Pattern of Cardiovascular Diseases Among Elderly Patients Admitted in Medical Wards at Muhimbili National Hospital Dar es salaam Tanzania

Cardiovascular disease is the most frequent cause of death in persons over the age 50 years and most importantly it is responsible for considerable morbidity and large burden of disability in the community. Cardiovascular diseases are an increasing cause of admissions among elderly in Africa, yet little research is available on pattern and magnitude of the problem. To determine the pattern of cardiovascular disease in elderly patients admitted in medical wards at Muhimbili National Hospital Dar es Salaam Tanzania. This was a descriptive cross sectional study that was carried our between September 2008 and September 2009. Social demographic information; medical history physical examination; electrocardiographic and echocardiography examination; biochemical and haematological parameters were collected from study patients One hundred eighty five elderly patients admitted at MNH, medical department, were enrolled into the study, all were of African black race. Majority, 116 (62.7%), were male. Their mean age was 66.1 (SD, 9.3; range, 50-87) years. The mean body mass index\ud (BMI) was 23.9 (SD, 3.9; range, 16.6-40.1) kg/m2. Hypertension was the most frequent condition encountered affecting both males (67.2%)and females (68.1%). Congestive heart failure was second common condition affecting 37% elderly patients. According to the echocardiogram findings, among 185 elderly patients 68.6% were diagnosed to have cardiovascular disease. There were no significant sex differences in the prevalence of cardiac disease (p>005). The commonest echocardiographic diagnosis were left ventricular hypertrophy (LVH) secondary to hypertension found in 45%, diastolic dysfunction found in 31% and systolic dysfunction 25%.The least common types were septal defect, pulmonary hypertension and calcified mitral valve found in one percent each. The commonest clinical presentations were palpitations, dyspnoea, orthopnoea, pedal oedema and right upper quadrant abdominal pain. Obese patients presenting with cardiovascular abnormalities were 9 (7.1%). Anaemia was the leading co- morbidity affecting 90.3% of the patients Hypertension, congestive heart failure and left ventricular hypertrophy were the commonest cardiovascular diseases among elderly patients at MNH. Coexistence of anaemia, stroke, renal impairment and diabetes was also frequent. Elderly patients should be screened for cardiovascular diseases especially hypertension whenever they are admitted to the hospital even if the reasons for admission are not cardiovascular problems.\u

Neonatal hypothermia on admission to a special care unit in Dar-es-Salaam, Tanzania: a cause for concern

A CAJM journal article.Objective: To determine the prevalence and risk factors for hypothermia among neonates on admission to the Neonatal Care Unit. Hypothermia in newborn babies is a problem in tropical countries despite warm environmental conditions and it contributes to a high neonatal morbidity and mortality. Methodology: A study was undertaken to determine the prevalence of hypothermia and its association with early neonatal outcome among neonates admitted to the Neonatal Care Unit of Muhimbili Medical Centre . At admission all neonates were examined and axillary temperature recorded using a low-reading thermometer. Six-hourly temperature was taken in all infants: Those with a temperature below 36.5°C were recruited as cases and those with normal temperature served as controls. These neonates were followed up for early neonatal outcome. Results: Hypothermia on admission was found in 366 out of 1632 babies (22.4%). In none of these was hypothermia recorded or reported as a reason for admission. Thirteen percent of the hypothermic neonates had severe hypothermia, with body temperature below 32°C on admission. Hypothermia was significantly associated with deliveries from outside hospitals and with those who had operative or instrumental delivery in the same hospital. It was also associated with prematurity, low birth weight babies, time taken to transfer the baby and inadequate clothing after delivery. It was found that hypothermic infants had a three fold higher mortality and morbidity. These infants had a longer stay in the unit and had a higher post natal weight loss. There was no low-reading thermometer in the unit. Conclusion: It is concluded that there is cause for concern about hypothermia in the neonates at Muhimbili Medical Centre, Efforts should be made to sensitize and educate all levels of staff dealing with neonates, and low-reading thermometers should be part of the essential kit in the unit

A pilot study to evaluate incorporating eye care for children into reproductive and child health services in Dar-es-Salaam, Tanzania: a historical comparison study.

BACKGROUND: Many blinding eye conditions of childhood are preventable or treatable, particularly in developing countries. However, primary eye care (PEC) for children is poorly developed, leading to unnecessary visual loss. Activities for control by health workers entail interventions for systemic conditions (measles, vitamin A deficiency), identification and referral of children with sight threatening conditions and health education for caregivers. This pilot study evaluated integrating a package of activities to promote child eye health into Reproductive and Child Health (RCH) services in Dar-es-Salaam, Tanzania. METHODS: DESIGN: historical comparison study. Fifteen Clinical Officers and 15 nurses in 15 randomly selected RCH clinics were trained in PEC for children in July 2010. They were given educational materials (poster and manual) and their supervisors were orientated. Knowledge and practices were assessed before and 3 weeks after training. One year later their knowledge and practices were compared with a different group of 15 Clinical Officers and 15 nurses who had not been trained. RESULTS: Before training staff had insufficient knowledge to identify, treat and refer children with eye diseases, even conjunctivitis. Some recommended harmful practices or did not know that cataract requires urgent referral. Eye examination, vitamin A supplementation of mothers after delivery and cleaning the eyes at birth with instillation of antibiotics (Crede's prophylaxis) were not routine, and there were no eye-specific educational materials. Three weeks after training several clinics delivering babies started Crede's prophylaxis, vitamin A supplementation of women after delivery increased from 83.7% to 100%, and all staff included eye conditions in health education sessions. At one year, trained staff were more likely to correctly describe, diagnose and treat conjunctivitis (z=2.34, p=0.04)(30%-vs-60.7%). Mystery mothers observed health education sessions in 7/10 RCH clinics with trained staff, five (71.4%) of which included eye conditions. CONCLUSIONS: Primary eye care for children in Dar-es-Salaam is inadequate but training RCH staff can improve knowledge in the short term and change practices. Attendance by mothers and their children is high in RCH clinics, making them ideal for delivery of PEC. Ongoing supportive supervision is required to maintain knowledge and practices, as well as systems to track referrals

Biomarkers of systemic inflammation and growth in early infancy are associated with stunting in young Tanzanian children

Stunting can afflict up to one-third of children in resource-constrained countries. We hypothesized that low-grade systemic inflammation (defined as elevations in serum C-reactive protein or alpha-1-acid glycoprotein) in infancy suppresses the growth hormone–insulin-like growth factor (IGF) axis and is associated with subsequent stunting. Blood samples of 590 children from periurban Dar es Salaam, Tanzania, were obtained at 6 weeks and 6 months of age as part of a randomized controlled trial. Primary outcomes were stunting, underweight, and wasting (defined as length-for-age, weight-for-age and weight-for-length z-scores < −2) between randomization and endline (18 months after randomization). Cox proportional hazards models were constructed to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of time to first stunting, underweight, and wasting as outcomes, with measures of systemic inflammation, insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) as exposures, adjusting for numerous demographic and clinical variables. The incidences of subsequent stunting, underweight, and wasting were 26%, 20%, and 18%, respectively. In multivariate analyses, systemic inflammation at 6 weeks of age was significantly associated with stunting (HR: 2.14, 95% CI: 1.23, 3.72; p = 0.002). Children with higher levels of IGF-1 at 6 weeks were less likely to become stunted (HR: 0.58, 95% CI: 0.37, 0.93; p for trend = 0.019); a similar trend was noted in children with higher levels of IGF-1 at 6 months of age (HR: 0.50, 95% CI: 0.22, 1.12; p for trend = 0.07). Systemic inflammation occurs as early as 6 weeks of age and is associated with the risk of future stunting among Tanzanian children.This research was funded by the National Institutes of Health (R01 HD048969, 2P30 DK040561, K24 DK104676-Dr. Duggan) and the Bill and Melinda Gates Foundation (OPP1066203-Dr. Duggan). (R01 HD048969 - National Institutes of Health; 2P30 DK040561 - National Institutes of Health; K24 DK104676 - National Institutes of Health; OPP1066203 - Bill and Melinda Gates Foundation)Accepted manuscrip

Predictors of Stunting, Wasting and Underweight among Tanzanian Children Born to HIV-Infected Women.

Children born to human immunodeficiency virus (HIV)-infected women are susceptible to undernutrition, but modifiable risk factors and the time course of the development of undernutrition have not been well characterized. The objective of this study was to identify maternal, socioeconomic and child characteristics that are associated with stunting, wasting and underweight among Tanzanian children born to HIV-infected mothers, followed from 6 weeks of age for 24 months. Maternal and socioeconomic characteristics were recorded during pregnancy, data pertaining to the infant's birth were collected immediately after delivery, morbidity histories and anthropometric measurements were performed monthly. Multivariate Cox proportional hazards methods were used to assess the association between potential predictors and the time to first episode of stunting, wasting and underweight. A total of 2387 infants (54.0% male) were enrolled and followed for a median duration of 21.2 months. The respective prevalence of prematurity (<37 weeks) and low birth weight (<2500 g) was 15.2% and 7.0%; 11.3% of infants were HIV-positive at 6 weeks. Median time to first episode of stunting, wasting and underweight was 8.7, 7.2 and 7.0 months, respectively. Low maternal education, few household possessions, low infant birth weight, child HIV infection and male sex were all independent predictors of stunting, wasting and underweight. In addition, preterm infants were more likely to become wasted and underweight, whereas those with a low Apgar score at birth were more likely to become stunted. Interventions to improve maternal education and nutritional status, reduce mother-to-child transmission of HIV, and increase birth weight may lower the risk of undernutrition among children born to HIV-infected women

Intronic variants in the long non-coding RNA CDKN2B-AS1 are strongly associated with the risk of coronary artery disease in the Northern Tribes of Tanzania

Introduction: Sub-Saharan Africa (SSA) is facing a rising epidemic of non-communicable diseases including the coronary artery disease (CAD) ranking at the top of the list. Chromosome locus 9p21.3 containing CDKN2B antisense RNA 1 (CDKN2B-AS1), identified in many genome-wide association studies for coronary artery disease (CAD), encompasses multiple single nucleotide polymorphisms (SNPs). This study aimed to conduct the first genetic study evaluating the common polymorphisms in 9p21.3 locus in Tanzanian CAD patients from different regions of Tanzania and their associations with CAD risk factors. Material and Methods: A total of 90 patients from Northern region (N-CAD) of Tanzania and 65 patients from other regions (South, East, West and Central) (R-CAD) were included in the study. Further the biochemical analysis the genotyping of common variants was performed with the LightSNiP typing assay using qRT-PCR method.&nbsp; Results: Our analyses revealed that both genotype and allele frequencies of rs10757274, rs10757278 and rs10811656 were significantly different between the groups (p&lt;0.05, respectively). We identified that one previously undescribed three-marker haplotype (rs1333049, rs10757274 and rs10757278) encompassing CDKN2B-AS1 was overrepresented (G-G-G, the risk haplotype, p&lt;0.05) in N-CAD group compared to R-CAD group. The AUC of a risk model based on non-genetic factors was 0.730 (0.654-0.797) and the combination with genetic risk factors improved the AUC to 0.784 (95%CI=0.713-0.844, p&lt;0.0001). Conclusion: Our results identified the presence of a novel three-marker haplotype having a significant association with CAD in Northern Tanzania. Moreover, combination of the nongenetic and genetic risk models were demonstrated to indicate good diagnostic accuracy for CAD in Northern Tanzania

Detecting virological failure in HIV-infected Tanzanian children

Background. The performance of clinical and immunological criteria to predict virological failure in HIV-infected children receiving antiretroviral therapy (ART) is not well documented.Objective. To determine the validity of clinical and immunological monitoring in detecting virological failure in children on ART.Methods. A total of 218 children were included in the study. All were from care and treatment clinics in Dar es Salaam, Tanzania. Their mean age was 10.6 years, 122 (56.0%) were males, and the mean time on ART was 40.9 months. The study was conducted from August 2011 to March 2012. Data on sociodemographic and clinical characteristics and immunological and virological failure were based on World Health Organization definitions. Blood samples were collected for CD4+ T-cell count and viral load tests.Results. Of 217 children with available viral load results, 124 (57.1%) had virological failure (&gt;400 copies/mL), 25.0% immunological failure and 11.5% clinical failure. The sensitivity, specificity, positive predictive value and negative predictive value of clinical criteria were 12.9%, 90.3%, 64.0% and 43.8%, respectively, those for immunological criteria 22.6%, 73.1%, 53.3% and 41.4%, and those for the combination of clinical and immunological monitoring 25.8%, 69.9%, 53.3% and 41.4%. Children who received nevirapine (NVP)-based regimens were two times more likely (odds ratio 2.0; 95% confidence interval 1.20 - 3.64) to have virological failure than those on efavirenz and protease inhibitor-based regimens. Conclusions. The study demonstrated poor performance of currently recommended clinical and immunological criteria for monitoring HIV-infected children on ART. Moreover, children on NVP-based regimens had a higher risk of developing virological failure than those on other regimens

Multivitamin Supplementation Improves Haematologic Status in Children Born to HIV-positive women in Tanzania.

Anaemia is prevalent among children born to HIV-positive women, and it is associated with adverse effects on cognitive and motor development, growth, and increased risks of morbidity and mortality. To examine the effect of daily multivitamin supplementation on haematologic status and mother-to-child transmission (MTCT) of HIV through breastfeeding. A total of 2387 infants born to HIV-positive women from Dar es Salaam, Tanzania were enrolled in a randomized, double-blind, placebo-controlled trial, and provided a daily oral supplement of multivitamins (vitamin B complex, C and E) or placebo at age 6 weeks for 24 months. Among them, 2008 infants provided blood samples and had haemoglobin concentrations measured at baseline and during a follow-up period. Anaemia was defined as haemoglobin concentrations <11 g/dL and severe anaemia <8.5 g/dL. Haemoglobin concentrations among children in the treatment group were significantly higher than those in the placebo group at 12 (9.77 vs. 9.64 g/dL, p=0.03), 18 (9.76 vs. 9.57 g/dL, p=0.004), and 24 months (9.93 vs. 9.75 g/dL, p=0.02) of follow-up. Compared to those in the placebo group, children in the treatment group had a 12% lower risk of anaemia (hazard ratio (HR): 0.88; 95% CI: 0.79-0.99; p=0.03). The treatment was associated with a 28% reduced risk of severe anaemia among children born to women without anaemia (HR: 0.72; 95% CI: 0.56-0.92; p=0.008), but not among those born to women with anaemia (HR: 1.10; 95% CI: 0.79-1.54; p=0.57; p for interaction=0.007). One thousand seven hundred fifty three infants who tested HIV-negative at baseline and had HIV testing during follow-up were included in the analysis for MTCT of HIV. No association was found between multivitamin supplements and MTCT of HIV. Multivitamin supplements improve haematologic status among children born to HIV-positive women. Further trials focusing on anaemia among HIV-exposed children are warranted in the context of antiretroviral therapy

Children's Medicines in Tanzania: A National Survey of Administration Practices and Preferences.

The dearth of age-appropriate formulations of many medicines for children poses a major challenge to pediatric therapeutic practice, adherence, and health care delivery worldwide. We provide information on current administration practices of pediatric medicines and describe key stakeholder preferences for new formulation characteristics. We surveyed children aged 6-12 years, parents/caregivers over age 18 with children under age 12, and healthcare workers in 10 regions of Tanzania to determine current pediatric medicine prescription and administration practices as well as preferences for new formulations. Analyses were stratified by setting, pediatric age group, parent/caregiver education, and healthcare worker cadre. Complete data were available for 206 children, 202 parents/caregivers, and 202 healthcare workers. Swallowing oral solid dosage forms whole or crushing/dissolving them and mixing with water were the two most frequently reported methods of administration. Children frequently reported disliking medication taste, and many had vomited doses. Healthcare workers reported medicine availability most significantly influences prescribing practices. Most parents/caregivers and children prefer sweet-tasting medicine. Parents/caregivers and healthcare workers prefer oral liquid dosage forms for young children, and had similar thresholds for the maximum number of oral solid dosage forms children at different ages can take. There are many impediments to acceptable and accurate administration of medicines to children. Current practices are associated with poor tolerability and the potential for under- or over-dosing. Children, parents/caregivers, and healthcare workers in Tanzania have clear preferences for tastes and formulations, which should inform the development, manufacturing, and marketing of pediatric medications for resource-limited settings

A Prospective Longitudinal Study of the Clinical Outcomes from Cryptococcal Meningitis following Treatment Induction with 800 mg Oral Fluconazole in Blantyre, Malawi

Introduction: Cryptococcal meningitis is the most common neurological infection in HIV infected patients in Sub Saharan Africa, where gold standard treatment with intravenous amphotericin B and 5 flucytosine is often unavailable or difficult to administer. Fluconazole monotherapy is frequently recommended in national guidelines but is a fungistatic drug compromised by uncertainty over optimal dosing and a paucity of clinical end-point outcome data. Methods: From July 2010 until March 2011, HIV infected adults with a first episode of cryptococcal meningitis were recruited at Queen Elizabeth Central Hospital, Blantyre, Malawi. Patients were treated with oral fluconazole monotherapy 800 mg daily, as per national guidelines. ART was started at 4 weeks. Outcomes and factors associated with treatment failure were assessed 4, 10 and 52 weeks after fluconazole initiation. Results: Sixty patients were recruited. 26/60 (43%) died by 4 weeks. 35/60 (58.0%) and 43/56 (77%) died or failed treatment by 10 or 52 weeks respectively. Reduced consciousness (Glasgow Coma Score ,14 of 15), moderate/severe neurological disability (modified Rankin Score .3 of 5) and confusion (Abbreviated Mental Test Score ,8 of 10) were all common at baseline and associated with death or treatment failure. ART prior to recruitment was not associated with better outcomes. Conclusions: Mortality and treatment failure from cryptococcal meningitis following initiation of treatment with 800 mg oral fluconazole is unacceptably high. To improve outcomes, there is an urgent need for better therapeutic strategies and point-of-care diagnostics, allowing earlier diagnosis before development of neurological deficit