Neurology Training and Medical Education in Resource-Limited Settings: Building and Growing the First Neurology Residency Program in East Africa.

The burden of neurological disease disproportionately affects low- and middle-income countries, where the lowest number of neurologists are located. Building local training opportunities in resource-limited settings is a foundational step to enhancing the neurological workforce and improving access to neurological care in these regions. In this article, we describe the development and growth of the first neurology residency program in East Africa, which was established in 2006 at Zewditu Memorial Hospital and the Tikur Anbessa Specialized Hospital, Addis Ababa University, Ethiopia. We highlight the impact of the program on clinical care, research, collaborations between neurologists across Ethiopia, and ways to build educational opportunities and mentorship while faced with limited resources. The main challenges in starting the residency program included lack of faculty with neurological expertise, lack of a precedent for subspecialty training in our setting, as well as limited resources and space. The formation of sustainable international collaborations with clinicians at established institutions in high-income countries and neurological societies has been a major source of support in developing the initial infrastructure, curriculum and educational content, knowledge assessments, and mentored research projects. Local partnerships with related medical specialties, including internal medicine, critical care, neurological surgery, and psychiatry, were also instrumental in creating training opportunities. As the program continues to evolve, many challenges remain, including limited diagnostics, lack of access to advanced treatment modalities, lack of fellowship training opportunities in various neurological subspecialties, and insufficient training and experience in scientific writing. Despite these challenges, the residency program has persevered and its creation resulted in many positive changes: since its inception in 2006, we graduated 80 neurologists and the number of practicing neurologists in Ethiopia has increased from 5 to 78, our institution has evolved into a national referral center for neurology, graduates have published 61 articles in the past 3 years and contributed to international neurology research, and alumni of the program have grown the Association of Ethiopian Neurologists. Future directions include development of fellowship opportunities, creation of international rotations, and implementation of teleneurology to further strengthen neurological care across Ethiopia.

BACTERIAL PROFILE, ANTIMICROBIAL RESISTANCE, AND FACTORS ASSOCIATED WITH URINARY TRACT INFECTION AMONG PREGNANT WOMEN AT HOSANNA TOWN HEALTH FACILITIES, CENTRAL ETHIOPIA.

Urinary tract infection in pregnancy is a common microbial infection. Antimicrobial resistance among uropathogens is becoming a major health problem worldwide. The antimicrobial agents used to manage urinary tract infections during pregnancy should be carefully chosen. Therefore, this study aimed to determine the bacterial profile, antibiotic susceptibility pattern, and factors associated with urinary tract infection among pregnant women at Hosanna town public health facilities. A facility-based cross-sectional study was conducted from March to August 2022 on a total of 312 pregnant women who attended antenatal care at Hosanna Town public health facilities. Sociodemographic, clinical data, and related information were collected by using a pre-tested questionnaire. In addition, mid-stream urine specimens were collected from study participants. Bacterial pathogens were identified by standard bacteriological techniques. Antibiotic susceptibility testing was performed by using the Kirby Bauer disk diffusion method. The data were analyzed by using SPSS version 25. Chi-square and odds ratios were calculated and a P-value≤0.05 at a 95% confidence interval was considered statistically significant. The results were presented with words and tables. Of a total of pregnant women, 59/312(18.9%) (95% CI: 14.7-23.7) were found to have significant bacteriuria. The predominant isolates were Escherichia coli (E. coli) 22(34.4%), followed by coagulase-negative staphylococci (CoNS) 10(15.6%), Staphylococci aureus (S. aureus) 7(10.9%), and Klebsiella pneumoniae (K. pneumoniae) 6(9.4%). Overall, 78.1% of these isolates were multidrug-resistant (MDR). Gram-negative bacteria were susceptible to meropenem (97.6%), gentamicin (85.7%), nitrofurantoin (82.1%), ciprofloxacin (73.8%), amoxicillin-clavulanic acid (73.8%) and ceftriaxone (71.8%), but highly resistant to ampicillin (95.5%), trimethoprim-sulfamethoxazole (74.4%), doxycycline (71.8%), cefuroxime (69.2%), and cephalexin (69.2%). The gram-positive bacteria were susceptible to gentamicin (86.4%), erythromycin (81.8%), and nitrofurantoin (77.3%): whereas they showed a high level of resistance to penicillin (72.7%), doxycycline (54.5%), trimethoprim-sulfamethoxazole (52.9%), and cefoxitin (52.9%). No formal education for the participant (AOR: 2.86, 95% CI: 1.03-7.98, p=0.044), family monthly income <1500 birr (AOR: 3.19, 95% CI: 1.48-6.89, p=0.003), and previous history of UTI (AOR: 4.52, 95% CI: 2.04-10.03, p=0.001) were significantly associated with bacteriuria. This study revealed a high prevalence of bacterial urinary tract infection among pregnant women and low susceptibility to ampicillin, trimethoprim-sulfamethoxazole, cefuroxime, and cephalexin. Therefore, regularly, culture-based bacterial identification and antibiotic susceptibility testing should be performed. Alternatively, empiric antibiotic therapy should consider the prevalence of antibiotic-resistant uropathogens and the factor that may increase the urinary tract infection occurrence due to multi-drug resistant uropathogens.

Electrodiagnostic referrals and neuromuscular disease pattern in East Africa: Experience from a tertiary hospital in Ethiopia.

Objective: We present a retrospective cross-sectional review of the electrodiagnostic (EDX) referral and diagnostic patterns in patients with suspected neuromuscular conditions at a tertiary hospital in Ethiopia. Methods: Between 2016 and 2019, 313 patients were evaluated at the EDX lab in Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia. In our patients, nerve conduction study and when appropriate needle electromyography was done. Demographic and clinical data were extracted from a digital registry. Results: Polyneuropathy (19.8%), carpal tunnel syndrome (12.1%), and lumbosacral radiculopathy (9.9 %) were the top three reasons for EDX referral in Ethiopia. Among them, polyneuropathy was the most frequent electrodiagnosis, where diffuse axonal and demyelinating subtypes accounted for 54% and 18.8%, respectively. Guillain-Barre syndrome was suspected in 18 patients and 15 had EDX confirmed motor axon polyneuropathy while three patients had demyelinating variant. Although a quarter (26.2%) of the referrals had a normal EDX, abnormal test results were significantly associated with weakness (95% CI: 3.29-7.04, p < 0.001), bound to wheelchair (95% CI: 1.86-2.87, p = 0.01) and having a specific diagnosis at time of referral (95% CI: 2.53-4.68, p = 0.007). Conclusions: Diffuse and entrapment neuropathies were the main reasons for electrodiagnosis test referrals in Ethiopia. Also, motor axonal variant was the most common type of inflammatory polyneuropathy diagnosed with EDX. Significance: Proper patient evaluation and documentation significantly improves the diagnostic yield and cost-effectiveness of EDX testing in a resource-poor countries like Ethiopia. This might be achieved through educating medical students, residents, and other care providers on the basics of EDX and its indications for correct use in the clinical care.

Determinants of stunting among under-five children in Ethiopia: a multilevel mixed-effects analysis of 2016 Ethiopian demographic and health survey data.

BACKGROUND: Childhood stunting is the most widely prevalent among under-five children in Ethiopia. Despite the individual-level factors of childhood stunting are well documented, community-level factors have not been given much attention in the country. This study aimed to identify individual- and community-level factors associated with stunting among under-five children in Ethiopia. METHODS: Cross-sectional data from the 2016 Ethiopian Demographic and Health Survey was used. A total of 8855 under-five children and 640 community clusters were included in the current analysis. A multilevel logistic regression model was used at 5% level of significance to determine the individual- and community-level factors associated with childhood stunting. RESULTS: The prevalence of stunting was found to be 38.39% in Ethiopian under-five children. The study showed that the percentage change in variance of the full model accounted for about 53.6% in odds of childhood stunting across the communities. At individual-level, ages of the child above 12 months, male gender, small size of the child at birth, children from poor households, low maternal education, and being multiple birth had significantly increased the odds of childhood stunting. At community-level, children from communities of Amhara, Tigray, and Benishangul more suffer from childhood stunting as compared to Addis Ababa's community children. Similarly, children from Muslim, Orthodox and other traditional religion followers had higher log odds of stunting relative to children of the protestant community. CONCLUSIONS: This study showed individual- and community-level factors determined childhood stunting in Ethiopian children. Promotion of girl education, improving the economic status of households, improving maternal nutrition, improving age-specific child feeding practices, nutritional care of low birth weight babies, promotion of context-specific child feeding practices and narrowing rural-urban disparities are recommended.

Hypouricemic and antioxidant activities of Allium cepa Lilliaceae and quercetin in normal and hyperuricemic rats.

OBJECTIVE: To evaluate the hypouricemic and antioxidant effects of Allium cepa Lilliaceae (Allium cepa L.) and quercetin in normal and hyperuricemic rats. METHODS: The following study was conducted in the Department of Nutrition and Biochemistry, Tehran University of Medical Science, Iran, between May 2007 and March 2008. A total of 48 male Wistar rats (body weights: 180-200 g) were randomly divided into 8 equal groups including normal; normal + Allium cepa L. (5g/kg); normal + quercetin (5mg/kg); normal + allopurinol (5mg/kg); hyperuricemic; hyperuricemic + Allium cepa L. (5g/kg); hyperuricemic + quercetin (5mg/kg); hyperuricemic + allopurinol (5mg/kg) once a day for 14 days. Experimentally, hyperuricemia in rats was induced by intraperitoneal injection of potassium oxonate (250mg/kg). RESULTS: Allium cepa L. and quercetin treatments for 14 days significantly reduced (p=0.000) the serum uric acid levels of hyperuricemic rats in a time-dependent manner. All treatments significantly inhibited hepatic xanthine oxidase/xanthine dehydrogenase activity. Allium cepa L. and quercetin treatments led also to a significant improvement in biomarkers of oxidative stress in hyperuricemic rats (p=0.000). Although the hypouricemic effect of allopurinol was much higher than that of Allium cepa L. and quercetin, it could not significantly change oxidative stress biomarkers. CONCLUSION: These results may be responsible partly for the beneficial effects of Allium cepa L. and its major flavonoid on hyperuricemia and oxidative stress.

Contrast transcranial Doppler compared to transesophageal echocardiography in detection of right-to-left shunt.

OBJECTIVE: To assess contrast transcranial Doppler (TCD) for detection of right-to-left shunt (RLSh). METHODS: We studied 30 patients aged between 25-45 years admitted to Al-Zahra Hospital, affiliated to Isfahan University of Medical Sciences, between May 2003 and May 2005. All patients underwent transesophageal echocardiography (TEE) with contrast and contrast TCD. RESULTS: Eleven (36.6%) patients had RLSh detected by TEE with contrast, and 19 (63.3%) patients had no shunt by TEE. Eighteen patients (60%) patients had no RLSh by contrast TCD, and 12 (40%) patients had RLSh by contrast TCD. Ten (33.3%) patients had RLSh by contrast TCD and TEE with contrast procedures. One patient had RLSh by TEE, and it was negative on TCD test, and 2 patients were positive on TCD test and negative in TEE. With contrast TEE as the gold standard, the sensitivity of contrast TCD was 90.9% and specificity was 89.4%, with an accuracy of 90%. Meanwhile, the positive predictive value of contrast TCD was 83.3% and the negative predictive value was 94.4%. CONCLUSION: In our study, the negative predictive value of contrast TCD was excellent. Therefore, this examination is able to exclude RLSh with a high level of confidence.

Free conjunctival autograft in the management of advanced primary and recurrent pterygia.

OBJECTIVES: To evaluate the outcome of free conjuctival autograft in patients with grades III and IV pterygia and to determine the post-operative recurrence rate. DESIGN: A prospective descriptive study. SETTING: Menelik II Hospital, Addis Ababa, Ethiopia. PARTICIPANTS: Thirty four patients, 32 with primary and two with recurrent pterygia. INTERVENTION: A superficial Keratectomy extending beyond the corneal lesion all around and sufficiently deep to Bowman's layer to produce a perfectly clear cornea in the excised area followed by suture a free conjuctival autograft on the excised area. MAIN OUTCOME MEASURES: Improvement in visual acuity and recurrence rate of pterygia at follow up. RESULTS: Of the 32 patients followed up, the visual acuity remained the same on eight and improved in 24 cases. There were no intraoperative complications. Pterygia recurred in two patients between three and four months postoperatively. CONCLUSION: This study suggests that a free conjuctival autograft in the management of stage III and IV pterygia is a useful operation resulting in a very low recurrence rate of the pathology.

Adenotonsillectomy in the very young patient: cost analysis of two methods of postoperative care.

Postoperative management of the patient younger than 36 months undergoing adenotonsillectomy has been the subject of many debates. Concerns for early postoperative complications such as airway obstruction, emesis, dehydration, and hemorrhage have led many physicians to consider overnight hospitalization following adenotonsillectomy in very young children. Trends in health care management have had increasing focus on cost effective means of treating patients to limit unnecessary expenditure on the part of the patient, physician, and hospital facility. The purpose of this retrospective review was to analyze two methods of early postoperative management in children less than 36 months old undergoing adenotonsillectomy at the Children's Hospital, San Diego from 1992 to 1997. Three hundred and seven cases were reviewed. Same-day discharge was compared with overnight inpatient observation based on the cost analysis of these two methods of postoperative care. Postoperative care was based on length of stay in the recovery room and as an inpatient. Expense of postoperative care was based on cost calculation for the recovery room and overnight hospitalization. Of the 307 patients, 194 went home the day of surgery and 113 were observed overnight in the hospital. Average hospital cost was higher in the outpatient group than in the inpatient group (P < 0.001). This difference reflects longer recovery room stay (350 min) in the outpatient group compared to the inpatient group (108 min) (P < 0.001). Outpatient adenotonsillectomy in the patient under 36 months may be safe; however, prolonged recovery room stays may actually make outpatient surgery less cost-effective than overnight admission. Recovery room costs are significantly higher per unit time than costs of inpatient hospitalization. Further investigation of cost-effective outpatient observation units may improve cost containment in the outpatient surgical setting.

Acute coalescent mastoiditis in an infant: an emerging trend?

There is some evidence to suggest that the incidence and complications of ACM may be increasing. However, in the current era of widespread access to health care and broad-spectrum antibiotics, an intratemporal or intracranial complication from acute otitis media may not initially be suspected. The reported case is significant in that the patient was very young, had no underlying disease or immunocompromise, and did not have a known antecedent acute otitis media. With the emergence of resistant streptococcal species and prolonged survival in immunocompromised patients, the relative incidence of complications caused by acute otitis media will probably continue to rise, making it imperative that we raise our index of suspicion for previously rare infectious complications of relatively common diseases.

Sutureless cartilage graft laryngotracheal reconstruction using fibrin sealant.

OBJECTIVE: To determine whether fibrin sealant can replace suture as a means of holding a cartilage graft securely in the trachea. DESIGN: Randomized blinded control study comparing the use of fibrin sealant vs sutures in laryngotracheal reconstruction in ferrets. We compared results at 7 and 30 days. SUBJECTS: Forty ferrets randomized into 2 groups of 20: fibrin sealant and sutures. Within each group, half were studied at 7 days and the rest at 30 days. No ferrets were withdrawn from study because of adverse effects of the intervention. INTERVENTION: A carved costal cartilage graft was placed in the anterior cricoid split incision, and was secured with either fibrin sealant or sutures. All animals were extubated after recovery from anesthesia. Specimens were examined grossly and histologically. RESULTS: All animals survived until humanely killed. The pathologist, unaware of the groupings, measured lumen expansion in millimeters, cartilage graft migration, mucosal in-growth, degree of inflammation, graft integration, and graft viability. The fibrin sealant group had statistically significant (P<.05) better results in mucosal in-growth. In no categories was the suture group better than the fibrin sealant group. In comparing 7-day with 30-day results, the 30-day group had significantly better results in inflammation and graft viability. CONCLUSIONS: Fibrin sealant can be used in place of sutures with improvement in mucosal growth in costal cartilage laryngotracheal reconstruction in the experimental animal model. Use of fibrin sealant (instead of sutures) may result in less surgical trauma and edema, less surgical time, and faster recovery.

Use of a prefabricated tunica vaginalis fascia flap to reconstruct the tunica albuginea after recurrent penile prosthesis extrusion.

PURPOSE: Although a penile prosthesis usually perforates into the urethra, it can extrude through the glans or corporeal shaft. Various materials have been used to reconstruct tunica albuginea but no method of repair has been satisfactory in such difficult cases. Repair of the weakened tunica albuginea should ideally be performed with autogenous tissues. Inasmuch as the scarred tissue bed is inadequate to ensure graft survival and no local flaps are available for this purpose, prefabrication of a local flap has been designed. MATERIALS AND METHODS: We present 2 cases in which the distal corpus was reconstructed with a prefabricated tunica vaginalis fascia flap. The first stage involves grafting rectus fascia onto the external tunica vaginalis of the testicle. At the second stage the prefabricated tunica vaginalis fascia flap is transposed to the distal corpus, placing it as a buttress between the cylinder and urethra medially or between the cylinder and thin lateral and distal tunica albuginea. The flap also replaces part of the tunica albuginea. RESULTS: In both patients repair of the tunica albuginea was successful and each has a functioning inflatable penile prosthesis at 2 1/2 1 1/2 years postoperatively, respectively. CONCLUSIONS: Reconstruction of the weak tunica albuginea with a prefabricated tunica vaginalis fascia flap is an excellent procedure in these difficult cases.

Perioperative psychosocial interventions for autistic children undergoing ENT surgery.

Tonsillectomy/adenoidectomy is one of the most frequently performed operations in the United States. It is therefore likely that pediatric ENG surgeons will encounter autistic and developmentally delayed children in routine practice. Autistic children differ from normal children in that they exhibit severe deficits in language and social functioning; abnormal reaction to stimuli such as light, sound, touch, and pain; attachments to particular unusual objects and rigidly stereotyped routines. They are often mentally retarded. With the increasing importance of managed care and continuous quality improvement, knowledge of how to manage the operative course of such children is crucial for the practising surgeon. Based on research and clinical knowledge of these children, certain psychosocial and medical interventions are presented which may improve the operative course of this population. Using the parent as a consultant; decreasing separation from familiar caretakers, objects, and routines; pre-operative role-playing; tailoring anesthetic induction; and using post-operative distractors are suggested techniques.

Discoordinate pharyngolaryngomalacia.

In cases of severe laryngomalacia, laser division of the aryepiglottic folds (AEFs) or endoscopic supraglottoplasty may be an ineffective solution. Failure of this technique is rare and the reasons for failure are not well established. The purpose of this study was to describe those cases of laryngomalacia in which endoscopic treatment did not reverse the clinical situation. We introduce the concept of discoordinate pharyngolaryngomalacia (DPLM). DPLM was defined as severe laryngomalacia with complete supraglottic collapse during inspiration, without shortened AEFs or redundant mucosa, and with associated pharyngomalacia. Twenty-seven of 82 children with severe laryngomalacia presented a DPLM. Endoscopic treatment was performed in 16 children and the surgical procedure was inadequate to reverse the clinical problem in these patients. In 10 children correction of additional sites of obstruction was required (uvulopharyngopalatoplasty, surgery of choanal atresia, aortopexy). Tracheostomy was necessary in 13 children. Bi-level positive airway pressure (BiPAP) was used successfully in 2 children and tracheotomy was avoided. Treatment still needs to be better defined.

Neonatal rhinitis.

Neonatal rhinitis as a distinct disease entity has not been well-studied. The recognition and treatment of this condition is important since neonates are obligate nasal breathers, and mismanagement of this entity can result in poor feeding or even death from respiratory distress. We undertook a retrospective analysis of 20 patients seen at the Children's Hospital of San Diego over the period 1990-1991. Eighteen patients developed neonatal rhinitis in the months of August to January and only two between February and July. Clinical presentation and an effective management algorithm are discussed. Early recognition on the basis of clinical features followed by a two-step therapeutic trial consisting of conservative therapy and corticosteroid drops are advocated. Based on the above findings we have defined neonatal rhinitis as mucoid rhinorrhea with nasal mucosal edema in the afebrile newborn that results in stertor, poor feeding and respiratory distress which responds promptly to decadron 0.1% drops within a week. We recommend reserving diagnostic procedures for complicated cases that do not respond to the proposed regimen.

Contrasting strategic approaches to the management of subglottic hemangiomas.

The standards of treatment of subglottic hemangiomas are steroids and laser vaporization. If these methods do not provide a sufficient airway, a tracheotomy may be required. Analysis of the data available in the literature shows that there is a place for other therapeutic solutions. Open surgical excision could be one of them but is controversial. So far, it represented a 'last' resort procedure before tracheotomy. Our approach to open surgical excision is different. A prospective decision is taken in the initial therapeutic approach. Infants are considered candidates for excision in cases of large hemangiomas that extend beyond the limits of laser. Laser is, then, avoided in order not to damage the overlying mucosa. Interferon is not utilized because a rapid effect is not expected on the respiratory distress. Open surgical excision without tracheotomy is performed. A cricoid enlargement is associated at the end of the procedure. Risk for post-operative subglottic stenosis is limited. When conceived this way, open surgical excision seems effective to manage large life-threatening hemangiomas.

Nager acrofacial dysostosis: management of a difficult airway.

Nager acrofacial dysostosis, first described by Nager and deReynier in 1948, is a rare syndrome characterized by mandibulofacial dysostosis with associated radial defects. The facial features include downward slanting palpebral fissures, absent eyelashes in the medial third of the lower lids, mandibular and malar hypoplasia, dysplastic ears with conductive deafness, and variable degrees of palatal clefting. Upper limb malformation is a constant feature of Nager syndrome and ranges from thumb hypoplasia to absence of the radial ray. The maxillo-mandibular hypoplasia and associated retroplaced tongue set the stage for early and significant upper airway obstruction. The craniofacial anomalies and associated trismus make emergent airway intubation challenging. We present a case of Nager syndrome with life threatening airway obstruction unresponsive to conservative management. This case and a review of the literature emphasize the importance of early tracheotomy for these patients.

One-stage tracheal reconstruction of congenital tracheal stenosis.

Congenital tracheal stenosis (CTS) is a condition difficult to manage and associated with a high mortality rate. The principles of one-stage laryngotracheoplasty have been adapted to the surgical management of CTS. Three children underwent a one-stage anterior tracheoplasty with costal cartilage grafting and without cardiopulmonary bypass. Extubation was performed within 13 days. One child developed granulation tissue one month postoperatively, and this was removed endoscopically. The three children were free of respiratory obstruction signs during follow-up ranging from 8 months to 3 years. Postoperative endoscopies have shown growth of the grafted trachea.

Coccidioides immitis subperiosteal abscess of the temporal bone in a child.

A destructive granulomatous lesion of the temporal bone caused by Coccidioides immitis disseminated from a pulmonary lesion was found in a 4-year-old immunocompetent child. To our knowledge, it is the first case of coccidioidomycosis of the temporal bone reported in the world literature. The child presented with pain in her right ear and a 6-month history of intermittent fever, which partially responded to multiple courses of antibiotics. A tender erythematous postauricular swelling consistent with a subperiosteal abscess subsequently developed over 1 month. A mastoidectomy showed granulation tissue with pockets of purulence, and histologic evaluation of the specimen revealed spherules of C immitis, later verified by culture. The patient responded to intravenous amphotericin B therapy, without evidence of disease recurrence. Coccidioides immitis is endemic in regions of the Southwestern United States, with extremely infectious characteristics and relative resistance to medical therapy. Coccidioidomycosis should be considered in the differential diagnosis of a granulomatous lesion of the temporal bone.