Internal Medicine Commons^™

Effective Monitoring Of Diabetic Patients On Progressive Chronic Kidney Disease Among Patients Attending Diabetic Clinic At Muhimbili National Hospital, Tanzania, Gudila Valentine Shirima, Paschal Ruggajo, Obadia Venance Nyongole, Francis Furia, Kimu Marko Njiku

Internal Medicine, East Africa

Background:

Diabetic Kidney Disease is a complication of Diabetes Mellitus (DM) following the natural history of diabetes. Worldwide up to 40 % of patients with diabetes mellitus will develop Diabetic Kidney Disease. Kidney Disease Outcome Quality Initiative (KDOQI) guidelines recommends monitoring for proteinuria, blood sugar, renal functions and blood pressure in the patients with DM so that progression to complications including renal failure is prevented. Our study aimed to audit on effective monitoring of progressive chronic kidney disease among patients attending diabetic clinic at Muhimbili National Hospital.

Material and methods:

This was a retrospective clinical audit which included patients who …

Seroprevalence Of Hepatitis B Virus Infection, Anti-Hcv Antibodies And Hiv And Knowledge Among People Who Use Drugs Attending Methadone Therapy Clinic In Tanzania: A Cross-Sectional Study, Semvua B. Kilonzo, Daniel I. W Gunda, David C. Majinge, Hyasinta Jaka, Paulina M. Manyiri, Fredrick Kalokola, Grahame Mtui, Elichilia R. Shao, Fatma Bakshi, Alex Stephano

Internal Medicine, East Africa

Background: Methadone therapy clinics have been recently introduced in Tanzania, aiming at reducing risk behaviors and infection rates of viral hepatitis and HIV among people who use drugs. The objective of this study was to estimate the prevalence, associated factors and knowledge level of these conditions among people who use drugs attending a methadone clinic in Tanzania.

Methods: We enrolled 253 People who using drugs receiving Methadone therapy. Clinical data was retrospectively collected from the medical records and face-to face interviews were conducted to determine the behavioral risk factors and respondents’ knowledge on viral hepatitis and HIV.

Results: An overall …

Prevalence Of Incidental Prostate Carcinoma Among Patients Undergoing Turp For Benign Prostatic Enlargement, Isaac H. Mawalla, Masawa Nyamuryekung’E, Authar Ali, Aidan Njau, Philip Adebayo, Ali A. Zehri

Internal Medicine, East Africa

Background: Incidental prostate cancer is detected by histological examination of resected biopsy tissue that has been previously diagnosed as benign. It has the potential for progressing to become a disease necessitating active treatment. There is paucity of data on detection of incidental prostate cancer in Tanzania. A study done in northern Tanzania among the urban public sector revealed an alarming detection rate of 21.71%. We aimed to establish the prevalence of incidental prostate cancer among men surgically treated for benign prostate enlargement with considered normal range of prostate specific antigen.

Methods: This was a retrospective hospital-based cross-sectional study conducted to …

A Rare Case Of Solid Pseudopapillary Neoplasm Of The Pancreas, Steven Michael, Nadeem Kassam, Aidan Njau, Omar A. Sherman, Harrison Chuwa, Salim Surani

General Surgery, East Africa

Solid pseudopapillary neoplasm of pancreas (SPN) is a rare entity. It is almost exclusively seen in females within the second and third decades of life with only small minority affecting children. Due to the paucity of the number of cases seen, the natural history of the disease is not fully understood. SPN tumors of the pancreas are usually found incidentally and usually have an excellent prognosis. We herein present a case of a 33-year-old lady diagnosed with SPN, who presented with abdominal fullness, two weeks post cesarean sectio

Anorectal Malformation, Associated With Colon Atresia And Intestinal Malrotation, A Case Report, Allyzain Ismail, Lazaro Mboma, Victor Ngotta, Masawa Nyamuryekung'e

Internal Medicine, East Africa

Introduction and importance: In this case report from Muhimbili National Hospital, Dar es salaam, Tanzania, we present the unexpected findings of anorectal malformation, colonic atresia, and intestinal malrotation in a 2-day old neonate. This combination is exceedingly rare, with only case reports published in the literature. We describe the challenges in diagnosis and offer our insights based on this experience and review of the literature.

Case presentation: Our patient was a male born at term, weighing 2600 g, diagnosed clinically with a high anorectal malformation. He was planned for colostomy, and we unexpectedly found a collapsed descending colon. Exploration revealed …

Covid-19 And Teleneurology In Sub-Saharan Africa: Leveraging The Current Exigency, Philip Adebayo, Olusegun John Oluwole, Funmilola Tolulope

Internal Medicine, East Africa

Africa has over 1.3 billion inhabitants, with over 60% of this population residing in rural areas that have poor access to medical experts. Despite having a ridiculously huge, underserved population, very few African countries currently have any form of sustained and organized telemedicine practice, and even fewer have dedicated tele-neurology services. The ongoing COVID-19 pandemic has proved to be one of the most significant disruptors of vital sectors of human endeavor in modern times. In the healthcare sector, there is an increasing advocacy to deliver non-urgent care via telemedicine. This paper examined the current state of tele-neurology practice and infrastructural …

F-Wave Parameters And Body Mass Index In Carpal Tunnel Syndrome, Philip Adebayo, Rose E. Mwakabatika

Internal Medicine, East Africa

Background: Severe carpal tunnel syndrome (CTS) readily lends itself to both clinical and electrophysiological recognition. The uncertainty sometimes is in identifying and quantifying motor involvement in mild and, perhaps, in moderate CTS. Our study aimed to evaluate F responses in mild and moderate CTS and determine the contribution of BMI to the F-wave parameters.

Methods: A retrospective review of the clinical and electrophysiological data of patients with CTS seen at the clinical neurophysiology laboratory of Aga Khan Hospital, Dar es Salaam, between 1 August 2017 and 31 July 2019 was retrieved. Carpal tunnel syndrome was graded according to the …

Predictors Of Mortality In Hospitalized Patients With Influenza: A Five-Year Experience From A Tertiary Care Centre In Pakistan, Iffat Khanum, Amber Sabeen Ahmed, Safia Awan, Sabiha Banu, Bushra Jamil

Department of Medicine

Influenza outbreaks are associated with significant morbidity. Our aim was to determine the factors associated with increased mortality in hospitalized patients admitted with diagnosis of influenza, at a tertiary care center in Pakistan. This study included all adult patients with an influenza infection, confirmed by realtime reverse-transcriptase polymerase-chain-reaction (RT-PCR) at Aga Khan University Hospital Pakistan. In our study, 112 patients with laboratory-confirmed influenza virus infection were admittedat our hospital from the 1st of January 2013 to the 31st of December 2018. Eighty-nine patients (79.46%) were managed in ward or special care units and 23 patients (20.5%) received treatment in intensive …

Rigorous Hand Hygiene Practices Among Health Care Workers Reduce Hospital-Associated Infections During The Covid-19 Pandemic, Rozina Roshan, Anam Shahil Feroz, Zohra Rafique, Nazleen Virani

Section of Internal Medicine

The experiences of these recent months have left us with as many new questions as they have given us new solutions. The main question that infection prevention and control department is having these days is "Why have hospital-associated infections (HAIs) reduced during COVID-19 pandemic?" What is the one unique strategy that has brought decline in increasing HAIs? Would it be appropriate to say that rigorous hand hygiene practices among health care workers (HCWs) have reduced HAIs in a tertiary care hospital of Pakistan? This commentary is written to understand the effect of rigorous hand hygiene among HCWs on number of …

Longitudinally Extensive Transverse Myelitis: A Sub-Saharan Conundrum, Antonina Obayo, Sylvia Mbugua, Sayed Karar

Internal Medicine, East Africa

Spinal cord schistosomiasis is a rare, underdiagnosed manifestation of schistosomiasis. We present the case of a 36-year-old male who presented to our institution with a one-week history of low back pain with rapidly progressive lower limb weakness, loss of sensation, and flaccid paraparesis. An MRI of the spine showed a longitudinally extensive transverse myelitis from T6 to L1, with enhancement at the cauda equina region. Further review of the images and serological tests eventually led to diagnosis of spinal schistosomiasis. He was treated with praziquantel and high-dose steroids, with minimal improvement in his symptoms.

Risk Factors For Intensive Care Unit Admission And Mortality In Hospitalized Covid-19 Patients, Ahmed Ayaz, Ainan Arshad, Hajra Malik, Haris Ali, Erfan Hussain, Bushra Jamil

Medical College Documents

Background: This study investigated the clinical features and outcome of hospitalized coronavirus disease 2019 (COVID-19) patients admitted to our quaternary care hospital.
Methods: In this retrospective cohort study, we included all adult patients with COVID-19 infection admitted to a quaternary care hospital in Pakistan from March 1 to April 15, 2020. The extracted variables included demographics, comorbidities, presenting symptoms, laboratory tests and radiological findings during admission. Outcome measures included in-hospital mortality and length of stay.
Results: Sixty-six COVID-19 patients were hospitalized during the study period. Sixty-one percent were male and 39% female; mean age was 50.6±19.1 years. Fever and cough …

Vasopressin In Conjunction With Norepinephrine In Septic Shock: A Retrospective Cohort Study From A Low Middle-Income Country, Hussain Ahmed Raza, Ainan Arshad, Ahmed Ayaz, Mohummad H R. Raja, Fatima Gohar, Maria Khan, Bushra Jamil

Medical College Documents

Objectives: Guidelines recommend use of norepinephrine as the first-line treatment for fluid-refractory septic shock and if septic shock persists vasopressin may be initiated. Since there are limited data from low middle-income countries with high disease burden of sepsis, we aimed to compare the outcomes of using vasopressin adjunct to norepinephrine in comparison with norepinephrine alone.
Design: Retrospective cohort study.
Setting: Aga Khan University Hospital, Karachi, Pakistan.
Patients: Six-hundred fifty-three patients diagnosed with septic shock from January 2019 to December 2019, with 498 given norepinephrine only and 155 given norepinephrine-vasopressin combination.
Interventions: None.
Measurements and main results: Primary outcome was in-hospital …

Overview Of Antiretropulsion Devices For Prevention Of Inadvertent Stone Migration During Pneumatic Lithotripsy For Ureteric Stone, Ali Akbar Zehri, Miten Patel, Philip Adebayo, Authar Ali

General Surgery, East Africa

The purpose of the present chapter is to provide an update about the use of preventive devices used to stop retrograde stone migration during pneumatic lithotripsy for ureteric stone management. The aim to reduce the cost, ancillary procedure, reduce the operative time and improve the stone free rate. The hunt for ideal cadget to stop retrograde stone migration is still continue in 21 century.

Adverse Health Effects Associated With Household Air Pollution: A Systematic Review, Meta-Analysis, And Burden Estimation Study, Kuan Ken Lee, Rong Bing, Joanne Kiang, Sophia Bashir, Nicholas Spath, Dominik Stelzle, Kevin Mortimer, Anda Bularga, Dimitrios Doudesis, Michael Chung

Internal Medicine, East Africa

Background: 3 billion people worldwide rely on polluting fuels and technologies for domestic cooking and heating. We estimate the global, regional, and national health burden associated with exposure to household air pollution.

Methods: For the systematic review and meta-analysis, we systematically searched four databases for studies published from database inception to April 2, 2020, that evaluated the risk of adverse cardiorespiratory, paediatric, and maternal outcomes from exposure to household air pollution, compared with no exposure. We used a random-effects model to calculate disease-specific relative risk (RR) meta-estimates. Household air pollution exposure was defined as use of polluting fuels (coal, wood, …

Ratings Of Performance In Multisource Feedback: Comparing Performance Theories Of Residents And Nurses, Muhammed Tariq, Marjan Govaerts, Azam Afzal, Syed Ahsan Ali, Tabassum Zehra

Department for Educational Development

Background: Multisource feedback (MSF) is increasingly being used to assess trainee performance, with different assessor groups fulfilling a crucial role in utility of assessment data. However, in health professions education, research on assessor behaviors in MSF is limited. When assessing trainee performance in work settings, assessors use multidimensional conceptualizations of what constitutes effective performance, also called personal performance theories, to distinguish between various behaviors and sub competencies., This may not only explain assessor variability in Multi Source Feedback, but also result in differing acceptance (and use) of assessment data for developmental purposes. The purpose of this study was to explore …

Adult Secondary Hemophagocytic Lymphohistiocytosis, Antonina Obayo, Karishma Sharma, Caroline Mithi, Riyat Malkit, Anne Mwirigi

Internal Medicine, East Africa

Background: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive inflammation and tissue destruction due to abnormal immune activation. HLH carries a very high mortality, and while delays in patients’ presentation to hospital, time to suspicion of HLH, investigation, and initiation of therapy all play a part, mortality remains high even with timely diagnosis and treatment. Classical manifestations of HLH include persistent fever, cytopenias, and liver dysfunction.

Case presentation: We present four cases of secondary HLH, highlighting the demographic and clinical characteristics of these patients, underlying triggers (including systemic lupus erythematosus, lymphoproliferative disorders, and leishmaniasis), together with challenges associated with the …

Reorganising For Covid-19 Pandemic: A Review Of Structural Modifications By The Department Of Internal Medicine In Low To Middle-Income Countries, Shakeel Ur Rehman, Muhammad Arslan Ahmed, Ghufran Adnan, Maria Ali Khan

Department of Medicine

Scientists classified the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a novel coronavirus on January 7, 2020. The World Health Organization (WHO) acknowledged the SARS-CoV-2 outburst a public health emergency of international concern on January 30, 2020. Since its origin, this virus has disrupted the best healthcare systems, economies, and strained financial resources; and for underdeveloped countries' healthcare systems, the virus has become a crisis. To tackle the potential hazards from this virus, our Department restructured the services that not only helped us to cope with the pandemic, but also provided an example to copy for other contemporary institutes. …

Building Focused Cardiac Ultrasound Capacity In A Lower Middle-Income Country: A Single Centre Study To Assess Training Impact, Wangari Siika, Anders Barasa, Benjamin Wachira, David Nekyon, Barbara Karau, Fatimah Juma, Grace Wanjiku, Harun Otieno, Gerald S. Bloomfield, Erik Sloth

Anaesthesiology, East Africa

Background: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment …

Inadvertent Stone Migration During Pneumatic Lithotripsy: Still A Conundrum In The 21st Century, Ali Akbar Zehri, Miten Patel, Philip Adebayo, Authar Ali

General Surgery, East Africa

Currently, an ideal gadget to stop retrograde stone migration remains a holy grail, and the hunt for such a device is still ongoing in the 21st century. The quest for an ideal instrument is driven by the need to reduce cost, minimize ancillary procedure rates, reduce the device's operative time, and improve the stone-free rate. The purpose of the present review is to provide an update on the use of preventive measures that are used to stop retrograde stone migration during pneumatic lithotripsy for ureteric stone management.

Postinfectious Cerebellar Syndrome With Paraneoplastic Antibodies: An Association Or Coincidence?, Sajid Hameed, Mukesh Kumar, Pal Satyajit Singh Athwal, Sukhmanii Kahlon, Nimit Dalal

Section of Neurology

Cerebellar ataxia has a very broad differential diagnosis in adults, including paraneoplastic and postinfectious etiologies. We report a case of a 56-year-old male presented with right-sided cerebellar dysfunction preceded by fever and headache. He was diagnosed with subacute postinfectious cerebellar ataxia. Blood serology showed the presence of anti-amphiphysin and anti-Ri (ANNA-2, antineuronal nuclear autoantibody type 2) antibodies, which have a known association with cerebellar syndrome. The patient subsequently improved with the steroids. Although no evidence of an underlying tumor was found in the patient, the presence of the paraneoplastic antibodies remains a mystery. We suggest a probable association of these …

Substance Use Service Availability In Hiv Treatment Programs: Data From The Global Iedea Consortium, 2014-2015 And 2017, Angela M. Parcesepe, Kathryn Lancaster, E. Jennifer Edelman, Raquel Deboni, The Foundation For Aids Research, Bangkok, Thailand, Lukoye Atwoli

Internal Medicine, East Africa

Background: Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes.

Methods: We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014–2015 …

Erythema Annulare Centrifugum: A Rare Skin Manifestation Of Hashimoto Thyroiditis, Palwasha Jalil, Sadia Masood, Saira Fatima

Section of Internal Medicine

Erythema annulare centrifugum (EAC) is an unusual skin condition appearing as recurrent erythematous annular eruptions associated with autoimmune disorders, infections, and various neoplastic conditions. We present a very rarely reported association of EAC with Hashimoto thyroiditis (HT) in a young male. A 26-year-old male recently diagnosed as case of HT presented in the dermatology clinic with nine-month history of non-itchy persistent annular lesions on the body. The morphology and biopsy of lesions confirmed the diagnosis of EAC. HT is a part of the spectrum of autoimmune thyroid diseases with its own specific cutaneous manifestations. Our case also depicts the impact …

Novel Use Of Fresh Frozen Plasma In Treating Hereditary Angioedema: A Success Story From Pakistan, Amber Sabeen Ahmed, Sidra Fayyaz

Section of Internal Medicine

Hereditary angioedema (HAE) due to a C1-esterase inhibitor(C1-INH) deficiency is a rare and potentially life-threatening disorder. It is characterized by an episodic and self-limiting increase in vascular permeability. The condition manifests itself as recurrent attacks of swelling in any part of the body. The angioedema can cause the involvement of the respiratory tract, skin, and gastrointestinal tract. Laryngeal involvement can make the condition life-threatening. It does not respond well to conventional angioedema therapy of steroids, adrenaline, and antihistamines. The targeted therapy for HAE consists of plasma-derived or recombinant C1-INH, ecallantide, and icatibant or bradykinin receptor antagonist. In the absence of …

Prevalence Of Risk Factors Of Acute Kidney Injury In A Tertiary Care Hospital In Pakistan, Ainan Arshad, Ahmed Ayaz

Section of Internal Medicine

The objective of this study was to determine the prevalence of preventable risk factors of acute kidney injury in a tertiary care hospital in Pakistan. All patients admitted at Aga Khan University Hospital, Karachi with diagnosis of acute kidney injury were included out of which 134 were selected via random sampling. Patients with existing CKD were excluded. Data was then collected retrospectively from medical records of these patients. Mean age was 60±11.7 years while mean serum creatinine on admission was 2.4±1.3 (mg/dl). Sepsis played a role in almost half of the patients [60 (45%)]. Other factors included diarrhoea [23 (17%)], …

Out-Patient Neurological Disorders In Tanzania: Experience From A Private Institution In Dar Es Salaam, Philip Adebayo, Omar Aziz, Rose E. Mwakabatika, Mandela Makakala, Mugisha Clement, Shabbir Adamjee, Noureen Mushi, Ahmed Jusabani, Eric Aris

Internal Medicine, East Africa

Background and introduction: Low and middle-income countries (LMIC) have a considerable burden of neurological disorders. Available profile of neurological disorders in our environment is biased towards neurological admissions. There is a paucity of data on out-patient neurological conditions in sub-Saharan Africa.

Objective: To determine the frequency and demographic data of neurological illnesses being managed at the adult out-patient neurology clinic of the Aga Khan Hospital, Dar es Salaam (AKHD).

Materials and methods: The electronic medical records of all cases with neurological diseases who presented to the adult neurology clinic of the AKHD between January 2018, and December 2019 were retrospectively …

Qualitative Approach To Understanding Barriers To Delivering Difficult News In Sub Saharan Africa, Karishma Sharma, Jasmit Shah, Sayed Karar

Internal Medicine, East Africa

Communication, especially delivery of difficult news (DDN), remains a key part of clinical practice. Despite its importance, many medical providers lack the skill and ability to effectively DDN to their patients. Due to lack of data specific to sub-Saharan Africa and to help us develop an appropriate training tool for this geographical area, we sought to explore what challenges and barriers residents at our institution faced when they deliver difficult news to their patients.

Invasive Pulmonary Infection By Syncephalastrum Species: Two Case Reports And Review Of Literature, Memoona Irshad, Nosheen Nasir, Urooj Haider Hashmi, Joveria Farooqi, Syed Faisal Mahmood

Section of Internal Medicine

Background: Syncephalastrum species belong to the class Zygomycetes and order Mucorale. These are found in the environment and tropical soil, usually presenting as colonizers and rarely cause human infection. Syncephalastrum racemosum is a species of the genus Syncephalastrum and is the most commonly identified pathogen. Most cases are reported in immunocompromised individuals, such as patients on long term steroids, poorly controlled diabetes, or patients with malignancy.
Case presentation: We are describing two cases of rare fungal infection by Syncephalastrum species causing invasive pulmonary manifestation. Both patients had compromised immune status and presented with worsening dyspnea to the emergency room. Both …

A Fatal Case Of Primary Amoebic Meningoencephalitis (Pam) Complicated With Diabetes Insipidus (Di): A Case Report And Review Of The Literature, Zain Mushtaq, Saad Bin Zafar Mahmood, Adil Aziz

Section of Internal Medicine

Naegleria fowleri is a highly infective free-living amoeba usually isolated from soil and fresh water and is primarily found to infect the central nervous system (CNS) resulting in primary amoebic meningoencephalitis (PAM). PAM as a cause of meningitis is often overlooked for other, more common causes of meningitis. Despite all the advances in antimicrobial therapy and supportive care systems, the mortality rate of this rare infection remains above 95% with the bulk of the cases being found in developed countries. We are presenting a case of a 44-year-old male with fever, worsening headache, and generalized weakness. Lumbar puncture showed a …

Covid-19 And Stroke In Sub-Saharan Africa: Case Series From Dar Es Salaam, Philip Adebayo, Nadeem Kassam, Omar Aziz, Ahmed Jusabani, Samina Somji, Mugisha Clement

Internal Medicine, East Africa

Low and middle-income countries including those in sub-Saharan (SSA) Africa are experiencing a steady increase in the number of COVID-19 cases. To the best of our knowledge, reports of COVID-19 related strokes are scarce in SSA. The peculiar situation of stroke care in SSA makes COVID-19 associated stroke a bothersome entity as it adds other dynamics that tilt the prognostic balance. We present a case series of COVID -19 related stroke in 3 patients from Tanzania. We emphasized protected code stroke protocol.

H2s Donor Gyy4137 Ameliorates Paclitaxel-Induced Neuropathic Pain In Mice, Bedoor Qabazard, Willias Masocha, Maitham Khajah, Philip Adebayo

Faculty of Health Sciences, East Africa

Paclitaxel-induced neuropathic pain (PINP) is a dose-limiting side effect that largely affects the patient’s quality of life and may limit the use of the drug as a chemotherapeutic agent for treating metastatic breast cancer and other solid tumors. Recently, a putative role for the gaseous mediator hydrogen sulfide (H2S) in nociception modulation has been suggested. The aim of the present study was to investigate the potential efficacy of the slow release H2S donor GYY4137 to alleviate and prevent PINP. Female BALB/c mice that were intraperitoneally (i.p.) injected with paclitaxel (2 mg/kg) for 5 consecutive days developed thermal hyperalgesia, cold and …