Acute Pulmonary Embolism in an Intensive Care Unit Setting in Sierra Leone.

INTRODUCTION: In Sierra Leone, the lack of information on pulmonary embolism (PE) limits the access to evidence-based standard of diagnostic work-up and management of the disease. The objective of this study was to describe the clinical characteristics and management of acute pulmonary embolism in our setting and to determine whether the pre-test probability scoring algorithms were used prior to Computed Tomography Pulmonary Angiogram (CTPA) request. METHODS: This retrospective observational study was conducted on CTPA-confirmed PE patients admitted to the Intensive Care Unit, Choithrams Memorial Hospital, in Freetown, Sierra Leone between July 2014 to June 2019. Clinical data, and pertinent investigations related to PE were determined. CTPA findings were correlated with the patient's hemodynamic status. The calculated pretest clinical probability scores (PCPS) for each patient were compared to the CTPA results. RESULTS: CTPA-confirmed PE in the study cohort was 79, with a rate of 16 new PE per year. The frequency of PE was 1.9% of the total hospital admission per year. The mean age was 64.1 ± 17.9 years, median age was 63.3years (range: 23-89 years), with 55.7% of the cohort being females. Dyspnea (78.5%) and tachycardia (69.6%) were the commonest signs and symptoms documented, with immobilization (34.2%) being the prevalent risk factor, while hypertension (48.1%) was the most common co-morbidity. The PCPS algorithm was underutilized, as "Wells Score" was documented in only 9.5% while "modified Geneva score" was never used by hospital physicians. PE with hemodynamic stability was significantly more common than PE with unstable hemodynamic status [55 (69.6%) vs 24 (30.4%), p=0.015]. All patients were managed only with anticoagulants. The overall in-hospital mortality was 17.7%. CONCLUSION: Since PCPS was hardly calculated by doctors in the diagnosis of PE, the study showed that the diagnostic algorithm for suspected PE was infrequently used in clinical practice. The use of empirical judgement by doctors in requesting for CTPA may have accounted for low rate in the diagnosis of PE per year. The establishment of P.E registry in Sierra Leone is imperative.

INTRODUCTION: En Sierra Leone, le manque d'informations sur l'embolie pulmonaire (EP) limite l'accès à des normes de diagnostic et de prise en charge de la maladie fondées sur des preuves. L'objectif de cette étude était de décrire les caractéristiques cliniques et la prise en charge de l'embolie pulmonaire aiguë dans notre établissement et de déterminer si les algorithmes de notation de la probabilité pré-test étaient utilisés avant la demande d'angiographie pulmonaire par tomodensitométrie (CTPA). MÉTHODES: Cette étude observationnelle rétrospective a été menée sur des patients atteints d'EP confirmée par CTPA admis à l'unité de soins intensifs, Choithrams Memorial Hospital, à Freetown, Sierra Leone, entre juillet 2014 et juin 2019. Les données cliniques, et les investigations pertinentes liées à l'EP ont été déterminées. Les résultats du CTPA ont été corrélés avec l'état hémodynamique du patient. Les scores de probabilité clinique prétest (PCPS) calculés pour chaque patient ont été comparés aux résultats du CTPA. RÉSULTATS: Le nombre d'EP confirmées par CTPA dans la cohorte étudiée était de 79, avec un taux de 16 nouvelles EP par an. La fréquence de l'EP était de 1,9 % du nombre total d'hospitalisations par an. L'âge moyen était de 64,1 ± 17,9 ans, l'âge médian de 63,3 ans (fourchette : 23-89 ans), 55,7 % de la cohorte étant des femmes. La dyspnée (78,5 %) et la tachycardie (69,6 %) étaient les signes et symptômes les plus fréquemment documentés, l'immobilisation (34,2%) étant le facteur de risque prévalent, tandis que l'hypertension (48,1 %) était la comorbidité la plus courante. L'algorithme PCPS était sous-utilisé, le " score de Wells " n'étant documenté que dans 9,5 % des cas, tandis que le " score de Genève modifié " n'était jamais utilisé par les médecins hospitaliers. L'EP avec stabilité hémodynamique était significativement plus fréquente que l'EP avec état hémodynamique instable [55 (69,6 %) vs 24 (30,4 %), p=0,015]. Tous les patients ont été traités uniquement par anticoagulants. La mortalité globale à l'hôpital était de 17,7 %. CONCLUSION: Étant donné que le PCPS était rarement calculé par les médecins pour le diagnostic de l'EP, l'étude a montré que l'algorithme diagnostique pour l'EP suspectée était rarement utilisé dans la pratique clinique. L'utilisation d'un jugement empirique par les médecins pour demander un CTPA peut expliquer le faible taux de diagnostic de l'EP par an. L'établissement d'un registre de l'E.P. en Sierra Leone est impératif. Mots-clés: Embolie pulmonaire, caractéristiques cliniques, gestion, Sierra Leone.

Prevalence, Awareness and Risk Factors of Hypertension among Health Workers at the Connaught Teaching Hospital, Sierra Leone.

BACKGROUND: Hypertension among the health workforce is a major public health problem due to its high prevalence and dire consequences. This study aimed to determine the prevalence of hypertension, awareness, and related cardiovascular risk factors among health workers in a Teaching Hospital in Sierra Leone. METHODS: This was a cross-sectional descriptive study conducted among 250 health workers. A modified World Health Organization Non-Communicable Disease (WHO NCD) questionnaire was used to collect information on the socio-demographic characteristics, anthropometric, and lifestyle variables. RESULTS: The prevalences of hypertension and pre-hypertension were 37.2% and 22.4% respectively. The level of hypertension awareness was 36.6 %. The univariate logistic regression showed a significant crude odds ratio for gender, age, marital status, smokers, alcohol, extra sugar to tea/coffee, years of employment, weight, Waist Circumference, Hip Circumference, and Waist-Hip-Ratio (WHR) in the prediction of hypertension. The multivariate logistic regression revealed that male sex (AOR = 1.89; C.I 95%: [0.01- >20], p = 0.002), duration of employment (AOR = 0.36; C.I 95%: [0.17- 0.94], p = 0.01), and Waist Circumference (WC) (AOR = 1.46; C.I 95%: [0.58 - 3.68], p = 0.017), were positive predictors of hypertension. Males were about 2 times more likely to have hypertension, (AOR = 1.89; C.I 95%: [0.01- >20]). Participants with abnormal Waist Circumference (WC) were 1.5 times more likely to have hypertension (AOR = 1.46; C.I 95%: [0.58 - 3.68]). CONCLUSION: The prevalence of hypertension in this study population was slightly higher than the 34.8% reported for the general population even though this study population is relatively younger. The level of awareness was low. This calls for the implementation of an effective workplace health education program to improve lifestyle and reduce the risk of cardiovascular diseases.

Stroke in Sierra Leonean Africans:Perspectives from a Private Health Facility.

BACKGROUND: Several stroke studies in West Africans have demonstrated a high proportion of haemorrhagic stroke and poor outcomes. This may be due to the socioeconomic status of patients and inadequate clinical care. Outcomes may well be different if more informed patients treated in better facilities are studied. OBJECTIVE: To study the pattern of stroke and stroke outcomes in African patients attending a private hospital in Sierra Leone METHODS: 150 consecutive African stroke patients admitted to a private hospital in Sierra Leone were studied. Demographic details, risk factors, clinical features including blood pressure were recorded. CT scans, ECG, serum cholesterol, and blood sugar were done. Patients were reviewed at day 30 and Rankin scores allocated. Two sample independent t-test was used to compare means, and chi square to compare variables. RESULTS: Hypertension was the most common risk factor present in 77.6% of patients prior to admission with diabetes in 29.5%. Other risk factors include previous stroke (11.7%), smoking (6.3%), hypercholesterolemia (23.4%), high alcohol intake (28.8%) and lack of exercise according to self-evaluation (87.5%). 76.3% of patients had ischaemic and 18.2% haemorrhagic stroke. 41% of patients aged 50 years or less had haemorrhagic stroke and 9.3% of patients had atrial fibrillation. In-patient mortality was 10.6%. CONCLUSION: Stroke types and outcomes are different from those generally reported from the sub-region. This may well be due to the population studied, and the level of care provided by a private facility. Socio-economic factors, literacy and clinical care are likely determinants of stroke types and outcomes in African patients. . More detailed studies to confirm the effects of socioeconomic factors on stroke pattern and outcomes in Africa are needed.

Posterior Reversible Encephalopathy Syndrome and Eclampsia in a Primigravid Woman: The First Reported Case from Sierra Leone.

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-neuroradiological entity with neurological symptoms and characteristic radiologic findings. It may complicate eclampsia either during pregnancy or in the puerperal period and it is a very serious neurological condition manifesting as acute headache,impairment of consciousness, seizures, cortical blindness and occasionally, focal neurological signs accompanied by a typical CT or MR imaging pattern.A 30 years old right handed primigravida housewife was managed for PRES and this is the first reported case in Sierra Leone. Clinicians in Africa should consider this diagnosis in all cases of eclampsia in order to reduce the morbidity and mortality that may result from delayed diagnosis.

Rapid weight gain and benign intracranial hypertension in an AIDS patient on treatment with highly active anti-retroviral therapy (HAART)

We present the case of a 30 year old woman with HIV/AIDS who experienced a 47 percent weight gain over a period of a year after commencing treatment with highly active anti-retroviral therapy (HAART) and went on to develop benign intracranial hypertension (BIH). She was not on any other medication associated with BIH. Although weight gain has been reported in patients on treatment with protease inhibitors, such gains have been minimal to moderate. We are unaware of any previous report of this degree of weight gain or BIH in a patient on protease inhibitors.(Au)

Rapid weight gain and benign intracranial hypertension in an AIDS patient on treatment with highly active anti-retroviral therapy (HAART)

We present the case of a 30-year-old woman with HIV/AIDS who experienced a 47 weight gain over a period of a year after commencing treatment with highly active anti-retroviral therapy (HAART) and went on to develop benign intracranial hypertension (BIH). She was not on any other medication associated with BIH. Although weight gain has been reported in patients on treatment with protease inhibitors, such gains have been minimal to moderate. We are unaware of any previous report of this degree of weight gain or BIH in a patient on protease inhibitors.

Rapid weight gain and benign intracranial hypertension in an AIDS patient on treatment with highly active anti-retroviral therapy (HAART).

We present the case of a 30-year-old woman with HIV/AIDS who experienced a 47% weight gain over a period of a year after commencing treatment with highly active anti-retroviral therapy (HAART) and went on to develop benign intracranial hypertension (BIH). She was not on any other medication associated with BIH. Although weight gain has been reported in patients on treatment with protease inhibitors, such gains have been minimal to moderate. We are unaware of any previous report of this degree of weight gain or BIH in a patient on protease inhibitors.

Blood pressure and hypertension in rural and urban Sierra Leoneans.

OBJECTIVE: To determine the prevalence and awareness of hypertension and determinants of blood pressure in rural and urban Sierra Leoneans. METHOD: 598 subjects from Freetown and 606 subjects from three villages in the northern province of Sierra Leone were selected for this study using multi-stage sampling. All were adults aged 15 years and over. Single blood pressure measurements were made after a minimum rest period of 10 minutes using a mercury sphygmomanometer. Korotkoffs phases I and V were used for systolic and diastolic blood pressures, respectively. Standard anthropometric measurements were made and a questionnaire used to collect information on demographic, dietary, and social factors, including consumption of tobacco products, alcohol, salt, palm oil, and kola nuts. Hypertension was diagnosed if systolic blood pressure(SBP) was equal or greater than 160 mm Hg and/or if diastolic blood pressure(DBP) was equal or greater than 95 mm Hg and/or there was a history of hypertensive therapy. RESULTS: The age-adjusted prevalence of hypertension in the Freetown and Port Loko subjects was 23.4% and 14.7%, respectively (P=0.006). Females had a higher prevalence in both populations. The most significant determinants of blood pressure were age, body mass index (BMI) and a low level of education. When adjusted for BMI and age, no significant difference in prevalence was observed between the two populations. The level of awareness was low, particularly in the rural areas. CONCLUSION: This survey confirms a high prevalence, and low level of awareness, of hypertension in rural and urban Sierra Leoneans.

A high prevalence of hypertension in rural Sierra Leone.

A cross sectional survey to determine the mean systolic and diastolic blood pressure, prevalence of hypertension, and possible risk factors in two villages, Kychum and Njala Komboya, in Sierra Leone was carried out. A total of 463 subjects were investigated. Hypertension was defined according to WHO criteria, i.e. a systolic pressure equal or greater than 160 mmHg, and/or diastolic equal or greater than 95 mmHg. The mean systolic blood pressure for the total population was 131.39 +/- 26.85 mmHg and the mean diastolic blood pressure was 82 +/- 14.80 mmHg. There was no significant difference in blood pressure levels between the two villages. The mean prevalence of hypertension was 22.4%, with Kychum 17.6%, and Njala Komboya 24.8% (X2 = 1.11, p > 0.05). Systolic and diastolic blood pressure levels were associated with age, snuff, (ground tobacco), smoking tobacco leaf, kolanut consumption and parity, but all these associations disappeared when the sample was controlled for age. Age was therefore the most significant correlate of blood pressure. Blood pressure levels were not related to gender, body mass index or cigarette smoking. Hypertension on the other hand was only 4.8% among the subjects found to be hypertensive. These rural populations studied had higher blood pressure levels and higher prevalence of hypertension than similar populations in other African countries in spite of a low body mass index. These findings emphasize the need for more studies in other areas of Sierra Leone, especially urban areas, and calls for improved screening facilities for the early detection and treatment of hypertension in Sierra Leoneans.

Prevalence of diabetes in rural and urban populations in southern Sierra Leone: a preliminary survey.

We conducted a preliminary community survey for diabetes in the Bo district of southern Sierra Leone. Five hundred and one subjects comprising 256 rural adults in two villages and 245 urban adults in Bo town were randomly selected and screened for diabetes using random capillary blood glucose according to WHO criteria. There were 6 diabetics, all in the urban area, giving a prevalence of 2.4% in the urban population, and 0% in the rural villages. The mean (s.d.) capillary random blood glucose (RBG) concentration was 5.7 +/- 1.7 mmol/l for the entire study population, while concentrations for the urban and rural populations were 5.8 +/- 2 and 5.5 +/- 1.4 mmol/l respectively (P > 0.05). RBG increased significantly with age. The mean (s.d.) body mass index (BMI) was 22.3 +/- 4.9 kg/m2 for the total population while those for the urban and rural populations were 23.0 +/- 5.8 and 21.6 +/- 3.6 respectively (P < 0.01). Only 5% of the population were obese, i.e. BMI > or = 30 kg/m2. Dietary habits were similar in both town and country. According to this survey, the prevalence of diabetes is very low in rural Sierra Leone, but urban areas may be experiencing increasing prevalence. Mechanisms for effective screening and promotion of proper diet and exercise must be incorporated into existing health services to prevent an escalation of diabetes in urban Sierra Leone.

The significance and trend of hypertension related deaths in urban Sierra Leonean Africans.

In order to determine the impact and trend of hypertension related deaths in the overall mortality of urban Sierra Leoneans, a review of death certificate records in the capital Freetown over the period 1983-1992 was undertaken. A total of 25119 consecutive records were examined to identify those with hypertension as a major or contributory cause of death. For the purpose of this study, hypertensive stroke, cardiac and renal deaths were selected as the main hypertension related disorders. Hypertension related deaths accounted for an average of 7.5% of all deaths and 13.7% of deaths in those aged 40 years and above between 1983 and 1992. For the latter group, stroke deaths accounted for 5.2%, cardiac deaths for 4.7%, and renal deaths for 0.8% of total mortality. There were more male hypertensive stroke deaths but when expressed as a percentage of the total deaths, no sex difference was noted. Hypertensive stroke deaths accounted for 7% of all deaths in the age group 50-69 years in females, while hypertensive cardiac deaths, caused 6% of deaths in the 60-69 year age group in both sexes. Hypertensive renal death was infrequently recorded being present mainly in the 40-49 year age group predominantly in males. When all hypertension related deaths were considered together, their major impact was in the seventh decade in females and in the eighth decade in males accounting for approximately 20% and 16% of all deaths respectively. Hypertension related deaths appeared to show a steady increase over the 10 year study period. Hypertension is a significant cause of death particularly in elderly urban Sierra Leoneans in Freetown and deaths from hypertension may be increasing.

Early presentation of hemispheric intracerebral hemorrhage: prediction of outcome and guidelines for treatment allocation.

Criteria for selecting patients for possible surgery in the management of intracerebral hemorrhage (ICH) are needed to plan a prospective therapeutic evaluation of surgical intervention. This study specifically addressed patients seen in the emergency room within a few hours of the ictus, many of whom were still awake, to identify and subsequently exclude from surgical procedure those expected to recover completely and those expected to die regardless of treatment. We retrospectively studied 75 patients evaluated at a mean time of 3 hours and 37 minutes after hemispheric ICH to determine factors that would predict both good and poor outcomes at the time of discharge. Eighty percent of our patients presented within 6 hours of symptom onset. These patients were younger and had more severe lesions than did those presenting later, yet most were still awake (mean admission Glasgow Coma Scale [GCS] score = 11.0). Using multivariate regression, we created two models. The first model predicts independent outcome, ie, Rankin 0 to 2, of all patients with a GCS score greater than 9 on admission who do not undergo surgery. The significant factors in this model were hemorrhage diameter, intraventricular extension, and age. The second model predicts poor outcome, ie, Rankin 5 and death, of all patients. GCS score, hemorrhage volume, age, and gender were the important factors in this model. We conclude that ICH patients presenting early to the emergency room have more severe lesions radiologically, although their initial clinical status may not be different from those seen late. Our models should identify and thus exclude those with very good and very poor prognoses from future randomized surgical trials.

Blood pressure profiles of pre-employed subjects in urban Sierra Leone

IN a survey of 298 clinic records of urban subjects undergoing routine medical examinations for employment; 19.4 per cent were found to be hypertensive; and in over half of these; the hypertension was moderate or severe i.e. Diastolic pressure of 105mm.Hg. or more; and/or systolic of 180mm. Hg.- or more. A further 21.5 per cent of subjects had borderline hypertension. Thus over 40 per cent of the study population were either hypertensive or had borderline hypertension. Of the hypertensive subjects; males were more affected than females; and blood pressure rose progressively with age. There was also a tendency towards higher blood pressures in obese subjects with body mass index (BMI) 27 kg/m2 and above. Males in the age group 40-49 years had the highest prevalence. The prevalence of hypertension in this selected group of urban subjects is high. An urban community survey of hypertension is required to determine the prevalence in the community as a whole

Should hypertension be treated after acute stroke? A randomized controlled trial using single photon emission computed tomography.

OBJECTIVE: To determine if previously hypertensive patients with acute ischemic stroke should be treated with antihypertensive medication in the immediate poststroke period. DESIGN: Randomized double-blind, placebo-controlled trial. SETTING: Sixteen consecutive hypertensive patients (four men and 12 women; mean age, 66 years [age range, 46 to 83 years]) with middle cerebral artery infarction within 72 hours of onset and blood pressure between 170 and 220 mm Hg(systolic) and 95 and 120 mm Hg (diastolic). INTERVENTION: Placebo (n = 6), nicardipine hydrochloride (20 mg [n = 5]), captopril (12.5 mg [n = 3]), or clonidine hydrochloride (0.1 mg [n = 2]) given every 8 hours for 3 days. MAIN OUTCOME MEASURES: Decline in blood pressure, change in cerebral blood flow as measured by single photon emission computed tomography, and clinical change as determined by the National Institutes of Health Stroke Scale. RESULTS: Blood pressure fell significantly in both the drug-treated group as a whole and in those patients receiving placebo (P < .001). There was no difference in blood pressure levels between these two groups throughout the study period. Patients receiving nicardipine had a consistently lower pressure than the other groups. A significant negative relationship was noted between the maximum blood pressure fall and improvement in cerebral blood flow. There were four patients whose blood pressure dropped by more than 16% of the baseline value on any 24 hours in the first 3 days. All either failed to increase or actually decreased their cerebral blood flow to the affected area. Three of these patients were treated with nicardipine. There was no significant difference in clinical course between the placebo-and drug-treated groups as a whole. CONCLUSIONS: Hypertensive ischemic stroke patients with a moderate elevation of blood pressure in the first few days may not require antihypertensive therapy. Nicardipine and possibly other calcium channel blockers may cause an excessive fall in blood pressure and impair cerebral blood flow in these patients and should therefore be used with caution.

Hypertension in Sierra Leone stroke population.

A retrospective study of 87 hospitalized Sierra Leonean stroke patients is presented. The mean age was 50.9 years with a male to female ratio of 2:1. Hypertension was present in 68% of patients but only in those above 30 years of age. It was also more prevalent in females than males. Mean arterial pressure increased with age up to 40 years after which is remained constant. Thirteen patients died during admission. Fatal cases were significantly older (p < 0.001), and had a higher mean arterial pressure (p < 0.05) than survivors. It is considered that hypertension is a greater risk factor in stroke in the West Africans than in other African regional groups. The historical relationship between the West African and black American, who also have a high prevalence of hypertension, is recognized and discussed. More research on hypertension and stroke in populations such as these may reveal important clues to the aetiology and pathogenesis of these serious vascular disorders.

Electrodiagnosis of neuromuscular disorders in Sierra Leoneans: service utilisation and problems of sustainability

The indications for nerve conduction studies and electromyography on 642 patients were referred to the neurology unit over a ten year period are reviewed. Mononeuropathies; peripheral neuropathies and proximal nerve lesions were the main clinical indications for the investigations and diagnosis was substantially aided in mononeuropathies; peripheral neuropathies; traumatic nerve damage; myopathies and myasthenia gravis. Conversely; patients referred with unilateral sensory disturbances; movement disorders and burning feet syndrome did not benefit. Skilled manpower and the high recurring cost of the tests were the most serious limiting factors threatening the sustainability of the service. Discretionary referrals and involvement of non-specialized medical officers in the performance of tests will improve service delivery; but fiscal contribution from the health sector to complement cost recovery is vital to sustain and expand this service

Epilepsy pattern and clinic compliance in Sierra Leonean epileptics

Two hundred and twenty patients with epilepsy attending the neurologic clinic at Connaught Hospital were reviewed. Male predominance; greater prevalence of primary generalised seizures and low family history are consistent with reports from other African countries. Similarly the majority of patients had idiopathic epilepsy. Only 35 per cent of patients attented clinic for six months and 12 per cent for two years. Cultural attitudes; cost of medication and distance from clinic may contribute to the low level of clinic attendance. It is suggested that integrating the follow up and treatment of epileptics into primary health care programmes will make a greater impact on epilepsy control

Stroke in Sierra Leoneans

The clinical and laboratory data of eighty-seven Sierra Leoneans with clinical stroke are presented. Male predominance and younger age distribution are consistent with other African series. Hypertension was present in 60 per cent of cases and tended to be more severe in fatal cases. Hypercholesterolaemia was also common. A larger and more detailed longitudinal study is required to determine fully the role of these and other risk factors of this condition in the Sierra Leone