting the International League Against Epilepsy's definition of epilepsy (49 male; mean age 10.3 years, 29 untreated with an antiepileptic drug; 0 with a prior EEG) were enrolled. Epileptiform discharges were detected on 21 (25.3%) SBS2 and 31 (37.3%) standard EEG recordings. The SBS2 had a sensitivity of 51.6% (95%CI 32.4%, 70.8%) and a specificity of 90.4% (95%CI 81.4%, 94.4%) for all types of epileptiform discharges, with positive and negative predictive values of 76.2% and 75.8% respectively. For generalized discharges, the SBS2 had a sensitivity of 43.5% with a specificity of 96.2%. CONCLUSIONS: The SBS2 has a moderate sensitivity and high specificity for the detection of epileptiform abnormalities in children with epilepsy in this low-income setting. Use of the SBS2+crowdEEG platform permits specialist input for patients with previously poor access to clinical neurophysiology expertise.

Epilepsy and traditional healers in the Republic of Guinea: A mixed methods study.

PURPOSE: The purpose of this study was to characterize the reasons, extent, and impact of traditional medicine use among people with epilepsy (PWE) in the Republic of Guinea. METHODS: Guinea is a low-income country in sub-Saharan Africa (SSA) with limited healthcare resources. People with epilepsy and their caregivers were seen at a public referral hospital in Conakry, the capital city, where they completed semi-structured interviews with physicians regarding their beliefs about epilepsy, medical care, and engagement with traditional healers. RESULTS: Of 132 participants (49% children, 44% female, 55% with a university-educated head of household), 79% had seen a traditional healer, and 71% saw a traditional healer before seeing a medical provider for their epilepsy. Participants were treated by a traditional healer for a mean of 39 months before seeing a medical provider. By contrast, 58% of participants reported taking antiepileptic drugs (AEDs) regularly; 46% reported having undergone a head computed tomography (CT) scan; 58% reported having had an electroencephalogram, and 4% reported having had a brain magnetic resonance imaging (MRI) scan. CONCLUSIONS: Traditional healers in Guinea provide frontline care for PWE in Guinea with considerable delays in AED initiation, even among a cohort of PWE actively seeking medical care. Engaging with these healers is critical for both influencing community perceptions and appropriately managing epilepsy throughout the country.

Impact of poorly controlled epilepsy in the Republic of Guinea.

PURPOSE: To characterize people with epilepsy (PWE) presenting to a free neurology consultation and antiepileptic drug (AED) service in the Republic of Guinea. METHODS: Guinea is a low-income country in West Africa that recently experienced an Ebola Virus Disease epidemic. Community-dwelling PWE were seen at a public referral hospital in Conakry, the capital city. During two visits in 2017, an African-U.S. team performed structured interviews and electroencephalograms and provided AEDs. RESULTS: Of 257 participants (143 children, 122 female), 25% had untreated epilepsy and 72% met our criteria for poorly controlled epilepsy. 59% had >100 lifetime seizures, and 58% reported a history consistent with status epilepticus. 38 school-aged children were not in school and 26 adults were unemployed. 115 were not currently taking an AED, including 50 participants who had previously taken an AED and stopped. Commonly cited reasons for AED discontinuation were perceived side effects, unaffordability, and unavailability of AEDs. Traditional medicine use was more frequent among children versus adults (92/143 vs. 60/114, p = 0.048). 57 participants had head injuries, 29 had burns, and 18 had fractures. In a multivariable regression analysis, >100 lifetime seizure count was strongly associated with seizure-related injury (p < 0.001). Burns were more likely to occur among females (p = 0.02). CONCLUSIONS: There is an urgent need to improve the standard of care for PWE in Guinea. Several missed opportunities were identified, including low use of AEDs and high use of traditional medicines, particularly in children. Targeted programs should be developed to prevent unintentional injury and improve seizure control.

Medullar Kock without Pott: 13 cases observed at the university hospital center of Conakry, Guinea.

Background: The diagnostic certainty of medullar tuberculosis (TB) without Pott disease is difficult to establish in a tropical environment with the large group of infectious, parasitic, and systemic myelopathies, despite the increasing availability of magnetic resonance imaging (MRI) data and improvement of biological exploration platforms. Methods: We retrospectively analyzed the files of 186 patients hospitalized in the Department of Neurology and Neurosurgery of the University Hospital Center of Conakry, Guinea, between 2008 and 2016 for the management of non-compressive and compressive myelopathy. Biological evidence of TB infection was demonstrated for 13 (6.9%) patients. Results: Infectious clinical picture prior to the development of neurological signs was reported in 11 patients (84.6%). The neurological signs were summed up by the existence of a sensitivo-motor semiology of progressive evolution (100% of cases) with sphincter disorders in 11 patients (84.6%) and a medullary compression symptomatology with a lesion and under lesion syndrome from the outset in 4 patients (30.8%). Medullary MRI revealed an extensive intramedullary hypersignal in 9 patients with non-compressive myelopathy and in 4 cases, the lesions appeared in T1 hypersignal and T2 isosignal were localized. Lumbar puncture (LP) revealed lymphocytic pleocytosis, hypoglucorrhage (0.3 to 0.5 g/l), and leukocytosis. Conclusion: This study reveals a classic clinical, biological, neuroradiological, and evolutionary profile of compressive and non-compressive myelopathies. These results are important for the therapeutic and evolutionary discussion of TB myelopathies for good management.