Adapting and usability testing of the Kansas city cardiomyopathy questionnaire (KCCQ) in a heart failure clinic in Tanzania: the Swahili KCCQ.

BACKGROUND: The integration of patient-reported outcome measures (PROMS) into health care delivery systems is being increasingly recognized as an important component of quality, person-centered care, especially for chronic illnesses like congestive heart failure (CHF). However, while PROMS are increasingly being used to follow up CHF patients in high income countries, their use in sub-Saharan Africa is still limited. We adapted the Kansas City Cardiomyopathy Questionnaire (KCCQ-23), an internationally validated, CHF-specific PROM and tested its use in measuring outcomes in an outpatient CHF clinic at a cardiac referral hospital in Tanzania. METHODS: Adaptation of the KCCQ-23 included translation into Swahili by linguistic experts, in-depth cognitive debriefing in native Swahili-speaking CHF patients, and input from Tanzanian Cardiologists, PROMS experts, and the tool developer. Using a cross-sectional design, we tested the usability and observed the results of the translated KCCQ-23 in a convenience sample of 60 CHF patients attending outpatient clinic at the Jakaya Kikwete Cardiac Institute (JKCI) in Dar es Salaam. RESULTS: The survey was successfully completed by 59 (98.3%) of 60 enrolled participants. The mean (SD) age of participants was 54.9 (14.8) years (range 22-83), 30.5% were women and 72.2% had class 3 or 4 New York Heart Association (NYHA) symptoms at enrollment. The overall KCCQ-23 score was low, with a mean (SD) score of 21.7 (20.4) indicating generally very poor to poor patient reported outcomes in this population. The mean (SD) scores for the specific KCCQ-23 domains were 15.25 (24.2) for social limitation, 23.8 (27.4) for physical limitation, 27.1 (24.1) for quality of life and 40.7 (17.0) for self-efficacy. No socio-demographic or clinical characteristics were associated with their overall KCCQ-23 scores. Comparing the short version (KCCQ-12) with the full KCCQ-23 revealed excellent correlation between the two (r = 0.95; p < 0.0001). CONCLUSIONS: We successfully translated a validated tool, the Swahili KCCQ, for use in improving the care of patients with CHF in Tanzania and a broader population of Swahili-speaking patients. Both the Swahili KCCQ-12 and KCCQ-23 can be used, with similar outcomes. Work to expand the use of the tool in the clinic and other settings is planned.

Characteristics and immediate outcomes of patients who underwent percutaneous balloon mitral valvuloplasty at the Jakaya Kikwete Cardiac Institute, Tanzania.

BACKGROUND: For rheumatic mitral stenosis (MS), a multidisciplinary evaluation is mandatory to determine the optimal treatment: medical, percutaneous balloon mitral valvuloplasty (PBMV) or valve surgery. Clinical and imaging evaluations are essential for procedural risk assessment and outcomes. PBMV interventions are increasingly available in Africa and are feasible options for selected candidates. Enhancing PBMV training/skills transfer across most of African countries is possible. OBJECTIVES: The aim of this study was to provide insight into the clinical practice of patients with rheumatic MS evaluated for PBMV in a Tanzanian teaching hospital and to define the role of imaging, and evaluate the heart team and training/skills transfer in PBMV interventions. METHODS: From August 2019 to May 2022, 290 patients with rheumatic MS were recruited consecutively in the Tanzania Mitral Stenosis study. In total, 43 (14.8%) patients were initially evaluated for eligibility for PBMV by a heart team. We carried out the clinical assessment, laboratory investigations, transthoracic/oesophageal echocardiography (TTE/TEE) and electrocardiography. RESULTS: The median age was 31 years (range 11-68), and two-thirds of the patients were female (four diagnosed during pregnancy). Two patients had symptomatic MS at six and eight years. Nine patients had atrial fibrillation with left atrial thrombus in three, and two were detected by TEE. Nine patients in normal sinus rhythm had spontaneous echo contrast. The mean Wilkins score was 8.6 (range 8-12). With re-evaluation by the local and visiting team, 17 patients were found to have unfavourable characteristics: Bi-commissural calcification (four), ≥ grade 2/4 mitral regurgitation (six), high scores and left atrial thrombus (three), left atrial thrombus (two), and severe pulmonary hypertension (two). Three patients died before the planned PBMV. Eleven patients were on a waiting list. We performed PBMV in 12 patients, with success in 10 of these, and good short-term outcomes [mean pre-PBMV (16.03 ± 5.52 mmHg) and post-PBMV gradients (3.08 ± 0.44 mmHg, p < 0.001)]. There were no complications. CONCLUSIONS: PBMV had good outcomes for selected candidates. TEE is mandatory in pre-PBMV screening and for procedural guidance. In our cohort, patients with Wilkins score of up to 11 underwent successful PBMV. We encourage PBMV skills expansion in low- and middle-income countries, concentrating on expertise centres.

Medication Adherence and Blood Pressure Control Among Hypertensive Outpatients Attending a Tertiary Cardiovascular Hospital in Tanzania: A Cross-Sectional Study.

Background: Notwithstanding the availability of effective treatments, asymptomatic nature and the interminable treatment length, adherence to medication remains a substantial challenge among patients with hypertension. Suboptimal adherence to BP-lowering agents is a growing global concern that is associated with the substantial worsening of disease, increased service utilization and health-care cost escalation. This study aimed to explore medication adherence and its associated factors among hypertension outpatients attending a tertiary-level cardiovascular hospital in Tanzania. Methods: The pill count adherence ratio (PCAR) was used to compute adherence rate. In descriptive analyses, adherence was dichotomized and consumption of less than 80% of the prescribed medications was used to denote poor adherence. Logistic regression analyses was used to determine factors associated with adherence. Results: A total of 849 outpatients taking antihypertensive drugs for ≥1 month prior to recruitment were randomly enrolled in this study. The mean age was 59.9 years and about two-thirds were females. Overall, a total of 653 (76.9%) participants had good adherence and 367 (43.2%) had their blood pressure controlled. Multivariate logistic regression analysis showed; lack of a health insurance (OR 0.5, 95% CI 0.3-0.7, p<0.01), last BP measurement >1 week (OR 0.6, 95% CI 0.4-0.8, p<0.01), last clinic attendance >1 month (OR 0.4, 95% CI 0.3-0.6, p<0.001), frequent unavailability of drugs (OR 0.6, 95% CI 0.3-0.9, p = 0.03), running out of medication before the next appointment (OR 0.6, 95% CI 0.4-0.9, p = 0.01) and stopping medications when asymptomatic (OR 0.6, 95% CI 0.4-0.8, p<0.001) to be independent associated factors for poor adherence. Conclusion: A substantial proportion of hypertensive outpatients in this tertiary-level setting had good medication adherence. Nonetheless, observed suboptimal blood pressure control regardless of a fairly satisfactory adherence rate suggests that lifestyle modification plays a central role in hypertension management.

Newborn Screening for Critical Congenital Heart Disease in a Low-Resource Setting; Research Protocol and Preliminary Results of the Tanzania Pulse Oximetry Study.

Background: Critical Congenital Heart Disease (CCHD) is the leading cause of early new-born mortality. Its early detection and intervention is crucial for the survival of affected new-born. Pulse Oximetry (POX) has shown to be one of the feasible, accurate and cost-effective tools in screening CCHD in developed nations, it is yet to be practiced and established as standard of care in a low-resource setting. Objectives: This paper reports on the research protocol and preliminary results of an ongoing study regarding the performance of POX in detecting CCHD in new-borns in a low resource setting. Secondary objectives include investigating the burdens of CCHD and outcome at 12 months of age. Methods: The Tanzanian Pulse Oximetry Study (TPOXS) is a prospective cohort study which plans to enrol 30,000 mothers and new-borns delivered at two referral hospitals in Tanzania. New-borns are offered POX test 12 hours after birth, those positively undergoes echocardiography examinations. Confirmed with CCHD are placed under observation for up to first birthday. Results: During a 5-months pilot period, a total of 1,592 infants at the Muhimbili National Hospital, received POX test .65% of them were post-caesarean section and 52% being male. Most babies delivered through Spontaneous Vertex Delivery (SVD) were promptly discharge and did not get screened. The detection-rate of CCHD was 2.5 per 1,000 live births (at 95% confidence interval [CI] 0.9 to 6.7 per 1000 live birth); with a POX false positive rate of 0.6%. Seven false-positive infants out of 10 were found to carry significant other neonatal conditions, including persistent pulmonary hypertension of the new-born, transient tachypnoeic and neonatal sepsis. Conclusion: This paper provides the protocol of the ongoing TPOXS with the preliminary results showing prevalence matching closely the global data. It shows acceptability of POX screening for CCHD in a well-prepared low resource setting. Highlight: This study addresses the utilization of pulse oximeter in detecting critical congenital heart disease (CCHD) in a low-resource setting (such as sub-Saharan African countries).

Non-Communicable Disease Risk Factors Among Caregivers of Patients Attending a Tertiary Cardiovascular Hospital in Tanzania.

Background: Notwithstanding the ever-present burden of infectious diseases, the sub-Saharan Africa (SSA) region has experienced a 67% rise in the non-communicable disease (NCD) burden in less than three decades. Furthermore, regardless of the increased recognition of NCDs threat in the region, reliable local estimates and associated drivers are generally lacking. We therefore conducted this cross-sectional study to establish the pattern and correlates of the modifiable NCD risk factors among caregivers of patients attending a tertiary cardiovascular centre in Tanzania. Methods: A cross-sectional survey was conducted at Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania. We used a structured questionnaire bearing a modified WHO STEPwise Approach to NCD Risk Factor Surveillance (STEPS) tool to explore the modifiable behavioral and modifiable biological NCD risk factors. Results: A total of 1063 caregivers were enrolled in this study. The mean age was 40.5 years, and 55.7% were female. Nearly 80% of participants had a good knowledge regarding NCDs and 85.4% had a positive family history of NCDs. Overall, 1027 (96.6%) participants had at least one modifiable NCD risk factor while 510 (48.0%) had three or more (i.e., clustering). With respect to modifiable behavioral NCD risk factors, 34 (3.2%) were tobacco users, 56 (5.3%) had harmful alcohol consumption, 691 (65%) had unhealthy eating behavior, and 820 (77.1%) were physically inactive. Pertaining to modifiable biological NCD risk factors, 710 (66.8%) had excess body weight, 420 (39.5%) had hypertension and 62 (5.8%) were diabetic. Conclusion: A vast majority of caregivers of NCD patients in this tertiary setting were found to have modifiable NCD risk factors with a strong tendency of clustering. These findings call for intensification of both population strategies and targeted group interventions for better control of the NCD threat and its correlates.

Complete heart block ensuing from a metastatic small cell carcinoma: a case report.

INTRODUCTION: Notwithstanding the diagnostic and therapeutic advancements, the incidence of cardiac metastases has increased in recent decades. Lung cancers are the most common primary malignant neoplasms with cardiac metastasis potential. The clinical presentation of cardiac metastases is either silent or vague, and largely depends on the infiltrated location and tumor burden. Although arrhythmias are not uncommon in metastatic cardiac tumors, complete heart block is relatively a rare manifestation. We present a case of complete heart block due to a metastatic small cell carcinoma in a 67-year-old male of African origin. CASE PRESENTATION: A 67-year-old male of African origin from rural Tanzania was referred to us for expert management. He is a retired agromechanic with over 30 years exposure to asbestos-containing brake linings. His past medical history was unremarkable, but the family-social history was evident for a heavy alcohol intake and chronic cigarette smoking. He presented with a 24-week history of progressive shortness of breath and an 8-week history of recurrent syncopal attacks coupled with a significant weight loss. He had normal echocardiographic findings, however, the electrocardiogram showed features of complete heart block. Chest X-ray showed a homogeneous opacification on the right side and computed tomography scan revealed a solid right lung mass with metastases to the liver, heart, bowels, and bone. He underwent bronchoscopy, which revealed an endobronchial mass obstructing the bronchus intermedius. Histological examination of a section of lung biopsy taken during bronchoscopy confirmed the diagnosis of a small cell carcinoma. The patient underwent dual chamber pacemaker implantation with successful sinus rhythm restoration. He made an informed refusal of chemotherapy and inevitably died 18 months post pacing. CONCLUSIONS: Despite the advancements in medical diagnostics and management, lung cancers are often diagnosed in advanced stages, with an inevitable grave prognosis. Small cell carcinoma has the potential to metastasize to the heart, resulting in complete heart block.

Prevalence and risk factors for Subclinical Rheumatic Heart Disease among primary school children in Dar es Salaam, Tanzania: a community based cross-sectional study.

BACKGROUND: Rheumatic heart disease (RHD) is the most common acquired heart disease occurring in children and adolescents. RHD is associated with significant morbidity and mortality particularly in low and middle- income countries (LMICs) where the burden is estimated to be higher compared to high income countries. Subclinical RHD is the presence of valvular lesion diagnosed by echocardiography in a person with no clinical manifestation of RHD. This study aimed at determining the prevalence, types and factors associated with subclinical RHD among primary school children in Dar Es Salaam, Tanzania. METHODS: A descriptive community-based cross-sectional study was conducted in primary school children from February to May 2019. A standardized structured questionnaire was used to collect demographic characteristics, history of upper respiratory tract infections (URTIs), anthropometric measurements, and chest auscultation findings. Moreover echocardiographic screening was done to all children recruited into the study. World Heart Federation echocardiographic classification was used to define the types and prevalence of subclinical RHD. RESULTS: A total of 949 primary school children were enrolled with females being predominant (57.1%). The prevalence of subclinical RHD was 34 per 1000. All the participants had mitral valve disease only whereby 17 had definite disease and 15 had a borderline disease. The associated factors for subclinical RHD were older age of more than 9 years (OR 10.8, 95% CI 1.4-82.2, P = 0.02) having three or more episodes of URTI in previous six months (OR 21, 95% CI 9.6-46, P = 0.00) and poor hygiene (OR 3, 95% CI 1.3-6.8, P = 0.009). CONCLUSION: Subclinical RHD as detected by echocardiographic screening is prevalent in primary school children, uniformly affects the mitral valve, and is associated with potentially modifiable risk factors. Children with a history of more than three episodes of URTI in six months represents a high-risk population that should be targeted for RHD screening.

Burden and correlates of cognitive impairment among hypertensive patients in Tanzania: a cross-sectional study.

BACKGROUND: The evolution of cognitive impairment of vascular origin is increasingly becoming a prominent health threat particularly in this era where hypertension is the leading contributor of global disease burden and overall health loss. Hypertension is associated with the alteration of the cerebral microcirculation coupled by unfavorable vascular remodeling with consequential slowing of mental processing speed, reduced abstract reasoning, loss of linguistic abilities, and attention and memory deficits. Owing to the rapidly rising burden of hypertension in Tanzania, we sought to assess the prevalence and correlates of cognitive impairment among hypertensive patients attending a tertiary cardiovascular hospital in Tanzania. METHODOLOGY: A hospital-based cross-sectional study was conducted at Jakaya Kikwete Cardiac Institute, a tertiary care public teaching hospital in Dar es Salaam, Tanzania between March 2020 and February 2021. A consecutive sampling method was utilized to recruit consented hypertensive outpatients during their scheduled clinic visit. General Practitioner Assessment of Cognition (GPCOG) Score was utilized in the assessment of cognitive functions. All statistical analyses utilized STATA v11.0 software. Pearson Chi square and Student's T-test were used to compare categorical and continuous variables respectively. Logistic regression analyses were used to assess for factors associated with cognitive impairment. Odd ratios with 95% confidence intervals and p-values are reported. All tests were 2-sided and p < 0.05 was used to denote a statistical significance. RESULTS: A total of 1201 hypertensive patients were enrolled in this study. The mean age was 58.1 years and females constituted nearly two-thirds of the study population. About three quarters had excess body weight, 16.6% had diabetes, 7.7% had history of stroke, 5.7% had heart failure, 16.7% had renal dysfunction, 53.7% had anemia, 27.7% had hypertriglyceridemia, 38.5% had elevated LDL, and 2.4% were HIV-infected. Nearly two-thirds of participants had uncontrolled blood pressure and 8.7% had orthostatic hypotension. Overall, 524 (43.6%) of participants had cognitive impairment. During bivariate analysis in a logistic regression model of 16 characteristics, 14 parameters showed association with cognitive functions. However, after controlling for confounders, multivariate analysis revealed ≤primary education (OR 3.5, 95%CI 2.4-5.2, p < 0.001), unemployed state (OR 1.7, 95%CI 1.2-2.6, p < 0.01), rural habitation (OR 1.8, 95%CI 1.1-2.9, p = 0.01) and renal dysfunction (OR 1.7, 95%CI 1.0-2.7, p = 0.04) to have independent association with cognitive impairment. CONCLUSION: This present study underscore that cognitive decline is considerably prevalent among individuals with systemic hypertension. In view of this, it is pivotal to incorporate cognitive assessment in routine evaluation of hypertensive patients.

Human immunodeficiency virus transmission from a 24-year-old woman to her 78-year-old grandmother: a case report.

INTRODUCTION: Since its debut recognition in 1981, human immunodeficiency virus/acquired immunodeficiency syndrome has affected over 77 million people and has resulted in premature cessation of 35.4 million lives worldwide. Commonly, human immunodeficiency virus is transmitted by sexual contact across mucosal surfaces, by sharing of injecting equipment, through contaminated blood transfusions, and by maternal-infant exposure. Nevertheless, accidental transmission incidences involving family members are rare but possible. CASE PRESENTATION: A 78-year-old woman of African descent from Mtwara Region south of Tanzania was referred to us for further evaluation and treatment. She is 30 years postmenopausal and has a 35-year history of hypertension. Her last attendance to our institute was 11 months prior the index visit and she tested negative for human immunodeficiency virus. She came with complaints of weight loss, recurrent fevers, and cough. Her hematological tests revealed leukopenia with lymphocytosis, together with a normocytic normochromic anemia. Enzyme-linked immunosorbent assay for human immunodeficiency virus was positive, and she had a CD4 count of 177 cells/µL. We went back to history taking to identify the potential source of infection. We were informed that for the past 6 months, the 78-year-old lady has been living with her unwell 24-year-old granddaughter who has been divorced. The granddaughter had a history of recurrent fevers, significant weight loss, and a suppurative skin condition. As a way to show love and care, the old lady was puncturing the suppurative lesions with bare hands; then she would suck them to clear away the discharge. We requested to see the young lady, and she tested positive for human immunodeficiency virus. Both were started on tenofovir/lamivudine/dolutegravir combination plus cotrimoxazole 960 mg. The family was in total disarray following these findings. The patient was discharged through infectious diseases department and died of Pneumocystis jirovecii pneumonia 12 weeks later. CONCLUSIONS: Certain sociocultural norms that are believed to express love, care, and togetherness in developing rural communities, particularly Sub-Saharan Africa, have a potential of spreading human immunodeficiency virus, thus warranting prompt transformation.

Feasibility of point-of-care cardiac ultrasound performed by clinicians at health centers in Tanzania.

BACKGROUND: Point-of-care cardiac ultrasound (cardiac POCUS) has potential to become a useful tool for improving cardiovascular care in Tanzania. We conducted a pilot program to train clinicians at peripheral health centers to obtain and interpret focused cardiac POCUS examinations using a hand-held portable device. METHODS: Over a 5-day period, didactic and experiential methods were used to train clinicians to conduct a pre-specified scanning protocol and recognize key pathologies. Pre- and post-training knowledge and post-training image acquisition competency were assessed. In their usual clinical practices, trainees then scanned patients with cardiovascular signs/symptoms, recorded a pre-specified set of images for each scan, and documented their interpretation as to presence or absence of key pathologies on a case report form. A cardiologist subsequently reviewed all images, graded them for image quality, and then documented their interpretation of key pathologies in a blinded fashion; the cardiologist interpretation was considered the gold standard. RESULTS: 8 trainees (6 Clinical Officers, 1 Assistant Medical Officer, and 1 Medical Doctor) initiated and completed the training. Trainees subsequently performed a total of 429 cardiac POCUS examinations in their clinical practices over a 9 week period. Stratified by trainee, the median percent of images that were of sufficient quality to be interpretable was 76.7% (range 18.0-94.2%). For five of eight trainees, 75% or more of images were interpretable. For detection of pre-specified key pathologies, kappa statistics for agreement between trainee and cardiologist ranged from - 0.03 (no agreement) for detection of pericardial effusion to 0.42 (moderate agreement) for detection of tricuspid valve regurgitation. Mean kappa values across the key pathologies varied by trainee from 0 (no agreement) to 0.32 (fair agreement). CONCLUSIONS: The 5-day training program was sufficient to train most clinicians to obtain basic cardiac images but not to accurately interpret them. Proficiency in image interpretation may require a more intensive training program.

Rationale, design and protocol of a cross-sectional study on pregnancy-related cardiovascular diseases in Tanzania (PRECARDT): burden, characterisation and prognostic significance at delivery.

INTRODUCTION: The paucity of data describing cardiovascular disease (CVD) in pregnancy in many parts of Africa including Tanzania has given rise to challenges in proper management by the healthcare providers. This study is set out to (1) determine the prevalence of a range of CVDs during pregnancy in women attending antenatal clinics in Tanzania and (2) determine the impact of these CVDs on maternal and fetal outcomes at delivery. METHODS AND ANALYSIS: This is a cross-sectional study with a prospective component to be conducted in two referral hospitals in Tanzania. Pregnant women aged ≥18 years diagnosed with a CVD during the antenatal period are being identified and extensively characterised by performing clinical assessment, modified WHO staging, electrocardiography, echocardiography and laboratory tests. Patients identified with CVDs (exposed) and a subset without (unexposed) will be followed up to determine maternal and fetal outcomes at delivery. A minimum sample of 1560 will be sufficient to estimate the prevalence of CVDs with a 95% CI of 2.75% to 5.25%. ETHICS AND DISSEMINATION: The study is being conducted in accordance with the Helsinki declaration on studies involving human subjects. Ethical approvals have been obtained from Muhimbili University (reference number DA.282/298/01.C/) and Bugando Medical Centre (reference number CREC/330/2019) Ethics Committees. Informed consent is sought from all potential participants before any interview or investigations are performed. Study findings will be disseminated to the scientific community through different methods. Results will also be communicated to policymakers and to the public, as appropriate.

Comparative Effectiveness of Reperfusion Strategies in Patients with ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) Trial.

Introduction: Substantial heterogeneity exists in reperfusion strategies for patients with ST-segment myocardial infarction (STEMI) in low- and middle-income countries (LMICs). We sought to compare outcomes associated with primary percutaneous coronary intervention (PPCI) and non-primary percutaneous coronary intervention (nPPCI) reperfusion strategies in patients with STEMI in Kerala, India. Methods: We performed a retrospective analysis of patients with STEMI (n = 8665) from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) randomized trial receiving either PPCI (n = 6623) or nPPCI (n = 2042). nPPCI included all PCI strategies implemented when PPCI was not available including all post-fibrinolysis PCI strategies and PCI without fibrinolysis. Clinical outcomes among patients undergoing PPCI and nPPCI were compared after propensity-score matching. The main outcomes were the rates of in-hospital and 30-day major adverse cardiovascular events (MACE), defined as the composite of death, reinfarction, stroke, and major bleeding. Results: In the propensity-score matched cohort (n = 1266 in each group), nPPCI had longer symptom onset to hospital arrival time (347.5 vs. 195.0 minutes, p < 0.001), door to balloon time (108 minutes vs. 75 minutes, p < 0.001), and were less likely to receive a coronary stent (89.4% vs. 95%, p < 0.001), including drug-eluting stents (89.5% vs. 94.4%, p < 0.001). There were no clinically meaningful differences in discharge medical therapy. However, patients treated with nPPCI were less commonly referred for cardiac rehabilitation (20.2% vs. 24.2%; p = 0.019). In-hospital (3.6% vs. 3.3%, p = 0.74%) and 30-day (4.4% vs. 4.6%, p = 0.77) MACE did not differ between nPPCI and PPCI matched groups. Conclusion: In a large, contemporary population of STEMI patients from a LMIC, patients treated with a nPPCI reperfusion strategy had comparable short- and intermediate-term outcomes compared to PPCI despite differences in hospital presentation time and coronary stent use. These findings are reassuring but highlight the need for continued quality improvement in the delivery of STEMI care in resource-limited settings.

Obesity epidemic in urban Tanzania: a public health calamity in an already overwhelmed and fragmented health system.

BACKGROUND: Worldwide, the epidemiological and demographic transitions have resulted in nutrition shift characterized by an increased consumption of high energy fast food products. In just over 3 decades, overweight and obesity rates have nearly tripled to currently affecting over a third of the global population. Notwithstanding the ever present under-nutrition burden, sub Saharan Africa (SSA) is witnessing a drastic escalation of overweight and obesity. We aimed to explore the prevalence and associated factors for obesity among residents of Dar es Salaam city in Tanzania. METHODS: Participants from this study were recruited in a community screening conducted during the Dar es Salaam International Trade Fair. Sociodemographic and clinical data were gathered using a structured questionnaire during enrollment. Dietary habits and anthropometric measurements were assessed using standard methods. All statistical analyses utilized STATA v11.0 software. Pearson Chi square and Student's T-test were used to compare categorical and continuous variables respectively. Logistic regression analyses were used to assess for factors associated with BMI ≥ 25. All tests were 2-sided and p < 0.05 was used to denote a statistical significance. RESULTS: A total of 6691 participants were enrolled. The mean age was 43.1 years and males constituted 54.2% of all participants. Over two-thirds of participants were alcohol consumers and 6.9% had a positive smoking history. 88.3% of participants were physically inactive, 4.7% had a history of diabetes mellitus and 18.1% were known to have elevated blood pressure. Overweight and obesity were observed in 34.8 and 32.4% of participants respectively. Among overweight and obese participants, 32.8% had a misperception of having a healthy weight. Age ≥ 40, female gender, a current working status, habitual breakfast skipping, poor water intake, high soft drink consumption, regular fast food intake, low vegetable and fruit consumption, alcohol consumption and hypertension were found to be independent associated factors for obesity. CONCLUSION: Amidst the ever present undernutrition in SSA, a significant proportion of participants had excess body weight. Concomitantly, the rates of physical inactivity and unhealthy eating are disproportionately high in Dar es Salaam. In view of this, community-based and multilevel public health strategies to promote and maintain healthy eating and physical activity require an urgent step-up in urban Tanzania.

Knowledge of cardiovascular risk factors among caretakers of outpatients attending a tertiary cardiovascular center in Tanzania: a cross-sectional survey.

BACKGROUND: Health literacy on cardiovascular diseases (CVDs) plays an effective role in preventing or delaying the disease onset as well as in impacting the efficacy of their management. In view of the projected low health literacy in Tanzania, we conducted this cross-sectional survey to assess for CVD risk knowledge and its associated factors among patient escorts. METHODS: A total of 1063 caretakers were consecutively enrolled in this cross-sectional study. An adopted questionnaire consisting of 22 statements assessing various CVD risk behaviors was utilized for assessment of knowledge. Logistic regression analyses were performed to assess for factors associated with poor knowledge of CVD risks. RESULTS: The mean age was 40.5 years and women predominated (55.7%). Over two-thirds had a body mass index (BMI) ≥25 kg/m2, 18.5% were alcohol drinkers, 3.2% were current smokers, and 47% were physically inactive. The mean score was 78.2 and 80.0% had good knowledge of CVD risks. About 16.3% believed CVDs are diseases of affluence, 17.4% thought CVDs are not preventable, and 56.7% had a perception that CVDs are curable. Low education (OR 2.6, 95%CI 1.9-3.7, p < 0.001), lack of health insurance (OR 1.5, 95%CI 1.1-2.3, p = 0.03), and negative family history of CVD death (OR 2.2, 95%CI 1.4-3.5, p < 0.001), were independently associated with poor CVD knowledge. CONCLUSIONS: In conclusion, despite of a good level of CVD knowledge established in this study, a disparity between individual's knowledge and self-care practices is apparent.

Burden and correlates of atrial fibrillation among hypertensive patients attending a tertiary hospital in Tanzania.

BACKGROUND: Atrial fibrillation (AF) is the most common supra ventricular cardiac arrhythmia, which presents with variety of clinical symptoms. Hypertension increases risk of developing Atrial fibrillation by 1.5 fold. Together Atrial fibrillation and hypertension doubles the risk of morbidity and mortality. We aimed to determine the prevalence of AF and describe associated factors among hypertensive patients attending tertiary hospital in Tanzania. METHODS: A cross-sectional hospital-based study, involving 391 hypertensive patients visiting the Jakaya Kikwete Cardiac Institute was conducted between October to December 2017. Categorical variables were analyzed using chi square while student t- test was used to analyze continuous variables. Multivariate logistic regression analysis was performed to determine factors associated with AF. All analysis was two sided and p- value of < 0.05 was used to be not significant. RESULTS: AF was detected in 40 (10.2%) patients. Atrial fibrillation was associated with BMI ≥ 25 (OR 4.4, 95% CI 1.1-7.7, p-value 0.02), ejection fraction < 50% (OR 3.0, 95%CI 1.1-8.2, p-value 0.03), Left Atrial diameter > 40 mm (OR 9.4,95%CI 2.1-43.2, p-value < 0.01) and eGFR< 60 (OR 2.9, 95%CI 1.1-7.8, p-value 0.04). CONCLUSION: Atrial fibrillation is considerably prevalent among the hypertensive sub-population. Prompt diagnosis and timely management is vital to prevent complications and premature mortality.

A Case of Wellens Syndrome in a 30-Year-Old Woman From Sub-Saharan Africa: A Perplexing Clinical Entity With Invaluable Lessons.

With an estimated contribution of up to 6% of all acute coronary events, young adults are experiencing an escalating burden and mortality attributable to coronary artery disease (CAD) worldwide. Wellens syndrome, a preinfarction clinical entity with distinctive electrocardiographic (ECG) features and high propensity for extensive anterior wall infarctions, affects about 15% of unstable angina subpopulation. We report challenges and lessons learnt from the first ever documented case of Wellens syndrome in Tanzania. A 30-year-old female of African descent was referred to us from an upcountry zonal referral hospital for etiological determination of chest pain and expert management. Her medical history was unremarkable, and she had no apparent risk factors for CAD. She presented with a 7-day history of ongoing sharp central chest pain that was radiating to the neck and jaws and relieved momentarily by morphine. She had stable vitals with an unremarkable systemic examination; however, a 12-lead ECG revealed deeply inverted T-waves on leads V2 through V4. Based on our extensive history and physical examination we came up with a diagnosis of type B Wellens syndrome with impending anterior wall myocardial infarction. She underwent cardiac catheterization that revealed a nonthrombogenic severe subocclusive (>95%) mid left anterior descending artery stenosis. Subsequently, angioplasty was performed successfully with a resolute integrity stent, and TIMI III flow was achieved. To conclude, despite its relative frequency, physicians' awareness of Wellens syndrome pathognomonic ECG features is of paramount importance to curb its attributable morbidity and mortality.

Massive Bilateral Hydroureteronephrosis and End-Stage Renal Disease Ensuing From Chronic Schistosomiasis: A Case Report.

Globally, schistosomal infections affect over 200 million people resulting in the loss of 70 million disability-adjusted life years. In the sub-Saharan Africa region, where over 85% of the global schistosomal infections are found, it is estimated that about 120 million people become symptomatic, over 20 million have severe disease, and nearly 200 000 die every year. Renal impairment is a severe consequence of schistosomiasis occurring in about 6% of all infected individuals and in 15% of those with the hepatosplenic form. We present a case of massive bilateral hydroureteronephrosis and end-stage renal disease resulting from chronic schistosomiasis in a 38-year-old male of African origin. A 38-year-old male rice farmer of African origin presented with a history of elevated blood pressure, abdominal swelling, and reduced urinary output for about 10 months. Abdominal examination revealed an intraabdominal mass measuring 30 cm × 17 cm extending from the right hypochrondrium region downward to right inguinal outward to umbilicus crossing the midline. He had an estimated glomerular filtration rate of 3.9 mL/min, hemoglobin of 6.78 g/dL, and had multiple electrolyte abnormalities. A computed tomography intravenous urogram scan of the abdomen revealed hepatomegaly (18 cm), bilateral renal enlargement with hydroureteronephrosis, and multiple calcifications on the urinary bladder. A rectal biopsy isolated haematobium eggs and confirmed the diagnosis. Urinary schistosomiasis can have distressing effects on the urinary system in particular and survival prospects in general. In view of this, extensive evaluation of the genitourinary system is pivotal for timely diagnosis and prompt management particularly in residents of schistosoma-endemic communities presenting with obstructive uropathy.

Factors influencing left ventricular ejection fraction in patients with coronary microvascular disease and obstructive coronary artery disease.

OBJECTIVE: The aim of our research was to evaluate the relationship involving left ventricular ejection fraction, low density lipoprotein, B-type natriuretic peptide, Troponin I and coronary flow reserve, and to determine the predictors of left ventricular ejection fraction in patients with coronary microvascular disease and obstructive coronary artery disease, and in patients with coronary microvascular disease. RESULTS: The mean age was 58.5 ± 12.5 years. In patients with obstructive coronary disease and coronary microvascular disease we found low density lipoprotein-c had significant inverse relationship with left ventricular ejection fraction, left ventricular ejection fraction also had significant negative relationship with B-type natriuretic peptide, and Troponin-I. While a significant direct relationship turned out to be observed linking left ventricular ejection fraction with coronary flow reserve. Left ventricular ejection fraction had significant negative relationship with low density lipoprotein, and B-type natriuretic peptide in patients with obstructive coronary artery disease only. Age, blood pressure, lipid levels, red cell distribution width, glycated hemoglobin, symptoms, New York heart association classification, alcohol drinking, hypertension, diabetes mellitus, troponin levels and B-type natriuretic peptide were the predictors for left ventricular ejection fraction in coronary microvascular disease patients.

Medication adherence and survival among hospitalized heart failure patients in a tertiary hospital in Tanzania: a prospective cohort study.

OBJECTIVE: Management of heart failure is complex and multifaceted but adherence to medications remains the cornerstone of preventing avoidable readmissions, premature deaths, and unnecessary healthcare expenses. Despite of evidence-based efficacy on anti-failure drugs, poor adherence is pervasive and remains a significant barrier to improving clinical outcomes in heart failure population. RESULTS: We enrolled 459 patients with diagnosis of heart failure admitted at a tertiary cardiovascular hospital in Dar es Salaam, Tanzania. The mean age was 46.4 years, there was a female predominance (56.5%), 67.5% resided in urban areas and 74.2% had primary education. Of the 419 participants eligible for assessment of medication adherence, 313 (74.7%) had poor adherence and 106 (25.3%) had good adherence. Possession of a health insurance was found to be the strongest associated factor for adherence (adjusted OR 8.7, 95% CI 4.7-16.0, p < 0.001). Participants with poor adherence displayed a 70% increased risk for rehospitalization compared to their counterparts with good adherence (adjusted RR 1.7, 95% CI 1.2-2.9, p = 0.04). Poor adherence was found to be the strongest predictor of early mortality (HR 2.5, 95% CI 1.3-4.6, p < 0.01). In conclusion, Poor medication adherence in patients with heart failure is associated with increased readmissions and mortality.

Takayasu Arteritis Mistaken for Epilepsy: A Case Presenting With Convulsive Syncope.

Takayasu arteritis (TA) is a chronic inflammatory disease characterized by granulomatous vasculitis that predominantly manifests as panaortitis. This occlusive thromboaortopathy lacks pathognomonic features often resulting in a diagnostic dilemma leading to its under-recognition, misdiagnosis and delayed management. Although neurological manifestations are not uncommon in TA, convulsive syncope as an initial clinical presentation is extremely rare. We report a case of convulsive syncope as a manifesting symptom of TA. A 17-year-old male patient of African origin was referred to us from an upcountry regional hospital with a diagnosis of medically intractable epilepsy for cardiovascular review. He presented with a 28-week history of generalized tonic-clonic seizures followed by loss of consciousness. He denied history of recurrent headaches, fever, visual disturbances, arthralgias, claudication or unintentional weight loss. Physical examination revealed feeble left-sided brachial and radial pulses, elevated blood pressure, differences in blood pressure between arms and left-sided carotid and vertebral bruits. Computed tomography angiogram of his thoracic and abdominal aorta revealed changes suggestive of a diffuse arteritis. Additionally, magnetic resonance angiogram of the brain revealed total occlusion of the left common carotid, left internal carotid, left external carotid and left vertebral arteries. Based on the physical examination and radiological findings, we reached a diagnosis of TA. He was prescribed dexamethasone, methotrexate, acetylsalicylic acid and amlodipine. He had a remarkable recovery and was seizure-free for the last 5 months after discharge. TA may manifest with convulsive syncope mimicking epilepsy. Despite its rarity, presentations of this nature continue to challenge clinicians resulting in delayed diagnosis with irreversible life-threatening consequences to patients. In view of this, physicians should strive to take detailed history and perform thorough physical examination so as to timely pick the characteristic signs of TA especially in patients presenting with unanticipated symptoms.