Iodine status in women attending Mnazi Mmoja Hospital in Zanzibar: a matched case-control study.

BACKGROUND: Iodine deficiency can have adverse health effects in all age groups affecting growth, development and cognitive functions as well as the incidence of goitre. Worldwide, the most important dietary source of iodine is iodised salt. In Tanzania, iodine intake has varied due to multiple salt suppliers producing iodised salt with varying quality. Zanzibar has faced challenges with the packing, storing and monitoring of salt iodisation, and universal salt iodisation has not been achieved. Furthermore, the number of available studies on the iodine status in Zanzibar are sparse. OBJECTIVE: The main objective of this study is to describe the iodine status of euthyroid female adult patients with and without goitre in Zanzibar. DESIGN AND METHODS: A single-centre matched case-control study was conducted among 48 female patients at the ear, nose and throat clinic of Mnazi Mmoja Hospital, Zanzibar. Blood samples were drawn for serum-analysis of the thyroid hormone profile to confirm that all patients were euthyroid prior to inclusion. Urinary iodine concentrations and the iodine concentration in household salt samples were analysed. A semiquantitative food frequency questionnaire (FFQ) was used to describe trends in the dietary intake of iodine-rich and goitrogenic foods. Clinical examinations were conducted, and the patients were categorised into goitre (cases) and non-goitre (controls) groups. RESULTS: A moderate iodine deficiency (median urinary iodine concentration between 20 and 49 µg/L) was found in patients both with and without goitre. In total, only 35 % of the salt samples were adequately iodised. The salt samples from the cases had a lower average concentration of iodine compared with the controls. The FFQ revealed that the daily consumption of marine fish and the weekly consumption of raw cassava were more frequent in the cases than the controls. CONCLUSION: These findings suggest that iodine deficiency may be a problem in both patients with and without goitre in Zanzibar. The salt iodisation programme may require monitoring and implementation of satisfactory quality control practices as universal salt iodisation is yet to be achieved in Zanzibar.

Tissue plasminogen activator overdose in acute ischemic stroke patients linked to poorer functional outcomes.

BACKGROUND: The dose of intravenous tissue plasminogen activator (tPA) administered in acute ischemic stroke patients is calculated using the patient's weight (0.9 mg/kg). Patients are rarely weighed before treatment in actual practice, although overestimating patient weights leads to higher doses of tPA, which may adversely influence outcome. METHODS: We investigated the weight used to calculate the dose of tPA compared to the actual measured weight in consecutive acute ischemic stroke patients treated over a 4-year period at our center. The rate of intracranial hemorrhage (ICH), discharge modified Rankin Scale (mRS) score, and mortality at 3 months were compared between groups, according to accuracy of the dose of tPA. RESULTS: We found that 140 of 164 (85%) acute ischemic stroke patients treated with tPA had a measured weight documented in the chart after treatment. Of these, 13 patients received ≥1.0 mg/kg and 16 patients received ≤0.8 mg/kg, based on a comparison of the weight used for the tPA dose calculation and the subsequent measured weight. Four of 13 (31%) patients treated with ≥1.0 mg/kg of tPA developed ICH. Patients who inadvertently received higher doses of tPA had a lower likelihood of a good functional outcome at discharge (mRS score 0-2; 0% v 34%; P = .009). No difference in 3-month mortality was observed, although patients who were not weighed in hospital had a threefold increase in discharge mortality (21% v 7%; P = .019). CONCLUSIONS: Our findings provide support for the practice of accurately weighing all acute ischemic stroke patients before thrombolysis.

Sensorineural deafness in Tanzanian children--is ototoxicity a significant cause? A pilot study.

OBJECTIVES: 9 years experience working in Tanzania revealed a surprisingly large population of profoundly deaf children. The object was to identify the cause. METHODS: 200 children between the ages of 5-12 with significant sensorineural hearing loss were identified in Stone town, Zanzibar. These were aged and neighbourhood matched with 218 normal hearing children. A parental questionnaire administered by health workers from the Zanzibar Outreach Programme was used to interview parents of the matched group of deaf and normal hearing children. Outcome measures included the genetic history especially first cousin marriage (common in Zanzibar), rubella, head injury, fever admission, and drug treatment of fever. The limitations were lack of hospital records and it was a retrospective study. The results were analysed from Excel spreadsheets. RESULTS: 36% of the deaf group had an infant fever admission history compared with 4% of the normal hearing group. Nearly all had i.m. quinine and/or gentamicin. The genetic history was equal in both groups, and rubella was rare. Most fevers were assumed to be malaria or pneumonia which are unlikely causes of deafness on their own. CONCLUSIONS: Ototoxic drugs given to sick infants with "fever", without weight recording or gentamicin level monitoring, was the probable cause of a third of all severe/profound deafened Zanzibarian children. The Ministry of Health and Social Welfare in Zanzibar have reacted by issuing posters to all health facilities advising hearing testing in all children three months after discharge following "fever" admission. This is a pilot study and the apparent findings need to be confirmed by a well designed prospective study as soon as possible.

Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. MRC asymptomatic carotid surgery trial (ACST) collaborative group. Lancet 2004; 363: 1491-502.

QUESTION: Is carotid endarterectomy (CEA) an effective and safe treatment for the prevention of stroke among patients with >60% internal carotid artery stenosis who had no neurologic symptoms in the previous 6 months. POPULATION: Men and women with severe (>60%) unilateral or bilateral carotid artery stenosis not associated with neurologic symptoms in the past 6 months, where both doctor and patient were uncertain whether to choose or to defer immediate CEA. DESIGN AND METHODS: During 1993-2003, 3120 asymptomatic patients with >60% carotid stenosis were randomized equally to immediate CEA versus indefinite deferral of CEA, and were followed for up to 5 years. The primary end point was risk of stroke or death at 5 years. Analysis was by intention to treat. The treatment of patients with antiplatelet agents, antihypertensive and lipid-lowering therapies was left to the discretion of the clinician. RESULTS: Among patients randomized to immediate CEA (50% had CEA by 1 month, 88% by 1 year) versus deferred, the incidence of stroke or death at 5 years was 6.4% versus 11.8% (95% CI: 3.0-7.7, p < 0.0001); 3.5% versus 6.1% for fatal or disabling strokes (95% CI: 0.8-4.3, p = 0.004), and 2.1% versus 4.2% for fatal strokes (95% CI: 0.6-3.6, p = 0.006). The perioperative stroke incidence was marginally higher in the delayed group versus the immediate group (4.5% versus 2.8%) and overall the risk per CEA of perioperative stroke or death was 3.1%. After excluding the perioperative events from the analysis, the 5-year stroke risks were 3.8% versus 11% (95% CI: 5.0-9.4], p < 0.0001). Surgery primarily prevented carotid territory ischemic strokes (2.7% vs 9.5%; gain 6.8% [4.8-8.8], p < 0.0001). The impact of immediate surgery was consistent in all age groups, among men and women, and across the spectrum of carotid stenosis (i.e. 70%, 80% and 90% carotid stenosis). CONCLUSION: In asymptomatic patients younger than 75 years of age with carotid stenosis of 70% or more on ultrasound, immediate CEA reduces the 5-year incidence of stroke and death.