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.

The need for a tailored national dementia plan in Ethiopia: A call for action.

Globally, a rapid demographic transition is occurring with a significant increment in the proportion of older individuals. For the first time in history, individuals aged 65 and above outnumber that of children under 5 years of age. In Ethiopia, the life expectancy has shown dramatic improvements in the past few decades and is expected to reach 74 years by mid-century. Older age is considered the most important non-modifiable risk factor for dementia. Likewise, other modifiable diseases such as infectious diseases, non-communicable diseases, particularly cardiovascular diseases, and traumatic brain injuries are associated with dementia. Despite, the high prevalence of dementia risk factors and impending economic and health impact from dementia, no country in the sub-Saharan Africa (SSA), including Ethiopia, has developed a standalone or an integrated national dementia strategic plan to guide the overall effort to improve dementia care in the country. It is vital to design and develop a national dementia plan in line with a framework outlined by the 2017 World Health Organization (WHO) global action plan. The health, social, and economic burden from dementia is expected to be high to the developing countries such as Ethiopia unless clear prevention and management strategies are designed at a national level to cascade the care to the primary care level. The planned strategic policy may focus on improving the knowledge and skills of health care professionals. Translation and cultural adaptation of cognitive, functional, and behavioral assessment batteries is of paramount importance in improving the diagnostic accuracy along with availability of advanced imaging, biomarkers, and dementia treatment.

Electroencephalographic Findings, Antiepileptic Drugs and Risk Factors of 433 Individuals Referred to a Tertiary Care Hospital in Ethiopia.

Background: Little is known about the characteristics of electroencephalogram (EEG) findings in epileptic patients in Ethiopia. The objective of this study was to characterize the EEG patterns, indications, antiepileptic drugs (AEDs), and epilepsy risk factors. Methods: A retrospective observational review of EEG test records of 433 patients referred to our electrophysiology unit between July 01, 2020 and December 31, 2021. Results: The age distribution in the study participants was right skewed unipolar age distribution for both sexes and the mean age of 33.8 (SD=15.7) years. Male accounted for 51.7%. Generalized tonic clonic seizure was the most common seizure type. The commonest indication for EEG was abnormal body movement with loss of consciousness (35.2%). Abnormal EEG findings were observed in 55.2%; more than half of them were Interictal epileptiform discharges, followed by focal/or generalized slowing. Phenobarbitone was the commonest AEDs. A quarter (20.1%) of the patients were getting a combination of two AEDs and 5.2% were on 3 different AEDs. Individuals taking the older AEDs and those on 2 or more AEDs tended to have abnormal EEG findings. A cerebrovascular disorder (27.4%) is the prevalent risk factor identified followed by brain tumor, HIV infection, and traumatic head injury respectively. Conclusions: High burden of abnormal EEG findings among epileptic patients referred to our unit. The proportion of abnormal EEG patterns was higher in patients taking older generation AEDs and in those on 2 or more AEDs. Stroke, brain tumor, HIV infection and traumatic head injury were the commonest identified epilepsy risk factors.

Electrodiagnostic referrals and neuromuscular disease pattern in East Africa: Experience from a tertiary hospital in Ethiopia.

Objective: We present a retrospective cross-sectional review of the electrodiagnostic (EDX) referral and diagnostic patterns in patients with suspected neuromuscular conditions at a tertiary hospital in Ethiopia. Methods: Between 2016 and 2019, 313 patients were evaluated at the EDX lab in Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia. In our patients, nerve conduction study and when appropriate needle electromyography was done. Demographic and clinical data were extracted from a digital registry. Results: Polyneuropathy (19.8%), carpal tunnel syndrome (12.1%), and lumbosacral radiculopathy (9.9 %) were the top three reasons for EDX referral in Ethiopia. Among them, polyneuropathy was the most frequent electrodiagnosis, where diffuse axonal and demyelinating subtypes accounted for 54% and 18.8%, respectively. Guillain-Barre syndrome was suspected in 18 patients and 15 had EDX confirmed motor axon polyneuropathy while three patients had demyelinating variant. Although a quarter (26.2%) of the referrals had a normal EDX, abnormal test results were significantly associated with weakness (95% CI: 3.29-7.04, p < 0.001), bound to wheelchair (95% CI: 1.86-2.87, p = 0.01) and having a specific diagnosis at time of referral (95% CI: 2.53-4.68, p = 0.007). Conclusions: Diffuse and entrapment neuropathies were the main reasons for electrodiagnosis test referrals in Ethiopia. Also, motor axonal variant was the most common type of inflammatory polyneuropathy diagnosed with EDX. Significance: Proper patient evaluation and documentation significantly improves the diagnostic yield and cost-effectiveness of EDX testing in a resource-poor countries like Ethiopia. This might be achieved through educating medical students, residents, and other care providers on the basics of EDX and its indications for correct use in the clinical care.

Electroencephalographic Findings, Antiepileptic Drugs and Risk Factors of 433 Individuals Referred to a Tertiary Care Hospital in Ethiopia

Little is known about the characteristics of electroencephalogram (EEG) findings in epileptic patients in Ethiopia. The objective of this study was to characterize the EEG patterns, indications, antiepileptic drugs (AEDs), and epilepsy risk factors. METHODS: A retrospective observational review of EEG test records of 433 patients referred to our electrophysiology unit between July 01, 2020, and December 31, 2021. Results: The age distribution in the study participants was right skewed unipolar age distribution for both sexes and the mean age of 33.8 (SD=15.7) years. Male accounted for 51.7%. Generalized tonic clonic seizure was the most common seizure type. The commonest indication for EEG was abnormal body movement with loss of consciousness (35.2%). Abnormal EEG findings were observed in 55.2%; more than half of them were Interictal epileptiform discharges, followed by focal/or generalized slowing. Phenobarbitone was the commonest AEDs. A quarter (20.1%) of the patients were getting a combination of two AEDs and 5.2% were on 3 different AEDs. Individuals taking the older AEDs and those on 2 or more AEDs tended to have abnormal EEG findings. A cerebrovascular disorder (27.4%) is the prevalent risk factor identified followed by brain tumor, HIV infection, and traumatic head injury respectively. CONCLUSION: High burden of abnormal EEG findings among epileptic patients referred to our unit. The proportion of abnormal EEG patterns was higher in patients taking older generation AEDs and in those on 2 or more AEDs. Stroke, brain tumor, HIV infection and traumatic head injury were the commonest identified epilepsy risk factors

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.

Ketoacidosis and the hyperosmolar hyperglycemic state in adult diabetic patients. Diagnosis and treatment.

Diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) are serious acute decompensations of type 1 and 2 diabetes mellitus due to various degrees of insulin deficiency and increased levels of counterregulatory hormones. They are characterized by hyperglycemia and hyperosmolarity in HHS, and by hyperglycemia and ketoacidosis in DKA with major electrolyte imbalance; both can co-exist. Precipitating factors can usually be identified. The diagnosis can usually be suspected on clinical grounds, but must be confirmed by laboratory investigation. Treatment consists of appropriate rehydration, intravenous insulin therapy and potassium supplementation. Careful monitoring of the patient's clinical and biochemical status throughout treatment is critical. Excess mortality still occurs, particularly for HHS, emphasizing the importance of patient education and regular follow-up to prevent these potentially fatal complications.

Long-term brain metabolic alterations in exogenous Cushing's syndrome as monitored by proton magnetic resonance spectroscopy.

The effects of exogenous Cushing's syndrome on the brain metabolism were investigated by proton magnetic resonance spectroscopy (MRS). Thirteen patients having been treated for 2 to 22 years with prednisone were recruited. On the average, none of the metabolites (NAA, Cr, Cho and mI) were significantly different from those of 40 normal subjects in any of the three regions studied: frontal area, thalamus and temporal area. However, the Cho/H(2)O ratios were found to decrease significantly in the thalamic area as a function of treatment period (-1.3%/year). In the frontal and temporal areas, decreases of the Cho/H(2)O ratios were measured with treatment period but they did not reach statistical significance. Effects on Cho levels can be related to those observed for patients with endogenous Cushing's syndrome and suggest an impairment at the membrane level. The Cho/H(2)O reductions were not found to be dose- or age-dependent. Other metabolite ratios did not vary with treatment period, dose or age.