Stroke Mortality Outcomes in Uganda.

BACKGROUND AND PURPOSE: Stroke outcome data in Uganda is lacking. The objective of this study was to capture 30-day mortality outcomes in patients presenting with acute and subacute stroke to Mbarara Regional Referral Hospital (MRRH) in Uganda. METHODS: A prospective study enrolling consecutive adults presenting to MRRH with abrupt onset of focal neurologic deficits suspicious for stroke, from August 2014 to March 2015. All patients had head computed tomography (CT) confirmation of ischemic or hemorrhagic stroke. Data was collected on mortality, morbidity, risk factors, and imaging characteristics. RESULTS: Investigators screened 134 potential subjects and enrolled 108 patients. Sixty-two percent had ischemic and 38% hemorrhagic stroke. The mean age of all patients was 62.5 (SD 17.4), and 52% were female. More patients had hypertension in the hemorrhagic stroke group than in the ischemic stroke group (53% vs. 32%, p = 0.0376). Thirty-day mortality was 38.1% (p = 0.0472), and significant risk factors were National Institutes of Health Stroke Scale (NIHSS) score, female sex, anemia, and HIV infection. A one unit increase of the NIHSS on admission increased the risk of death at 30 days by 6%. Patients with hemorrhagic stroke had statistically higher NIHSS scores (p = 0.0408) on admission compared to patients with ischemic stroke, and also had statistically higher Modified Rankin Scale (mRS) scores at discharge (p = 0.0063), and mRS score change from baseline (p = 0.04). CONCLUSIONS: Our study highlights an overall 30-day stroke mortality of 38.1% in southwestern Uganda, and identifies NIHSS at admission, female sex, anemia, and HIV infection as predictors of mortality.

Validation of the Intracerebral Hemorrhage Score in Uganda.

Background and Purpose- Rates of intracerebral hemorrhage (ICH) are estimated to be highest globally in sub-Saharan Africa. However, outcomes of ICH are poorly described and standard prognostic markers for ICH have not been validated in the region. Methods- We enrolled consecutive patients with computed tomography-confirmed ICH at a referral hospital in southwestern Uganda. We recorded demographic, clinical, and radiographic features of ICH, and calculated ICH scores. We fit Poisson regression models with robust variance estimation to determine predictors of case fatality at 30 days. Results- We enrolled 73 individuals presenting with computed tomography-confirmed ICH (mean age 60 years, 45% [33/73] female, and 14% [10/73] HIV-positive). The median ICH score was 2 (interquartile range, 1-3; range, 0-5). Case fatality at 30 days was 44% (32/73; 95% CI, 33%-57%). The 30-day case fatality increased with increasing ICH score of 0, 1, and 5 from 17%, 23%, to 100%, respectively. In multivariable-adjusted models, ICH score was associated with case fatality (adjusted relative risk, 1.48; 95% CI, 1.23-1.78), as were HIV infection (adjusted relative risk, 1.92; 95% CI, 1.07-3.43) and female sex (adjusted relative risk, 2.17; 95% CI, 1.32-3.59). The ICH score moderately improved with the addition of a point each for female sex and HIV serostatus (0.81 versus 0.73). Conclusions- ICH score at admission is a strong prognostic indicator of 30-day case fatality in Uganda. Our results support its role in guiding the care of patients presenting with ICH in the region.

Acute flaccid myelitis: not uncommon in rural Uganda?

Acute Flaccid Myelitis is a paralytic illness with significant similarities to poliomyelitis, and which affects predominantly children. It was first fully delineated only in 2014 in the USA, occurring in epidemic clusters with a likely overall increasing incidence. It has subsequently rapidly been identified in Europe, the UK, and Australasia and the Far East, confirming it to be an emerging, global, infectious neurological disease. It has, however, been very little studied in low- and middle-income countries-reflecting partly of the global imbalance in science and medical research, and partly the extremely low provision of neurological care in most low- and middle-income countries: Uganda currently has no specialized neurology services outside the capital Kampala. During extended visits over a 2-year period with involvement in acute adult and paediatric internal medicine, one of us (NS) encountered at least six new patients with acute flaccid myelitis, suggesting that both the geographical reach and the frequency of the disorder may be significantly greater than previously thought. Here, these cases are described together with their clinical features and, where available, course and (limited) investigation results. These observations have significant implications concerning the current, and potentially the future geographical spread of the disease, and its clinical phenomenology. In addition, they highlight serious problems concerning the global applicability of the current Acute Flaccid Myelitis diagnostic criteria.

The neurology of chronic nodding syndrome.

Nodding syndrome is an uncommon disorder of childhood onset and unknown cause, presenting with nodding seizures, and which appears to occur exclusively in clusters in sub-Saharan Africa. An endemic pattern of disease was initially described in Tanzania and in Liberia; epidemic occurrences were later reported in South Sudan and northern Uganda. Not the least significant of the many questions remaining about nodding syndrome concerns the common presence or otherwise of neurological features other than seizures-clearly relevant to the core issue of whether this is a focal, primary epileptic disease, or a multi-system CNS disorder, with, in turn implications for its aetiology. We had the opportunity to interview and clinically to examine 57 affected individuals in rural northern Uganda some 10 years after onset. In this observational cross-sectional study, nodding onset was invariably between the ages of 5 and 14, presenting with food-triggered nodding attacks in over 75% of cases; 86% went on to develop other seizure types. In 53 of 57 nodding syndrome individuals (93%), there was a definite history of the child and his or her family having resided in or been fed from an internally displaced person camp for some time prior to the onset of nodding. A half of nodding syndrome sufferers (28/57) had focal neurological abnormalities-mainly pyramidal signs (92%), often asymmetric, some with extrapyramidal abnormalities. Many individuals (28/57) were severely functionally disabled, ranging from 'sometimes can dig' to 'can do nothing at home' or 'cannot even feed herself'. Such sufferers tended more frequently to have significant burns, and clear cognitive impairment. We conclude that nodding syndrome is a unique multisystem CNS disorder of childhood onset and then slow progression over several years often followed by spontaneous stabilisation, consistent with an underlying self-limiting neurodegenerative process. We discuss the possibility that this might be triggered by food-related mycotoxins, within a fixed window of CNS vulnerability during childhood.

Refractory convulsive syncope in pregnancy: a rare presentation of Takayasu's arteritis - a case report and literature review.

BACKGROUND: Neurological manifestation of Takayasu's Arteritis (TA) in pregnancy presenting as convulsive syncope is extremely rare, and poses a serious diagnostic dilemma due to other vast causes of fits in pregnancy. OBJECTIVE: We aimed to present and shed more light on a case of TA with convulsive syncope in pregnancy refractory to anticonvulsants for seven weeks, and review the literature on the management of TA in pregnancy. CASE PRESENTATION: A gravida 4 para 3+0 at 28 weeks of amenorrhea presented with repeated episodes of the sudden loss of consciousness, followed by a fall and jerking of the limbs. These were refractory to anticonvulsants that she had used for seven weeks. Physical examination revealed undetectable pulse and blood pressure (BP) in the upper limbs but elevated BP in the lower limbs. Further investigations confirmed TA and she improved on steroids and antihypertensives. CONCLUSION: This case typically describes the unexpected presentation of TA with convulsive syncope. It calls for meticulous clinical assessment of epileptic seizures in pregnancy to avoid a late diagnosis of TA and its potential poor outcomes.

Tetanus in a rural low-income intensive care unit setting.

Tetanus is a potentially severe but preventable infection. In resource-rich settings, vaccination programmes have reduced tetanus to a rare disease, though still carrying an overall mortality of some 13%. However, in low-income settings, tetanus remains common, and is a significant cause of mortality-though major World Health Organisation programmes are successfully targeting neonatal and maternal disease. Data concerning the frequency and outcomes of non-neonatal tetanus in low-income settings are very sparse. We aimed to utilize a unique intensive care unit-based dataset to elicit clinical and demographic features and mortality in a large cohort of tetanus patients admitted over an eleven-year period to a single hospital centre in a rural low-income setting in northern Uganda. A total of 268 patients with tetanus were admitted to the Intensive Care Unit at St Mary's Hospital, Lacor between 2005 and 2015; the records of 190 were retrievable and had sufficient information to be assessed. 29 were neonates (median age 7 days, IQR 0), 52 children (1-16yrs; median age 11 years, IQR 4.5) and 109 were adults (median age 42 years, IQR 23). There was no seasonal pattern in the frequency of admissions. Of the 190 patients, 69 had endotracheal intubation with intermitent positive pressure ventilation, and 57 patients had central line placement. The overall mortality was 51.5-72.4% in neonatal disease, 25% in children and 57.8% in adults. The requirements for neither central line insertion, nor endotracheal intubation, nor intermittent positive pressure ventilation were independently linked to mortality rates. By contrast with neonatal and childhood disease, there was a marked male preponderance in adult tetanus-94 males and 15 females (gender difference P < 0.001)-and although year-on-year breakdown suggested no obvious upward or downward trend over the span of our study in total numbers of tetanus admissions, a trend towards an increasing incidence of adult tetanus was apparent.These findings confirm that adult tetanus remains a major problem in rural low-income settings, particularly in males, and suggests that more resources should be devoted to vaccination programmes targeting men.

Nodding syndrome: a concise review.

Nodding syndrome is an uncommon epileptic disorder of childhood onset, which appears to occur exclusively in clusters in sub-Saharan Africa. It was first reported in the 1960s, in what is now southern Tanzania, then in Liberia, and later in South Sudan and northern Uganda, with both epidemic and endemic patterns described. The cause remains unknown. Here we describe the background and development of descriptions of the disorder, review its clinical features and summarize current theories and studies concerning its cause, outlining the principal remaining research questions relating to this highly unusual disease.

Outcomes of patients with severe sepsis after the first 6 hours of resuscitation at a regional referral hospital in Uganda.

INTRODUCTION: The optimal resuscitation strategy for patients with severe sepsis in resource-limited settings is unknown. Therefore, we determined the association between intravenous fluids, changes in vital signs and lactate after the first 6 hours of resuscitation from severe sepsis, and in-hospital mortality at a hospital in Uganda. MATERIALS AND METHODS: We enrolled patients admitted with severe sepsis to Mbarara Regional Referral Hospital and obtained vital signs and point-of-care blood lactate concentration at admission and after 6 hours of resuscitation. We used logistic regression to determine predictors of in-hospital mortality. RESULTS: We enrolled 218 patients and had 6 hour postresuscitation data for 202 patients. The median (interquartile range) age was 35 (26-50) years, 49% of patients were female, and 57% were HIV infected. The in-hospital mortality was 32% and was associated with admission Glasgow Coma Score (adjusted odds ratio [aOR], 0.749; 95% confidence interval [CI], 0.642-0.875; P < .001), mid-upper arm circumference (aOR, 0.876; 95% CI, 0.797-0.964; P = .007), and 6-hour systolic blood pressure (aOR, 0.979; 95% CI, 0.963-0.995; P = .009) but not lactate clearance of 10% or greater (aOR, 1.2; 95% CI, 0.46-3.10; P = .73). CONCLUSIONS: In patients with severe sepsis in Uganda, obtundation and wasting were more closely associated with in-hospital mortality than lactate clearance of 10% or greater.