Transforming Parkinson's Care in Africa (TraPCAf): protocol for a multimethodology National Institute for Health and Care Research Global Health Research Group project.

BACKGROUND: Parkinson's disease (PD) is the second most common neurodegenerative disorder and, according to the Global Burden of Disease estimates in 2015, was the fastest growing neurological disorder globally with respect to associated prevalence, disability, and deaths. Information regarding the awareness, diagnosis, phenotypic characteristics, epidemiology, prevalence, risk factors, treatment, economic impact and lived experiences of people with PD from the African perspective is relatively sparse in contrast to the developed world, and much remains to be learned from, and about, the continent. METHODS: Transforming Parkinson's Care in Africa (TraPCAf) is a multi-faceted, mixed-methods, multi-national research grant. The study design includes multiple sub-studies, combining observational (qualitative and quantitative) approaches for the epidemiological, clinical, risk factor and lived experience components, as appropriate, and interventional methods (clinical trial component). The aim of TraPCAf is to describe and gain a better understanding of the current situation of PD in Africa. The countries included in this National Institute for Health and Care Research (NIHR) Global Health Research Group (Egypt, Ethiopia, Ghana, Kenya, Nigeria, South Africa and Tanzania) represent diverse African geographies and genetic profiles, with differing resources, healthcare systems, health and social protection schemes, and policies. The research team is composed of experts in the field with vast experience in PD, jointly led by a UK-based and Africa-based investigator. DISCUSSION: Despite the increasing prevalence of PD globally, robust data on the disease from Africa are lacking. Existing data point towards the poor awareness of PD and other neurological disorders on the continent and subsequent challenges with stigma, and limited access to affordable services and medication. This multi-site study will be the first of its kind in Africa. The data collected across the proposed sub-studies will provide novel and conclusive insights into the situation of PD. The selected country sites will allow for useful comparisons and make results relevant to other low- and middle-income countries. This grant is timely, as global recognition of PD and the public health challenge it poses builds. The work will contribute to broader initiatives, including the World Health Organization's Intersectoral global action plan on epilepsy and other neurological disorders. TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN77014546 .

Tramadol and Codeine Stacking/Boosting Dose Exposure Induced Neurotoxic Behaviors, Oxidative Stress, Mitochondrial Dysfunction, and Neurotoxic Genes in Adolescent Mice.

In spite of the increasing epidemic of pharmaceutical opioids (codeine and tramadol) misuse and abuse among the adolescents, little is known about the neurotoxic consequences of the widespread practice of tramadol and codeine abuse involving increasing multiple doses across days, referred to as stacking and boosting. Hence, in this study, we replicated stacking and boosting doses of tramadol, codeine alone, or in combination on spontaneous motor activity and cognitive function in adolescent mice and adduced a plausible mechanism of possible neurotoxicity. Ninety-six adolescent mice were randomly distributed into 4 groups (n = 24 per group) and treated thrice daily for 9 days with vehicle, tramadol (20, 40, or 80 mg/kg), codeine (40, 80, or 160 mg/kg), or their combinations. Exposure of mice to tramadol induced hyperactivity and stereotypic behavior while codeine exposure caused hypoactivity and nootropic effect but tramadol-codeine cocktail led to marked reduction in spontaneous motor activity and cognitive function. In addition, tramadol, codeine, and their cocktail caused marked induction of nitroso-oxidative stress and inhibition of mitochondrial complex I activity in the prefrontal cortex (PFC) and midbrain (MB). Real-time PCR expression profiling of genes encoding neurotoxicity (RT) showed that tramadol exposure upregulate 57 and downregulate 16 neurotoxic genes, codeine upregulate 45 and downregulate 25 neurotoxic genes while tramadol-codeine cocktail upregulate 52 and downregulate 20 neurotoxic genes in the PFC. Findings from this study demonstrate that the exposure of adolescents mice to multiple and increasing doses of tramadol, codeine, or their cocktail lead to spontaneous motor coordination deficits indicative of neurotoxicity through induction of oxidative stress, inhibition of mitochondrial complex I activity and upregulation of neurotoxicity encoding genes in mice.

Barriers and solutions to effective mentorship in health research and training institutions in Nigeria: Mentors, mentees, and organizational perspectives.

Aims and Background: Mentoring relationships and programs have become a subject of global interest and their relevance is high in the ever-evolving health system. In Nigeria, informal system of mentoring is largely practiced. To be able to institutionalize mentoring program, there is need to explore the various challenges of mentoring process and suggest potential approaches for effective mentor-mentee relationship in health research institutions in Nigeria. Subjects and Methods: The study was designed to explore the barriers and solutions to mentoring process from the perspectives of the mentor, mentee, and organization in health research and training institutions in Nigeria. A cross-sectional descriptive design was employed and the study was conducted among 21 health researchers drawn from 24 health research institutions across the 6 regions of Nigeria. The nominal group technique was adopted in the data collection process. Results: The most frequently reported mentor challenges were "lack of understanding of mentorship process" (84.2%) and "lack of capacity for mentoring" (78.9%), while those of mentee were "mentor preference" (73.7%) and "lack of freedom of expression" (47.4%). "Culture of selfishness/individualism" (84.2%) and "lack of formal relationship" (63.2%) were the most mentioned systemic challenges. Training on mentoring process and relationship was mentioned as the most frequent approach to overcoming challenges for the three perspectives. Conclusion: Significant mentorship challenges exist in the Nigerian health, academic and research institution. Systematic approaches to finding and implementing the appropriate solutions are needed to circumvent these bottlenecks.

The Promise of Telemedicine for Movement Disorders: an Interdisciplinary Approach.

PURPOSE OF REVIEW: Advances in technology have expanded telemedicine opportunities covering medical practice, research, and education. This is of particular importance in movement disorders (MDs), where the combination of disease progression, mobility limitations, and the sparse distribution of MD specialists increase the difficulty to access. In this review, we discuss the prospects, challenges, and strategies for telemedicine in MDs. RECENT FINDINGS: Telemedicine for MDs has been mainly evaluated in Parkinson's disease (PD) and compared to in-office care is cost-effective with similar clinical care, despite the barriers to engagement. However, particular groups including pediatric patients, rare MDs, and the use of telemedicine in underserved areas need further research. Interdisciplinary telemedicine and tele-education for MDs are feasible, provide similar care, and reduce travel costs and travel time compared to in-person visits. These benefits have been mainly demonstrated for PD but serve as a model for further validation in other movement disorders.

Translation and validation of the Rhinosinusitis Disability Index for use in Nigeria.

The Rhinosinusitis Disability Index (RSDI) is a validated and reliable measure of severity of chronic rhinosinusitis. The objective of this study was to translate and validate the instrument for use in Nigeria. This is a methodological study. 71 patients with chronic rhinosinusitis attending two Otolaryngology clinics in Lagos, Nigeria. Using standardized methods and trained translators, the RSDI was translated to vernacular (Yoruba language) and back-translated to culturally appropriate English. Data analysis comprised of assessment of the item quality, content validity and internal consistency of the back-translated Rhinosinusitis Disability Index (bRSDI), and correlation to the original RSDI. Content validity (floor and ceiling effects) showed 0% floor and ceiling effects for the total scores, 0% ceiling effects for all domains and floor effect for physical domain, and 9.9 and 8.5% floor effects for functional and emotional domains, respectively. The mean item-own correlation for physical domain was 0.54 ± 0.08, 0.72 ± 0.08 for functional domain and 0.74 ± 0.07 for emotional domain. All domain item-own correlations were higher than item-other domain correlations. The total Cronbach's alpha was 0.936 and was higher than 0.70 for all the domains representing good internal consistency. Pearson correlation analysis showed strong correlation of RSDI to bRSDI (total score 0.881; p = 0.000, and domain subscores-physical: 0.788; p = 0.000, functional: 0.830; p = 0.000, and emotional: 0.888; p = 0.000). The back-translated Rhinosinusitis Disability Index shows good face and content validity with good internal consistency while correlating linearly and significantly with the original Rhinosinusitis Disability Index and is recommended for use in Nigeria.

Efficacy of endoscopic third ventriculostomy in the management of hydrocephalus in children under 2 years of age: experience from a tertiary institution in Nigeria.

BACKGROUND: The management of hydrocephalus in developing countries is challenging. Hydrocephalus is a common childhood disorder in developing countries in particular and its management is quite challenging. Ventriculoperitoneal (VP) shunt is associated with high failure rates and complications. Endoscopic third ventriculostomy (ETV) with potentially lower complication rate could improve care and reduce cost of management of hydrocephalus. OBJECTIVE: The aim of this study was to evaluate the efficacy (success rate) of ETV in children ≤2 years and to find out factors that may be responsible for good outcome of ETV. METHODS: This prospective observational study was conducted at Lagos University Teaching Hospital, Lagos. Nigeria. All consecutive children ≤2 years of age with hydrocephalus were recruited into the study. Relevant demographic and clinical data documented. All cases had ETV and were followed up to document 6 months outcome. RESULTS: A total of 34 patients (M: F ratio 1.1:1) were recruited over a 2-year period. Age, sex, presumed aetiology and image findings were not statistically significant in influencing outcome of ETV. Good outcome (defined as uneventful postoperative period, not requiring repeat ETV or VP shunt) was documented in 26 (73.5%). A total of 8 (26.5%) experienced poor outcome. Complication occurred in 2 (5.9%) as follows: Wound infection 1 (2.9%) and ventriculitis 1 (2.9%). Aetiology was divided into non post-infective hydrocephalus-20 (58.8%), post-infective hydrocephalus-5 (14.7%) and post-myelomeningocoele repair-9 (26.5%). CONCLUSIONS: This study shows that ETV success rate is high in the management of hydrocephalus in children ≤2 years in our clinical practice. Regardless of the clinical diagnosis, where the facilities are available, children with hydrocephalus will benefit from ETV irrespective of the age and aetiology in sub Saharan Africa.

Relationship between admission serum C-reactive protein and short term outcome following acute ischaemic stroke at a tertiary health institution in Nigeria.

BACKGROUND: There is evidence of an association between mediators of inflammation, particularly C-reactive protein (CRP), and outcome of acute ischaemic stroke. This provides a potential opportunity for interventions aimed at improving outcome. There is sparse data exploring the role of inflammatory markers such as CRP and stroke outcome in Africans. The study objective was to determine the association between admission serum CRP levels and short-term outcome in the Nigerian patient presenting with acute ischaemic stroke. MATERIALS AND METHODS: Consecutive patients hospitalized for first-ever acute ischaemic stroke at the Lagos University Teaching Hospital, Lagos, Nigeria, were prospectively enrolled between October 2007 and June 2008. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Serum CRP was determined on samples obtained within 7 days of stroke onset. All stroke patients were followed up till day 30 post-stroke. Outcome measures were 30 day Glasgow outcome scale score and functional impairment on the modified Rankin Scale (mRS). An age- and gender-matched healthy control group had serum CRP determined at inclusion. Elevated CRP was defined as any level above the cutoff (mean +2 x standard deviation of CRP level of controls). RESULTS: Eighty patients with acute ischaemic stroke (47 men and 33 women) and 40 controls (27 male and 13 female) (P = 0.47) were studied. Mean age in cases was 59.1 ± 15.0 years. Mean CRP was significantly higher in stroke cases than controls (17.7 ± 14.4 mg/L versus 1.1 ± 1.7 mg/L respectively) (P < 0.00001). The frequency of elevated CRP (>4.5 mg/L) was 76.3% in stroke (N = 61) and 5% (N = 2) in controls (P < 0.0001). The case fatality rate in stroke with elevated CRP (32.8%) was significantly higher than stroke with normal admission CRP (0%; P = 0.015). The association of higher admission CRP with fatality () was statistically significant (P < 0.0001). Amongst survivors, mean CRP levels were markedly higher in the patients with unfavorable motor outcome (moderate/severe disability; n = 22; 21.5 ± 11.1) compared to those with favorable outcome (mild disability; n = 38; 6.5 ± 6.2) (P < 0.00001). In multivariate regression analysis, only high NIHSS score (P = 0.004) and admission CRP (P = 0.008) were independently associated with case fatality. CONCLUSIONS: Elevated admission CRP and high NIHSS score are independent predictors of short-term case fatality and adverse functional outcome following acute ischaemic stroke in Nigerians.

Echocardiographic patterns in treatment-naïve HIV-positive patients in Lagos, south-west Nigeria.

INTRODUCTION: Cardiovascular abnormalities are common in HIV-infected patients, although often clinically quiescent. This study sought to identify by echocardiography early abnormalities in treatment-naïve patients. METHODS: One hundred patients and 50 controls with no known traditional risk factors for cardiovascular disease were recruited for the study. The cases and controls were matched for age, gender and body mass index. Both groups had clinical and echocardiographic evaluation for cardiac abnormalities, and CD4 count was measured in all patients. RESULTS: The cases comprised 57 females (57.0%) and 43 males (43.0%), while the controls were 28 females (56.0%) and 22 males (44.0%) (χ(2) = 0.01; p = 0.913). The mean age of the cases was 33.2 ± 7.7, while that of the controls was 31.7 ± 9.7 (t = 1.02; p = 0.31). Echocardiographic abnormalities were significantly more common in the cases than the controls (78 vs 16%; p = 0.000), including systolic dysfunction (30 vs 8%; p = 0.024) and diastolic dysfunction (32 vs 8%; p = 0.002). Other abnormalities noted in the cases were pericardial effusion in 47% (χ(2) = 32.10; p = 0.000) and dilated cardiomyopathy in 5% (five); none of the controls had either complication. One patient each had aortic root dilatation, mitral valve prolapse and isolated right heart dilatation and dysfunction. CONCLUSION: Cardiac abnormalities are more common in HIV-infected people than in normal controls. A careful initial and periodic cardiac evaluation to detect early involvement of the heart in the HIV disease is recommended.

Plasma homocysteine level and its relationship to clinical profile in Parkinson's disease patients at the Lagos University Teaching Hospital.

BACKGROUND: Hyperhomocysteinaemia (HHcy) is as a long-term sequelum of levodopa therapy in Parkinson's disease (PD). Information on its frequency and effects in Africans with PD is sparse. OBJECTIVE: To determine the frequency of HHcy and its relationship to clinical features of PD in African patients. METHODS: Using a case-control design, 40 consecutively attending PD patients and 40 age- and gender-matched healthy volunteering controls were studied. Parkinson's disease cases were evaluated for disease and treatment characteristics, using the Unified Parkinson Disease Rating Scale (UPDRS) motor and activities of daily living scores and disease stage (Hoehn and Yahr scale). Fasting total plasma homocysteine (Hcy) was determined in all subjects. Hyperhomocysteinaemia was defined as a Hcy level above the 90th percentile for the controls. RESULTS: Mean Hcy was 13.8 ± 5.4mmol/L in PD and 12.4±3mmol/L in controls (P>0.05). Hyperhomocysteinaemia (Hcy > 16.26umol/L) occurred in nine (22.5%) PD patients (all on levodopa) and 6 (15%) controls (P>0.05). Mean duration of levodopa use was 92 ± 105.3 months in PD with HHcy compared to PD patients with normal Hcy 33.9 ± 33.2 (p < 0.05). Disease severity and disability were similar regardless of Hcy levels. None of current age, disease duration, Hoehn and Yahr stage, UPDRS scores, total levodopa dose and duration was independent predictor of homocysteine level. CONCLUSION: There is increased occurrence of hyper-homocysteinaemia in Nigerian subjects with Parkinson's disease, receiving Levodopa. This hyperhomocysteinaemia is more common with prolonged use but appears to have no relationship with disease severity or disability.

A preliminary study of the frequency of focal neurological deficits in HIV/AIDS patients seropositive for Toxoplasma gondii IgG in Lagos, Nigeria.

BACKGROUND: Cerebral toxoplasmosis is a common cause of focal neurologic deficits in HIV/AIDS. Financial constraints and access to neuroradiological facilities limit definitive diagnosis and first-line treatments are largely expensive and cumbersome. OBJECTIVE: This study examined the frequency of focal neurological signs in HIV/AIDS patients with positive Toxoplasma gondii IgG antibodies (and thus at high risk of reactivation), and the relationship to CD4 count. METHODS: Using a case-control design, T. gondii IgG serology was determined in 83 HIV/AIDS patients on HAART and 42 HIV seronegative controls. Neurological evaluation and CD4 count (mm3) was conducted in all subjects. RESULTS: A total of 71 (85.5%) HIV/AIDS patients were seropositive for T. gondii IgG. The IgG seroprevalence was 84.8% for cases with CD4 count < 200 and 86.0% with CD4 < or = 200 (P = 0.46). Of the cases with positive Toxoplasma antibodies, the frequency of neurological lateralizing signs was higher in those with CD4 count < 200 (32.6%) compared to persons with CD4 count > or = 200 (7.1%) (chi2 = 4.90, Fisher exact P <0.01). The mean CD4 count of cases with lateralizing signs was 113.7 +/- 113.9 in contrast to 254.0 +/- 218.9 in those without lateralizing signs (P < 0.01). CONCLUSION: In our study, a higher frequency of focal neurological signs was found in the T. gondii seropositive HIV/AIDS patients with a higher degree of immune compromise (CD4 count < 200). We suggest the adoption of routine prophylactic anti-toxoplasma therapy in this subgroup given that cerebral toxoplasmosis is a leading cause of intracranial space occupying lesions in HIV/AIDS.

Eligibility of Nigerians with Type 2 Diabetes Mellitus for Inhaled Insulin

Parenteral delivery of insulin has been shown to reduce acceptance of insulin as a treatment option in type 2 diabetes mellitus (DM) patients.The advent of inhaled insulin is aimed at circumventing this problem; however inhaled insulin is a treatment option only for DM patients with normal lung function.The study set out to evaluate the forced expiratory volume in the first second in Liters (FEV1) of Nigerians with type 2 DM and thus determine the proportion potentially eligible for inhaled insulin.FEV1 was measured in 101 subjects with type 2 DM and 104 age; gender and body mass index matched controls without DM. All subjects were 'never smokers' without any physical condition that could compromise lung function. We then determined the proportion of subjects with FEV1; more than 70of normal; which defines eligibility for inhaled insulin.On the basis of the mean FEV1 in Liters of matched controls in this study being 2.58+ 0.62; the cot off for minimium FEV1 to qualify for inhaled insulin therapy was determined as 1.80 liters (i.e 70of 2.58). A total of 83 (84) of the 101 subjects with type 2 DM had FEV1 1.8 liters indicative of eligibility for inhaled insulin. Male sex; shorter duration of DM; normal body mass index (BMI) and younger age were associated with eligibility.A high proportion of Nigerians with type 2 DM attending tertiary care are eligible for inhaled insulin therapy making it a treatment option. The feasibility of this treatment option in terms of acceptability; affordability; side effect profile and efficacy in blood glucose control in Nigerians is an important research focus

Prevalence and clinical characteristics of headache in medical students of the University of Lagos, Nigeria.

We investigated the 1-year prevalence, clinical features and mode of treatment of headache in medical students of the University of Lagos, Nigeria, using a self-administered headache questionnaire. Headache prevalence was 46.0% and was significantly higher in women than in men (62.8% vs. 34.1%). Prevalence of tension-type headache was higher than that of migraine (18.1% vs. 6.4%). Although tension-type headache had a similar prevalence in both sexes (male 17.3%, female 19.2%), migraine was three times more common in women (10.9% vs. 3.2%). A family history of headache was present in 22.0%. Only 4.6% sought medical assistance, whereas 68.2% took non-prescription drugs, mainly simple analgesics. Specific drugs for migraine and tension-type headache were rarely used. In conclusion, 1-year headache prevalence is high among medical students at this university. The low consultation rate and the rarity of usage of specific anti-headache drugs probably reflect inadequacies in the management of primary headaches in this population.

Factors influencing non-compliance with anti-hypertensive drug therapy in Nigerians.

BACKGROUND: Non-compliance with antihypertensive drug therapy can have a negative impact on cardiovascular outcome. The objective of this study was to determine compliance rate with anti-hypertensive therapy and factors affecting compliance among patients attending a Nigerian tertiary hospital. METHODS: A cross sectional study was conducted on 225 black hypertensive patients attending a tertiary clinic in Lagos, Nigeria. Demographic data, current anti-hypertensive therapy, compliance with prescribed therapy, factors affecting compliance and BP were documented via an investigator administered questionnaire and open-ended interviews. RESULTS: In this study, 77(34.2%) of the hypertensive patients were non-compliant. Blood pressure control was significantly better among compliant patients (45.9%) than in non-compliant patients (27.3%) (x(2) = 7.35 p=0.007). Gender, age, number of drugs used, educational level and presence of co-morbidities did not affect compliance. The major reasons for non-compliance were miscellaneous factors (60%) related to both patient's attitudes and beliefs (reflecting ignorance),and consultation failure on the part of clinicians. Lack of finances and side effects of medications accounted for 23.8% and 16.2% of non-compliances respectively. CONCLUSION: Although lack of finances is the single most self reported reason, miscellaneous factors related to patients' attitudes and belief contribute frequently. Incorporating patient education and counselling in routine follow-up may improve compliance, BP control, and ultimately impact positively on cardiovascular outcome.

Prospective case-control study of interictal depression and suicidal ideation in Nigerians with epilepsy.

BACKGROUND: Co-morbid depression and suicidal ideation in people with epilepsy (PWE) in developing countries are under-recognised, and so may be consequently undertreated. This study was designed to determine the frequency and clinical correlates of interictal depression and suicidal ideation in PWE. PATIENTS AND METHODS: Using a prospective design, we evaluated 96 PWE and two groups of controls (103 age- and sex-matched population controls and 13 persons with DSM - IV diagnosis of major depression (controls with depression - CWD) without epilepsy. Depression was assessed using Zung Self-rating depression scale (scores =40 indicating depression). RESULTS: Depression was more prevalent in PWE (25/96 i.e. 26.0%) than normal controls (10/103 i.e. 9.7%) (P = 0.004). Suicidal ideation scores were similar for depressed PWE and depressed normal controls (1.7 +/-1.0 v. 1.5 +/- 1.0; P>0.05), but significantly higher in CWD (2.61.3; P=0.04). Among PWE, mean duration of epilepsy (years) was the only variable significantly related to depression (i.e. 12.7 8.8 in depressed PWE v. 8.3 6.6 in non-depressed PWE (P=0.01). CONCLUSION: Depressive symptomatology is a frequent co-morbidity in our tertiary care population of PWE. However, suicidal ideation is less common in contrast to persons with major depression.

Magnitude and gender distribution of obesity and abdominal adiposity in Nigerians with type 2 diabetes mellitus.

BACKGROUND: Obesity and abdominal adiposity are associated with increased cardiovascular morbidity in diabetes. This study evaluated their magnitude and gender distribution in Nigerians with Type 2 DM attending a tertiary care clinic. PATIENTS AND METHODS: 258 consecutive patients with type 2 DM were evaluated. Base line characteristics (gender, age, duration of DM), weight, height, waist circumference (WC), and hip circumference were recorded. Body mass index (BMI), waist-hip ratios (WHR), and waist-to-height ratios (WHtR) were calculated for each patient. RESULTS: Despite similar demographics (mean age and duration of DM), the prevalence of of DM was significantly higher in females (35/135 i.e.25.9% compared to 13/123 i.e. 10.6% in males) (2; P=0.007). Median BMI (27.1 v. 25.6), WHtR (0.58 v. 0.54), and frequency of elevated WC (71.9% v. 21.1%) and elevated WHR (94.1% v. 49.6%) were all significantly higher in females compared to males (P<0.05). Amongst obese persons, the magnitude of obesity and abdominal adiposity was also significantly higher in females as exemplified by median BMI (females: 34.3 v. males 31.6; P=0.014) and median WHtR (0.70 v. 0.64; P=0.0016). CONCLUSIONS: The evident gender disparity of obesity and abdominal adiposity in females with type 2 DM represented by this cohort buttresses the need to focus on obesity management in African women with DM as a special at-risk group in order to minimize the potential for adverse cardiovascular outcome.

Comparative study of the effect of tocotrienols and -tocopherol on fasting serum lipid profiles in patients with mild hypercholesterolaemia: a preliminary report.

OBJECTIVES: Hypercholesterolaemia is a risk factor for cardiovascular diseases. Tocotrienols reportedly possess hypocholesterolaemic activity. This study examined the effect of tocotrienols (T3) in TOCOVIDTM Suprabio TM on serum lipids. Patients and Methods :A randomised (2:1), open-label study of patients with mild hypercholesterolaemia (= 5.18mmol/L to <7.77mmol/L) and one additional cardiovascular risk factor was carried out. Subjects received either tocotrienols (as TOCOVIDTM Suprabio TM ) (n=28) or vitamin E (a-tocopherol) 500mg daily (n=16). Fasting lipids were compared at baseline and after 4 weeks therapy. RESULTS: Following 4 weeks therapy, mean +/- SD total cholesterol declined significantly in the tocotrienol group (from 6.10+/-0.66 to 5.47+/-1.16; P=0.02) compared to the a-tocopherol group (from 5.92+/-0.52 to 5.47+/-0.76; P>0.05). Mean LDL-C levels (mmol/L) were also significantly reduced in the tocotrienol group (3.82+/-0.85 to 3.24+/-1.26; P=0.04), but not in those on a-tocopherol (3.84+/-0.75 to 3.28+/-0.94; P>0.05). There were no significant changes in HDL-C and triglycerides in both groups. The tocotrienol group experienced a net decline in TG (7.1+/-31.4 %; P>0.05) while the a-tocopherol group had a net increase at week 4 (38.6+/-61.7%; P>0.05). CONCLUSION: The study adds to existing evidence of the favourable effect of tocotrienols on total cholesterol and LDL-C. However, the results need further evaluation.

Longitudinal study of mortality predictors in Parkinson's disease in Nigerians.

Parkinson's disease (PD) has been associated with increased mortality. The mortality in Nigerians has not been described. This study was designed to assess mortality in PD and relate it to gender, age at onset of PD and at baseline, and duration of PD. A case-control study of 28 PD and 28 age- and sex-matched controls from similar geographic locality was conducted. Baseline clinical characteristics of the PD patients and controls were documented at study inception. Cases and controls selected between January and June 1997 were followed up after a 6-year interval (May 2002). The case fatality rate (CFR) in PD was 25% compared to 7.1% in controls (Mantel-Haenszel test, P=0.07). PD survivors (compared to PD patients who died) were significantly younger both at study onset (mean age 59.8 +/- 10.3 v. 72.3 +/- 6.8; P=0.002) and at onset of PD (mean age 57.3 +/- 10.3 v. 69.3 +/- 6.5; P=0.003), and had significantly less severe disease at baseline (mean Hoehn & Yahr stage 2.1 < or = 0.7 v. 2.9 +/- 1.1; P=0.04). CFR was significantly higher in PD cases aged =70 years at study onset (Mantel-Haenszel test, P=0.004) and at onset of PD (Mantel-Haenszel test, P=0.001), but not in age-matched controls. PD affecting Nigerians is associated with increased mortality as has been demonstrated in other geographic locations. Factors associated with increased mortality include advanced age, older age at onset of PD, and more severe disease.

Diagnostic issues in cerebral malaria: a study of 112 adolescents and adults in Lagos, Nigeria.

OBJECTIVE: To determine the accuracy of initial diagnosis of cerebral malaria in adolescents and adults presenting at our tertiary centre and identify the clinical and laboratory parameters helpful in distinguishing cerebral malaria from other differential diagnosis. METHODS: A retrospective review of 112 adolescents and adults initially diagnosed as having cerebral malaria was carried out. Clinical features (risk factors, mode of presentation, clinical course and final diagnosis) and laboratory parameters (level of parasitaemia, haematologic and biochemical values) were documented. RESULTS: A correct diagnosis was made in 52 patients (46.4%), with septicaemia (20.5%) and meningitis (15.2%) accounting for most misdiagnosis. The majority of correctly diagnosed were aged 11-25 years (92.3%), and a predisposing factor was identifiable in 46.2%. Parasitaemia was predominantly moderate to heavy in correctly diagnosed cases, compared to those misdiagnosed in whom it was mild to moderate. Case fatality was higher for misdiagnosed cases (18.6%). CONCLUSION: The probability of an alternate diagnosis amenable to other treatment regimes should always be explored. This is particularly important in patients of middle age and those with either absent predisposing factors or mild parasitaemia, in order to reduce case fatality.

Frequency and predictors of autonomic dysfunction in Parkinson's disease: a study of African patients in Lagos, Nigeria.

UNLABELLED: The degenerative changes in PD also affect the autonomic nervous system. The frequency and predictors of such involvement in Africans with PD has not been reported. OBJECTIVE: i) To determine the frequency and type of autonomic dysfunction in Nigerians with idiopathic Parkinson's disease (PD). ii) To determine the predictors of autonomic dysfunction in PD. METHODS: Cardiovascular autonomic function assessed in 33 study subjects with PD and 33 age-matched controls, utilising heart rate variability to deep breathing, standing and the Valsalva manoeuvre, and the blood pressure (BP) response to standing. The results were compared based on treatment category, grade of severity on the Columbia scale of Hoehn and Yahr, duration of PD, age at onset of PD, present age and occurrence of autonomic symptoms. RESULTS: Parasympathetic function was abnormal in 51.5% of PD subjects, significantly higher than controls (P<0.001). Of these, 76.5% had early parasympathetic involvement and 23.5% definite parasympathetic involvement. Age above 65 years (at time of study or onset of PD) was the only clinical variable associated with parasympathetic autonomic dysfunction (p<0.05). Symptoms dysfunction occurred in 60.6% of PD patients and only 6.1% of controls (p<0. 001). There was however no demonstrable relationship between the occurrence of symptoms and objective evidence of autonomic dysfunction: 41.2% of PD patients with parasympathetic dysfunction had no symptoms. CONCLUSION: Autonomic dysfunction was found to be common in Africans with PD, particularly those above 65 years and tends to affect the parasympathetic system. However, the abnormality may be detectable even before symptoms appear. As such, we recommend that cardiovascular tests of autonomic function be a routine aspect of the evaluation of PD patients, especially with advancing age.