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.

Factors Associated with EEG Slowing in Individuals with Parkinson's Disease.

BACKGROUND: A plethora of scientific studies has shown diffuse slowing on electroencephalograph (EEG) study is a frequent occurrence in Parkinson's disease (PD) patients, compared to the healthy controls. Little is known about EEG slowing and PD in the sub-Saharan Africa, especially in Ethiopia. The objective of this study was to assess factors associated with EEG slowing in individuals with Parkinson's disease. METHOD: A cross-sectional observational study was conducted in 40 PD patients at Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia. Both descriptive and analytical statistics were used to analyze the data. RESULTS: Total of 40 patients with PD was included in the present survey. The median age was 66 (IQR: 52.5 - 72.5 years) and young onset PD accounted 20%. Males accounted for twothird of the participants. Diffuse EEG slowing was observed in 52.5% (n=21) of participants. Majority (85%) were on levodopa treatment. Hypovitaminosis D was observed in 93.1% of the study participants. White matter hyperintensity (WMH) and global brain atrophy were seen in 47.5% and 27.5% respectively. Even though statistically not significant, PD patients with EEG slowing, reported more forgetfulness and had WMH on their brain MRI, compared to those with normal EEG. Age was associated with diffuse EEG slowing when adjusted for forgetfulness and WMH (Adjusted OR 1.18 95% CI (1.01 - 1.37) p=0.03). CONCLUSION: The present study indicates high prevalence of diffuse EEG slowing in PD patients. Age was associated with diffuse EEG slowing. Higher proportion of patients with EEG slowing reported forgetfulness and hypovitaminosis D compared to those with normal EEG recordings.

Serum Vitamin D Level among Multiple Sclerosis Patients in the Tropics: Experience from a Private Clinic in Addis Ababa, Ethiopia.

BACKGROUND: Multiple sclerosis (MS) is an immune mediated disabling neurological disorder. Very little is known about MS in Ethiopia. The objective of this study was to determine the prevalence of hypovitaminosis D and associated factors in cohort of MS patients in Ethiopia. METHOD: A cross-sectional observational study was conducted among 25 multiple sclerosis patients at Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia. RESULTS: The prevalence of vitamin D deficiency was 96% (n=24). The average serum vitamin D was 14.8 (±10.4) ng/mL. The mean age was 35.8 (±10) years. Females accounted for 80% (n=20). Relapsing and remitting MS was the commonest variant. Motor, sensory, and mixed symptoms accounted for 40% (n=10), 20% (n=5), and 24% (n=6), respectively. Cold or hot weather and stress were reported as worsening factors in 24% (n=6). Relapse rate was 44% (n=11). Fatigue and seizure disorder were reported by 80% (n=20) and 16% (n=4) respectively. Steroid is the commonest prescribed medication for the patients. A negative correlation was found between serum vitamin D and age (r = -0.062, p = 0.7). Similarly, a negative association was observed between vitamin D and duration of illness (r = -0.311, p = 0.1). Fatigue was reported by those with moderate hypovitaminosis compared to those having severe hypovitaminosis (p=0.002). Seizure was reported more by those with vitamin D below 10ng/mL compared to those having above 10 ng/mL (p=0.004). CONCLUSION: Our study demonstrates a high prevalence of hypovitaminosis D in Ethiopian MS patients. Hypovitaminosis D was associated with increment in age and duration of illness.

Neuroimaging Features and Associated Factors in Multiple Sclerosis Patients: A Perspective from a Private Care Center in Addis Ababa, Ethiopia.

BACKGROUND: Brain and spine magnetic resonance image (MRI) have an invaluable importance in diagnosing multiple sclerosis (MS) in low prevalence countries such as Ethiopia. The objective of our study was to characterize the neuroimaging features and associated factors in Multiple sclerosis patients in Addis Ababa, Ethiopia. METHOD: A cross-sectional observational study was conducted in 30 multiple sclerosis patients at Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia. Both descriptive and analytical statistics were used to analyze the data. RESULTS: We have enrolled 30 patients with confirmed multiple sclerosis and clinically isolate syndrome. The mean age was 34.7 years (1SD=8.9). Female accounted 86.7%. The mean duration of illness was 3.4 years (1SD=3.1) (range: 1 - 11 years). Relapsing and remitting variant was the commonest sub type (66.7%). Alcohol use and head injury were the commonest identified risk factors reported by the patients. Classical radiological features of MS such as white matter lesions involving juxtacortical, U-fiber, corpus callosum (CC), and Dawson's finger projections pattern were observed in 46.7%, 23.3%, 70%, and 40% respectively. Cervical and thoracic cords were affected in 40% and 6.7% respectively. Global cortical and CC atrophy was observed in 16.7% and 6.7% respectively. Advanced age was associated with lesions of corpus callosum when adjusted for duration of illness and history of head injury (AOR 1.13, 95% CI 1.01-1.28, p=0.04). CONCLUSION: Typical neuroimaging features of MS were prevalent among Ethiopian MS patients. Age was an independent predictor of lesions involving corpus callosum. Global cortical atrophy was common among Ethiopian MS patients.