A Prospective Study of Causes of Illness and Death in Preterm Infants in Ethiopia: The SIP Study Protocol.

BACKGROUND: With nearly 15 million annual preterm births globally, preterm birth is the most common cause of neonatal death. Forty to 60 % of neonatal deaths are directly or indirectly associated with preterm mortality. As countries aim to meet the Sustainable Development Goals to reduce neonatal mortality, significant reductions in preterm mortality are needed. This study aims to identify the common causes of preterm illness and their contribution to preterm mortality in low-resource settings. This article will describe the methods used to undertake the study. METHODS: This is a prospective, multi-centre, descriptive clinical study. Socio-demographic, obstetric, and maternal factors, and clinical and laboratory findings will be documented. The major causes of preterm mortality will be identified using clinical, laboratory, imaging, and autopsy methods and use the national Ethiopian guidelines on management of preterm infants including required investigations to reach final diagnoses. The study will document the clinical and management protocols followed in these settings. The approach consists of clinical examinations and monitoring, laboratory investigations, and determination of primary and contributory causes of mortality through both clinical means and by post-mortem examinations. An independent panel of experts will validate the primary and contributory causes of mortality. To obtain the estimated sample size of 5000 preterm births, the study will be undertaken in five hospitals in three regions of Ethiopia, which are geographically distributed across the country. All preterm infants who are either born or transferred to these hospitals will be eligible for the study. Three methods (last menstrual period, physical examination using the New Ballard Score, and ultrasound) will be used to determine gestational age. All clinical procedures will be conducted per hospital protocol and informed consent will be taken from parents or caretakers prior to their participation in the study as well as for autopsy if the infant dies. DISCUSSION: This study will determine the major causes of death and illness among hospitalized preterm infants in a low-resource setting. The result will inform policy makers and implementers of areas that can be prioritized in order to contribute to a significant reduction in neonatal mortality.

High burden of hypertension across the age groups among residents of Gondar city in Ethiopia: a population based cross sectional study.

BACKGROUND: According to a report on the worldwide trends in blood pressure from 1975 to 2015, mean blood pressure is increasing in low and middle income countries while it is either decreasing or stabilizing in high income countries. Few studies have been published on the prevalence of hypertension in Ethiopia demonstrating an increased trend; however, these studies had small sample size and were limited to participants older than 35 years; which left the burden among adolescents and young adults unaddressed. The aim of this study was to assess prevalence of hypertension (HTN) and associated factors in Gondar city. METHOD: A population based cross-sectional study was conducted among 3227 individuals in Gondar city. A multistage cluster random sampling was used. The Kish method from World Health Organization (WHO) STEPS instrument of random sampling method was used for selecting one individual older than or equal to 18 years from each household. WHO and International Diabetic Association (IDA) criterion was used to classify HTN. RESULT: The overall prevalence of HTN was 27. 4% [95% CI: (25. 8-28.9)]. The prevalence for participants in the age group of ≥35 years was 36. 1%. It consistently increased from 9.5% in the age group of 18-25 years to 46.3% in the age group of ≥65 years (P-value < 0. 001). Only 47% of the participants had ever had any kind of blood pressure measurement. Being elderly (AOR = 5. 56; 95% CI: 3. 71-8. 35), obese (AOR =2. 62; 95%CI: 1. 70-4. 03), widowed (AOR = 1. 87; 95%CI: 1. 27-2. 75), separated (AOR = 1. 87; 95%CI: 1. 27-2. 75), daily alcohol user (AOR = 1. 51; 95%CI: 1. 02-2. 23), male gender (AOR = 1. 42; 95%CI: 1. 18-1. 72) and born in urban area (AOR = 1. 31; 95%CI: 1. 10-1. 56) were found to be independently associated with HTN. CONCLUSION: There is a high prevalence of hypertension in Gondar city and is showing increasing trend compared to previous reports. Interventions to raise awareness and to improve both capacity and accessibility of facilities for screening hypertension are highly recommended.

Appendiceal duplication an unusual cause of abdominal pain: A case report.

Appendiceal duplication is exceedingly rare, with a prevalence of 0.004% to 0.009% in appendectomy specimens. Appendiceal duplications can occur alone or in conjunction with cecal duplication. The persistence of the temporary embryologic second cecal appendix is hypothesized to cause appendiceal duplications. We present a case of appendiceal duplication in a 26-year-old Ethiopian female patient who had been experiencing abdominal pain in the right lower quadrant for 1 week. She developed anorexia, a loss of appetite, and a low-grade fever as a result of this. She reported direct and rebound mild discomfort in the right lower quadrant on abdominal examination. She was then operated on and she had an appendiceal duplication intraoperatively. As a result, an appendectomy was performed, and the patient was discharged with improved health. To avoid unfavorable patient outcomes and medicolegal difficulties, surgeons and surgical trainees who conduct several appendectomies throughout their training should be aware of the likelihood of appendiceal duplication.

Atypical Mucocutaneous Leishmaniasis Presentation Mimicking Rectal Cancer.

Cutaneous leishmaniasis is a neglected tropical disease affecting mostly the exposed skin, causing severe and disfiguring lesions in Ethiopia. In this report, we present two cases of atypical mucocutaneous leishmaniasis; one HIV positive and one HIV negative patient. Cases. A 32-year-old male HIV patient presented with 40 days of bleeding per-rectum and a perianal lesion of 5 years. An erythematous nontender plaque measuring 5 cm by 5 cm was observed over the right perianal area with circumferential constricting firm swelling of the rectum. The patient was cured with AmBisome and miltefosine after an incisional biopsy revealed leishmaniasis. A 40-year-old presented with bleeding per-rectum and stool incontinence of 3 months, generalized body swelling of 2 months, and mass around his anus for ten years. A 6 by 3 cm indurated ulcerating mass surrounding the anus and a fungating circumferential mass of 8 cm were seen above the proximal anal verge. An excisional biopsy revealed leishmaniasis, and the patient was treated with AmBisome but passed away due to complications with colostomy diarrhea. Conclusion. Clinicians should consider atypical mucocutaneous leishmaniasis as a possible diagnosis in patients with chronic skin lesions resembling hemorrhoids and colorectal masses, especially in endemic areas such as Ethiopia, regardless of their HIV status.

Evaluation of modified bleach technique for the detection of acid fast bacilli in lymph node aspirate at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

Background: Tuberculous Lymphadenitis (TBLN) is the commonest form of extrapulmonary tuberculosis. Definitive diagnosis of TBLN is difficult due to the low efficacy of the routine diagnostic techniques as compared to culture. Objective: To determine whether prior bleach concentration can improve the detection of acid-fast bacilli when compared with conventional Ziehl-Neelsen (ZN) staining by using culture as the gold standard. Methods: Cross-sectional study was conducted from March 01, 2015 to May 30, 2015. The study subjects were clinically suspected TBLN patients. Fine needle aspiration (FNA) was performed. Two different smears were prepared directly from the first needle pass for cytology and ZN staining. The remaining aspirate was used for the modified bleach concentration. The second needle pass aspirate was transferred into a sterile container containing sterile normal saline. The sediment was inoculated on the Lowenstein Jensen (LJ) medium. Measurement parameters for reliability and validity were used to analyze the results. Result: A total of 93 participants were included in the study. Fifty-six out of the 93 (60.2 %) cases were positive for mycobacterium tuberculosis complex on LJ culture. The detection rates of direct ZN staining and modified bleach method were 20.4 % and 44.1 %, respectively. 73.1 % of the cases showed cytomorphological features consistent with TBLN by cytologic examination. The sensitivities of direct ZN staining and modified bleach method and cytomorphology were 32.0 %, 67.8 %, and 92.8 %, respectively. Conclusion: Implementation of bleach concentration increases the detection rate of AFB over the direct ZN method. The bleach method can also be easily performed and provide a safe working environment by reducing infections.

Case Report: Atypical Presentation of Visceral Leishmaniasis: Two Cases from Northwest Ethiopia.

Human visceral leishmaniasis (VL) is a life-threatening disease caused by protozoan parasites belonging to the Leishmania donovani complex. Atypical cases of leishmaniasis and HIV coinfection have been documented in case reports, mostly associated with gastrointestinal tract, kidney, and skin involvement. We report two VL cases with atypical localizations not reported from east Africa before, both diagnosed and treated at the Leishmaniasis Research and Treatment Center, Gondar, Ethiopia. The first case was an HIV-infected patient with scrotal and penile involvement. Leishmania parasites were detected in the spleen and the scrotum. The second case was an immunocompetent individual with esophageal, laryngeal, and pharyngeal involvement and facial lesions. Leishmania parasites were detected in the spleen, skin, and esophageal biopsies. Current evidence suggests atypical presentation can occur in patients irrespective of their HIV status. Therefore, we suggest a high index of suspicion for VL among clinicians working in endemic areas of Ethiopia.

Magnitude of metabolic syndrome in Gondar town, Northwest Ethiopia: A community-based cross-sectional study.

BACKGROUND: Metabolic syndrome (MetS) is becoming a major public health problem globally; it is clear that the burden of MetS is rapidly increasing the rates of non-communicable diseases (NCD). In Ethiopia studies done so far have shown a large disparity in magnitude of the prevalence of MetS and were mainly institution-based studies. Therefore, this study assess the prevalence of MetS among adults who are residing in Gondar city using Adult Treatment Panel III (ATP III) and the International Diabetes Federation (IDF) assessment tool. The findings are imperative to developing and strengthening national NCD prevention and control programs. METHODS: This study was conducted in Gondar city Northwest Ethiopia in 2018. It employs a community-based cross-sectional study design among 3,227 individuals 18 years of age or older. Data was collected using the WHO stepwise tool, lipid profile, blood pressure (BP), waist circumference (WC) body mass index (BMI), fasting blood glucose levels (FG), and anthropometric measurements. The prevalence estimation was made along with a 95% confidence interval (CI). The Kappa statistic was used to analyze the statistical agreement between ATP III and IDF definitions of the MetS. Stratified analysis was also performed for description and analysis components using ATP III and IDF as an outcome. RESULT: Of the total study participants (3227), 3059 (94.8%) were included in the final analysis and 52.5% were female. The mean (±SD) age of the study participant was 40.8 years (16.2 ±SD). The overall prevalence of MetS using ATP III was 11.2% [95%CI: 10.1, 12.3] and using IDF was 11.9% [95%CI: 10.8, 13.2]. The sex-specific proportion was high in females rather than males irrespective of the criteria. The overall level of agreement between ATP III and IDF prevalence was 91.7% and the Kappa statistics was 0.594. Older age, low-density lipoprotein cholesterol, body mass index, being female, born in an urban area, consumption of an alcoholic drink in the preceding 30 days, and non-fasting practice was significantly associated with MetS. CONCLUSION AND RECOMMENDATION: There was a higher prevalence of metabolic syndrome among females than males irrespective of metabolic syndrome diagnostic criteria. This also shows good agreement between ATP III and IDF. Being female, urban birthplace, frequent alcohol consumption in the last 30 days, and non-fasting practice are factors associated with higher rates of metabolic syndrome. Hence, awareness campaigns, physical exercise, and nutrition education intervention should be undertaken to promote health behavioral practice.

Minimally Invasive Tissue Sampling in Preterm Deaths: A Validation Study.

Uncertainty about the causes of neonatal deaths impedes achieving global health targets to reduce mortality. Complete diagnostic autopsy (CDA) is the gold standard to determine cause of death. However, it is often difficult to perform in high-burden, low-income settings. Validations of more feasible methods to determine cause of death are needed. This prospective, multi-center study in Ethiopia assessed the validity of the minimally invasive tissue sampling (MITS) approach to contribute to causes of death in preterm neonates compared to CDA. The MITS and CDA of 105 cases were reviewed. The MITS sampling success for lungs and liver was 100% and 84%, respectively. The kidney and brain had sampling successes of 58% each. MITS showed good agreement with CDA for the diagnosis of hyaline membrane disease (kappa = 0.78), and moderate to substantial agreement for pneumonia and pulmonary hemorrhage (kappa = 0.59 and 0.68, respectively). Even though CDA is the gold standard in identifying the cause of death, we believe that the MITS method can be a useful alternative method in supporting determination of cause of death in low-resource settings.

Home-based HPV self-sampling assisted by a cloud-based electronic data system: Lessons learnt from a pilot community cervical cancer screening campaign in rural Ethiopia.

Primary HPV testing and triage of HPV-positive women is an effective cervical cancer screening strategy. Such a multi-visit screening algorithm is also promising for community-based screening in resource-poor communities, provided a robust tracking system is in place. A cervical cancer screening campaign was conducted in a rural community in Ethiopia. All women aged 25-65 years were offered genital self-sampling using the Evalyn Brush®. Samples were HPV-DNA-tested at a central laboratory. Key indicators were captured on tablet computers and linked by a cloud-based information system. HPV-positive women were examined at the local clinic using portable colposcopy, p16/Ki-67 dual stain cytology and biopsy examination. CIN2+ women were referred for LEEP to the referral hospital. Of 749 enumerated age-eligible women 634 (85%, (95% CI 82-88)) consented to screening, 429 samples were adequate for HPV testing, giving a total testing coverage of 57% (95% CI 53-62). The hrHPV prevalence was 14% (95% CI 5-22), 72% (95% CI 60-84) attended the clinic for a triage examination. Home-based HPV-DNA self-sampling and clinic-based triage assisted by cloud-based information technology is feasible in rural Ethiopia. Key components of such strategy are broad community awareness, high competency of community workers, and establishment of an adequate self-sampling and HPV-DNA testing platform.

Major causes of death in preterm infants in selected hospitals in Ethiopia (SIP): a prospective, cross-sectional, observational study.

BACKGROUND: Neonatal deaths now account for 47% of all deaths in children younger than 5 years globally. More than a third of newborn deaths are due to preterm birth complications, which is the leading cause of death. Understanding the causes and factors contributing to neonatal deaths is needed to identify interventions that will reduce mortality. We aimed to establish the major causes of preterm mortality in preterm infants in the first 28 days of life in Ethiopia. METHODS: We did a prospective, cross-sectional, observational study in five hospitals in Ethiopia. Study participants were preterm infants born in the study hospitals at younger than 37 gestational weeks. Infants whose gestational age could not be reliably estimated and those born as a result of induced abortion were excluded from the study. Data were collected on maternal and obstetric history, clinical maternal and neonatal conditions, and laboratory investigations. For neonates who died of those enrolled, consent was requested from parents for post-mortem examinations (both complete diagnostic autopsy and minimally invasive tissue sampling). An independent panel of experts established the primary and contributory causes of preterm mortality with available data. FINDINGS: Between July 1, 2016, to May 31, 2018, 4919 preterm infants were enrolled in the study and 3852 were admitted to neonatal intensive care units. By 28 days of post-natal age, 1109 (29%) of those admitted to the neonatal intensive care unit died. Complete diagnostic autopsy was done in 441 (40%) and minimally invasive tissue sampling in 126 (11%) of the neonatal intensive care unit deaths. The main primary causes of death in the 1109 infants were established as respiratory distress syndrome (502 [45%]); sepsis, pneumonia and meningitis (combined as neonatal infections; 331 [30%]), and asphyxia (151 [14%]). Hypothermia was the most common contributory cause of preterm mortality (770 [69%]). The highest mortality occurred in infants younger than 28 weeks of gestation (89 [86%] of 104), followed by infants aged 28-31 weeks (512 [54%] of 952), 32-34 weeks (349 [18%] of 1975), and 35-36 weeks (159 [8%] of 1888). INTERPRETATION: Three conditions accounted for 89% of all deaths among preterm infants in Ethiopia. Scale-up interventions are needed to prevent or treat these conditions. Further research is required to develop effective and affordable interventions to prevent and treat the major causes of preterm death. FUNDING: Bill & Melinda Gates Foundation.