Entrance surface air kerma to patients during digital radiographic examinations in Tanzania.

The aim of this study was to determine the entrance surface air kerma (ESAK) in adult patients during digital radiography and to evaluate the optimisation potential in five common X-ray examinations in Tanzania. Based on a sample of 240-610 patients, ESAK was estimated using X-ray tube output measurements, patient information and backscatter factors. The results show that the mean ESAK values were higher or comparable to data from the literature. The diagnostic reference values of ESAK for digital radiography were 0.31 mGy (chest PA), 4 mGy (lumbar spine AP), 5.4 mGy (lumbar spine LAT), 3.8 mGy (abdomen AP) and 2.4 mGy (pelvis AP). For computed radiography, the mean ESAK ranges were 0.44-0.57 mGy (thoracic AP), 3.59-3.72 mGy (lumbar spine AP), 6.16-6.35 mGy (lumbar spine LAT), 3.89-3.44 mGy (abdominal AP) and 2.92-3.47 mGy (pelvic AP). In conclusion, high ESAK variations show the potential for optimising protection in digital radiology.

Radiation exposure during CT procedures in Tanzania.

The aim of this study was to evaluate optimisation status during common computed tomography (CT) procedures by determining values of volume computed tomography dose index (CTDIvol) and dose-length product (DLP) per examination. Patient and exposure data were collected from the CT console during various CT procedures. The results show that variations in CTDIvol and DLP values were mainly because of differences in the techniques used. The 75th percentile values were set as the third quartile of the median CTDIvol or DLP values for all hospitals. These values of 40.9, 9.0, 9.4 and 16.2 mGy for CTDIvol were determined for head, high-resolution chest, abdomen-pelvis and lumbar spine, respectively. The corresponding DLP values for the same sequence of CT procedures were 900, 360, 487 and 721 mGy.cm, respectively. The updated results provide a basis for optimising the procedures of CT in this country.

Dorsal pancreas agenesis, an incidental finding during acute appendicitis diagnosis; A case report.

INTRODUCTION AND IMPORTANCE: Dorsal pancreas agenesis is a rare congenital anomaly characterized by the absence or severe underdevelopment of the dorsal pancreatic bud. We report a case of a man who presented with features of appendicitis only to the incidentally discovery of dorsal pancreas agenesis during the diagnosis of acute appendicitis. We describe our experience on radiological diagnostic formulation and work up. CASE PRESENTATION: We present the case of a 45-year-old male patient who presented to the emergency department with symptoms and signs suggestive of acute appendicitis. A computed tomography scan and laboratory investigations confirmed the diagnosis of appendicitis. Incidentally, the scan also revealed the absence of dorsal pancreatic tissue, leading to the incidental diagnosis of dorsal pancreas agenesis. CLINICAL DISCUSSION: Dorsal pancreas agenesis is often asymptomatic and can be incidentally discovered during imaging studies or surgical interventions for unrelated conditions. In our case, the initial presentation of acute appendicitis provided an opportunity for the fortuitous diagnosis of dorsal pancreas agenesis. This emphasizes the importance of comprehensive imaging reporting in patients who undergo imaging for other conditions. CONCLUSION: This case report highlights the fortuitous discovery of dorsal pancreas agenesis during the diagnostic workup for acute appendicitis. It emphasizes the need for thorough imaging evaluation and reporting along with the importance of considering anatomical variations in patients presenting with abdominal symptoms. Increased awareness among healthcare professionals about such congenital anomalies can lead to their early recognition and appropriate management.

Couvelaire uterus in a previable pregnancy: Complication in abruptio placenta, case series from Tanzanian tertiary hospital.

INTRODUCTION AND IMPORTANCE: Couvelaire uterus, also previously known as uteroplacental apoplexy. This is a life-threatening condition resulting from bleeding into the myometrium that may extend to the parametrium and peritoneum. Couvelaire uterus is typically associated with abruptio placentae, the premature separation of the placenta. This syndrome can only be diagnosed by direct visualization during caesarean section or biopsy (or both). For this reason, its prevalence is under-reported and underestimated in the literature. CASES FINDINGS: We present a rare case series of two patients with Couvelaire uterus in previable pregnancy at Aga Khan Hospital, Dar es salaam. This combination is a rare occurrence and there are no cases reported in sub-Saharan Africa to the best of our knowledge. CLINICAL DISCUSSION AND CONCLUSION: Couvelaire uterus is a rare manifestation to find in a previable pregnancy. The incidence of Couvelaire uterus is difficult to estimate since the diagnosis can only be reached intra-operatively. In most cases it occurs with abruptio placentae which develops due to a disruption in the vessels within the placenta allowing for blood to seep into the decidua basalis leading to premature separation of the placenta and bleeding into the myometrium which may extend to the parametrium and peritoneum. Clinicians should be vigilant when dealing with vaginal bleeding in a pre-viable pregnancy and placental separation is considered as an important differential to avoid the maternal morbidity and mortality that may ensue.

To err is human; acute appendicitis a mistaken clinical identity for metastatic follicular thyroid carcinoma, a case report.

INTRODUCTION AND IMPORTANCE: Thyroid cancer accounts for majority of endocrine cancers with follicular thyroid cancer the second most common. It tends to spread via hematogenous route with distant metastasis thus besides presenting as a neck mass it may also present with symptoms tallying to regions of metastasis which may misguide the diagnosis. We report a case of a 50-year-old man who presented with features of appendicitis only to discover metastatic right iliac bone follicular thyroid cancer. We describe our experience on diagnostic formulation, radiological work up, surgery, radioactive iodine therapy and follow up. CASE PRESENTATION: 50-year-old man presenting with acute abdomen and fevers with suspicion for appendicitis, worked up and found to have metastatic follicular carcinoma. Underwent total thyroidectomy and radioactive iodine therapy to achieve disease stability without progression with a 5 year follow up completed. CLINICAL DISCUSSION: The tendency to jump to medical imaging to establish a diagnosis in a lab oriented rather than clinical oriented approach. The role of radiology to establish the underlying disease and identify the primary lesion. Successfully halting disease progression for metastatic follicular thyroid carcinoma with surgery and radioactive iodine therapy. CONCLUSION: Right iliac fossa tenderness does not always equate to acute appendicitis hence the use of diagnostic imaging to diagnose the metastatic lesion thus simplifying the puzzle to identify the primary. We hope through sharing our experience, we encourage the use of interventional radiology in a region that tends to opt for open approach when percutaneous approaches have shown to be successful.

Evaluation of venous thromboembolism (VTE) risk assessment and thrombo-prophylaxis practices in hospitalized medical and surgical patients at Aga Khan Hospital Dar es Salaam: single-centre retrospective study.

Introduction: venous thromboembolism is a complication among admitted medical and surgical patients. International guidelines recommend patients are assessed upon admission and appropriate thromboprophylaxis should be initiated. However, studies have shown that thromboprophylaxis for patients at risk of venous thromboembolism is underutilized. Methods: this was a retrospective study conducted on hospitalized medical and surgical patients at Aga Khan Hospital Dar es salaam from January to June 2019. Patient's medical records were reviewed and data was collected for analysis of venous thromboembolism assessment and compliance with Caprini risk assessment model. The data was entered into statistical package for the social sciences (SPSS) 25 and categorized into risk groups, frequency of patients' demographic and clinical characteristics data was calculated and the main study outcomes were analyzed with Fisher´s exact test or Pearson chi-square test for categorical variables and student t-test for continuous variables. Regression analyses were done to identify significant risk factors where by P ≤ 0.05 was considered statistically significant. Results: compliance of venous thromboembolism assessment among medical and surgical patients was similar at 78% and 80%, respectively, with a baseline 22% of all admitted patients considered at risk of venous thromboembolism, hence needing thromboprophylaxis following the Caprini risk assessment modelscore. Thromboprophylaxis practices was identified at just 25% of at-risk individuals received pharmacological prophylaxis with enoxaparin; the most commonly used agent (92%). Identified risk factors for venous thromboembolism were advancing age (>60 years), history of prior major surgery, Major surgery lasting > 60 minutes, obesity, and immobilization. Conclusion: risk assessment for venous thromboembolism should be emphasized upon admission of both surgical and medical patients. Adequate thromboprophylaxis should be prescribed upon identification of patients at risk.

Diagnostic accuracy of computed tomography in adults with suspected acute appendicitis at the emergency department in a private tertiary hospital in Tanzania.

INTRODUCTION: The increasing incidence of acute appendicitis in sub-Saharan Africa emphasizes the need for accurate and reliable diagnostic tools. However, the variability in the diagnostic performance of computed tomography for suspected acute appendicitis coupled with comparatively higher negative appendectomy rates in this setting highlight a possible concern regarding the diagnostic accuracy. This study evaluated the diagnostic accuracy of a computed tomography scan for suspected acute appendicitis at the emergency department in Tanzania. METHODS: A retrospective diagnostic accuracy study was conducted from July to October 2020. All patients above 14 years of age who presented at the emergency department with right iliac fossa abdominal pain of fewer than ten days and underwent computed tomography for suspected acute appendicitis were evaluated, and the Alvarado score was computed. Histological diagnosis and clinical follow-up of 14 days were considered the reference standard. Ethical clearance was sought from the Aga Khan University Ethical review committee. RESULTS: 176 patients were included in this study. The sensitivity, specificity, and diagnostic accuracy were 100% (95% CI 91.8-100), 96.9% (95% CI 92.2-99.1), and 96.9% (95% CI 93.1-98.3), respectively. The mean Alvarado score in those without acute appendicitis was 4 (95% CI 3.7-4.3) compared to a mean score of 6.6 (95% CI 6.0-7.2) amongst those with acute appendicitis. The area under the receiver operator characteristics curve of computed tomography was 98.4%, and that of the Alvarado score was 84.1%. CONCLUSIONS: The diagnostic performance of computed tomography in this study is similar to that established elsewhere. However, the Alvarado score is not routinely used for the initial screening of suspected acute appendicitis patients. A threshold of Alvarado score of 4 as a guide to conduct computed tomography for suspected acute appendicitis would have decreased computed tomography use by 50%, and missed 4 cases. Implementation studies that address Alvarado score use should be conducted.

Incidence and characteristics of stroke in Zanzibar-a hospital-based prospective study in a low-income island population.

Background: Stroke in adults is a critical clinical condition and a leading cause of death and disability globally. Epidemiological data on stroke in sub-Saharan Africa are limited. This study describes incidence rates, stroke types and antecedent factors among patients hospitalized with stroke in Zanzibar. Methods: This was a prospective, observational study of stroke patients at hospitals in Unguja, Zanzibar. Socioeconomic and demographic data were recorded alongside relevant past medical history, medicine use and risk factors. The modified National Institute of Health Stroke Scale (mNIHSS) was used to assess admission stroke severity and, when possible, stroke was confirmed by neuroimaging. Results: A total of 869 stroke admissions were observed from 1st October 2019 through 30th September 2020. Age-standardized to the World Health Organization global population, the yearly incidence was 286.8 per 100,000 adult population (95%CI: 272.4-301.9). Among these patients, 720 (82.9%) gave consent to participate in the study. Median age of participants was 62 years (53-70), 377 (52.2%) were women, and 463 (64.3%) had a first-ever stroke. Known stroke risk factors included hypertension in 503 (72.3%) patients, of whom 279 (55.5%) reported regularly using antihypertensive medication, of whom 161 (57.7%) had used this medication within the last week before stroke onset. A total of 460 (63.9%) participants had neuroimaging performed; among these there was evidence of intracerebral hemorrhage (ICH) in 140 (30.4%). Median stroke severity score using mNIHSS was 19 (10-27). Conclusion: Zanzibar has high incidence of hospitalization for stroke, indicating a very high population incidence of stroke. The proportion of strokes due to ICH is substantially higher than in high-income countries. Most stroke patients had been in contact with health care providers prior to stroke onset and been diagnosed with hypertension. However, few were using antihypertensive medication at the time of stroke onset.www.ClinicalTrial.gov registration NCT04095806.

Bilateral tubal ectopic gestation: Complication in a patient with previous ectopic pregnancy, rare case report.

INTRODUCTION: Ectopic pregnancy results of implantation of conceptus outside of endometrial cavity. It remains an important cause of maternal mortality. Spontaneous bilateral tubal pregnancies are the rare form of ectopic and are considered spontaneous when no fertility treatments are involved. CASE FINDINGS: A 31-year-old nulliparous woman presented at the Family Medicine Clinic with complaints of non-specific mild lower abdominal pain for 3 days and amenorrhea for 5 weeks. Transvaginal Ultrasound showed bilateral unruptured adnexa pregnancies. The trial of medical therapy was done without success and later laparotomy salpingostomy was done. One year later patient was able to conceive and delivery well by cesareans section. DISCUSSION: Bilateral ectopic pregnancy is a unique from of twin pregnancy frequently occurring with assisted reproductive technology rather than spontaneous pregnancy. Diagnosis of bilateral ectopic pregnancy is often challenging as the clinical symptoms and signs may not be indicative of bilateral involvement. Laboratory test with ßhcg levels cannot suggestive if is unilateral or bilateral nature and sonographers may be falsely reassured if they are not careful and satisfied with visualization of ectopic gestation on one side. Laparoscopic salpingostomy or salpingectomy is the gold standard treatment modality for bilateral tubal ectopic pregnancy although laparotomy may be indicated in unstable patient. CONCLUSION AND RECOMMENDATION: Therefore, any women in childbearing age presenting with clinical features of acute lower abdominal pain should be considered to have potential ectopic gestation.

Heterotopic gestation in polycystic ovary disease: Termination of tubal pregnancy and intrauterine pregnancy progressing to term.

Heterotopic pregnancy is rare. We report a 27-year-old lady with polycystic ovarian disease. She presented at our health facility with acute abdomen. Her evaluation revealed heterotopic pregnancy. High index of suspicion for heterotopic pregnancy in any woman with early pregnancy presenting with acute abdomen is crucial. Therefore, correct and early diagnosis allows appropriate management while it preserves the intrauterine pregnancy as in the index case.

A case report of minimally invasive percutaneous ultrasound guided tuberculous iliopsoas abscess drainage in an immunocompromised patient.

INTRODUCTION AND IMPORTANCE: Iliopsoas abscess is a collection of pus that presents with nonspecific features with often delays in diagnosis however cause significant morbidity and mortality with Mycobacterium tuberculosis to be considered as causative agent in at risk individuals in tuberculous endemic regions. Management involves drainage and initiation of adequate antibiotics with radiological guided percutaneous approach considered the appropriate initial approach. CASE PRESENTATION: 50-year-old immunosuppressed presenting with left iliopsoas abscess who underwent ultrasound guided drainage and placement of pigtail catheter successfully without the need for open surgical drainage. Our experience of interventional radiology for diagnosis of causative agent and treatment in a sub-Saharan Africa. CLINICAL DISCUSSION: We concur with the recommendation to analyse fluid for tuberculosis in at risk individuals with minimally invasive procedures via interventional radiology as an adequate first line diagnostic and treatment option of psoas abscess. Ultrasound guided catheter placement and drainage successfully drained the abscess by day 10 similarly seen as the average duration in a case series from India. CONCLUSION: The importance of the role of interventional radiology in treatment for complex abdominal pathologies in sub-Saharan Africa with its ability to diagnose and treat via minimally invasive procedures at highest precision and lowest risks and complications while maintaining a high level of suspicion for tuberculosis as the underlying etiology is highlighted.

Thinking Outside Malaria: A Rare Case of Disseminated Cysticercosis With Cardiopulmonary Involvement From Urban Tanzania.

Dissemination of the cysticerci throughout the body with cardiopulmonary involvement represents a very rare occurrence and an uncommon form of cysticercosis manifestation. We report a rare case of a 48-year-old African male from urban Tanzania who was, at first, referred to our radiology department for a coronary computed tomography angiography (CCTA), but incidentally on further evaluation of the patient revealed a history of recurrent convulsions, loss of consciousness, a single episode of temporary loss of vision and recent skin nodules. The value of a full clinical and radiological evaluation of the patient presenting with adult-onset seizures cannot be overemphasized for the diagnosis of this disease. Management of disseminated cysticercosis is complex and, therefore, should be tailored to fit the individual cases and focus on clinical manifestations.

The changing trend of teleconsultations during COVID-19 era at a tertiary facility in Tanzania.

INTRODUCTION: the current COVID-19 pandemic has occasioned the increased adoption of telemedicine. This study reports the uptake and trend of a new teleconsultation service in a Tanzanian hospital. METHODS: this is a retrospective observational study that profiled requests for teleconsultations and uptake of the service between April 1, 2020, and June 30, 2020. RESULTS: two hundred and eighteen telephone inquiries were received over the 3 months. One hundred and sixteen (53.2%) individuals followed through with the teleconsultations. Paediatric (38.8%) and Internal medicine (32.8%) were the subspecialties with the highest number of teleconsultations. In a frame of 3 months, teleconsultation uptake was highest in May and lowest in June. CONCLUSION: there was a steady rise and a rapid fall in requests and uptake of teleconsultation services over the period under evaluation. Lack of insurance coverage for teleconsultations was a significant barrier. We propose a re-education and reiteration of the benefits of telemedicine to all stakeholders. This is important for the current era and beyond.

Out-patient neurological disorders in Tanzania: Experience from a private institution in Dar es Salaam.

BACKGROUND AND INTRODUCTION: Low and middle-income countries (LMIC) have a considerable burden of neurological disorders. Available profile of neurological disorders in our environment is biased towards neurological admissions. There is a paucity of data on out-patient neurological conditions in sub-Saharan Africa. OBJECTIVE: To determine the frequency and demographic data of neurological illnesses being managed at the adult out-patient neurology clinic of the Aga Khan Hospital, Dar es Salaam (AKHD). MATERIALS AND METHODS: The electronic medical records of all cases with neurological diseases who presented to the adult neurology clinic of the AKHD between January 2018, and December 2019 were retrospectively reviewed and analyzed. Neurological disorders are categorized according to the international classification of diseases version-11(ICD-11). RESULTS: Of the 1186 patients seen in a period of 2 years, there were 597 (50.4%) females and 588(49.6%) males, with median age (IQR) of 38 (30.0-52.0) and 42 (33.0-54.5) years respectively (p = 0.001). Headache disorders (27.0%); disorders of the nerve root, plexus or peripheral nerves (23.4%); epilepsy (9.3%), cerebrovascular disorders (8.9%); movement disorders (3.6%) and disorders of cognition (3.5%) were the primary neurological conditions encountered. Musculoskeletal disorders (7.5%) and mental/behavioral disorders (5.4%) were other conditions seen in the clinic. CONCLUSION: The pattern of neurological disorders in this cohort mirrors that of high-income countries. However, the manpower to tackle these conditions pales in comparison. Increasing the neurology workforce and paying extra attention to non-communicable disorders in SSA is advocated.

Myocardial Echinococcosis: Rare Manifestation of a Common Parasitic Disease in Northern Tanzania.

Hydatid (Echinococcal) disease often involves the liver and lungs but in sporadic cases, it can involve cardiac structures. A 24-year-old male was referred with symptoms of cough and shortness of breath and a provisional diagnosis of metastatic disease of unknown primary to the lung, which was based on a chest X-ray (CXR). Incidentally, on echocardiogram, he was found to have right ventricular (RV) and myocardial multiseptated cysts, which were compatible with cardiac echinococcosis, as the patient had multiple bilateral lung cysts as well. Imaging with ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI) has ameliorated the diagnosis of hydatid disease location in various body parts. However, for earlier and accurate diagnosis, a high index of suspicion is required in endemic areas, especially in vulnerable populations such as pastoralists.

COVID-19 and stroke in sub-Saharan Africa: case series from Dar es Salaam.

Low and middle-income countries including those in sub-Saharan (SSA) Africa are experiencing a steady increase in the number of COVID-19 cases. To the best of our knowledge, reports of COVID-19 related strokes are scarce in SSA. The peculiar situation of stroke care in SSA makes COVID-19 associated stroke a bothersome entity as it adds other dynamics that tilt the prognostic balance. We present a case series of COVID -19 related stroke in 3 patients from Tanzania. We emphasized protected code stroke protocol.

Ogilvie syndrome: peculiar manifestation of acquired immunodeficiency syndrome in non-institutionalized middle age female in Tanzania.

Since it was first documented in 1948 by Sir William Heneage Ogilvie, numerous cases of Ogilvie syndrome have been described in literature due to various medical and surgical causes. Nonetheless, only a handful of cases only have been documented due to underlying Acquired Immunodeficiency Syndrome (AIDS). A 41-year-old female was admitted with an acute abdomen secondary to partial mechanical intestinal obstruction or paralytic ileus based on signs and symptoms and Abdominal X-Ray (AXR). She was known to be HIV/AIDS WHO clinical stage II on treatment. On diagnostic imaging studies she had distended large bowels without features of mechanical intestinal obstruction and the diagnosis of Ogilvie syndrome was suspected after other differentials were excluded. Early recognition and appropriate management are essential, because if left untreated the bowel distension may progress to caecal perforation and fatal peritonitis. Medical imaging with Computer Tomography (CT) scan and colonoscopy has helped in achieving an accurate diagnosis and avoiding unnecessary laparotomies. Although an uncommon disorder, for earlier and accurate diagnosis a high index of suspicion is required by clinicians and radiologists who are treating patients with underlying HIV/AIDS. Ogilvie's syndrome is a rare condition and if missed can be fatal. In patients with HIV/AIDS, the symptoms may be directly due to HIV infection, secondary to opportunistic infections or possible neurotoxic effects of HIV treatment or lack of vitamin and minerals. It is important to exclude Ogilvie syndrome in patients from surgical causes of the acute abdomen to avoid unnecessary surgical procedures.

The changing trend of teleconsultations during COVID-19 era at a tertiary facility in Tanzania

Introduction: the current COVID-19 pandemic has occasioned the increased adoption of telemedicine. This study reports the uptake and trend of a new teleconsultation service in a Tanzanian hospital. Methods: this is a retrospective observational study that profiled requests for teleconsultations and uptake of the service between April 1, 2020, and June 30, 2020. Results: two hundred and eighteen telephone inquiries were received over the 3 months. One hundred and sixteen (53.2%) individuals followed through with the teleconsultations. Paediatric (38.8%) and Internal medicine (32.8%) were the subspecialties with the highest number of teleconsultations. In a frame of 3 months, teleconsultation uptake was highest in May and lowest in June. Conclusion: there was a steady rise and a rapid fall in requests and uptake of teleconsultation services over the period under evaluation. Lack of insurance coverage for teleconsultations was a significant barrier. We propose a re-education and reiteration of the benefits of telemedicine to all stakeholders. This is important for the current era and beyond

Pseudomyxoma pleurii and peritonei secondary to sigmoid colon adenocarcinoma: a rare clinico-pathologico-radiological presentation.

Pseudomyxoma peritonei (PMP) is a rare condition resulting from mucin-producing tumors that have disseminated into intraperitoneal implants and mucinous ascites. The extra-abdominal spread of PMP is exceptionally rare, with few reported cases in the medical literature. Pseudomyxoma pleurii is an infrequently encountered clinical syndrome characterized by transdiaphragmatic pleural extension and spread of PMP. The disease is highly fatal. We hereby report a case of 58 years old woman who presented with an abdominal distension and shortness of breath of 2 months duration. Histopathology confirmed the diagnosis of large mucin-producing rectosigmoid adenomatous polypoid lesion with malignant transformation and PMP that had spread to the right pleural space. PMP from colon tumor is uncommon and its transdiaphragmatic pleural extension is very unusual complicated by management challenge and high mortality rate.