Introduction of automated blood pressure devices intended for a low resource setting in rural Tanzania.

Regular blood pressure (BP) monitoring is a cost-effective means of early identification and management of hypertensive disease in pregnancy. In much of rural sub-Saharan Africa, the ability to take and act on accurate BP measurements is lacking as a result of poorly functioning or absent equipment and/or inadequate staff education. This study describes the feasibility of using validated automated BP devices suitable for low-resource settings (LRS) in primary health-care facilities in rural Tanzania. Following a primary survey, 19 BP devices were distributed to 11 clinics and re-assessed at one, three, six, 12 and 36 months. Devices were used frequently with high levels of user satisfaction and good durability. We conclude that the use of automated BP devices in LRS is feasible and sustainable. An assessment of their ability to reduce maternal and perinatal morbidity and mortality is vital.

Characterization of symptoms immediately preceding eclampsia.

OBJECTIVE: To characterize the symptoms that immediately precede eclamptic seizures. METHODS: We did a prospective observational study of all women admitted to a single center in Tanzania between May 1, 2007 and April 30, 2008 who had an eclamptic seizure. During their admission they were asked a uniform set of questions related to symptoms preceding the seizure. RESULTS: There were 3,267 deliveries and 46 cases of eclampsia (1.4%). Neurologic symptoms (headache [80%] with or without visual disturbance [45%]) were the most common prodrome symptoms, regardless of degree of hypertension or whether the seizure occurred antepartum or postpartum. Twenty percent of women with eclampsia reported no neurologic symptoms before seizure. CONCLUSION: Neurologic symptoms commonly precede eclampsia. A minority of patients with eclampsia (17%) had no prodromal symptoms before their eclamptic seizure. Premonitory symptoms may provide an early warning of imminent eclampsia.

Sweet's syndrome after adalimumab therapy for refractory relapsing polychondritis.

Relapsing polychondritis and Sweet's syndrome are rare systemic inflammatory conditions. The authors present a patient who developed Sweet's syndrome 1 week after adalimumab therapy for refractory relapsing polychondritis. Coexistent relapsing polychondritis and Sweet's syndrome is rare, however, is likely to represent a true disease association and signifies a high risk of myelodysplasia. Antitumour necrosis factor α (TNFα) therapy is a treatment option in both relapsing polychondritis and Sweet's syndrome, and switching anti-TNFα agents may be feasible in the event of adverse reaction.

Evaluation of a dried blood spot HIV-1 RNA program for early infant diagnosis and viral load monitoring at rural and remote healthcare facilities.

OBJECTIVE: To assess technical and operational performance of a dried blood spot (DBS)-based HIV-1 RNA service for remote healthcare facilities in a low-income country. DESIGN: A method comparison and operational evaluation of DBS RNA against conventional tests for early infant diagnosis of HIV and HIV RNA quantitation under field conditions in Tanzania. METHODS: DBSs were prepared and plasma was frozen at -80 degrees C. DBSs were mailed and plasma couriered to a central laboratory for testing using the Abbott m2000 system. Infant diagnosis DBSs were also tested for HIV-1 DNA by ROCHE COBAS AmpliPrep/COBAS TaqMan System. Results of DBS RNA were compared with conventional tests; program performance was described. RESULTS: Among 176 infant diagnosis participants, using a threshold of at least 1000 copies/ml, sensitivity and specificity of DBS versus plasma RNA were 1.00 and 0.99, and of DBS RNA versus DBS DNA were 0.97 and 1.00. Among 137 viral load monitoring participants, when plasma and DBS RNA were compared, r value was 0.9709; r value was 0.9675 for at least 5000 copies/ml but was 0.7301 for less than 5000 copies/ml. The highest plasma RNA value at which DBS RNA was not detected was 2084 copies/ml. Median (range) turnaround time from sample collection to result receipt at sites was 23 (4-69) days. The Tanzania mail service successfully transmitted all DBS and results between sites and the central laboratory. CONCLUSION: Under program conditions in Tanzania, DBS provided HIV-1 RNA results comparable to conventional methods to remote healthcare facilities. DBS RNA testing is an alternative to liquid plasma for HIV-1 RNA services in remote areas.

Therapeutic targets for osteoarthritis.

Osteoarthritis (OA) is a multi-factorial disease, which, as the population ages, puts an ever increasing burden on health care resources. The treatment of OA, in terms of disease modifying drugs, has lagged well behind that of the inflammatory arthritides, and it may be that research in this area has been misguided. It is unlikely that a single therapy will be effective in what is a very heterogeneous condition. There is evidence that OA should be thought of as a disease of the whole musculoskeletal system, affecting not only cartilage, but also muscle, ligaments, bone and even adipose tissue. In developing novel therapies, greater attention needs to be given to the mechanics of the joint environment. Whilst, as yet, there is no disease modifying therapy available for the treatment of OA, many of the existing, more conservative therapies have been shown to be effective. In particular, the management of obesity is important both for the prevention and progression of the disease. Other interventions, such as exercise therapy and visco-supplementation also have their place. However, patient compliance with these therapies is often less than optimal and looking for ways of improving this may be an area for future research.

Hypertension and maternal-fetal conflict during placental malaria.

BACKGROUND: Malaria and hypertension are major causes of maternal mortality in tropical countries, especially during first pregnancies, but evidence for a relationship between these syndromes is contradictory. METHODS AND FINDINGS: In a cross-sectional survey of Tanzanian parturients, the rate of hypertension was similar in placental malaria (PM)-positive (11/85 = 13%) and PM-negative (73/602 = 12%) individuals. However, we found that PM was associated with hypertension in first-time mothers aged 18-20 y but not other mothers. Hypertension was also associated with histologic features of chronic malaria, which is common in first-time mothers. Levels of soluble vascular endothelial growth factor receptor 1 (sVEGFR1), a preeclampsia biomarker, were elevated in first-time mothers with either PM, hypertension, or both, but levels were not elevated in other mothers with these conditions. In first-time mothers with PM, the inflammatory mediator vascular endothelial growth factor (VEGF) was localized to maternal macrophages in the placenta, while sVEGFR1, its soluble inhibitor, was localized to the fetal trophoblast. CONCLUSIONS: The data suggest that maternal-fetal conflict involving the VEGF pathway occurs during PM, and that sVEGFR1 may be involved in the relationship between chronic PM and hypertension in first-time mothers. Because placental inflammation causes poor fetal outcomes, we hypothesize that fetal mechanisms that promote sVEGFR1 expression may be under selective pressure during first pregnancies in malaria-endemic areas.

Malaria in pregnancy.

Malaria in pregnancy is one of the major causes of maternal morbidity worldwide, and leads to poor birth outcomes. There is a complex interaction between pregnancy and parasite-all favour the parasite and disadvantage the pregnant woman. Women who are semi-immune lose much of that immunity. They may present with placental malaria but with no parasites in their peripheral blood. A non-immune pregnant women and her fetus are at serious risk from falciparum malaria. The diagnosis and management of malaria in pregnancy, including the safety of antimalarial drugs and interactions of malaria with HIV in pregnancy are reviewed.

Hand function after the menopause.

Hand function declines with age, and therefore, by implication, after the menopause. The simple ageing process clearly affects both women and men, but women may experience more of a decline of hand function in older age. This is not readily explained in terms of straightforward ageing, but women are more likely to be adversely affected by diseases such as osteoarthritis and rheumatoid arthritis. Hormonal influences, particularly in osteoarthritis, may be the reason for women experiencing more severe disease. Both arthritides are multi-factorial in their aetiology, and the same is true of the declining hand function that is seen as part of the ageing process.