Influenza outbreak and deaths at a Queensland nursing home highlight the importance of people aged over 65 getting a flu vaccine...once available.
German HCoV-EMC-local transmission
A 2nd case of the most recently identified HCoV, HCoV-EMC, reported on ProMED, in Germany. The Robert Koch Institute notes that There is still no evidence of continuous human-to-human transmission.
[VDU's first blog post!]
[VDU's first blog post!]
Neurological Education and Practice in Uganda
Craig Williamson
MGH/BWH Neurology Resident
It is certainly with reluctance that I leave Uganda and return to the US. Working here has been an educational and humbling experience that challenged me to think about how to manage common and uncommon neurological conditions without the resources available at MGH or the Brigham. On my final day, I prepared a talk for the post-graduates on the clinical evaluation and differential diagnosis of spinal cord disorders. Just before the talk, I was called to the ED to examine a 22 year-old woman who has had one month of progressive lower extremity weakness, progressing to total inability to walk. She had been seen in the ED four days prior and had been sent out to get plain X-rays of her lumbosacral spine, which not surprisingly appeared normal. On examination, she had flaccid weakness of the lower extremities with extremely brisk reflexes, sustained clonus in the ankles and upgoing toes - without any upper extremity symptoms her problems easily localize to the thoracic spinal cord. For all of my recently acquired knowledge about the many causes of myelopathy in tropical settings, it wasn't at all clear to me how to proceed with her evaluation and treatment. At MGH, she would be admitted, have an MRI of at least her thoracic spine, probably also of her cervical spine and brain, then would undergo a lumbar puncture that would be sent for a dizzying array of laboratory tests for infectious and inflammatory causes of myelopathy, in addition to other tests for various metabolic and nutritional causes. Depending on our determination of the etiology, she would most likely be treated with a course of high-dose steroids. It was informative to talk through the case with the post-graduates and get their recommendations on how they would manage the patient without MRI and most laboratory tests. Essentially, they would probably test her for HIV and then treat her for things they can treat - most likely TB. My own uncertainty with the case illustrates how difficult it is to come in to an unfamiliar setting for a short period of time and make constructive management recommendations.
Fortunately, another of my colleagues from the MGH/BWH neurology residency will be visiting Mbarara in just a few weeks and can build on some of the things I learned. In addition to spending more time working with the very eager medical students, we can hopefully develop some clinical protocols to assist with management of common neurological issues. In particular, there appears to be a tremendous need for improved prevention and management of traumatic brain injuries - one of the most common reasons for ICU admissions - though it isn't at all clear how best to do this with less access to CT scanning and laboratory testing. This is just one of many potential areas of academic inquiry that would be extremely rewarding to pursue.
Here, one of the medicine post-graduates waxes eloquently to the third-year students at the beside about the subtypes of Guillain-Barre syndrome and the side-effects of treatment with IVIG, which isn't available at MRRH.
An 8 bed ICU was recently opened in MRRH's new building. The use of motorcycles as the primary means of transportation in Mbarara - typically without helmets for the drivers or passengers - leads to an extremely high volume of TBI requiring neurosurgical intervention.
Some of the talented post-graduates waiting for me to begin my final talk.
Looking silly for the sake of education as I attempt to act out features of an MCA stroke.
MGH/BWH Neurology Resident
It is certainly with reluctance that I leave Uganda and return to the US. Working here has been an educational and humbling experience that challenged me to think about how to manage common and uncommon neurological conditions without the resources available at MGH or the Brigham. On my final day, I prepared a talk for the post-graduates on the clinical evaluation and differential diagnosis of spinal cord disorders. Just before the talk, I was called to the ED to examine a 22 year-old woman who has had one month of progressive lower extremity weakness, progressing to total inability to walk. She had been seen in the ED four days prior and had been sent out to get plain X-rays of her lumbosacral spine, which not surprisingly appeared normal. On examination, she had flaccid weakness of the lower extremities with extremely brisk reflexes, sustained clonus in the ankles and upgoing toes - without any upper extremity symptoms her problems easily localize to the thoracic spinal cord. For all of my recently acquired knowledge about the many causes of myelopathy in tropical settings, it wasn't at all clear to me how to proceed with her evaluation and treatment. At MGH, she would be admitted, have an MRI of at least her thoracic spine, probably also of her cervical spine and brain, then would undergo a lumbar puncture that would be sent for a dizzying array of laboratory tests for infectious and inflammatory causes of myelopathy, in addition to other tests for various metabolic and nutritional causes. Depending on our determination of the etiology, she would most likely be treated with a course of high-dose steroids. It was informative to talk through the case with the post-graduates and get their recommendations on how they would manage the patient without MRI and most laboratory tests. Essentially, they would probably test her for HIV and then treat her for things they can treat - most likely TB. My own uncertainty with the case illustrates how difficult it is to come in to an unfamiliar setting for a short period of time and make constructive management recommendations.
Fortunately, another of my colleagues from the MGH/BWH neurology residency will be visiting Mbarara in just a few weeks and can build on some of the things I learned. In addition to spending more time working with the very eager medical students, we can hopefully develop some clinical protocols to assist with management of common neurological issues. In particular, there appears to be a tremendous need for improved prevention and management of traumatic brain injuries - one of the most common reasons for ICU admissions - though it isn't at all clear how best to do this with less access to CT scanning and laboratory testing. This is just one of many potential areas of academic inquiry that would be extremely rewarding to pursue.
Here, one of the medicine post-graduates waxes eloquently to the third-year students at the beside about the subtypes of Guillain-Barre syndrome and the side-effects of treatment with IVIG, which isn't available at MRRH.
An 8 bed ICU was recently opened in MRRH's new building. The use of motorcycles as the primary means of transportation in Mbarara - typically without helmets for the drivers or passengers - leads to an extremely high volume of TBI requiring neurosurgical intervention.
Some of the talented post-graduates waiting for me to begin my final talk.
Looking silly for the sake of education as I attempt to act out features of an MCA stroke.
Neurological Practice and Education in Uganda
Craig Williamson
MGH/BWH Neurology Resident
3/11/2013
The first week of my visit to Mbarara Regional Referral Hospital (MRRH)/ Mbarara University of Science and Technology (MUST) has been rich in learning, new experiences and new people. It has also been quite rich in terms of neurological cases and teaching opportunities. If meningitis is included, one-third of the admissions to the medical service are primarily neurological.
Many of the types of cases I have been seeing are our bread and butter admissions to the MGH and BWH Neurology Services: hypertensive hemorrhages, ischemic strokes, guillain-barre syndrome and subdural hematomas. However, as anticipated, there is a much higher incidence of neuro-infectious diseases, particularly complications of AIDS - cryptococcal meningitis and tuberculous meningitis in particular.
My visit comes at an exciting time, as MRRH just acquired a CT scanner a few months ago and residents are still learning how best to use this new technology. There are no radiologists available, so I have found myself spending a lot of time helping with both CT scan interpretation, and deciding when scanning is clinically indicated. I gave a formal teaching session to the medicine postgraduates on this topic, and have been doing informal consultations amongst the various ward teams. Patients and their families are expected to pay upfront for CT scans � a significant financial hardship for most � so it becomes important to decide when obtaining a scan will genuinely affect management.
The structure of the MRRH medical teams was well-described in the last blog post. There are a large number of medical students, and bedside medical student teaching is a core aspect of medical education. Given the large numbers of neurological cases, there has been ample opportunity for informal teaching about physical exam skills and clinical reasoning at the bedside. Sometimes after rounds, I will take the medical students and go over the clinical presentation and examination of a particular patient or discuss specific aspects of the neurological examination. For example, last week we examined a patient with guillain-barre together and discussed the differential diagnosis of acute bilateral weakness and paresthesias, and also did a session where the students practiced the cranial nerve examination on one another.
Finally, while it has been gratifying to feel like my neurological training enables me to teach and contribute to clinical care, the medicine post-graduates have also been able to teach me a great deal. In the US, we generally don't think of tuberculous meningitis as a primary cause of stroke in young patients. However, here I have seen several cases of stroke due to TB or cryptococcal meningitis and the residents have been sharing their clinical pearls for deciding when to treat empirically for TB in HIV patients presenting with ischemic stroke. I have also had a chance to learn about differentiating cerebral malaria from other infectious causes of altered mental status, and the management of organophosphate pesticide poisoning, which is much more common here.
