105 EVALUATION OF A NEW PHYSIOTHERAPY-LED VESTIBULAR SERVICE EMBEDDED IN THE FALLS AND SYNCOPE UNIT

Background

Clinical presentations in the falls and syncope unit (FASU) are diverse and require a range of skillsets. Vestibular disorders amount to a significant proportion of presentations. In our FASU, we embedded a 0.5 FTE specialist physiotherapist with expertise in vestibular disorders to work alongside medical and nursing staff. We conducted a service evaluation of the activity of this new service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office. Pseudonymised data was collected corresponding to all new FASU physiotherapy service attendances between August 2021 and May 2022. Descriptive statistics were complemented by a binary logistic regression model to establish independent predictors of more than one physiotherapy session being required over the period.

Results

There were 104 episodes recorded by the new service, corresponding to 101 unique patients. Mean age was 67.7 (SD 19.0, range 17-93), and 73.1% were women. 67% were treated and discharged in 1 session. On average, patients had had a mean of 2 falls prior to the consultation (range 0-25). 28.8% were using a walking aid, and 54.8% self-reported fear of falling. 25% of the referrals to the service were due to suspected vestibular disorders, 62% of which were directly treated by the physiotherapy service. The logistic regression model adjusting by age, sex, use of walking aid, number of falls, and fear of falling showed that only referral for vestibular disorder was an independent predictor of patients needing more than 1 physiotherapy treatment (OR 3.91, 95% CI 1.32-11.58, P=0.014).

Conclusion

Vestibular disorders are common in FASU, and a majority can be treated by a specialist physiotherapy service. Repeated vestibular maneuvers are often needed in such patients. A responsive, embedded physiotherapy service in FASU can directly address this need and further evaluation will focus on the impact of this service on avoidance of ED attendances.

The prevalence of epilepsy and other seizure disorders in an Arab population: a community-based study

PURPOSE

To determine the prevalence of epilepsy and other convulsive disorders and the causes of symptomatic epilepsies in a Saudi Arabian population.

METHODS

Door to door survey of a restricted area inhabited by 23 700 Saudi nationals. The World Health Organization (WHO) protocol designed to detect neurological disorders was used as screening instrument. All patients with probable seizures were examined by a neurologist and 92% of positive cases were investigated by brain computed tomography (CT) and electroencephalogram (EEG).

RESULTS

Prevalence rate (PR) for active epilepsy was 6.54 /1000 population (95% confidence interval 5.48-7.60). Twenty-eight percent of the patients had partial seizures, 21% generalized seizures and in 51%, it was not possible to determine if the generalized seizures had focal onset or not. The epilepsy was symptomatic in 32% of the cases: pre or perinatal encephalopathy 23%, head injury 4%, childhood neurological infection 4% and stroke 1%. Febrile convulsions PR was 3.55 /1000 children under the age of 6 years and isolated seizures were documented in only 0.18 /1000 population.

CONCLUSIONS

The PR of epilepsy in Saudi Arabs is within the range of the values reported in most communities. The causes of symptomatic epilepsies revealed a predominance of perinatal and inherited factors. Isolated and non-convulsive seizures were probably under-recognized due to various social and cultural factors as well as to lack of sensitivity of the questionnaire for non-convulsive seizures.

Stroke in Saudi children

This study reports the clinical features and neuroimaging correlates of stroke in Saudi children seen over a 5-year period at the King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. During the study period, 31 (18 boys, 13 girls; mean age, 26.2 months) of the 20,895 children seen had stroke; the annual stroke incidence was 29.7 per 100,000 in the pediatric population. Ischemic strokes accounted for 90% and hemorrhagic 10% of the cases, respectively. The boys-to-girls ratio for ischemic stroke was 2:1. Cranial computed tomographic scans and magnetic resonance imaging findings were abnormal in 82% and 91%, respectively. The etiologic factor was undetermined in 65% of the cases. Our results suggest that stroke is uncommon in Saudi children. However, further studies evaluating a larger population in different clinical settings are required to provide a more comprehensive picture of stroke in children in this area.

Stroke register: experience from the eastern province of Saudi Arabia

A stroke registry was established in the Eastern Province of Saudi Arabia with an estimated population of 750,000 inhabitants of whom 545,000 are Saudi citizens. The register started in July 1989 and ended in July 1993. The Gulf war led to its interruption from August 1990 to August 1991. Four hundred eighty-eight cases (314 males, 174 females) of first-ever strokes affecting Saudi nationals were registered over the 3-year period. The crude incidence rate for first-ever strokes was 29.8/100,000/year (95% CI: 25.2-34.3/100,000 year). When standardized to the 1976 US population, it rose up to 125.8/100,000/year. Ischemic strokes (69%) predominated as in other studies but subarachnoid hemorrhage (SAH) was extremely rare (1.4%). The important risk factors were: systemic hypertension (38%), diabetes mellitus (37%), heart disease (27%), smoking (19%) and family history of stroke (14%). Previous transient ischemic attacks (3%) and carotid bruits (1%) were uncommon. The 30-day case fatality rate was 15%. The study showed that the age-adjusted stroke incidence rate for Saudis in this region is lower than the rates reported in developed countries but within the range reported worldwide. The pattern of stroke in Saudi Arabia is not different from that reported in other communities with the exception of the low incidence of SAH. The risk factors are similar to findings in other studies except for the high frequency of diabetes mellitus in our cases. The lower mortality rate was probably due to the younger age of the population and the availability of free medical services for management of cases.

Community survey of neurological disorders in Saudi Arabia: Results of the pilot study in Agrabiah

A pilot study of the Agrabiah area in Al-Khobar was undertaken to field test study methodologies and identify possible limitations and constraints to a planned community survey for neurological disorders in the Eastern Province of Saudi Arabia. The survey used a pre-tested questionnaire administered by trained personnel to all subjects living within 50 blocks randomly selected from the 198 inhabited ones in the area. Subjects with abnormal responses on screening were then evaluated by neurologists using specific guidelines and criteria to establish the diagnosis of neurological disease. One thousand four hundred and eighty-five subjects (98.3% of all eligible subjects) were screened: 227 (15%) had abnormal responses. Of the 202 subsequently evaluated by neurologists, 178 had definite neurological disease. The overall crude prevalence rate (PR) per 1000 population for neurological morbidity was 120.5 (95% confidence limits [CL] 103.5 to 136.5). Headache syndromes (PR 99.7, CL 83 to 114.7) were common. The other common disorders were seizures (PR 10.2, CL 5.1 to 15.3), peripheral nerve disorders (PR 2.7), and stroke (PR 2.0). Mental retardation and cerebral palsy were the main pediatric problems with PRs of 1.4 and 0.7 respectively. Our results show that a community survey for neurological disorders is feasible in Saudi Arabia and the modified questionnaire was a good screening instrument (sensitivity 94.7%, specificity 96.8%). However, the findings on the pattern and prevalence of neurological disorders need to be viewed with caution, particularly against the background of the scope of the study and the small number of subjects assessed. Cultural practices, local time and social events, and climatic conditions significantly affected community participation and the coverage achieved by the study. These factors should be considered when planning community surveys in Saudi Arabia and other environments with similar sociocultural settings.

Pattern of degenerative ataxias in the eastern province of Saudi Arabia

The patterns of degenerative ataxias as seen over a six year period at the King Fahad Hospital of the University, Al Khobar in the Eastern Province of Saudi Arabia are reported. Twenty two cases were seen, giving a hospital frequency of 7/100,000 patients. Early onset ataxias were the most common, particularly Friedreich disease (9/22). Uncommon types such as ataxia with hypogonadotropic hypogonadism and ataxia with oculomotor apraxia were encountered. There were six late onset ataxias: "pure cerebellar" ataxias were the most common. These data are discussed and compared with other reports, keeping in mind that these disorders are evelotive and their nosologic patterns can change with their progression.

A community survey of neurological disorders in Saudi Arabia: the Thugbah study

We report the findings of a total population survey of Thugbah community in the Eastern Province of Saudi Arabia (SA) to determine its point prevalence of neurological diseases. During this two-phase door-to-door study, all Saudi nationals living in Thugbah were first screened by trained interviewers using a pretested questionnaire (sensitivity 98%, specificity 89%) administered at a face-to-face interview. Individuals with abnormal responses were then evaluated by a neurologist using specific guidelines and defined diagnostic criteria to document neurological disease. The questionnaire was readministered blind by a neurologist to all those with abnormal responses and a 1-in-20 random sample of those without abnormal responses, respectively. The family members of an individual with an abnormal response were also screened to improve accuracy. A total of 23,227 Saudis (98% of the eligible subjects) were screened and those residing in Thugbah on the reference date (22,630) were used to calculate the point prevalence rates. Forty-two percent of those screened were in the first decade of life and only 1.5% were more than 60 years old. There were marginally more females (50.2%) than males (49.8%). Consanguineous marriages especially between first cousins were present in 54.6%. The demographic characteristics of Thugbah community were similar to those in other parts of SA. The overall crude prevalence ratio (PR) for all forms of neurological disease was 131/1,000 population. All subsequent PRs are per 1,000 population. Headache syndromes were the most prevalent disorder (PR 20.7). The PR for all seizure disorders was 7.60, and the epilepsies (6.54) were more frequent than febrile convulsions (0.84). Mental retardation, cerebral palsy syndrome, and microcephaly were common pediatric problems with PRs of 6.27, 5.30 and 1.99, respectively. Stroke, Parkinson's disease, and Alzheimer's disease were uncommon with respective PRs of 1.8, 0.27 and 0.22. Central nervous system (CNS) malformations (0.49) such as hydrocephalus and meningomyelocele were more prevalent than spinal muscular atrophy (0.13), congenital brachial palsy (0.13) and narcolepsy (0.04). Multiple sclerosis was rare (0.04). Osteoarthritis and low back pain syndromes were the main non-neurological conditions seen. The major medical diseases that may be neurologically relevant were diabetes mellitus, hypertension, and connective tissue disorders.(ABSTRACT TRUNCATED AT 400 WORDS)

Aetiology of status epilepticus in Ibadan: a neuropathologic study

In this neuropathologic study of 41 cases diagnosed as status epilepticus (SE) over a 10-year period at the University College Hospital, Ibadan (UCH), we found that the commonest cause was infection of the central nervous system (17 cases). The other aetiologic factors were: metabolic derrangement/toxic (14 cases) and cerebrovascular disease which was the most frequent cause in subjects above 12 years of age. It was encountered in 6 cases. Space occupying lesions which involved the frontal lobes were found in 4 cases. The conditions associated with the disease at death were: cerebral oedema, pulmonary oedema; pulmonary consolidation and pulmonary embolism. Our findings highlight the importance of looking for treatable conditions in patients presenting with this grave condition in this environment.

Prevalence of headache and migrainous headache in Nigerian Africans: a community-based study

In a door-to-door survey in a Nigerian town with stable population of about twenty thousand, 18,594 subjects were screened with a questionnaire, which involved a complete census, administered by non-doctor, including primary health care personnel. Migrainous headache was diagnosed on the basis of combination of responses to the questionnaire shown in a pilot study validated by neurological examination to have 92% sensitivity and 99% specificity. Crude life time prevalence ratio of at least one episode of headache unspecified was 51 percent (50% in males and 52% in females). The crude prevalence ratio of migrainous headache was 5.3 per 100 (5 per 100 in males and 5.6 per 100 in females), with peak age-specific prevalence ratios in the first decade in both males and females. Migrainous headache was three times as common in females as in males in the second and third decades. Prevalence of migrainous headache in Nigerian Africans appears less than in Caucasians. No social status was at special risk to developing migrainous headache.

Werdnig Hoffman's disease (spinal muscular atrophy type I): A clinical study of 25 Saudi nationals in Al-Khobar

We describe the clinical features of 25 cases of Werdnig Hoffman's disease (spinal muscular atrophy (SMA) type I) seen propectively over a two-year period at the King Fahd Hospital of the University (KFHU), Al-Khobar. The hospital incidence rate was 1.93 per 1,000 live births (95% confidence limits, 0.80-3.06/1,000). The estimated prevalence rate for the community was 0.92/10,000 with 0.59-1.25 per 10,000 children as its 95% confidence limits. The male to female ratio was 2:3. Reduced fetal movements were reported by six mothers; 8 children (32%) had symptoms at birth, and 24 (96%) had symptoms by the time they were six months old. Other features apart from hypotonia, muscle weakness, and absent deep tendon reflexes included head lag with inability to achive head control at six months (88%), respiratory problems consisting of difficulty with breathing or frequent chest infections (44%), and difficulty with feeding (40%). Wasting with fisciculations of the tongue was seen in 64%. Death occurred within six months of presentation in 75% of the cases. The parents were consanguineous in 64% of the cases. This high consanguinity rate was probably the major cause for the high population prevalence rate.

Cerebral palsy in Saudi Arabia: a case-control study of risk factors

There is increasing evidence that cerebral palsy (CP) in developed countries results mainly from antenatal factors, whereas reports from developing countries suggest that perinatal and postnatal factors may be more important because of less than optimal delivery conditions. The authors studied 103 Saudi children with CP and compared their antecedent factors with those of a control group. The major risk factors identified were a history of CP in a sibling and consanguinity of the parents. Low birthweight (less than 2000g), gestational age less than 32 weeks, twin pregnancy and respiratory distress were significantly more frequent among CP cases than controls. The results suggest that antenatal factors, including inherited ones, play a major role in the pathogenesis of CP in Saudi Arabia, which is contrary to previous reports from this region. Their contribution to the pathogenesis of CP in developing countries may be greater than previously assumed.

Pattern and ethnic variations in stroke in Saudi Arabia

We report our observations in 427 stroke patients (305 Saudis, 122 non-Saudis with an age range of 14 months to 85 years) seen in a tertiary hospital in the eastern province of Saudi Arabia over an 8-year period. Of these patients, 115 (27%) were between 18 and 45 years old, and constituted the "young stroke patients" for this study. The hospital frequency for the young was 5/10,000 inpatients. In general, there was a male preponderance, with a male:female ratio of 2.2:1 and 7:1 for Saudis and non-Saudis, respectively. Ischemic stroke (55%) was more frequent than hemorrhagic stroke (25%), and the stroke was unspecified in 20%. The main etiologic factors were hypertension, diabetes mellitus and cardiac disorders. In the young population, the frequencies of hemorrhagic and ischemic strokes were similar. In this group, the main causes of intracerebral hemorrhage were aneurysms and arteriovenous malformations, while arteriosclerosis and embolism of cardiac origin were responsible for the ischemic strokes. In Saudis, the stroke types were 59% ischemic, and 17% hemorrhagic, as against 45 and 48% in non-Saudis, respectively. Most ischemic strokes were found in Saudis (78%). Intracerebral hemorrhage accounted for 63% of all hemorrhagic strokes, and was more frequent in Saudis but subarachnoid hemorrhage was three times more common in non-Saudis. In the young stroke patients, interethnic comparison showed that individuals from the Far East were nine times more likely to have hemorrhagic than ischemic stroke compared to the others (odd's ratio = 8.7), and the etiology of ischemic stroke remained undetermined in 67% of those from the Indian subcontinent.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke in a tertiary hospital in Saudi Arabia: a study of 372 cases

Epidemiological studies have shown a consistent downward trend in the incidence and mortality of stroke in industrialized communities. There are however no reports on the pattern of stroke in Saudi nationals and expatriates in Saudi Arabia. The types and etiologies in 372 subjects (262 Saudis, 110 non-Saudis) are described. Males outnumbered females in the ratios of 2.2:1 and 8.2:1 for Saudis and non-Saudis, respectively. The frequency of stroke increased steadily with age until the 7th decade in Saudis but dropped sharply after the 6th in expatriates. The frequency of stroke types in Saudis was ischemic (61%), hemorrhagic (17%) and unspecified (22%) as against 46, 47, and 7% respectively in non-Saudis. Intracerebral hemorrhage was more frequent than subarachnoid hemorrhage (SAH) and was encountered more often in Saudis than in non-Saudis; SAH was 3 times more common in expatriates than in Saudis. The major predisposing factors for stroke were hypertension, diabetes mellitus, and cardiac disorders. Abnormal hemoglobinopathies, especially sickle cell anemia, were rare. The differences observed in the age and sex distribution and in the stroke pattern between Saudi nationals and expatriates most likely reflect the demographic structure existing in Saudi Arabia.

Epilepsy and other convulsive disorders in Saudi Arabia: a prospective study of 1,000 consecutive cases

The pattern of epilepsy and other convulsive disorders in 1,000 consecutive Saudi nationals is described. These disorders were common with a hospital frequency rate of 8 per 1,000. Men were more frequently affected than women and 60% of the patients were under 10 years old at the onset of their illness. The epilepsies were the commonest type (74%). Febrile convulsions (20%) presented mainly between the ages of one and five years. Isolated seizures (3%) and acute symptomatic convulsions (3%) were uncommon. In the epileptic group, generalised seizures (71%) were more frequent than partial (29%) and complex partial seizures occurred mainly in those above 21 years old. Absences (4%), infantile spasms (3%) and atonic seizures (3%) were uncommon. No specific etiology of the epilepsy was determined in the majority of the cases (63%). The identified major etiologic factors of the epilepsies were perinatal encephalopathy (21%), cerebral trauma (11%), sequelae of meningitis or encephalitis (2%), brain tumors (0.5%), and vascular lesions such as stroke and arteriovenous malformation. Perinatal encephalopathy accounted for 40% of the epilepsies in children less than 5 years old, and trauma for 20% of those above 20 years old. A family history of epilepsy in close relations was obtained in 23% of the cases, and the consanguinity rate among the parents was 53%. The high incidence of associated perinatal encephalopathy found in this study suggests that perinatal factors play a major role in the pathogenesis of epilepsy in Saudi Arabia. The high frequency of cerebral trauma was also striking. Although consanguinity of the parents appeared not to be a major factor in the genetics of convulsive disorders in this environment, it might have potentiated the tendency of familial aggregation of convulsive disorders in this community. Consanguinity may be an important factor in the production of some of these disorders but its precise role has not been determined.

Headache syndromes in the eastern province of Saudi Arabia

The pattern of headache syndromes in 222 subjects (142 Saudi nationals, 80 non-Saudis) seen at Al-Khobar, Saudi Arabia is presented. Headaches were common, and accounted for 13% of all neurological outpatients. They affected mainly young adults, with a peak frequency in the third decade for Saudis and the fourth for non-Saudis. They were rare in those under 10 and above 50 years old. Among Saudis, females outnumbered non-Saudi males were more frequent than females in all age groups except the second decade. The main types were tension headache (66%) and migraine (22%). Acute/chronic sinusitis was an uncommon cause of headache. Tension headache affected mainly individuals between 21 and 40 years of age (69%). It showed a female preponderance in Saudis aged 11-20 and above 40 years, unlike the male predilection in non-Saudis. Migraine showed a definite female predilection only in Saudis in the fourth decade (female to male ratio of 4:1). A positive family history for headache was present in 10% of the cases. The major precipitating factor for headaches was stress related to family or working conditions. Other triggers included hunger and prolonged exposure to excessive heat or sunlight. The pattern of headaches in Saudi nationals may be related to the prevalent sociocultural factors, and the differences observed between them and non-Saudis probably reflect the demographic status of non-Saudis in the Kingdom as a consequence of governmental recruitment policy.

A clinical study of stroke

The records of 99 Saudis (68 males and 31 females) admitted to the King Fahd Hospital of the University (KFHU) over a two-year period were reviewed. There was a male to female ratio of 2.2:1. Eighty-five (86%) patients were above 44 years old. All the patients under 44 years old were males. The major predisposing factors identified were hypertension (65%), diabetes mellitus (36%), cardiac disease (20%) and cigarette smoking (29%). The combination of hypertension and diabetes mellitus seemed to carry a higher risk especially in women. Motor dysfunction, encountered in 95 (96%) patients was the dominant clinical feature, and presented mainly as hemiparesis (83 out of 95). Impaired level of consciousness at presentation carried a poor prognosis particularly in the elderly.

Comparison of the prevalence of Parkinson's disease in black populations in the rural United States and in rural Nigeria: door-to-door community studies

A door-to-door survey of Parkinson's disease (PD) in Copiah County, Mississippi, using a pretested screening procedure (with a high sensitivity for detecting PD), followed by examination of all positives by a senior neurologist, revealed similar prevalence ratios for blacks and whites. The same procedure was applied in the community of Igbo-Ora, Nigeria, a black population of West Africa. To assure uniformity in the procedures and application of the diagnostic criteria, a neurologist from each survey site visited the other site. Among a black population of 3,521 over age 39 in Copiah County, there were 12 cases of PD, with an age-adjusted prevalence ratio of 341/100,000. The comparable figures for Igbo-Ora were as follows: population over age 39 = 3,412; cases of PD = 2; age-adjusted prevalence ratio = 67/100,000.

Clinical study of unilateral peripheral facial nerve paralysis in Nigerians

The clinical feature of isolated unilateral peripheral facial nerve paralysis (PFP), seen in 153 consecutive Nigerians over a 14-year period at the University College Hospital (UCH), Ibadan, are presented. The hospital incidence rate was 2.67 per 10,000 with a mean annual rate of 11 per 100,000. Although males (61%) were more frequently affected than females (39%), the peak incidence for both sexes was in the third decade, and 53% of the cases were between 20 years old and 39 years old. Bell's palsy (ninety-three cases) was the most common type encountered. Hypertension (eleven cases) was associated with PFP only in patients above 50 years old. Herpes zoster infection (six cases) and otogenous (eight patients) were not uncommon. Although conjunctivitis (8%) was the most frequent complication, post-paralytic motor features in the form of synkinesia (eight cases), hemispasmas or contractures, and autonomic disturbances such as the crocodile-tear phenomenon (three cases) and auriculo-temporal syndrome (one case) were rare.

Risk factors for epilepsy: case-control study in Nigerians

In a case-control study we compared 155 Nigerians affected by epilepsy, with an equal number of controls matched for age and sex, with the aim of identifying risk factors of epilepsy. Febrile convulsions and head trauma (with odds ratios of 11.0 and 13.0, respectively) were significant risk factors (p less than 0.01). Childhood immunizations were found associated with a decreased risk of epilepsy. None of the following factors was significantly associated with epilepsy: hemoglobinopathy, venereal disease, use of psychotropic drugs or alcohol, and cerebrovascular disease. Preventive measures for the risk factors identified are suggested as ways of reducing the burden of epilepsy in Nigeria.

Prevalence of the epilepsies in Nigerian Africans: a community-based study

A door-to-door survey to detect commonly occurring neurologic diseases was carried out in Igbo-Ora, a large Nigerian town with a population of approximately 20,000. Effective health care facilities have been operating in the community since 1963. Primary health care workers and nondoctor personnel administered a complete census, a screening questionnaire, and a simple screening neurologic examination. The pretested screening questionnaire had been shown in a pilot study to have a sensitivity of 95% for identifying those with epilepsy. Individuals positive on the screening phase of the survey were evaluated by neurologists and neurosurgeons, who used well-defined criteria to make the diagnosis. There were 101 (48 males and 53 females) who suffered from active epilepsy (5.3 cases/1,000) on prevalence day. The highest age-specific prevalence ratios occurred in those below age 20. The most common of the identifiable seizure types was complex partial seizures (52 cases). The prevalence ratio of epilepsy in this Nigerian town (with an effective health care system) is similar to that reported in some developed countries and several times lower than figures derived from studies in developing countries. These data suggest that an improved health care system would probably reduce the prevalence and burden of epilepsy in developing countries.

Neurological disorders in Nigerian Africans: a community-based study

In a Nigerian town with a stable population of 20,000, a door-to-door survey was conducted, using a questionnaire involving a complete census and a simple neurological evaluation which had previously showed a 95% sensitivity and an 80% specificity for detecting neurological disease. Positive responders were evaluated and categorised, using agreed criteria for diagnoses. Nearly 100% cooperation was obtained. Life prevalence ratio for at least one episode of headache was 51/1000. Crude point prevalence ratio for migrainous headache was 5.3/100, and peak age-specific ratio was in the first decade. Prevalence ratio for epilepsy was 533/100,000 and peak age-specific prevalence ratio occurred in the 5-14 years age groups. The prevalence ratio for peripheral nerve disorders was 268/100,000, and age-specific prevalence ratio for tropical neuropathy increased with age. Prevalence ratio for stroke was rather low at 58/100,000, but was probably due to the people's attitude to the disabled elderly and high mortality of stroke which showed annual mortality rate of 70/100,000 which increased with age to 1519/100,000 per year in the eighth decade. Crude prevalence ratios (cases per 100,000) for others are 112 for neurological complications (including sciatica) of spondylosis, 15 each for poliomyelitis, motor neurone disease, development speech disorders, 10 each for syncope, hereditary neuropathies. Parkinson's disease, benign essential tremor, primary cerebellar degeneration, cerebral palsy, mental retardation, organic psychosis (probable intracranial tumor) and 5 each for muscular dystrophy, pyomyositis, spina bifida occulta, alcohol dependence and cerebral malaria. The implications of the findings are important for development of community neurological services in the developing countries.

Vitamin B nutrition in the Nigerian tropical ataxic neuropathy

Assessment of nutritional status of vitamin B components by plasma or blood levels indicated riboflavin deficiency and possibly thiamine deficiency in Nigerian patients who suffered from tropical ataxic neuropathy and neurologically normal Nigerians who subsisted on predominant cassava diet. Serum levels of folate, niacin, pyridoxine and panthothenic acid were normal. Vitamin deficiencies probably are minor factors, if any, in the pathogenesis of tropical ataxic neuropathy in Nigerians.

Hereditary neurodegenerative disorders in Nigerian Africans

Of 2.1 million patients seen in 25 years at the University College Hospital, Ibadan, Nigeria, only 25 suffered from heredodegenerative disorders of the nervous system. Six patients had hereditary ataxia, 10 essential tremor, 4 Huntington's chorea, 2 ataxia telangiectasia, and 3 Charcot-Marie-Tooth disease.

Diseases of peripheral nerves as seen in the Nigerian African

The anatomical and aetiological diagnoses of peripheral nerve disease excluding its primary benign and malignant disorders, as seen in 358 Nigerians are presented. There is a male preponderance and the peak incidence is in the fourth decade. Sensori-motor neuropathy was the commonest presentation (50%). Guillain-Barré syndrome was the commonest identifiable cause (15.6%), accounting for half of the cases with motor neuropathy. Peripheral neuropathy due to nutritional deficiency of thiamine and riboflavin was common (10.1%) and presented mainly as sensory and sensori-motor neuropathy. Diabetes mellitus was the major cause of autonomic neuropathy. Isoniazid was the most frequent agent in drug-induced neuropathy. Migraine (20%) was not an uncommon cause of cranial neuropathy although malignancies arising from the reticuloendothelial system or related structures of the head and neck were more frequent (26%). In 26.5% of all the cases, the aetiology of the neuropathy was undetermined. Heredofamilial and connective tissue disorders were rare. Some of the factors related to the clinical presentation and pathogenesis of the neuropathies are briefly discussed.

Obstetric neuropraxia in the Nigerian African

The results of a prospective study of 34 Nigerian women with obstetric neuropraxia (puerperal paresis of the lower limbs) seen at the University College Hospital, Ibadan, are presented. The height of 29 (84%) was under 62 in (1.58 m). All were younger than 45, and 41% (14) were primiparous. Lumbosacral plexus injury with a foot-drop was the most frequent presenting feature (88%), bilateral involvement was observed in 13 patients (38%), femoral neuropathy was observed in nine (26%) and the ankle tendon jerks were absent in 35%. Spastic paraparesis was not uncommon (15%). Results of electromyographic examination and determinations of conduction velocities were consistent with proximal neuropraxia of the lumbasacral trunk in many of them (88%). The presentation of the fetus was cephalic in 97% of the women. The major predisposing factor was prolonged labor. Among the complications associated with the neuropraxia were hydroureters above the pelvic brim and vesico- and rectovaginal fistulae. Perinatal mortality was high particularly with labor of more than 18 hours. Recovery from the neuropraxia was complete for 76% of the patients. It is concluded that direct pressure on the lumbosacral plexus and nerve trunks by the presenting fetal part is the major factor in the pathogenesis of obstetric neuropraxia encountered in Nigerians.

The prognostic features of biochemical investigations in tetanus

Factors determining prognosis in tetanus have been based mainly on clinical grounds and mortality is high especially in the developing countries. The biochemical changes occurring in tetanus before any form of therapy or sedation, were examined to determine screening parameters for earlier institution of intensive care in high risk patients. The results obtained from a prospective study of 73 patients are presented. The blood sugar and serum transaminases correlated well with the severity of the disease. The serum glutamic oxalate transaminase and blood urea were significantly higher in fatal cases. These findings as well as the clinical criteria utilized in determining the severity of the disease in this study are useful in predicting the outcome of the disease. It is suggested that these simple investigations could serve as screening parameters for instituting early intensive care in tetanus.

Incidence of stroke in an African City: results from the Stroke Registry at Ibadan, Nigeria, 1973-1975

Studies based on hospital populations reported from negro communities in several countries in Africa suggest that cerebrovascular disease (CBVD) shows increasing mortality and morbidity in Africans although 2 decades ago CBVD was believed to be uncommon. We report the first study in the African to determine the incidence of stroke in an urban area, Ibadan, Nigeria.

Prednisolone in the treatment of pneumococcal meningitis

The results of a steroid on 52 Nigerians (27 males, 25 females, aged 10 to 59 years) with bacteriologically proven pneumococcal meningitis are presented. Twenty-four of the patients were treated with steroids in addition to a standard regime. The clinical features on admission in the two groups were comparable and management other than steroid administration identical. Personality change with impairment of intellect was more frequent and mortality higher in the steroid-treated group although the differences wre not statistically significant. It is concluded that steroids apparently have no beneficial effect and may worsen the prognosis in pneumococcal meningitis.

Neuropsychiatric manifestations of infective endocarditis: a study of 95 patients at Ibadan, Nigeria

Thirty-eight percent of patients with infective endocarditis (36 of 95) had neuropsychiatric manifestations. In 75% (27 of 36), these features were the major presenting picture. Fifteen patients (42%) presented with cerebrovascular lesions and seven (19%) with meningitis. Toxic encephalopathy (12.5%) was not uncommon. Other neurological syndromes seen included psychosis and spinal cord lesions. The mortality was high especially when the infective endocarditis was acute in onset. It is essential to search diligently for an underlying cardiac cause in patients who present with neuropsychiatric symptoms because treatment of the underlying pathology improves prognosis.

Monoclonal gammopathy (Waldenström's macroglobulinaemia) producing specific red cell antibody

Two cases of Waldenström's macroglobulinaemia have been seen at University College Hospital, Ibadan in the last four years, Case 1 was a 30-year-old soldier who presented with splenomegaly and anaemia, was treated with chlorambucil, and had a complete remission sustained for over two years. Case 2 was a 58-year-old retired civil servant who presented with very severe anaemia and also splenomegaly, and died within three weeks of admission. Both patients had most of the typical features of Waldenström's disease, including retinal changes and serum IgM levels of 4200 and 5500 mg/dl respectively. In both cases an atypical cold antibody was detected in the course of blood cross-matching procedures. In case 1, the antibody agglutinated all adult and cord red cells tested, including the patient's own cells, to a titre of 8000 and above at 4 degrees C. Suprisingly enough, when the patient went into remission and the serum IgM level had fallen to 400 mg/dl, this antibody was no longer detectable and has not reappeared two years later. In case 2, the antibody agglutinated all adult red cells tested to a titre of 2000 at 20 degrees C but not the patient's own red cells. Since cord cells were agglutinated only to a titre of 4 to 20 degrees C it was concluded that the patient had an alloantibody with I-specificity. Therefore in both these patients the monoclonal immunoglobulin produced by the neoplastic lymphoid cell clone had specific activity against red cell antigens.