Managing hypertension in nurse-led primary care clinics in rural Ethiopia

Background: Providing health care for patients with hypertension has been difficult in rural areas of sub-Saharan Africa because of lack of medical staff and facilities. The use of non-physician healthcare workers offers a possible solution, but little is known about the feasibility and clinical response to treatment.Methods: We carried out a descriptive, retrospective review of the records of a sequential sample of 249 hypertensive patients aged 52.3 (SD 12.7) years from eight health centres in a rural area of southern Ethiopia where nurses and health officers had been previously trained to diagnose, treat and manage non-communicable diseases including hypertension. The study evaluated the changes in systolic and diastolic blood pressures following treatment over a 30 month period.Results: The mean systolic blood pressure on admission was 156.1(SD 21.1) mm Hg and the mean diastolic pressure 95.7(SD 12.7) mm Hg. Of the 249 subjects, 105(42.1%) defaulted from clinic follow-up during the period of the study. More than half (53.8%) were controlled on monotherapy with a thiazide diuretic, the remainder required combination therapy. Significant declines in systolic and diastolic blood pressure were achieved in each blood pressure group with the exception of the lowest pressure groups.Conclusion: Our study demonstrates that nurses and heath officers working in remote rural health centres can obtain worthwhile reductions in blood pressure in patients with hypertension. Moreover, this could often be achieved with a single, inexpensive diuretic, hydrochlorthiazide, although combination therapy was sometimes required. [Ethiop. J. Health Dev. 2018; 32(2):104-109]Key words: Hypertension, blood pressure, task-shifting, delivery of health care, nurses, Ethiopia

Pharmacokinetics and metabolism of ifosfamide in relation to DNA damage assessed by the COMET assay in children with cancer

The degree of damage to DNA following ifosfamide (IFO) treatment may be linked to the therapeutic efficacy. The pharmacokinetics and metabolism of IFO were studied in 19 paediatric patients, mostly with rhabdomyosarcoma or Ewings sarcoma. Ifosfamide was dosed either as a continuous infusion or as fractionated doses over 2 or 3 days. Samples of peripheral blood lymphocytes were obtained during and up to 96 h after treatment, and again prior to the next cycle of chemotherapy. DNA damage was measured using the alkaline COMET assay, and quantified as the percentage of highly damaged cells per sample. Samples were also taken for the determination of IFO and metabolites. Pharmacokinetics and metabolism of IFO were comparable with previous studies. Elevations in DNA damage could be determined in all patients after IFO administration. The degree of damage increased to a peak at 72 h, but had returned to pretreatment values prior to the next dose of chemotherapy. There was a good correlation between area under the curve of IFO and the cumulative percentage of cells with DNA damage (r2 = 0.554, P = 0.004), but only in those patients receiving fractionated dosing. The latter patients had more DNA damage (mean ± s.d., 2736 ± 597) than those patients in whom IFO was administered by continuous infusion (1453 ± 730). The COMET assay can be used to quantify DNA damage following IFO therapy. Fractionated dosing causes a greater degree of DNA damage, which may suggest a greater degree of efficacy, with a good correlation between pharmacokinetic and pharmacodynamic data

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability