Challenges in the Management of a Patient with Myxoedema Coma in Ghana: A Case Report

Myxoedema coma is a rare life-threatening disease, and it is essential that it is managed appropriately to reduce the associated high mortality. However, in the setting where efficient healthcare delivery is hampered by inadequacies, the management of such cases may pose a significant challenge. We present the case of a middle-aged woman diagnosed with myxoedema coma and severe hyponatremia. The case report highlights some of the challenges that may be encountered during the management of myxoedema coma in similar settings and outlines the management strategies undertaken to overcome them in the absence of national guidelines. It also brings to the fore the need for clinicians to look out for clinical features suggestive of hypothyroidism particularly among high risk individuals for early diagnosis and treatment.Funding: None declaredKeywords: myxoedema coma, management, challenges, Ghan

Establishment of a General Medicine Residency Training Program in Rural West Africa

Ghana, a developing country in West Africa, has major medical burdens in taking care of a large population with limited resources. Its three medical schools produce more than 200 graduates per year, but most emigrate to developed lands after training. Ghana is working to educate and retain locally trained physicians, but it is difficult to get them to work in rural settings where the need is greatest. This article details the establishment of a General Medicine residency at a 150-bed hospital in rural Ghana. Early training comprises 6 months each in Medicine, Surgery, OB/GYN, and Pediatrics; the hospital in Techiman also has a Surgery residency. House officers choose the program for more hands-on experience than they can get in larger centers. They perform many tasks, including surgery, sooner and more independently than do residents in developed countries. The training program includes a morning report, clinical teaching rounds, and rotations on in-patient wards and in the Emergency Department and clinics. Teaching focuses on history, physical examination, good communication, and proper follow-up, with rigorous training in the OR and some clinical research projects pertinent to Ghana. Trainees work hard and learn from one another, from a dedicated faculty, and by evaluating and treating very sick patients. Ghana’s rural residencies offer rigorous and attractive training, but it is too soon to tell whether this will help stem the “brain drain” of young physicians out of West Africa

The Medical System in Ghana

Ghana is a developing country in West Africa with a population of about 25 million. Medical illnesses in Ghana overlap with those in developed countries, but infection, trauma, and women’s health problems are much more prominent. Medical practice in rural Africa faces extremely limited resources, a multiplicity of languages (hundreds in Ghana), and presentation of severe illnesses at later stages than seen elsewhere. Despite these limitations, Ghana has established a relatively successful national medical insurance system, and the quality of medical practice is high, at least where it is available. Ghana also has a well-established and sophisticated administrative structure for the supervision of medical education and accreditation, but it has proven very difficult to extend medical training to rural areas, where health care facilities are particularly short of personnel. Physicians are sorely needed in rural areas, but there are few because of the working conditions and financial limitations. Hospital wards and clinics are crowded; time per patient is limited. This article details some of the differences between medical practice in Ghana and that in wealthier countries and how it functions with very limited resources. It also introduces the medical education and training system in Ghana. The following article describes an attempt to establish and maintain a residency training program in General Medicine in a rural area of Ghana

Prevalence and risk factors for Active Convulsive Epilepsy in Kintampo, Ghana

Introduction: epilepsy is common in sub-Saharan Africa, but there is little data in West Africa, to develop public health measures for epilepsy in this region. Methods: we conducted a three-stage cross-sectional survey to determine the prevalence and risk factors for active convulsive epilepsy (ACE), and estimated the treatment gap in Kintampo situated in the middle of Ghana. Results: 249 people with ACE were identified in a study population of 113,796 individuals. After adjusting for attrition and the sensitivity of the screening method, the prevalence of ACE was 10.1/1000 (95% Confidence Interval (95%CI) 9.5-10.7). In children aged \u3c18 years, risk factors for ACE were: family history of seizures (OR=3.31; 95%CI: 1.83-5.96), abnormal delivery (OR=2.99; 95%CI: 1.07-8.34), problems after birth (OR=3.51; 95%CI: 1.02-12.06), and exposure to Onchocerca volvulus (OR=2.32; 95%CI: 1.12-4.78). In adults, a family history of seizures (OR=1.83; 95%CI: 1.05-3.20), never attended school (OR=11.68; 95%CI: 4.80-28.40), cassava consumption (OR=3.92; 95%CI: 1.14-13.54), pork consumption (OR=1.68; 95%CI: 1.09-2.58), history of snoring at least 3 nights per week (OR=3.40: 95%CI: 1.56-7.41), exposure to Toxoplasma gondii (OR=1.99; 95%CI: 1.15-3.45) and Onchocerca volvulus (OR=2.09: 95%CI: 1.29-3.40) were significant risk factors for the development of ACE. The self-reported treatment gap was 86.9% (95%CI: 83.5%-90.3%). Conclusion: ACE is common within the middle belt of Ghana and could be reduced with improved obstetric care and prevention of parasite infestations such as Onchocerca volvulus and Toxoplasma gondii

Multi-disciplinary stroke care in developing countries – lessons from the Wessex-Ghana Stroke Partnership

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Psychological comorbidities in epilepsy: a cross-sectional survey among Ghanaian epilepsy patients

Objective: To evaluate the prevalence and patterns of psychiatric disorders in epilepsy patients at the Korle-Bu Teaching hospital, Accra, Ghana.Design: The study design was a cross-sectional surveySetting: The study was conducted at the Neurology Clinic of the Department of Medicine and Therapeutics, Korle-nBu Teaching hospital, Accra, Ghana.Participants: A total of one hundred and sixty-six patients diagnosed with epilepsy aged at least 18 years and accessing services at the neurology clinic participated in the study.Main Outcome Measure: Prevalence and patterns of psychiatric disorders among patients diagnosed with epilepsy using the Brief Symptom Inventory.Results: The mean age for onset of epilepsy was 20.1 ± 16.9 years, and generalized epilepsy (73.2%) was the major type of epilepsy identified. The aetiology of the epilepsy condition was unknown in most patients (71.1%). The estimated mean Brief Symptom Inventory scores in all the nine diagnostic psychiatry characteristics (Depression, Anxiety, Somatization, Hostility, Phobic Anxiety, Obsessive Compulsive Disorder, Psychoticism, Interpersonal Sensitivity, and Paranoid Ideation) were higher in the epilepsy patients compared to the normative data scores for non-patients. Global Severity Index scores for females were significantly higher (p=0.002) than the scores for males on all the psychological outcomes except hostility.Conclusion: Psychological disorders were prevalent among epilepsy patients, with females more likely to experience psychological problems than males. The findings call for a holistic approach in managing epilepsy to highlight and manage some exceptional psychological comorbidities

Determinants of first‐ever stroke severity in West Africans: evidence from the SIREN study

Background: Baseline stroke severity is probably partly responsible for poor stroke outcomes in sub-Saharan Africa. However, there is a paucity of information on determinants of stroke severity among indigenous Africans. We sought to identify the factors associated with stroke severity among West Africans in the SIREN (Stroke Investigative Research and Educational Networks) study. Methods and Results: Stroke was diagnosed clinically and confirmed with brain neuroimaging. Severe stroke was defined as a Stroke Levity Scale score of ≤5. A multivariate logistic regression model was constructed to identify factors associated with stroke severity at 95% CI and a nominal cutoff of 5% type 1 error. A total of 3660 stroke cases were included. Overall, 50.7%% had severe stroke, including 47.6% of all ischemic strokes and 56.1% of intracerebral hemorrhage. Factors independently associated with severe stroke were meat consumption (adjusted odds ratio [aOR], 1.97 [95% CI, 1.43-2.73]), low vegetable consumption (aOR, 2.45 [95% CI, 1.93-3.12]), and lesion volume, with an aOR of 1.67 (95% CI, 1.03-2.72) for lesion volume of 10 to 30 cm3 and aOR of 3.88 (95% CI, 1.93-7.81) for lesion volume \u3e30 cm3. Severe ischemic stroke was independently associated with total anterior circulation infarction (aOR, 3.1 [95% CI, 1.5-6.9]), posterior circulation infarction (aOR, 2.2 [95% CI, 1.1-4.2]), and partial anterior circulation infarction (aOR, 2.0 [95% CI, 1.2-3.3]) compared with lacunar stroke. Increasing age (aOR, 2.6 [95% CI, 1.3-5.2]) and lesion volume \u3e30 cm3 (aOR, 6.2 [95% CI, 2.0-19.3]) were independently associated with severe intracerebral hemorrhage. Conclusions: Severe stroke is common among indigenous West Africans, where modifiable dietary factors are independently associated with it. These factors could be targeted to reduce the burden of severe stroke

Clinical characteristics of COVID-19 patients admitted at the Korle-Bu Teaching Hospital, Accra, Ghana

Design: Study design was a retrospective single-center review of hospital data.Setting: The study was conducted at the COVID-19 Treatment Center of the Department of Medicine and Therapeutics of the Korle-Bu Teaching hospital in Accra, Ghana.Participants and study tools: A total of fifty patients with laboratory (rRT-PCR) confirmed COVID-19 infection were involved in the study. A chart review of the medical records of the patients was conducted and the data obtained was documented using a data extraction form.Results: The median age was 53 years and most (36% (18/50)) of the patients were at least 60 years of age. Eighty percent (40/50) of the patients were symptomatic, with cough and difficulty in breathing being the commonest presenting symptoms. The mean duration of hospitalization was 12.3 ± 7.3 days. Hypertension and Diabetes Mellitus were the commonest co-morbidities occurring in 52% (26/50) and 42% (21/50) of patients respectively. Fifty percent of patients developed COVID-19 pneumonia as a complication. The mortality rate was 12% (6/50).Conclusion: In this study, SARS-CoV2 infection affected older adults with hypertension and diabetes mellitus being the common comorbidities. Patients with these comorbid conditions should be counselled by their clinicians to strictly observe the COVID-19 prevention protocols to reduce their risk of acquiring the infection. There is a need to pay critical and prompt attention to the management of patients with COVID-19 pneumonia particularly among people with diabetes to improve outcomes

Mucuna pruriens for Parkinson's disease: Low-cost preparation method, laboratory measures and pharmacokinetics profile

Abstract Background Parkinson's disease (PD) is a progressive neurological condition. Levodopa (LD) is the gold standard therapy for PD patients. Most PD patients in low-income areas cannot afford long-term daily Levodopa therapy. The aim of our study was to investigate if Mucuna pruriens (MP), a legume with high LD content that grows in tropical regions worldwide, might be potential alternative for poor PD patients. Methods We analyzed 25 samples of MP from Africa, Latin America and Asia. We measured the content in LD in various MP preparations (dried, roasted, boiled). LD pharmacokinetics and motor response were recorded in four PD patients, comparing MP vs. LD+Dopa-Decarboxylase Inhibitor (DDCI) formulations. Results Median LD concentration in dried MP seeds was 5.29%; similar results were obtained in roasted powder samples (5.3%), while boiling reduced LD content up to 70%. Compared to LD+DDCI, MP extract at similar LD dose provided less clinical benefit, with a 3.5-fold lower median AUC. Conclusion Considering the lack of a DDCI, MP therapy may provide clinical benefit only when content of LD is at least 3.5-fold the standard LD+DDCI. If long-term MP proves to be safe and effective in controlled clinical trials, it may be a sustainable alternative therapy for PD in low-income countries

Clinical features, proximate causes, and consequences of active convulsive epilepsy in Africa

Purpose: Epilepsy is common in sub-Saharan Africa (SSA), but the clinical features and consequences are poorly characterized. Most studies are hospital-based, and few studies have compared different ecological sites in SSA. We described active convulsive epilepsy (ACE) identified in cross-sectional community-based surveys in SSA, to understand the proximate causes, features, and consequences. Methods: We performed a detailed clinical and neurophysiologic description of ACE cases identified from a community survey of 584,586 people using medical history, neurologic examination, and electroencephalography (EEG) data from five sites in Africa: South Africa; Tanzania; Uganda; Kenya; and Ghana. The cases were examined by clinicians to discover risk factors, clinical features, and consequences of epilepsy. We used logistic regression to determine the epilepsy factors associated with medical comorbidities. Key Findings: Half (51%) of the 2,170 people with ACE were children and 69% of seizures began in childhood. Focal features (EEG, seizure types, and neurologic deficits) were present in 58% of ACE cases, and these varied significantly with site. Status epilepticus occurred in 25% of people with ACE. Only 36% received antiepileptic drugs (phenobarbital was the most common drug [95%]), and the proportion varied significantly with the site. Proximate causes of ACE were adverse perinatal events (11%) for onset of seizures before 18 years; and acute encephalopathy (10%) and head injury prior to seizure onset (3%). Important comorbidities were malnutrition (15%), cognitive impairment (23%), and neurologic deficits (15%). The consequences of ACE were burns (16%), head injuries (postseizure) (1%), lack of education (43%), and being unmarried (67%) or unemployed (57%) in adults, all significantly more common than in those without epilepsy. Significance: There were significant differences in the comorbidities across sites. Focal features are common in ACE, suggesting identifiable and preventable causes. Malnutrition and cognitive and neurologic deficits are common in people with ACE and should be integrated into the management of epilepsy in this region. Consequences of epilepsy such as burns, lack of education, poor marriage prospects, and unemployment need to be addressed