Single voxel magnetic resonance spectroscopy in distinguishing focal neoplastic from non-neoplatic brain lesions

Objective: Assess diagnostic utility of combined magnetic resonance imaging and magnetic resonance spectroscopy (MRI, MRS) in differentiating focal neoplastic lesions from focal non- neoplastic (infective or degenerative) brain lesions.Design: Descriptive, analytical - prospective study.Setting: The Aga Khan University MRI department.Subject: Seventy four consecutive patients.Main outcome measures: Kappa measurement of agreement was used to determine the agreement between MRI and MRI, MRS with the final diagnosis. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the two tests were calculated. The difference between the number of indeterminate lesions in the twotests was determined. Logistic regression demonstrated the role of confounding factors in the diagnostic use of MRS.Results: MRI, MRS had a higher agreement with the final diagnosis than MRI in isolation. The sensitivity of MRI, MRS was 4.82 times greater than that of MRI. MRI, MRS had a 1.7% increase in accuracy. MRI, MRS reduced the indeterminate MRI lesions by 5.4%. Logistic regression showed that for lesions which were enhancing, MRS yield was more helpful if the voxel position included the enhancing part.Conclusion: MRI,MRS is better than MRI alone in characterisation of neoplastic from non- neoplastic focal brain lesions

Physical activity and cardiovascular disease risk factors among young and middleaged men in urban Mwanza, Tanzania

Background: Cardiovascular diseases (CVD) risk factors are increasing at an unprecedented rate in developing countries. However, fewer studies have evaluated the role of physical activity in preventing CVD in these countries. We assessed level physical activity and its relationship with CVD risk factors among young and middle aged men in a fast growing city of Mwanza in Tanzania. Methods: Physical activity was assessed among 97 healthy men aged 20-50years using Sub-Saharan Africa Activity Questionnaire. An updated compendium of physical activity was used to code the metabolic equivalent. Energy expenditure was calculated using Harris Benedict equation. Anthropometric measurements, blood pressure,  fasting blood glucose and serum lipids were also measured. Results: The mean energy expenditure in this population was 6,466 ± 252 kcal/week. More than half (53.6%) of the participants had energy expenditure of H4,000 kcal/week. Only three (3.1%) had energy expenditure below the recommended 1,000 kcal/week. Except for hypertension, prevalence of CVD risk factors was low in this population; hypertension 23.7%, low HDLcholesterol 10.3%, high LDL-cholesterol 9.3% and obesity 4.1%. Physical activity energy expenditure had an inversely relationship with waist to hip ratio, systolic blood pressure, heart rate, total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and fasting blood glucose. Conclusion: Physical activity energy expenditure was high in this population and was inversely correlated with CVD risk factors. Physical activity may play an important role in the prevention of CVD in this urban population of young and middle aged men

Nutritional variation and cardiovascular risk factors in Tanzania — rural-urban difference

Objective. To assess the relationship between dietary factors and cardiovascular (CVD) risk factors in middle-aged men and women, in urban, rural and pastoral settings in Tanzania.Design. Cross-sectional epidemiological study designed according to the protocol of the World Health Organisation (WHO) Cardiovascular Diseases and Alimentary Comparison (CARDIAC) study.Setting. Three centres in Tanzania, namely Dar es Salaam (urban), Handeni (rural) and Monduli (pastoral population).                                                                                                                                                     Subjects. The subjects, aged 47 - 57 years, were recruited randomly from administrative lists available from each centre.Outcome measures. Blood pressure (BP) was measured using a centrally calibrated automatic BP machine (Khi machine). Dietary history of the participants was obtained using a standard questionnaire designed on the basis of a seven-day recall system. Height, weight, serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDLC), haemoglobin A1c , sodium, potassium and magnesium were measured.Results. The prevalence of hypertension (BP ≥ 140/90 mmHg or antihypertensive drug use), obesity (body mass index (BMI)≥ 30 kg/m2) and hypercholesterolaemia (TC > 5.2 mmol/l) were lowest in the rural area. Consumption of green vegetables, milk, coconut milk, meat, and fish varied significantly between the three areas. Important determinants for BP among men were BMI (p < 0.001), and salt intake (p < 0.05). Among women, TC (p < 0.05), age (p < 0.05), BMI (p < 0.001) and coconut milk consumption (p < 0.001)were important BP determinants. Salt intake was positively associated with systolic BP (SBP) and diastolic BP (DBP) in men but not among women (both SBP and DBP p < 0.05 respectively). Dietary determinants of serum TC were meat, fish and green vegetable consumption.Conclusion. Differences in dietary habits contributed significantly to the urban-rural-pastoral variations in CVD risk pattern in Tanzania

The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa

Introduction Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. Methods The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Results Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced‐prophylaxis components. Enhanced‐prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced‐prophylaxis still conveyed health gains in CrAg‐negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost‐effective unless the price of CrAg testing fell below US$2.30. Conclusions The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices

Late Presentation With HIV in Africa: Phenotypes, Risk, and Risk Stratification in the REALITY Trial.

This article has been accepted for publication in Clinical Infectious Diseases Published by Oxford University PressBackground: Severely immunocompromised human immunodeficiency virus (HIV)-infected individuals have high mortality shortly after starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods: The Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children ≥5 years of age with CD4 counts .1). Results: Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P < .04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P = .02). Of five late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/µL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/µL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/µL), but low symptom burden and maintained fat mass. The remaining groups had 4%-6% mortality. Conclusions: Clinical and laboratory features identified groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up. Clinical Trials Registration: ISRCTN43622374.REALITY was funded by the Joint Global Health Trials Scheme (JGHTS) of the UK Department for International Development, the Wellcome Trust, and Medical Research Council (MRC) (grant number G1100693). Additional funding support was provided by the PENTA Foundation and core support to the MRC Clinical Trials Unit at University College London (grant numbers MC_UU_12023/23 and MC_UU_12023/26). Cipla Ltd, Gilead Sciences, ViiV Healthcare/GlaxoSmithKline, and Merck Sharp & Dohme donated drugs for REALITY, and ready-to-use supplementary food was purchased from Valid International. A. J. P. is funded by the Wellcome Trust (grant number 108065/Z/15/Z). J. A. B. is funded by the JGHTS (grant number MR/M007367/1). The Malawi-Liverpool–Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine (grant number 101113/Z/13/Z) and the Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi (grant number 203077/Z/16/Z) are supported by strategic awards from the Wellcome Trust, United Kingdom. Permission to publish was granted by the Director of KEMRI. This supplement was supported by funds from the Bill & Melinda Gates Foundation

Prevalence of sickle cell, malaria and glucose-6-phosphate dehydrogenase deficiency among primary school children in Nyamagana District, Mwanza-Tanzania

Background: Sickle cell disease and glucose-6-phosphate dehydrogenase (G-6-PD) deficiency are relatively common genetic disorders in population exposed to malaria in sub-Saharan Africa. The prevalence of these two genetic disorders differs between different malaria transmission areas.Objectives: This cross sectional study was conducted to determine the prevalence and co-existence of sickle cell, malaria and G6PD deficiency in school children and determine their association with anaemia.Methods: Venous blood samples from 385 school children aged 9 to 18 years and then fluorescent spot test, cyanmethaemoglobin, sickling test and haemoglobin electrophoresis methods were performed to determine G6PD deficiency, haemoglobin level and sickle cell traits. Two thick and one thin smear were prepared from the obtained blood samples for diagnosis of malaria parasites parasitaemia.Results: Of 385 children 63(16.4 %) were found to have malaria parasites; sickle cell traits/ disease and G-6-PD deficiency was observed in 40(10.4 %) and 20 (5.2 %) respectively. The prevalence of G6PD deficiency + malaria, sickle cell traits + malaria and sickle cell + G6PD deficiency were 6.3%, 20% and 10% respectively. Low hemoglobin (&lt;100mg/dl) was observed in 157 (40.8 %) of children. Asymptomatic malaria and G6PD deficiency were found significantly to contribute to low hemoglobin among school children (P&lt;0.001). Schools with higher prevalence of asymptomatic malaria had also higher prevalence of both G6PD deficiency and sickle celltraits (P&lt;0.05). Malaria, anaemia and genetic disorders were significantly found more in peri-urban school than urban schools (p=0.0001).Conclusion and recommendation: Asymptomatic malaria infection is prevalent in individuals with G6PD deficiency and sickle cells traits in our setting, and this confirms the protection of genetic disorders against severe malaria. School children from peri-urban schools were more affected by malaria, anaemia and genetic disorders, more studies are recommended in these areas.Key words: Prevalence, sickle cell, malaria, G6PD deficiency, Tanzani

Determinants of hyperleptinaemia in an African population

Objective: To examine the determinants for elevated plasma leptin concentration in normal weight (NW), obese (OB), and morbidly obese (MO) individuals in Tanzania. Design: Cross-sectional epidemiological study, the CARDIAC study. Setting: Three areas in Tanzania; Dar es Salaam, urban(U), Handeni, rural(R) and Monduli, pastoralists(P), in August 1998. Subjects: Five hundred and forty five participants from a random sample of 600 people aged 46-58 years. Main outcome measures: Plasma leptin concentrations, height, weight, body mass index (BMI), lipid profiles, haemoglobin Alc (HBA1c), and blood pressure (BP). Results: Plasma leptin concentrations were higher in women than in men (women; 16.0 ng/ mL, men; 3.1 ng/mL;