Addressing antimicrobial resistance in Nigerian hospitals: exploring physicians prescribing behavior, knowledge, and perception of antimicrobial resistance and stewardship programs.

INTRODUCTION: We assessed the knowledge of, attitude toward antimicrobial resistance (AMR) and practice of antimicrobial stewardship (AMS) among physicians in Nigeria to provide future guidance to the Nigerian National Action Plan for AMR. METHODS: A descriptive cross-sectional questionnaire-based study explored the physicians' self-reported practice of antibiotic prescribing, knowledge, attitude, and practice of AMR and components of ASPs. RESULTS: The majority (217; 67.2%) of respondents prescribed antibiotics daily in their clinical practice AMR was recognized as a global and local problem by 308 (95.4%) and 262 (81.1%) respondents, respectively. Only 91 (28.2%) of respondents have ever heard of antibiotic stewardship. The median AMR knowledge score was 40 (19-45)out of 45while that for ASP was 46.0(32-57) out of 60. There was significant statistical difference between the ASP median scores among the medical specialties category (P value <0.0001) More respondents had good knowledge of AMR than ASPs (82.7% versus 36.5%; p < 0.0001). CONCLUSION: Respondents in this study were more knowledgeable about AMR than AMS and its core components.

Targeted next-generation sequencing identifies novel variants in candidate genes for Parkinson's disease in Black South African and Nigerian patients.

BACKGROUND: The prevalence of Parkinson's disease (PD) is increasing in sub-Saharan Africa, but little is known about the genetics of PD in these populations. Due to their unique ancestry and diversity, sub-Saharan African populations have the potential to reveal novel insights into the pathobiology of PD. In this study, we aimed to characterise the genetic variation in known and novel PD genes in a group of Black South African and Nigerian patients. METHODS: We recruited 33 Black South African and 14 Nigerian PD patients, and screened them for sequence variants in 751 genes using an Ion AmpliSeq™ Neurological Research panel. We used bcftools to filter variants and annovar software for the annotation. Rare variants were prioritised using MetaLR and MetaSVM prediction scores. The effect of a variant on ATP13A2's protein structure was investigated by molecular modelling. RESULTS: We identified 14,655 rare variants with a minor allele frequency ≤ 0.01, which included 2448 missense variants. Notably, no common pathogenic mutations were identified in these patients. Also, none of the known PD-associated mutations were found highlighting the need for more studies in African populations. Altogether, 54 rare variants in 42 genes were considered deleterious and were prioritized, based on MetaLR and MetaSVM scores, for follow-up studies. Protein modelling showed that the S1004R variant in ATP13A2 possibly alters the conformation of the protein. CONCLUSIONS: We identified several rare variants predicted to be deleterious in sub-Saharan Africa PD patients; however, further studies are required to determine the biological effects of these variants and their possible role in PD. Studies such as these are important to elucidate the genetic aetiology of this disorder in patients of African ancestry.

Drug promotional activities in Nigeria: impact on the prescribing patterns and practices of medical practitioners and the implications.

OBJECTIVE: Pharmaceutical companies spend significant amount of resources on promotion influencing the prescribing behavior of physicians. Drug promotion can negatively impact on rational prescribing, which may adversely affect the quality of patient care. However, little is known about these activities in Nigeria as the most populous country in Africa. We therefore aimed to explore the nature of encounters between Nigerian physicians and pharmaceutical sales representatives (PSRs), and how these encounters influence prescribing habits. METHODS: Cross-sectional questionnaire-based study conducted among practicing physicians working in tertiary hospitals in four regions of Nigeria. RESULTS: 176 questionnaires were completed. 154 respondents (87.5%) had medicines promoted to them in the previous three months, with most encounters taking place in outpatients' clinics (60.2%), clinical meetings (46%) and new medicine launches (17.6%). Information about potential adverse effects and drug interactions was provided in 41.5%, and 27.3% of cases, respectively. Food, in the form of lunch or dinner, was the most common form of incentive (70.5%) given to physicians during promotional activities. 61% of physicians felt motivated to prescribe the drug promoted to them, with the quality of information provided being the driving factor. Most physicians (64.8%) would agree to some form of regulation of the relationship between medical doctors and the pharmaceutical industry. CONCLUSION: Interaction between PSRs and physicians is a regular occurrence in Nigeria, influencing prescribing practices. Meals and cheap gifts were the most common items offered to physicians during their encounters with PSRs. The need for some form of regulation by professional organizations and the government was expressed by most respondents to address current concerns.

Medication adherence and adverse effect profile of antiepileptic drugs in Nigerian patients with epilepsy.

AIM: Medication adherence remains a major challenge among patients with epilepsy (PWE) with the adverse effect profile of antiepileptic drugs (AEDs) as one of its main drivers. METHODS: This was a cross-sectional questionnaire-based study among PWE in selected Nigerian tertiary healthcare facilities using the Morisky Medication Adherence Scale and the Liverpool Adverse Effect Profile (LAEP). RESULTS: 126 PWE from four tertiary healthcare facilities were included in this study comprising of 59 (46.8%) males and 67 (53.2%) females. Carbamazepine (104/70.7%), sodium valproate (23/15.6%) and phenytoin (11/7.5%) were the most commonly prescribed AEDs. Using the Morisky Medication Adherence Scale, 17.2, 38.3 and 44.5% of patients were classified as having high, medium and low adherence, respectively. The mean LAEP score was 23.69 ± 6.07. The most common reported adverse effects among respondents were tiredness (30.4%) and headache (22.5%). CONCLUSION: Medication adherence to AED was poor among patients in this study.

The prescribing of generic medicines in Nigeria: knowledge, perceptions and attitudes of physicians.

Generic medicines have the same efficacy and safety as originators at lower prices; however, there are concerns with their utilization in Nigeria. Objective was to evaluate physicians' understanding and perception of generics. A questionnaire was administered among physicians working in tertiary healthcare facilities in four geo-political regions of Nigeria. Questionnaire response was 74.3% (191/257) among mainly males (85.9%). The mean knowledge score regarding generics was 5.3 (maximum of 9) with 36.6%, 36.1% and 27.2% having poor, average and good knowledge respectively. Cross-tabulation showed statistical significance (p = 0.047) with the duration of practice but not with position, subspecialty or sex. The majority of respondents did not believe that generic medicines are of lower quality than branded medicines. Therapeutic failure was a major concern in 82.7%, potentially discouraging the prescribing of generics, and a majority (63.9%) did not support generic substitution by pharmacists. Knowledge gaps were identified especially with the perception of generics, which need to be addressed.

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.

Cognitive functions in patients with liver cirrhosis: assessment using community screening interview for dementia.

INTRODUCTION: Neurocognitive dysfunction is common in patients with liver cirrhosis who have no evidence of overt hepatic encephalopathy and is usually associated with impairment of activities of daily living in the patients. MATERIALS AND METHODS: Forty patients with liver cirrhosis without overt hepatic encephalopathy were studied along with forty-one healthy controls. Blood samples were taken from the patients for liver function tests and Hepatitis B and C screening. Liver disease severity was graded using the Child-Pugh scoring system. Community Screening Interview for the Dementia (CSID) questionnaire was administered to all subjects. The CSID questionnaire assesses the cognitive functions of the subjects in the domains of language, memory, orientation, attention/calculation, and praxis. The data were collated and analyzed with the aid of SPSS 15.0 software for frequency, means, and comparison of means using Student's t-test and one-way ANOVA. Significant level was put at P< 0.05. RESULTS: The mean age ± SD of the patients was 46.15 ± 15.31 years and the controls was 45.66 ± 11.54 years. There were 30 males and 10 females in the patients group while the control had has 26 males and 15 females. Majority of the patients had secondary level of education. Nine out of 40 patients (23%) had abnormally low total CSID score. The patients with liver cirrhosis performed poorly in the domains of language, memory, attention/calculation, and praxis. There was no difference in the orientation scores between the patients and the normal controls. The type of Hepatitis virus infection, serum liver enzyme, serum albumin, serum bilirubin, prothrombin time and Child Pugh class of the patients did not influence cognitive performance in the patients. CONCLUSION: Patients with liver cirrhosis have significant cognitive impairment compared with controls and liver function tests/ clinical parameters in the patients did not correlate with their cognitive functions.

Cognitive function in patients with liver cirrhosis without overt hepatic encephalopathy: assessment using an automated neuropsychological test battery.

BACKGROUND AND STUDY AIMS: A wide range of neuropsychiatric disorders occur in patients with liver cirrhosis without overt hepatic encephalopathy. Cognitive dysfunctions do occur and these tend to impair patients' vocational and social life as well as activities of daily living. The aim of this study is to evaluate cognitive functions in patients with liver cirrhosis without overt HE in Nigeria. PATIENTS AND METHODS: Thirty-four patients with liver cirrhosis and 41 normal subjects as control were studied. Medical history and general physical/neurological examinations were carried out on all the subjects. Blood samples were obtained for viral serological markers and liver functions tests. The 'Fepsy' automated neuropsychological test battery was performed for the assessment of auditory reaction time (psychomotor speed). Recognition memory test (memory), binary choice reaction task (psychomotor speed/attention) and vigilance task were also administered. The data were analysed with the aid of Statistical Package for Social Sciences (SPSS) version 15.0 software. RESULTS: The mean age of patients with liver cirrhosis was 45.00 ± 13.83 years, while that of control subjects was 41.88 ± 139.49 years. The visual/auditory reaction time, binary choice reaction time and computerised visual reaction time were prolonged in patients with liver cirrhosis when compared with control subjects. However, there were differences in the recognition memory test and vigilance performances between the two groups. The patients with liver cirrhosis who had hepatitis C virus infection had poor psychomotor speed when compared with patients who were hepatitis C virus negative, but there was no statistical significant correlation between other aspects of liver function tests and cognitive functions in patients with cirrhosis. CONCLUSION: Patients with liver cirrhosis had similar cognitive functions on measures of memory and vigilance when compared with normal control subjects. However, there were significant differences in other aspects of cognitive functions between the two groups.

The social and economic impacts of epilepsy on women in Nigeria.

BACKGROUND: Persons with epilepsy in sub-Saharan Africa experience stigma and social marginalization. There is paucity of data on the social and economic impacts of epilepsy in these patients and in particular, groups like women. We sought to determine the social and economic impacts of epilepsy on Nigerian women and especially how it affects their treatment and outcomes. METHODS: We carried out a cross-sectional survey of 63 women with epilepsy (WWE) and 69 controls matched for age, social status and site of care. A structured questionnaire was used to document information on demographic characteristics, education, employment status, economic status, health care use, personal safety and perceived stigma. The data were collated and analyzed with SPSS version 15. RESULTS: Unemployment, fewer years of formal education, lower marriage rates and higher stigma scores were more frequent among WWE than controls. Physical and sexual abuse with transactional sex was also reported among WWE. We also noted poorer environmental and housing conditions and lower mean personal and household incomes among WWE compared to the control group. CONCLUSION: WWE in this sample from Nigeria have worse social and economic status when compared with women with other non-stigmatized chronic medical conditions.

New onset neuromyelitis optica in a young Nigerian woman with possible antiphospholipid syndrome: a case report.

INTRODUCTION: Devic's neuromyelitis optica is an inflammatory demyelinating disease that targets the optic nerves and spinal cord. It has a worldwide distribution and distinctive features that distinguish it from multiple sclerosis. There has been no previous report of neuromyelitis optica from our practice environment, and we are not aware of any case associated with antiphospholipid syndrome in an African person. CASE PRESENTATION: We report the case of a 28-year-old Nigerian woman who presented with neck pain, paroxysmal tonic spasms, a positive Lhermitte's sign and spastic quadriplegia. She later developed bilateral optic neuritis and had clinical and biochemical features of antiphospholipid syndrome. Her initial magnetic resonance imaging showed a central linear hyperintense focus in the intramedullary portion of C2 to C4. Repeat magnetic resonance imaging after treatment revealed resolution of the signal intensity noticed earlier. CONCLUSION: Neuromyelitis optica should be considered in the differential diagnoses of acute myelopathy in Africans. We also highlight the unusual association with antiphospholipid syndrome. Physicians should screen such patients for autoimmune disorders.

Tuberculous meningitis presenting with unusual clinical features in Nigerians: Two case reports.

BACKGROUND: Tuberculous meningitis is common in developing countries and accounts for about 7.8% to 14% of all cases of tuberculosis in Nigeria. CASE PRESENTATION: Case 1 was a 17-year-old woman who presented with a 3-week history of weakness of the right upper and lower limbs, a 6-hour history of inability to speak and irrational behaviour. She had no remarkable past medical history. Physical examination revealed pyrexia (temperature of 38.2 degrees C) and altered level of consciousness (Glasgow coma score = 7/15). The signs of meningeal irritation were present and she had anisocoria and right spastic hemiparesis. Other aspects of physical examination were normal. Laboratory investigations showed an elevated erythrocyte sedimentation rate, normal cerebrospinal fluid protein and reduced glucose. The brain computed tomography scan showed features in keeping with obstructive hydrocephalus and she was immediately commenced on antituberculous drugs, intravenous steroids and mannitol. She made a remarkable clinical recovery and was discharged home 6 weeks after admission. Case 2 was a 40-year-old man who presented with a 6-week history of headache and fever and a 2-week history of alteration in level of consciousness. There was no history of neck pain and/or stiffness, nausea or vomiting. He had no other remarkable past medical history. He had been placed on various intravenous antibiotics in private hospitals before presentation, with no clinical improvement. Physical examination showed a young man in a coma (Glasgow coma score = 4/15) and febrile (temperature of 38.5 degrees C) with signs of meningeal irritation. The brain stem reflexes were impaired and he had spastic quadriparesis. Further physical examination was essentially normal. The cerebrospinal fluid analysis showed features in keeping with meningeal inflammation and he had a raised erythrocyte sedimentation rate. The brain computed tomography scan showed features in keeping with obstructive hydrocephalus. He was placed on antituberculous drugs and intravenous steroids but despite this his clinical condition deteriorated and he died on the sixth day after admission. CONCLUSION: Late presentation of tuberculous meningitis is not rare in Nigerians and we report two cases of tuberculous meningitis that presented late to our health care facility. This report is intended to make clinicians aware of the unusual clinical presentations of tuberculous meningitis.