Cardiovascular Findings in Adult Patients with Sickle Cell Anaemia in Steady State seen in Calabar, Nigeria.

BACKGROUND: Sickle cell anaemia (SCA) is associated with significant morbidity and mortality linked to multi-systemic complications. With recent improvements in healthcare globally, it is expected that SCA patients in Nigeria will live longer. The cardiovascular complications may thus become prevalent. SUBJECTS AND METHODS: Fifty-two patients with sickle cell anemia in steady state and 52 controls were recruited. The assessment included history, physical examination, 12-lead resting electrocardiography, 2D, M-Mode and Doppler echocardiography, six-minute walk test and NTerminal pro Brain Natriuretic Peptide (NT-pro BNP) assay. RESULTS: The mean age of the sickle cell patients was 28.87±7.89 years and most were post-secondary or tertiary institutions. They had faster pulse rates (84.69±9.48 vs75.48±10.35 beats/minute, p=0.000), lower blood pressure (Systolic 112.56 ±10.87 mmHg vs 115.42 ± 14.75mmHg; Diastolic 70.79±9.03mmHg vs 71.27±9.23 mmHg) and lower Body Mass Index (21.55±3.51 vs 24.94±4.56kg/m2; p=0.000). Mean left ventricular (LV) internal diameters in systole and diastole were (3.19 ±0.57cm vs 2.81±0.45 cm; p=0.000) and (4.99±0.69cm vs 4.29±0.56 cm; p=0.00) respectively. Left and right ventricular systolic functions were normal. None of the patients with SCA met the criteria for pulmonary hypertension while 88.89% of those screened using Natriuretic peptide were at risk of developing pulmonary hypertension (NT-proBNP levels ≥ 160pg/ml). Functional status assessed by sixminute walk test was normal (373.00 ±60.40m vs 403.83±72.87 m; but significantly lower than in controls (p= 0.021). CONCLUSION: The cardiovascular system is adversely affected in persons with sickle cell anaemia especially as they grow older. Despite the presence of left ventricular remodeling, the patients with SCA in this study maintained good functional status. Regular cardiovascular assessment is advised.

CONTEXTE: La drépanocytose (SCA) est associée à une morbidité et une mortalité importantes liées à des complications multisystémiques. Avec les récentes améliorations des soins de santé dans le monde, on s'attend à ce que les patients atteints d'ACS au Nigeria vivent plus longtemps. Les complications cardiovasculaires pourraient donc devenir prévalentes. SUJETS ET MÉTHODES: Cinquante-deux patients atteints de drépanocytose à l'état d'équilibre et 52 témoins ont été recrutés. L'éva lua tion c om prena it l'histoire, l'exa m en physique, l'électrocardiographie de repos à 12 dérivations, l'échocardiographie 2D, M-Mode et Doppler, un test de marche de six minutes et un test d'apnée du sommeil. le dosage du NTerminal pro Brain Natriuretic Peptide (NT-pro BNP). RÉSULTATS: L'âge moyen des patients drépanocytaires était de 28,87±7,89 ans et la plupart étaient issus d'établissements post-secondaires ou tertiaires. Ils avaient un pouls plus rapides (84,69±9,48 vs75,48±10,35 battements/minute, p=0,000), une pression artérielle plus basse (Systolique 112,56 ±10,87 mmHg vs 115,42 ± 14,75 mmHg ; diastolique 70,79±9,03 mmHg vs 71,27±9,23 mmHg) et un indice de masse corporelle plus faible (21,55±3,51 vs 24,94±4,56kg/m2 ; p=0,000). Les diamètres internes moyens du ventricule gauche (VG) en systole et en diastole étaient de (3,19 ±0,57 cm vs 2,81±0,45 cm ; p=0,000) et (4,99±0,69 cm vs 4,29±0,56 cm ; p=0,00) respectivement. Les fonctions systoliques des ventricules gauche et droit étaient normales. Aucun des patients atteints d'ACS ne répondait aux critères d'hypertension pulmonaire, tandis que 88,89 % des patients dépistés à l'aide du peptide natriurétique étaient à risque de développer une hypertension pulmonaire(taux de NT-proBNP ≥160pg/ml). L'état fonctionnel évalué par le test de marche de six minutes était normal (373,00 ±60,40 m vs 403,83±72,87 m ; mais significativement plus faible que chez les témoins (p= 0,021). CONCLUSION: Le système cardiovasculaire est affecté de manière négative chez personnes atteintes de drépanocytose, en particulier lorsqu'elles vieillissent. Malgré la présence d'un remodelage ventriculaire gauche, les patients atteints d'ACS dans cette étude ont conservé un bon état fonctionnel. Une évaluation cardiovasculaire régulière est conseillée. MOTS CLÉS: Fonction ventriculaire, Drépanocytaires adultes, État d'équilibre, Hypertension pulmonaire.

The clinical utility of echocardiography as a cardiological diagnostic tool in poor resource settings.

BACKGROUND: There has been a decline in the auscultatory and other clinical skills of physicians especially in developed countries. The advent of echocardiography has revolutionized the diagnosis of cardiovascular diseases and made up for the decline in clinical skills. OBJECTIVE: To assess the sensitivity and specificity of auscultatory and clinical skills in the diagnosis of cardiovascular diseases using echocardiography as the gold standard. MATERIALS AND METHODS: All the adult echocardiographic studies (321) performed over a 1-year period were collated for analysis. The clinical indications of the studies were compared with the final diagnoses by echocardiography. The sensitivity and specificity of the clinical diagnosis of hypertensive heart disease (HHD), rheumatic heart disease (RHD), and the cardiomyopathies were determined. RESULTS: Of the 244 (76.0%) clinically diagnosed as HHD, 188 (58.6%) were confirmed by echocardiography. For RHD 9 (2.8%) were diagnosed clinically while on echocardiography, 13 (4.1%) were diagnosed. All the 31 (9.7%) cases of dilated cardiomyopathy were confirmed on echocardiography. No case of ischemic heart disease was confirmed. Seventy-one (22.0%) had normal studies. The sensitivity of clinical diagnosis for RHD was low (41.7%) while for HHD and dilated cardiomyopathy, sensitivity was high, 95.7% and 75.0%, respectively. Specificity was high for all three cardiovascular diseases analyzed. CONCLUSION: Auscultatory and clinical skills are still sensitive and specific tools in the diagnosis of cardiovascular diseases in developing countries and should be sustained. However, echocardiography is indispensable in the diagnosis of cases with subtle clinical signs and should be made more available and affordable.

Recurrent pericardial effusion associated with hypothyroidism in Down Syndrome: a case report.

BACKGROUND: The complex of Down Syndrome-hypothyroidism-pericardial effusion is largely unreported in sub-Sahara. OBJECTIVE: To present and highlight an unusual manifestation of hypothyroidism. METHODS: A 16-year-old girl with confirmed Down Syndrome presented with complaints of generalised body swelling of eight months' duration. Her work-up consisted of full clinical and laboratory evaluation including ECG and echocardiography. RESULTS: The patient was diagnosed of Down's Syndrome at birth but was lost to follow-up after at eight years of age. Body swelling was associated with clinical features of heart failure. Echocardiography showed massive pericardial effusion. Serum l-thyroxine was less than 0.5mg/dl and TSH >40iu/l. The heart failure and menstrual irregularities responded to l-thyroxine therapy. CONCLUSION: This appears to be the first report of the complex of Down syndrome, hypothyroidism and pericardial effusion in a Nigerian child. Thyroid function test is therefore recommended as a part of baseline investigation for Nigerian children with Down syndrome as is the practice.

Discrete subaortic stenosis in an adult Nigerian: a case report.

BACKGROUND: Cases of discrete subaortic stenosis are rare in adults. To our knowledge, no case has been reported in Nigerian literature. Cases are thus likely to be missed or wrongly managed. OBJECTIVE: To present a case of discrete membranous subaortic stenosis in an adult Nigerian with a view to creating awareness of the existence of this entity in our milieu. METHODS: The patient a 46-year-old Nigerian presented with symptoms of angina pectoris and near syncope. Transthoracic 2-Dimensional / M-mode echocardiography demonstrated thickened and calcific aortic valves and laboratory investigations showed that he also had artherogenic dyslipidaemia. He was initially managed as a case of severe valvular aortic stenosis of rheumatic origin with associated dyslipidaemia and was referred for further evaluation and management abroad. RESULTS: On further assessment at the referral centre, the diagnosis was reviewed to subaortic stenosis with severe left ventricular outflow tract obstruction (LVOTO) arising from a fibro muscular subaortic membrane after a repeat 2-D/M-mode and Doppler echocardiography. Coronary angiography showed normal coronaries. He had excision of the membrane with marked reduction in gradient across the left ventricular outflow tract. He has remained symptom free and stable thereafter. CONCLUSION: Discrete membranous subaortic stenosis though rare in adults should be suspected in patients with clinical features of valvular aortic stenosis. Doppler echocardiography is thus mandatory in the evaluation of these patients.

Relationship between parental socio-economic status and casual blood pressure in coastal Nigerian adolescents.

BACKGROUND: Emerging data suggest that essential or primary hypertension occurs in the young. Parental socioeconomic status may play a role but the exact mechanisms still remain unclear. OBJECTIVE: This study was aimed at determining the relationship between parental socioeconomic status and casual blood pressure in adolescents. METHODS: One thousand and eight adolescents attending two secondary schools in Calabar, Nigeria were selected by stratified random sampling. Their blood pressure, weights and heights were taken using standard methods and sociodemographic data were obtained using a pretested semistructured questionnaire. RESULTS: Blood pressure was increased with age with males having higher values. The other major determinants of blood pressure were weight, height, body mass index, level of physical activity and parental socioeconomic status (p <0.05). No relationship was established between these determinants as well as dietary habits with parental socioeconomic status (p > 0.05). Female adolescents with parents in the lower socioeconomic classes had significantly higher systolic and diastolic blood pressure (p < 0.05). In contrast, parental socioeconomic status showed no significant relationship with systolic blood pressure and diastolic blood pressure in males (p >0.05).The prevalence of elevated blood pressure was higher in females than in males. CONCLUSION: Low parental socioeconomic status appear to be associated with higher casual blood pressure especially in female coastal Nigerian adolescents. Traditional determinants did not appear to play a significant role. Psychological stress arising from environmental and economic stressors may be responsible.

Systemic thromboembolism in endomyocardial fibrosis (EMF): clinical observations, aetio-pathogenesis and treatment.

Mural thrombi and thromboemboli are very common in idiopathic hypereosinophilic syndrome (HES), whose cardiac pathology is indistinguishable from endomyocardial fibrosis (EMF). Although mural thrombi are common in EMF cases, and post mortem embolic infarcts are frequently seen; clinical recognition of thromboembolism in EMF is unusual. We report here 4 cases of clinically recognized thromboembolism among 106 consecutive cases of EMF (including a case with a sudden onset of vascular occlusion and a below knee infarction and auto-amputation of the right leg). Two of the 4 cases had hypereosinophilia that was probably induced by microfilaria. The mechanisms of mural thrombosis and thromboembolic infarcts in EMF cases are discussed, and the possibility shown that helminth induced eosinophilic myocarditis can induce similar acute mural thrombosis and thromboembolism. The place of anticoagulant therapy in EMF is discussed.

Relationship between parental socio-economic status and casual blood pressure in coastal nigerian adolescents

BACKGROUND: Emerging data suggest that essential or primary hypertension occurs in the young. Parental socioeconomic status may play a role but the exact mechanisms still remain unclear. OBJECTIVE: This study was aimed at determining the relationship between parental socioeconomic status and casual blood pressure in adolescents. METHODS: One thousand and eight adolescents attending two secondary schools in Calabar; Nigeria were selected by stratified random sampling. Their blood pressure; weights and heights were taken using standard methods and sociodemographic data were obtained using a pretested semistructured questionnaire. RESULTS: Blood pressure was increased with age with males having higher values. The other major determinants of blood pressure were weight; height; body mass index; level of physical activity and parental socioeconomic status (p 0.05). Female adolescents with parents in the lower socioeconomic classes had significantly higher systolic and diastolic blood pressure (p 0.05). In contrast; parental socioeconomic status showed no significant relationship with systolic blood pressure and diastolic blood pressure in males (p 0.05).The prevalence of elevated blood pressure was higher in females than in males. CONCLUSION: Low parental socioeconomic status appear to be associated with higher casual blood pressure especially in female coastal Nigerian adolescents. Traditional determinants did not appear to play a significant role. Psychological stress arising from environmental and economic stressors may be responsible

Profile and outcome of cardiovascular admissions at the University of Uyo Teaching Hospital, Uyo--a five year review.

OBJECTIVE: The incidence of cardiovascular diseases (CVD) in developing countries has been on the increase in the last few decades. Demographic changes and adoption of negative life style associated with urbanization have been incriminated. This study is to ascertain the burden of cardiovascular disease in Uyo, a town which has been undergoing rapid urbanization in the last decade. SUBJECTS AND METHODS: A five-year retrospective analysis of cardiovascular admissions into the Medical Wards of the University of Uyo Teaching Hospital between September 1996 and September 2001 was carried out. Medical records of patients were used. The Epi Info 2002 software was used to analyse data. RESULTS: Five hundred and fifty eight (19.8%) of the 2875 medical admissions were patients with cardiovascular diseases. Their mean age was 52 +/- 12.7 years and mean duration of hospital stay was 9 +/- 7 days. Hypertension accounted for 311 (55.7%) of the cases, of these 107 (34.4%) presented with cerebrovascular accident (CVA). 44.3% presented in Heart failure and causes included Hypertension (14.9%), Cardiomyopathies particularly the dilated type (15.1%), Rheumatic heart disease (6.6%) and Anaemia (7.7%). 69 (12.4%) cardiovascular deaths were recorded, of these 34 (6.1%) were in patients with Cerebrovascular accident. Most deaths occurred within seven (7) days of admission. Duration of stay significantly influenced outcome (p = 0.000). CONCLUSION: Cardiovascular diseases constitute a significant health problem in our community. Intensive cardiovascular health education and promotion of healthy life style are advocated. Tertiary health care facilities should be equipped to cope with cardiovascular care in view of the looming epidemic of cardiovascular disease even in developing countries.

Treatment of relatives by doctors: experience from Calabar, Nigeria.

OBJECTIVE: To determine the involvement of medical practitioners working in a tropical setting in the treatment of their relatives. DESIGN: Cross-sectional. SUBJECTS: Medical practitioners of all cadres working in the University of Calabar Teaching Hospital, Calabar, Nigeria. SETTING: A large teaching hospital in Calabar, Nigeria. A referral centre for two states. MAIN OUTCOME MEASURES: Extent, type and effect of involvement in the practice. RESULTS: Majority (90.9%) of medical practitioners in our centre were found to have been involved in the treatment of their relatives. Services rendered included consultation, in which all respondents (100%) have partaken. Cardiopulmonary resuscitation (16.9%) and emergency surgery were performed by only a few (3.1%). Though fees were not charged for services provided by most; a few (13.1%) did so. Outcome of involvement was unfavourable in some instances: 9.4% lost relatives they were involved in treating. Majority of the respondents 51.7% believed it is unethical to treat relatives and advocated for only limited involvement. This is because the pressure from relatives for care cannot be entirely ignored. CONCLUSION: It is difficult in our environment not to accede to request to treat family members. We recommend that practitioners may offer only consultation, and in some cases treat minor ailments while referring more serious ones to appropriate colleagues.

Seasonal variation in admission for heart failure, hypertension and stroke in Uyo, South-Eastern Nigeria.

BACKGROUND: Seasonal variation in hospitalization for cardiovascular disease has been described in the temperate regions of the world as well as in Northern Nigeria. Increase admission rates during the cold seasons have been reported in these areas. No studies have been done in Southern Nigeria. This study is thus aimed at describing the seasonal variation in admissions for heart failure, uncontrolled hypertension and hypertension related-stroke in Southern Nigeria. METHODS: Hospital records of patients admitted to the medical wards of the University of Uyo Hospital (UUTH) with heart failure of all causes, uncontrolled hypertension and hypertension-related stroke (Cerebrovascular accident) between January 1998 and December 2001 were used. Epi-info 2002 software was used to analyze data. RESULTS: Of the 3500 patients admitted during the study period 542 (15.3%) were on account of heart failure, uncontrolled hypertension and hypertension related cerebrovascular accident (CVA). The mean age of patients was 52 +/- 12.8 years. The average monthly admission was eleven (11). More admissions were recorded in the rainy (cold) season than in the dry (hot) season. The observed difference was however statistically significant only for heart failure and uncontrolled hyper tension (P < .05). CONCLUSION: Admissions for heart failure and uncontrolled hypertension are therefore more during the wet (cold) season in southern Nigeria. This may be attributed to the high default rate to follow up visit in this season when agricultural activity is intense and less attention given to medical care. This leads to poor compliance to medications and clinical deterioration. The already bad road network both in rural and urban centers also become worse at this time making access to medical care difficult. Facilities and measures should thus be put in place to provide adequate medical care for these patients during that period of the year.

Seasonal variation in admission for heart failure, hypertension and stroke in Uyo, south-eastern Nigeria

Background:Seasonal variation in hospitalization for cardiovascular disease has been described in thetemperate regions of the world as well as in Northern Nigeria. Increase admission rates during the coldseasons have been reported in these areas. No studies have been done in Southern Nigeria. This studyis thus aimed at describing the seasonal variation in admissions for heart failure, uncontrolledhypertension and hypertension related-stroke in Southern Nigeria.Methods:Hospital records of patients admitted to the medical wards of the University of Uyo Hospital(UUTH) with heart failure of all causes, uncontrolled hypertension and hypertension­related stroke(Cerebrovascular accident) between January 1998 and December 2001 were used. Epi-Info 2002software was used to analyze data.Results:Of the 3500 patients admitted during the study period 542 (15.3%) were on account of heartfailure, uncontrolled hypertension and hypertension related cerebrovascular accident (CVA). The meanage of patients was 52±12.8 years. The average monthly admission was eleven (11). More admissionswere recorded in the rainy (cold) season than in the dry (hot) season. The observed difference washowever statistically significant only for heart failure and uncontrolled hypertension (P<.05).Conclusion:Admissions for heart failure and uncontrolled hypertension are therefore more during thewet (cold) season in southern Nigeria. This may be attributed to the high default rate to follow up visitin this season when agriculturalactivity is intense and less attention given to medical care. This leads topoor compliance to medications and clinical deterioration. The already bad road network both in ruraland urban centers also become worse at this time making access to medical care difficult. Facilities andmeasures should thus be put in place to provide adequate medical care for these patients during thatperiod of the yea

Perception of ischaemic heart disease, knowledge of and attitude to reduction of its risk factors.

OBJECTIVES: To assess the perception of ischaemic heart disease (heart attack) as a cause of mortality and determine the current knowledge of its risk factors as well as the level of adoption of preventive strategies among Nigerians working in a tertiary institution. DESIGN: Cross-sectional study. SETTING: University of Calabar, Calabar, Nigeria. SUBJECTS: Five hundred randomly selected University workers both senior and junior staff. MAIN OUTCOME MEASURES: Assessment of the awareness of ischaemic heart disease as a cause of morbidity and mortality, knowledge of risk factors and degree of adoption of lifestyle modification strategies. RESULTS: Only 136 (27.7%) of respondents considered ischaemic heart disease (heart attack) as the leading cause of death in their environment while 201 (40.2%) thought it was hypertension. Smoking was readily identified by 70.6% as a risk factor, excessive alcohol use by 52.8% and 41.6% of respondents identified obesity. Sedentary life-style and oral contraceptive use were least identified with only 16.6% and 6.4% of respondents respectively identifying them. This knowledge was significantly influenced by the educational status and cadre of the subjects. The senior staff who were also better educated demonstrated more knowledge. Two point two percent of respondents were smokers and smoked ten sticks of cigarettes or less per day. All expressed willingness to stop. One hundred and fifty eight admitted taking alcohol, most taking less than ten units a week and of these, only 64 were willing to quit. Fifty three point four percent (29.2% of senior and 24.2% of junior undertook some exercise while only 45.6% checked their body weights regularly. Only 25% of all the respondents visited the hospital or clinic for routine medical check-up. No statistically significant difference was found between the senior/better educated and the junior/less educated members of staff in the adoption of these life style modification measures. Sixty four point four percent got medical information from doctors and other health workers. CONCLUSION: Level of awareness of ishaemic heart disease as a leading cause of death is poor even in an academic environment. Knowledge of risk factors is also poor and is influenced by the level of educational attainment. Life style modification strategies are still not widely accepted irrespective of educational status. A concerted public health response is advocated to improve the present level of knowledge and establish behavioural changes.

Occupational risk of infection by human immunodeficiency and hepatitis B viruses among health workers in south-eastern Nigeria.

OBJECTIVE: To assess the occupational risk of infection by human immunodeficiency virus (HIV) as well as hepatitis B virus (HBV) among healthcare workers in south-eastern Nigeria. DESIGN: Cross-sectional study. SETTING: Three tertiary health institutions in south-eastern Nigeria. SUBJECTS: Doctors, nurses, laboratory staff and cleaners. MAIN OUTCOME MEASURES: Observation of the availability and use of protective equipment and materials in the various departments of the hospitals. RESULTS: Materials and equipments needed for protective and hygienic practices (adequate water supply, protective clothing and availability of disinfectants) were inadequate in all hospitals. Where available, they were found to be inconsistently used. Health workers in the three institutions were thus constantly exposed unnecessarily to blood and other body fluids which might be potentially infectious as well as injury from used sharps. CONCLUSION: The risk of acquiring HIV and HBV infections by health workers in this region of Nigeria in the course of performing their duties is therefore still apparently high. Though distinct viruses, they share similar mode of transmission and risk factors. Use of personal protective equipment and adoption of standard hygienic practices among health workers must be encouraged. Supply of protective materials and equipment should be greatly improved. It is recommended that reduction of occupational risks among health workers using this approach should form part of control strategies for both infections in the country.

Profile of body mass index and obesity in Nigerian children and adolescents.

This cross-sectional anthropometric study involved one thousand and five randomly selected children and adolescents aged 6 to 18 years resident in Calabar, Nigeria. It was aimed at determining the profile of Body Mass Index (BMI) as well as the prevalence of obesity in the group. Subjects had their heights and weights measured using standard methods and Body Mass Index calculated. Those with BMI of 95th percentile for their ages and sexes were considered obese. Body Mass Index as well as other anthropometric parameters were found to increase progressively with age with females having higher values. The prevalence of obesity in 6-12 years old children was 2.3%. Adolescents 13-15 years had a prevalence of 4.0% while those 16-18 years had 3.0%. Though females had a higher prevalence in both groups, the difference was not statistically significant (l2 = 4.90 df = 2, P > 0.5) We conclude that obesity hitherto seen predominantly in developed countries is a potential health problem in developing countries despite the prevailing poor socioeconomic situation. The significant role played by factors other than the environment in the development of obesity has since been recognised. Since treatment of adult obesity is largely difficult, the need for intervention during childhood and adolescence which includes early detection and prevention cannot be overemphasized.

Time of presentation for treatment and profile of deformities among leprosy patients in South Eastern Nigeria.

A 10 year review of leprosy patients seen at Leprosy Hospital Ekpene Obom in South Eastern Nigeria (1988-1997) was carried out to evaluate the effect of early identification and treatment of leprosy patients in the limitation of deformities among them. A total of 2,597 patients comprising 1,714 (66%) males and 883 (34.0%) females formed subjects for the study. Of these 288(11.1%) were aged 15 and below while 2,309 (88.9) were above 15 years. Their case records were thoroughly reviewed noting the duration of disease before presentation, type and location of deformity as well as the type of leprosy. Though there was a steady decline in the total number of leprosy patients seen over the study period as well as a decrease in the mean duration of illness before presentation, approximately 19% of patients still had deformities at presentation, a figure much lower than those reported by other workers. Analysis of the pattern of deformities shows that most patients 71.2% presented with affectation of the upper and lower limbs with consequent functional disability. We conclude that early treatment is an effective means of reducing the prevalence of deformity and thus disability from leprosy. More effective implementation of health education and treatment programmes initiated by the W.H.O should further reduce the scourge of leprosy in our community.