Exploring naturally occurring clinical subgroups of post-traumatic headache.

OBJECTIVE: To explore naturally occurring clinical subgroups of post-traumatic headache. BACKGROUND: Persistent post-traumatic headache (PTH) is defined as a headache developing within 7 days of an injury that lasts for greater than 3 months. However, there is no evidence available from the International Classification of Headache Disorders (ICHD) based classification between persistent and acute PTH based on clinical phenotypes. METHODS: We conducted a retrospective study using the Stanford Research Repository Cohort Discovery Tool. We reviewed 500 electronic patient charts between January 2015 to September 2019 using inclusion criteria of adults older than 18 years with a diagnosis of PTH. The following variables were extracted from each patient's chart: diagnosis of PTH as dependent variable, and predictor variables as age, sex, history of migraine, loss of consciousness during head injury, pre-existing psychological history, duration of PTH and new PTH-associated comorbidities (e.g. new onset vertigo, post-traumatic stress disorder). Logistic regression was employed to identify clinical phenotypes predicting persistent PTH. All predictor variables were tested in one block to determine their predictive capacity while controlling for other predictors in the model. Two-step cluster analysis was conducted to identify naturally occurring PTH subgroups. RESULTS: A total of 300 patients were included (150 acute, 150 persistent PTH) with a median age of 47 years (IQR 31, 59) and female: male ratio of 2.7:1. Two hundred patients were excluded due to misdiagnoses. Pre-existing psychological history (standardized beta 0.16), history of migraine (0.20), new PTH-associated comorbidities (0.23) and medication overuse (0.37) statistically significantly predicted the presence of persistent PTH (p <  0.0001). Clustering analysis revealed PTH subgrouping comparable to ICHD-based classification: 140 patients in Cluster 1 (76% persistent PTH) and 160 patients in Cluster 2 (83% acute PTH). Four distinct clusters were found within persistent PTH. CONCLUSION: Pre-existing psychological history, history of migraine, new PTH-associated comorbidities and medication overuse predicted the occurrence of persistent PTH as well as two naturally occurring PTH clusters correlating to acute and persistent PTH. Management emphasis should focus on these phenotypes.

High utility of active tuberculosis case finding in an Ethiopian prison.

SETTING: Hawassa Prison, Southern Region of Ethiopia. OBJECTIVE: To determine the burden of pulmonary tuberculosis (TB) using active case finding among prisoners. DESIGN: In this cross-sectional study, prisoners were screened for TB using a symptom screen. Those with cough of 2 weeks had spot and morning sputum samples collected for acid-fast bacilli (AFB) smear microscopy and molecular diagnostic testing (Xpert® MTB/RIF). RESULTS: Among 2068 prisoners, 372 (18%) had a positive cough screen. The median age of these 372 persons was 23 years, 97% were male and 63% were from urban areas. Among those with a positive symptom screen, 8 (2%) were AFB sputum smear-positive and 31 (8%) were Xpert-positive. The point prevalence of pulmonary TB at the prison was 1748 per 100 000 persons. In multivariate analysis, persons with cough >4 weeks were more likely to have TB (OR 3.34, 95%CI 1.54-7.23). CONCLUSION: A high prevalence of TB was detected among inmates at a large Ethiopian prison. Active case finding using a cough symptom screen in combination with Xpert had high utility, and has the potential to interrupt transmission of Mycobacterium tuberculosis in correctional facilities in low- and middle-income, high-burden countries.

The place of corticosteroids in migraine attack management: A 65-year systematic review with pooled analysis and critical appraisal.

BACKGROUND AND OBJECTIVES: Headaches recur in up to 87% of migraine patients visiting the emergency department (ED), making ED recidivism a management challenge. We aimed herein to determine the role of corticosteroids in the acute management of migraine in the ED and outpatient care. METHODS: Advanced search strategies employing PubMed/MEDLINE, Web of Science, and Cochrane Library databases inclusive of a relevant gray literature search was employed for Clinical Studies and Systematic Reviews by combining the terms "migraine" and "corticosteroids" spanning all previous years since the production of synthetic corticosteroids ca. 1950 until August 30, 2014. Methods were in accordance with MOOSE guidelines. RESULTS: Twenty-five studies (n = 3989, median age 37.5 years, interquartile range or IQR 35-41 years; median male:female ratio 1:4.23, IQR 1:2.1-6.14; 52% ED-based, 56% randomized-controlled) and four systematic reviews were included. International Classification of Headache Disorders criteria were applied in 64%. Nineteen studies (76%) indicated observed outcome differences favoring benefits of corticosteroids, while six (24%) studies indicated non-inferior outcomes for corticosteroids. Median absolute risk reduction was 30% (range 6%-48.2%), and 11% (6%-48.6%) for 24-, and 72-hour headache recurrence, respectively. Parenteral dexamethasone was the most commonly (56%) administered steroid, at a median single dose of 10 mg (range 4-24 mg). All meta-analyses revealed efficacy of adjuvant corticosteroids to various abortive medications-indicating generalizability. Adverse effects were tolerable. Higher disability, status migrainosus, incomplete pain relief, and previous history of headache recurrence predicted outcome favorability. CONCLUSIONS: Our literature review suggests that with corticosteroid treatment, recurrent headaches become milder than pretreated headaches and later respond to nonsteroidal therapy. Single-dose intravenous dexamethasone is a reasonable option for managing resistant, severe, or prolonged migraine attacks.

What is the evidence for the use of corticosteroids in migraine?

Corticosteroids are widely prescribed for the management of migraine attacks. The earliest clinical studies examining the efficacy of corticosteroid monotherapy for managing migraine attacks date back to 1952. Since then, 26 heterogeneous clinical studies and four meta-analyses have been conducted to assess the efficacy of corticosteroids in either aborting acute migraine attacks, prolonged migraine attacks or recurrent headaches. Most of these (86 %) studies employed different comparator arms with corticosteroids monotherapy administration while some studies (14 %) evaluated adjunctive corticosteroid therapy. The majority of these clinical studies revealed the superior efficacy of corticosteroids as mono- or adjunctive-therapy both for recurrent and acute migraine attacks, while the remaining showed non-inferior efficacy. Different forms of oral and parenteral corticosteroids in either single-dose or short-tapering schedules are prescribed; there are clinical studies supporting the efficacy of both methods. Corticosteroids can be administered safely up to six times annually. Corticosteroids are also useful in managing patients who frequent emergency departments with "medication-seeking behavior." Migraine patients with refractory headaches, history of recurrent headaches, severe baseline disability, and status migrainosus were found to have the most beneficial response from corticosteroid therapy.

Evaluation of Toluidine Blue O staining for the diagnosis of Pneumocystis jiroveci in expectorated sputum sample and bronchoalveolar lavage from HIV-infected patients in a tertiary care referral center in Ethiopia.

BACKGROUND: Pneumocystis pneumonia (PCP) is becoming increasingly recognized in sub-Saharan Africa. The currently recommended diagnostic methods using induced sputum (IS) and bronchoalveolar lavage (BAL) are neither technically feasible nor affordable for a wider clinical use in developing countries. Therefore, there is a need for a simple and affordable diagnostic test. METHODS: The yield of Toluidine Blue O (TBO) stain, immunofluorescence (IF), and polymerase chain reaction (PCR) for the diagnosis of Pneumocystis jiroveci were compared in 78 expectorated sputum and 118 BAL samples of 131 HIV-infected patients presenting with atypical chest X-ray and sputum smear-negative for acid-fast bacilli. RESULTS: A total of 56 (42.7%) patients tested positive for P. jiroveci by PCR, 39 (29.4%) by IF, and 28 (21.4%) by TBO stain. The sensitivity of TBO as compared to IF and PCR was 71.4% and 34.5% in expectorated sputum and 68% and 41.5% in BAL samples, respectively, with a specificity approaching 100% in both. The sputum PCR showed high concordance rate with BAL PCR. The sensitivity and specificity of sputum PCR as compared to BALPCR was 78.9% and 89%, respectively. In both TBO and IF positive BAL samples, majority were from patients who could not produce sputum (p<0.001). The density of P. jiroveci clusters in BAL samples did not correlate with prior co-trimoxazole use, immunologic status of the patient or overall mortality. CONCLUSION: Compared to IF, TBO staining has an acceptable sensitivity and very high specificity both in expectorated sputum and BAL samples. Expectorated sputum is, therefore, the most practical specimen and TBO staining an inexpensive diagnostic method to be recommended for high-HIV, resource-constrained settings. Bronchoscopy for the diagnosis of PCP is often not required for patients who can produce sputum. For patients who cannot produce sputum, however, the cost and efficacy of TBO in IS sample needs to be investigated in resource-poor countries.

Microscopic-observation drug susceptibility assay provides rapid and reliable identification of MDR-TB.

BACKGROUND: Liquid culture systems are more rapid and sensitive for both the detection and drug susceptibility testing (DST) of Mycobacterium tuberculosis. SETTING: St Peter's TB Specialised Hospital and public health laboratory, Addis Ababa. OBJECTIVE: To compare the microscopic-observation drug susceptibility (MODS) assay with the BACTEC-MGIT 960 system for isoniazid and rifampicin DST (i.e., multidrug-resistant tuberculosis [MDR-TB] identification) of M. tuberculosis. DESIGN: The evaluation was based on 58 smear- and culture-positive sputum samples from patients diagnosed in Addis Ababa, Ethiopia. BACTEC-MGIT was used as the reference standard. RESULTS: For the detection of MDR-TB, MODS has a sensitivity, specificity and accuracy rate of respectively 95%, 100% and 98.3% (kappa 0.981, concordance 98.3%). Concurrent culture detection and DST results are obtained in a median of 9 days with MODS, while indirect DST results with BACTEC-MGIT are obtained in a median of 8 days (this does not include time to primary isolate). CONCLUSION: MODS is an accurate, rapid and relatively inexpensive method for the identification of MDR-TB.

Clinico-mycological profile of dermatophytosis in a reference centre for leprosy and dermatological diseases in Addis Ababa.

To assess the clinical and fungal species spectrum of dermatophyte infection in a reference centre in Addis Ababa, 539 dermatological patients with signs of dermatophytosis were investigated. Seventy-one percent were female and 29% male, aged 2-66 years (median 9). Four hundred-fifteen (77%) had at least one skin lesion. Tinea capitis was diagnosed in 138/155 males (89%) as compared to 214/384 females (40%) (p < 0.05). T. capitis was diagnosed in 69% of the 374 children. Fingernails were affected in 132/145 (91%) of onychomycosis, 118 (90%) of these patients were females and 14 males (p < 0.05). Tinea corporis was observed in 45, and other types of tinea in 12 patients. Thirty-six percent of all patients had also other skin lesions, mostly impetigo. Of 490 cultured samples 364 (74%) grew dermatophytes: Trichophyton violaceum in 84%, Trichophyton verrucosum in 9.6%, Trichophyton tonsurans in 1.4% and T. rubrum in 0.5%. Additionally, 15 isolates were identified as white variants of T. violaceum, in 3 cases confirmed by sequencing of the rDNA ITS 2 region. T. capitis in young males and T. unguium of fingernails in females were the most common manifestations of dermatophytosis in Addis Ababa, usually caused by T.violaceum.

White variants of Trichophyton violaceum isolated in Ethiopia.

Certain dermatophytes are geographically restricted and endemic in particular parts of the world, while other species may have a sporadic but worldwide distribution. Trichophyton violaceum is one of the most common dermatophytes causing tinea capitis, and is the predominant cause of tinea in Africa, South America and the Indian subcontinent. Among 1187 dermatophyte isolates collected from Ethiopian patients with various types of tinea, 32 isolates had uncharacteristic phenotypic features. Based on conventional methods complemented by sequence analysis of the rDNA ITS2 region, these isolates were identified as white variants of T. violaceum. This is the first time that white isolates of T. violaceum have been identified in Ethiopia.

Prevalence of tinea capitis in Ethiopian schoolchildren.

The prevalence of dermatophytosis and the spectrum of dermatophyte species were determined in children attending two schools in Addis Ababa, Ethiopia. Demographic and clinico-dermatological data were collected. Specimens were taken for microscopy and culture from all suspected lesions. Dermatophyte species were identified by morphology and biochemical tests, supplemented by sequencing of the rDNA ITS 2 region in selected isolates. From the Biruh Tesfa Elementary School (BTES) 824 students, and from Mount Olive Academy (MOA) all 124 students, were included. In BTES 513 (62.3%) students were clinically diagnosed with dermatophytosis, 463 (90.3 %) of them with tinea capitis. In 200 consecutive samples from BTES, and in 66 from MOA, 75 and 62%, respectively, contained fungal elements at microscopy. From BTES, 163/496 (33%) samples were culture-positive, of which 149 (91.4%) grew with dark purple colonies identified as Trichophyton violaceum, while 244 (49.4%) samples were contaminated. A few strains grew slowly developing white to cream colonies, two were identified as T. verrucosum, and 12 as white T. violaceum. From MOA 44 (66.7%) of samples were culture-positive, 38 (87%) were identified as T. violaceum, and one (2.3%) as T. verrucosum, while 33% showed no growth. Four white isolates of T.violaceum were confirmed by DNA-sequencing. Dermatophytosis was thus diagnosed in 55-62% of children screened at two schools of different socioeconomic standards in the Ethiopian capital. Trichophyton violaceum constituted 87-90% of all isolates. White variants of T. violaceum were diagnosed in 16 cases.

Characterization of Candida albicans isolates from the oral cavity of HIV-positive patients.

Characterization of Candida albicans isolates from the oral cavity of Ethiopian Human Immunodeficiency Virus (HIV)-positive patients and HIV-negative individuals was undertaken. After identification of isolates using conventional methods and determination of carbohydrate assimilation profiles, serotyping was performed by slide agglutination with the Iatron IF6 serotyping system. Sensitivity of the isolates to 5-Fluorocytosine (5-FC) was assessed using the broth macrodilution method. There was no difference in phenotype, by any of the three methods used, between the HIV-positive and HIV-negative individuals. Serotype A was found to be dominant in strains isolated from both HIV-positive (34/40 = 85%) and HIV-negative (17/20 = 85%) study subjects. These data suggest that the C. albicans strains causing oral candidiasis in patients with HIV infection are identical to the commensal ones found in healthy individuals.