Community-based prevalence of rheumatic heart disease in rural Ethiopia: Five-year follow-up.

BACKGROUND: As little is known about the prevalence and clinical progression of subclinical (latent) rheumatic heart disease (RHD) in sub-Saharan Africa, we report the results of a 5 year follow-up of a community based, echocardiographic study of the disease, originally carried out in a rural area around Jimma, Ethiopia. METHODS: Individuals with evidence of RHD detected during the baseline study as well as controls and their family members were screened with a short questionnaire together with transthoracic echocardiography. RESULTS: Of 56 individuals with RHD (37 definite and 19 borderline) in the original study, 36 (26 definite and 10 borderline) were successfully located 57.3 (range 44.9-70.7) months later. At follow-up two thirds of the definite cases still had definite disease; while a third had regressed. Approximately equal numbers of the borderline cases had progressed and regressed. Features of RHD had appeared in 5 of the 60 controls. There was an increased risk of RHD in the family relatives of borderline and definite cases (3.8 and 4.0 times respectively), notably among siblings. Compliance with penicillin prophylaxis was very poor. CONCLUSIONS: We show the persistence of echocardiographically demonstrable RHD in a rural sub-Saharan population. Both progression and regression of the disease were found; however, the majority of the individuals who had definite features of RHD had evidence of continuing RHD lesions five years later. There was an increased risk of RHD in the family relatives of borderline and definite cases, notably among siblings. The findings highlight the problems faced in addressing the problem of RHD in the rural areas of sub-Saharan Africa. They add to the evidence that community-based interventions for RHD will be required, together with appropriate ways of identifying active disease, achieving adequate penicillin prophylaxis and developing vaccines for primary prevention.

Diabetic Retinopathy in Type 2 Diabetes Mellitus Patients Attending the Diabetic Clinic of the University of Gondar Hospital, Northwest Ethiopia.

OBJECTIVE: To investigate the level of diabetic retinopathy in type 2 diabetes (T2DM) patients attending the University of Gondar Hospital (UGH) Diabetic Clinic, Northwest Ethiopia. METHODS: An audit was carried out involving a total of 739 T2DM patients attending at the diabetic clinic of UGH. They represented approximately 90% and 50% of all T2DM patients under regular review at the urban and rural diabetic clinics of UGH, respectively. All were supervised by the same clinical team for a long period. Eye examinations were performed for visual acuity, cataract, and retinal changes (retinal photography and slit-lamp biomicroscopy). Body mass index (BMI) and HbA1c levels were measured. The presence or absence of hypertension was recorded. RESULTS: Men constituted 41.5% of the group, the mean age at diagnosis of T2DM was 50.4 years, and 50.2% were hypertensive. The BMI was 25.0 ± 4.1 kg/m2, and HbA1c was 7.75 ± 1.63% (61.2 ± 17.8 mmol/mol) (mean ± SD, for BMI and HbA1c)). Severe visual impairment/blindness was reported in 10.6%, 15.2% had cataract, 16.0% had retinopathy, and 11.1% had maculopathy. The prevalence of retinopathy increased with time from diagnosis of T2DM (chi-square for trend, p < 0.001) and with increasing HbA1c level (chi-square for trend, p=0.03). CONCLUSION: These results compare well with the most recent results in well-equipped, wealthier regions of the world and show the importance of stable healthcare infrastructure for chronic-disease management.

Retinopathy in type 1 diabetes mellitus: Major differences between rural and urban dwellers in northwest Ethiopia.

AIM: To audit levels of diabetes-related eye disease in Type 1 diabetes mellitus (T1DM) patients in northwest Ethiopia. In particular to establish whether, despite identical clinical goals, major differences between the physically demanding life-style of rural subsistence farmers and the sedentary life-style of urban dwellers would influence the prevalence of diabetes-related eye complications. METHODS: A robust infrastructure for chronic disease management that comprehensively includes all rural dwellers was a pre-requisite for the investigation. A total of 544 T1DM were examined, representing 80% of all T1DM patients under regular review at both the urban and rural clinics and representative of patient age and gender (62.1% male, 37.9% female) of T1DM patients from this region; all were supervised by the same clinical team. Eye examinations were performed for visual acuity, cataract and retinal changes (retinal photography). HbA1c levels and the presence or absence of hypertension were recorded. RESULTS/CONCLUSIONS: Urban and rural groups had similar prevalences of severe visual impairment/blindness (7.0% urban, 5.2% rural) and cataract (7.3% urban, 7.1% rural). By contrast, urban dwellers had a significantly higher prevalence of retinopathy compared to rural patients, 16.1% and 5.0%, respectively (OR 2.9, p<0.02, after adjustment for duration, age, gender and hypertension). There was a 3-fold greater prevalence of hypertension in urban patients, whereas HbA1c levels were similar in the two groups. Since diabetic retinopathy is closely associated with microvascular disease and endothelial dysfunction, the possible influences of hypertension to increase and of sustained physical activity to reduce endothelial dysfunction are discussed.

Migrants and health: a cultural dilemma.

Culture profoundly affects what those who come to the UK as migrants believe about disease and thus how they behave during illness. Their beliefs may be very different from the beliefs of healthcare professionals and so there can be difficulties in understanding and barriers which inhibit effective clinical management. The behaviour of healthcare professionals towards those of a different race can lead to feelings of discrimination and lack of sympathy, so that a gulf can be allowed to develop. This gulf can be bridged if simple measures are adopted: training in communication, culturally sensitive health-promotion programmes, specific programmes relevant for those of defined ethnic groups and, as a basic means to increase confidence and trust, elementary skills in the language of the migrants.

Epilepsy, poverty and early under-nutrition in rural Ethiopia.

PURPOSE: The incidence of epilepsy in Ethiopia is high compared with industrialised countries, but in most cases the cause of epilepsy is unknown. Childhood malnutrition remains widespread. We performed a case-control study to determine whether epilepsy is associated with poverty and markers of early under-nutrition. METHODS: Patients with epilepsy (n=112), aged 18-45years, were recruited from epilepsy clinics in and around two towns in Ethiopia. Controls with a similar age and gender distribution (n=149) were recruited from patients and relatives attending general outpatient clinics. We administered a questionnaire to define the medical and social history of cases and controls, and then performed a series of anthropometric measurements. Unconditional logistic regression was used to estimate multivariate adjusted odds ratios. Multiple linear regression was used to estimate adjusted case-control differences for continuously distributed outcomes. RESULTS: Epilepsy was associated with illiteracy/low levels of education, odds ratio=3.0 (95% confidence interval: 1.7-5.6), subsistence farming, odds ratio=2.6 (1.2-5.6) and markers of poverty including poorer access to sanitation (p=0.009), greater overcrowding (p=0.008) and fewer possessions (p<0.001). Epilepsy was also associated with the father's death during childhood, odds ratio=2.2 (1.0-4.6). Body mass index was similar in cases and controls, but patients with epilepsy were shorter and lighter with reduced sitting height (p<0.001), bitrochanteric diameter (p=0.029) and hip size (p=0.003). Patients with epilepsy also had lower mid-upper arm circumference (p=0.011) and lean body mass (p=0.037). CONCLUSION: Epilepsy in Ethiopia is strongly associated with poor education and markers of poverty. Patients with epilepsy also had evidence of stunting and disproportionate skeletal growth, raising the possibility of a link between early under-nutrition and epilepsy.