Clinical profile and mortality among adult patients presenting with altered mental status to the emergency departments of a tertiary hospital in Tanzania: a descriptive cohort study.

Introduction: Altered mental status (AMS) in the Emergency Department (ED) can be associated with morbidity and mortality. In high income countries, mortality rate is under 10% for patients presenting with AMS. There is a paucity of data on the profile and mortality amongst this group of patients in limited income countries. Methods: this was a prospective cohort study of adults ≥18 years presenting to the Emergency Departments of Muhimbili National Hospital (MNH) Upanga and Mloganzila in Tanzania with Altered Mental Status (AMS) unrelated to psychiatric illness or trauma, from August 2019 to February 2020. Patient demographic data, clinical profile, disposition and 7-day outcome were recorded. The outcome of mortality was summarized using descriptive statistics. Results: among 26,125 patients presenting during the study period, 2,311 (8.9%) patients had AMS and after exclusion for trauma and psychiatric etiology, 226 (9.8%) patients were included. The median age was 56 years (43-69 years) and 127 (56.2%) were male. Confusion 88 (38.9%) was the most common presenting symptom. Hypertension 121 (53.5%) was the most frequent associated comorbidity. The overall mortality was 80 (35.4%) within 7 days. Of 173 patients admitted to the wards, 54 (31.2%) died and of the 46 (20.4%) admitted to the intensive care unit (ICU), 20 (43.5%) died within 7 days. Six (2.7%) patients died in the emergency department. Conclusion: patients with AMS presenting to two EDs in Tanzania have substantially higher mortality than reported from Hospital Incident Command System (HICS). This could be due to underlying disease, comorbidities or management. Further research could help identify individual etiologies involved and high risk groups which can cater to better understanding this population.

SARS-CoV-2 precipitating a stroke in a child? A case report from Tanzania.

There is scanty data on overall pediatric presentations with COVID-19 in sub-Saharan Africa and none reported related to stroke. Management of acute stroke in children has been challenging due to delays in presentation and difficulties in deducing the exact etiology. This is the first such case of a stroke in a child with COVID-19 infection reported in Tanzania to the best of our knowledge. A six-and-a-half-year-old male child of Asian origin with no history of chronic illness presented to our facility with fever, rash, gastrointestinal symptoms and conjunctivitis. Subsequently, he developed headache, irritability, altered mentation, loss of speech, facial nerve palsy and hemiparesis. He was provisionally diagnosed with bacterial meningitis with a differential diagnosis of viral encephalitis and received standard treatment for the same. On further investigations, magnetic resonance imaging (MRI) of the brain showed ischemic infarct along the territory of left middle cerebral artery and given the history of the child´s exposure to a relative with COVID-19 infection, child underwent a nasopharyngeal swab for polymerase chain reaction testing which was negative but the serum IgG for COVID was positive. Despite the severe presentation initially, early detection and appropriate management resulted in survival, regained speech and motor function. Due to constraints in health care systems in sub-Saharan Africa, it is difficult to exhaust the diagnostics in order to narrow down the list of differentials in a child with stroke. This case is reported to further describe the diverse presentations of COVID-19 particularly in children which has been under-represented especially in sub-Saharan Africa. Attending physicians should have a high index of suspicion for SARS-CoV-2 as the etiology for exposed children presenting with neurological symptoms.

Authorship representation in global emergency medicine: a bibliometric analysis from 2016 to 2020.

INTRODUCTION: High-income country (HIC) authors are disproportionately represented in authorship bylines compared with those affiliated with low and middle-income countries (LMICs) in global health research. An assessment of authorship representation in the global emergency medicine (GEM) literature is lacking but may inform equitable academic collaborations in this relatively new field. METHODS: We conducted a bibliometric analysis of original research articles reporting studies conducted in LMICs from the annual GEM Literature Review from 2016 to 2020. Data extracted included study topic, journal, study country(s) and region, country income classification, author order, country(s) of authors' affiliations and funding sources. We compared the proportion of authors affiliated with each income bracket using Χ2 analysis. We conducted logistic regression to identify factors associated with first or last authorship affiliated with the study country. RESULTS: There were 14 113 authors in 1751 articles. Nearly half (45.5%) of the articles reported work conducted in lower middle-income countries (MICs), 23.6% in upper MICs, 22.5% in low-income countries (LICs). Authors affiliated with HICs were most represented (40.7%); 26.4% were affiliated with lower MICs, 17.4% with upper MICs, 10.3% with LICs and 5.1% with mixed affiliations. Among single-country studies, those without any local authors (8.7%) were most common among those conducted in LICs (14.4%). Only 31.0% of first authors and 21.3% of last authors were affiliated with LIC study countries. Studies in upper MICs (adjusted OR (aOR) 3.6, 95% CI 2.46 to 5.26) and those funded by the study country (aOR 2.94, 95% CI 2.05 to 4.20) had greater odds of having a local first author. CONCLUSIONS: There were significant disparities in authorship representation. Authors affiliated with HICs more commonly occupied the most prominent authorship positions. Recognising and addressing power imbalances in international, collaborative emergency medicine (EM) research is warranted. Innovative methods are needed to increase funding opportunities and other support for EM researchers in LMICs, particularly in LICs.

Guillain-Barré syndrome associated with COVID-19 infection.

We are reporting a case of Acute Post-Infectious Flaccid paralysis also commonly known as Guillain-Barré Syndrome (GBS) in a patient with confirmed COVID-19 infection. GBS often occurs following an infectious trigger which induces autoimmune reaction causing damage to peripheral nerves. So far, only 8 cases have been described in association with COVID-19. This is the first to be described in Tanzania in an African Child, and probably the first in the continent. This report is presented for clinicians to be aware and for the medical fraternity to look into this unusual presentation which may shed some more light on possible pathways of the pathogenesis and clinical manifestations. We recommend that the presentation of GBS with acute respiratory distress should warrant extra precaution and a testing for COVID-19 especially when the symptoms of COVID-19 are protean.