Tuberculosis along the continuum of HIV care in a cohort of adolescents living with HIV in Ethiopia.

SETTING: Eight health facilities in Ethiopia. OBJECTIVE: To determine tuberculosis (TB) incidence rates and associated factors among adolescents living with the human immunodeficiency virus (ALHIV). DESIGN: This was a retrospective cohort study. Adolescents enrolled in HIV care between January 2005 and 31 December 2013 constituted the study population. The main outcome variable was TB diagnosis during follow-up. Baseline World Health Organization (WHO) clinical stage, CD4 count, previous history of TB and use of isoniazid preventive therapy (IPT) were the main independent variables. We estimated TB incidence rates as incident cases per 100 person-years of observation (PYO). Cox regression analysis was used to control for confounders. RESULTS: Of the 1221 adolescents screened, 1072 were studied; 60.1% were girls. TB incidence rate was 16.32 per 100 PYO during pre-antiretroviral therapy (pre-ART) follow-up but declined to 2.25 per 100 PYO after initiation of ART. Advanced WHO clinical stage (adjusted hazard ratio [aHR] 2.71, 95%CI 1.69-4.33) and CD4 count <350 cells/µl (aHR 2.28, 95%CI 1.10-4.81) predicted TB incidence in the pre-ART cohort. IPT use was associated with a significant reduction in TB incidence in the ART cohort, but not in the pre-ART group. CONCLUSION: Although TB was a significant problem in ALHIV, timely administration of ART and IPT had a significant protective effect.

Feasibility of rapid ethical assessment for the Ethiopian health research ethics review system

One of the challenges in the process of ethical medical research in developing countries; including Ethiopia; is translating universal principles of medical ethics into appropriate informed consent documents and their implementation. Rapid Ethical Assessment (REA) has been suggested as a feasible approach to meet this application gap. In the past few years REA has been employed in few research project in Ethiopia and have been found to be a useful and practical approach. Feasibility assessment of REA for the Ethiopian research setting was conducted between 2012-2013 in order to inform the subsequent introduction of REA into research ethics review and governance system in the country. REA was found to be an appropriate; relevant and feasible venture. We argue that REA can be integrated as part of the ethics review and governance system in Ethiopia. REA tools and techniques are considered relevant and acceptable to the Ethiopian research community; with few practical challenges anticipated in their implementation. REA are considered feasible for integration in the Ethiopian ethics review system

Assessment of Risk Behaviors and Factors Associated with Oral and Peri-oral Lesions in Adult HIV Patients at Tikur Anbessa Specialized Hospital; Addis Ababa; Ethiopia

Background: HIV patients have several habits that can produce oral lesions. However; the association of oral habits and risk behaviors with oral and peri-oral lesions in HIV patients has not been studied in Ethiopia to date. Objective: To assess the relationship of oral and peri-oral lesions with oral habits; risk behaviors; socio-demographicfactors and clinical stages of disease among HIV infected adult Ethiopians. Methodology A cross-sectional study was conducted on consecutive adult ART naive HIV patients at ART clinic of Tikur Anbessa Specialized University Hospital; Addis Ababa; Ethiopia during December 2005 to July 2006. The EC-clearing house's classification and diagnostic criteria for oral lesions in HIV infection was used. Written informed consent was obtained before enrollment to the study. Results A total of 384 patients; 126 (33) males and 258 (67) females were evaluated. The mean + SD age of males was 39.9 +10.56; and females was 33.17 + 8.85 years. Fifty seven (15) of the unit of analysis were smokers; 178 (46) alcohol consumers and 217(57.1) khat chewers; use tooth sticks for dental cleaning. Of which; 132 (34.7) clean their teeth at least once a day and 302 (79) gave history of recent significant weight loss. Linear regression analysis showed association of oral and peri-oral lesions with less frequent cleaning (p=0.038; p=0.03; respectively); means of cleaning (p=0.004; p=0.001); broad-spectrum antibiotic use (p=0.019; p=0.008); advanced stage of HIV (p=0.016; p=0.001) and CD4 level below 200 Cells/mm3 (p=0.001; p=0.01). The oral lesions were seen more frequently among smokers (p=0.028); heavy alcohol consumers (p=0.041); those with age above 40 years (p=0.016) and recent weight loss (p=0.001). At the level of binary logistic regression analysis smoking (p=0.005); CD4 count less than 200 (p=0.039) and stage 3 (p=0.022) and stage 4 disease (p=0.046) were found to be independent risks while daily dental cleaning habit was found to be protective (p=0.021). Conclusion Oral and peri-oral diseases among HIV/AIDS patients and are significantly associated with correctable risk factors like smoking and poor oral cleaning habits. Lesions are also frequent with evidence of advanced HIV disease and low CD4 count. These findings demonstrate the need for oral health examination and education to improve on risk behaviors and oral care in HIV/AIDS patients

Retinopathy in patients of Tikur Anbessa Hospital diabetic clinic.

A total of 302 diabetic patients were selected from regular attendants of the Tikur Anbessa Hospital (TAH) diabetic clinic to determine the prevalence of retinopathy from December 1994 to March 1995. The mean age was 41.4 +/- 14.4 years (range 14-85). There were 160 males (53%) and 142 females (47%). One hundred forty (46%) were type 1 and 162 (53.6%) were type 2. The mean duration of diabetes was 9.4 +/- 5.4 years and the mean Hemoglobin Alc (HbAlc) was 10.4 + 2.2%. On the day of the examination the mean fasting blood glucose (FBG) and random blood glucose (RBG) were 195.5 +/- 79.9 mg/dl and 273.1 +/- 114.5 mg/dl respectively. The mean serum total cholesterol, triglycerides, LDL, VLDL and GDL were 166.5 +/- 45.5 mg/dl, 129.9 +/- 92.4 mg/dl, 94.5 +/- 36.4 mg/dl, 24.4 +/- 15.1 mg/dl and 44.3 +/- 11.5 mg/dl respectively. The overall prevalence of retinopathy was 37.8% out of which 108 patients (36.1%) had background retinopathy and 5 patients (1.7%) had proliferative retinopathy. The retina could not be visualized in three patients because of dense cataract. Retinopathy correlated positively with age, duration of diabetes and blood pressure respectively, however no significant correlation was seen with mean total HgAlc and serum lipids. Prevalence of retinopathy was comparable in type 1 and type 2 (p > 0.05). The prevalence of retinopathy in our patients relative to the duration of diabetes mellitus is high. Therefore, improving facilities for the diagnosis and treatment of retinopathy is recommended.

Neonatal congenital hypothyroidism screening in Addis Ababa, Ethiopia.

OBJECTIVES: To determine the prevalence of congenital hypothyroidism, establish reference levels for thyroid stimulating hormone (TSH), and determine the cut-off points of TSH level for neonatal screening in congenital hypothyroidism. DESIGN: A cross-sectional study. SETTING: Ghandhi Memorial, Zewditu, Tikur Anbessa and St Paulo's referral hospitals in Addis Ababa, Ethiopia, from July 1996 to January 1997. SUBJECTS: Four thousand two hundred and six consecutive newborns. MAIN OUTCOME MEASURES: TSH and T4 values using standard TSH level estimation approach. RESULTS: The overall mean TSH value was 9.6 mIU/l with standard deviation of 7.8 mIU/l. Transient hypothyroidism occurred in 3.6% of the neonates. No true case of congenital hypothyroidism was identified. The mean(SD) sampling time was 12.8(6.7) hours and the recall rate 4.8%. Most neonates (98.6%) were screened at or less than 24 hours of age. Twins had lower mean TSH value of 7.9(SD=6.4) mIU/l than single neonates with 9.6(SD=7.8) mIU/l, while females had significantly lower mean TSH value of 9.4(SD=7.9) mIU/l than males of 9.8(SD=7.6) mIU/l. The mean TSH level decreased significantly as sampling time increases, the mean TSH level for neonates older than 24 hours is significantly lower than the mean TSH level for those with 24 hours old or less. No significant difference was found in the mean TSH levels in relation to maternal age, parity and gestational age. No significant correlation was found between TSH value and birth weight (r=0.02), height (r=0.03), and head circumference (r=0.02) of the neonates. The most appropriate TSH level cut-off point was found to be at 29.4 mIU/l. The reference range (the range between 2.5th and 97.5th percentiles) for serum thyrotrophin value was higher in the age range of 6 to 12 hours and then declined. CONCLUSION: This pilot study has highlighted important findings, however larger studies should be conducted to assess the magnitude and associated factors of congenital hypothyroidism because congenital hypothyroidism represents one of the most common preventable causes of mental retardation.

Low levels of serum calcidiol in an African population compared to a North European population.

OBJECTIVE: To compare vitamin D status in an African population living at 10 degrees N with a Norwegian population living at 60 degrees N. DESIGN: Serum samples from 30 healthy young Ethiopians and 31 full term pregnant women from Addis Ababa were collected in September, and from 24 healthy Norwegians in March and 23 pregnant women from Oslo in February to June. METHODS: Serum (s) levels of calcidiol and intact parathyroid hormone (iPTH) were measured. RESULTS: The median values for s-calcidiol were significantly lower in Ethiopians compared with Norwegians (young Ethiopians 23.5nmol/l vs young Norwegians 81nmol/l, P<0.001; pregnant Ethiopians 25nmol/l vs pregnant Norwegians 36nmol/l, P<0.05) while those for s-iPTH were significantly higher (young Ethiopians 5.7pmol/l vs young Norwegians 2.4pmol/l, P<0.001; pregnant Ethiopians 4.8pmol/l vs pregnant Norwegians 2.8pmol/l, P<0.02). CONCLUSION: In spite of abundant availability of ultraviolet radiation, the population from Addis Ababa had a high rate of biochemical vitamin D deficiency compared with the Norwegian group.

Maternal age, parity and gestational age on the size of the newborn in Addis Ababa.

OBJECTIVE: To assess birthweight, length and head circumference of live births, and to examine the effect of maternal age, parity and gestational age on birth size of the live births. DESIGN: A prospective study. SETTING: Tikur Anbessa, Zewditu, Gandhi memorial and St. Pauls hospitals, in Addis Ababa, Ethiopia. SUBJECTS: Four thousand two hundred and six consecutive live births from July 1996 to January 1997. MAIN OUTCOME MEASURES: Weight, length and head circumference of the newborns. RESULTS: Among the 4206 consecutive live births, 4047 were singleton and 159 were twins. Two thousand one hundred and sixty (51.7%) were males and 2046 (48.6%) were females. The mean birthweight of singleton live births was 3065 +/- 465 g, with modal group of 3000-4000 g. The incidence of low birthweight was 9.1%. The mean length for all singleton live births was 48.6 +/- 3.3 cm and modal group of 46-52 cm. The mean head circumference was 34.4 + 2.9 cm; modal group 31-37 cm. The incidence of low birthweight of the newborns was significantly higher for females, younger maternal age, primiparas and pre-term babies. On the multivariate analysis, gestational age and sex of the newborn respectively had significant effects on birthweight, length and head circumference of the neonates controlling for the other variables. On the other hand parity and maternal age had significant effects only on the birthweight of the neonates. CONCLUSION: This study has provided information on the effects of some of maternal characteristics on the size, particularly length and head circumference of newborns which were not given emphasis on previous birthweight studies. We suggest proper recording and analysis of birthweight, length and head circumferences be given importance for monitoring and evaluating maternal and child health programmes.

PIP: This prospective study examined the effect of maternal age, parity, and gestational age on the size of the newborn and assessed the birth weight, length, and head circumference of live births in Addis Ababa, Ethiopia. Birth sizes of a total of 4206 consecutive live births from the four referral hospitals from July 1996 to January 1997 were measured. The mean birth weight of the 4047 singleton live births was 3065 +or- 465 g, with a modal group of 3000-4000 g; 9.1% were of low birth weight. Their mean length was 48.6 +or- 3.3 cm, with a modal group of 46-52 cm. Moreover, the incidence of low birth weight was found to be significantly higher for female neonates, younger maternal age, primiparas, and preterm live births. Multivariate analysis showed that gestational age and sex of the newborn, respectively, had significant effects on birth weight, length, and head circumference of the newborns controlling for the other variables, while parity and age of the mother had significant effects only on the birth weight of the newborns. In conclusion, proper recording and analysis of birth weight, length, and head measurements should be given importance for monitoring and evaluating maternal and child health programs.

Prevalence and clinical features of tuberculosis in Ethiopian diabetic patients.

OBJECTIVE: To determine the prevalence and clinical characteristics of tuberculosis (TB) in diabetic patients. DESIGN: This study was a cross-sectional survey based on the retrospective analysis of data on tuberculosis in diabetic patients. SETTINGS: The study was conducted at Endocrinology and Metabolism Unit of the Department of Internal Medicine, Faculty of Medicine, Addis Ababa, Ethiopia. SUBJECTS: Seventy-eight cases of tuberculosis among 1352 diabetic patients were included from September 1989 to 1996. MAIN OUTCOME MEASURES: Clinical evaluation, chest x-ray, acid fast bacilli (AFB) in sputum or measures tissue and histopathologic characteristic of biopsy specimens. RESULTS: Seventy-eight cases of TB were identified among 1352 diabetic patients giving a prevalence of 5.8%. Among 1352 diabetic patients, 713 (52.7%) were males, 639 (43.3%) were females, 619 (45.8%) were IDDM and 733 (54.2%) were NIDDM. The mean age of the 71 TB patients whose records could be retrieved was 34.0 +/- 11.9 years, 42(59%) were males, 29 (41%) were females. Fifty-four (76.1%) were IDDM and 17(23.9%) were NIDDM, 17 of the IDDM had clinical characteristics of malnutrition-related diabetes mellitus (MRDM), 36 (56%) of 71 patients were admitted for management. The three most common symptoms of tuberculosis were fever (80.5%), sweating (80.4%) and cough (70.5%). Twenty six (36.6%) of 71 cases were positive for AFB and six (8.5%) were seropositive for HIV. Fifty-six (78.9%) had pulmonary,eight (11.2%) had extrapulmonary and seven(9.8%) had disseminated TB. Forty-eight of 53 abnormal chest x-ray showed unilateral involvement. Thirty-eight of 41 (53.6%) had completed TB treatment, relapse occurred in seven (9.8%), eight (11.2%) are currently on treatment, 13 (18.3%) were lost to follow up, four (5.6%) defaulted and three (4.2%) died. The relative risk of developing TB in IDDM and NIDDM patients was being 26 times and seven times than the general population respectively. CONCLUSION: The prevalence of tuberculosis in the diabetic population is high and this warrants a prospective study to determine association between pulmonary tuberculosis and diabetes.

PIP: This retrospective, cross-sectional analysis examines the prevalence and clinical characteristics of tuberculosis (TB) in Ethiopian diabetic patients. Using the records of 1352 patients seen at the Endocrinology and Metabolism Unit of the Department of Internal Medicine, Faculty of Medicine, Addis Ababa, Ethiopia, 78 cases (5.8%) of TB were identified. Diagnosis of the disease includes clinical evaluations, chest x-ray, and detection of acid-fast bacilli (AFB) in the sputum or measures tissue and histopathologic characteristics of biopsy specimens. Prevalence was 52.7% among males, 54.25% among those with non-insulin-dependent diabetes mellitus (NIDDM), 47.3% among females, and 45.8% among those with insulin-dependent diabetes mellitus (IDDM). The mean age of 71 patients with TB was 34 +or- 19 years (14-85 years); 76.0% were IDDM and 23.9% were NIDDM patients. 17 of the IDDM patients also had clinical characteristics similar to those of malnutrition-related diabetes mellitus. The most frequent symptoms of TB included fever (80.5%), sweating (80.5%), and cough (76%); 78.9% of patients suffered from pulmonary, 11.2% from extrapulmonary, and 9.9% from disseminated TB. On the other hand, chest X-ray reports revealed that 48 of the patients had unilateral or multiple lobe involvement and 5 had bilateral involvement. Of the 71 patients, 38 were able to complete antituberculosis treatment, 4 patients defaulted, 7 had relapse, 6 were still in treatment, 13 were lost to follow-up, and 3 died. In conclusion, this study confirmed the 26- and 7-fold risk of developing TB among IDDM and NIDDM patients, respectively.

Cushing's syndrome: a ten year experience at Tikur Anbassa Hospital.

A retrospective analysis of Cushing's syndrome from the retrieved records of 24 out of a total of 27 referred cases over a period of 10 years (January 1985-January 1995) showed confirmation in 16 cases. Fourteen (88%) were females, 9 (56%) were in their third decade. Duration of symptoms before admission was one year or less in eleven (69%) patients. Among symptoms weakness, fatigue and weight gain and among signs moon face, truncal obesity and buffalo hump were found in all patients. Amenorrhea occurred in all the women of childbearing age. Basal urinary 17-hydroxycorticoid (17-OHCS) values were elevated in 9/12 patients and low dose dexamethasone suppression test favoured Cushing's syndrome in 8/9 patients. Definitive treatment consisted of bilateral adrenalectomy in 7 and transfrontal pituitary adenomectomy in 3. Two patients declined surgery; 4 patients were lost to follow up before definitive treatment. Two patients who had bilateral adrenalectomy and two who had transfrontal adenomectomy died subsequently while three remained in good health on corticosteroid replacement therapy. Three of the 7 patients who had bilateral adrenalectomy developed Nelson's syndrome. It is concluded that Cushing's disease is the most frequent cause of Cushing's syndrome in our series. The patients presented with the well-known clinical manifestations of hypercortisolism. However, our laboratory facilities require considerable improvement to serve as a reliable adjunct to clinical evaluation. Since Cushing's syndrome, whatever the cause, is eventually fatal if left untreated, surgical intervention is mandatory after confirmation of the cause with appropriate laboratory tests.

Urine glucose testing: another look at its relevance when blood glucose monitoring is unaffordable.

The reliability of urine glucose testing to monitor diabetic control was investigated in patients attending the Diabetic Clinic of the Tikur Anbassa Hospital in Addis Ababa between October 1994 and January 1995 with the aim of utilising it for those with a normal renal threshold who cannot afford the cost of home blood glucose monitoring. Clinically important fasting blood glucose values were taken as those > 180 mg/dl and important urine glucose values as those > or = 0.25% by Clinitest. Capillary blood glucose was determined by visual and metre readings. Urine was tested for glucose by the standard Clinitest method. There were 265 patients, 126 IDDM and 139 NIDDM. Urine glucose corresponded satisfactorily with FBG in 80% of the patients. The sensitivity, specificity, positive and negative predictive values of urine glucose results by Clinitest in comparison with FBG by metre determination were 71%, 90%, 90% and 70% and by visual determination 71%, 86%, 80%, 79% respectively. On the basis of these results we conclude that urine glucose testing by Clinitest provides reliable information in more than 70% of our diabetic patients the majority of whom cannot afford the cost of home blood glucose monitoring.

Prolonged paresis in a primigravida during and after caesarean section.

A primigravida, who had a Caesarean section because of cervical dystocia and relative cephalo-pelvic disproportion, in Nov. 1988 in Yekatit 12 Hospital, Addis Ababa, remained relaxed and without spontaneous respiration for about four hours after the completion of the operation, requiring assisted respiration. This condition is the result of a decreased plasma cholinesterase (PCE) activity which is responsible for the breaking down of succinylcholine used in general anaesthesia as a muscle relaxant. Although the incidence of PCE deficiency in our population is not known, it should be remembered that such a complication may be seen in hospitals where operations are carried out using succinylcholine as a muscle relaxant.