Knowledge and utilization of electrocardiogram among resident doctors in family medicine in Nigeria.

BACKGROUND: Electrocardiogram (ECG) is a simple, readily affordable, and noninvasive tool for the evaluation of cardiac disorders. There is a dearth of information on the utility of ECG in general practice in Nigeria. We assessed the knowledge and utilization of ECG among family medicine residents in Nigeria. MATERIALS AND METHODS: A cross-sectional evaluation was conducted between November 2011 and May 2012 in four family medicine training centers in Nigeria. A self-administered questionnaire was used to obtain information from the resident doctors regarding their ECG requests, preferred source of interpretation, most common ECG diagnosis, and update of ECG knowledge. RESULTS: Only 61 out of 120 questionnaires (50.8%) were returned. The respondents were mostly between 31 and 40 years (54.7%) and were predominantly males (73.8%) and senior residents (65.6%). Fifty-four (88.3%) respondents made <5 ECG requests/week, and the most common indication was hypertension (50%). ECG interpretation was either self-reported (41%), by a cardiologist (26.5%), or automated reports (21.3%). Self-reporting of ECG was more common among senior residents (P < 0.01). Left ventricular hypertrophy was the most common ECG diagnosis (55.8%). About 69% of respondents did not update their knowledge of ECG. Most respondents (50%) reported basic interpretation as the aspect of ECG for which further learning was desired. Teaching ECG to resident doctors in the update courses of the postgraduate medical colleges and continuing medical education (CME) activities was adjudged the best way to improve knowledge/utility (61.1%). CONCLUSION: The attitude to and utility of ECG among family medicine residents in Nigeria is poor. Improved knowledge, attitude, and utilization of ECG through curriculum revision, hands-on tutorials, and CMEs are highly recommended.

A survey of asthma management practices and implementation of Global Initiative for Asthma guidelines among doctors in a resource-limited setting in Nigeria.

BACKGROUND: Bronchial asthma is a global health problem that causes significant morbidity and mortality in all age groups. Global Initiative for Asthma (GINA) seeks to standardize the care asthma patients receive. We assessed the knowledge, attitude, and practices of doctors in Umuahia, Southeast Nigeria, regarding asthma and determined the extent to which they abide by GINA guidelines in their management of asthma. METHODOLOGY: It was a descriptive cross-sectional study. A pretested self-administered questionnaire was used to obtain information from the participants regarding knowledge of asthma prevalence, asthma risk factors, and management practices. RESULTS: Out of 142 questionnaires administered, 117 were retrieved giving a response rate of 82%. About 70% were men, and the most common age group was 30-39 years (57.3%). The median duration of medical practice was 6 (3-12) years. About 77% reported asthma prevalence to be on the increase. While 105 (89.7%) respondents had seen a spirometer, only 28 (23.9%) use spirometry in asthma diagnosis. Similarly, 95 (81.2%) had seen a peak flow meter, but only 41 (35.5%) use it in asthma diagnosis. Only 7 (6.0%) respondents reported that their patients keep a peak flow diary. Of 117 respondents, 94 (80.3%) know about GINA guidelines for asthma control, 45 (38.5%) apply GINA guidelines in patient care, 86 (73.5%) regularly review patient inhaler technique, 33 (28.2%) use adult asthma control test while 17 (14.5%) regularly review asthma action plan with patients. CONCLUSION: There is a wide gap between GINA guidelines and the knowledge, attitude, and practices of doctors in Umuahia regarding asthma management. Improvement and standardization of asthma care are recommended.

Insulin resistance, metabolic syndrome, and lipids in African women.

BACKGROUND: The metabolic syndrome is closely related to insulin resistance (IR) and cardiovascular disease. This study examined the prevalence of IR and metabolic syndrome as well as factors associated with IR among Nigerian women. MATERIALS AND METHODS: Eighty-six women living in an urban area in Enugu, South-East Nigeria, were assessed. Demographic information included age, residence, physical activity, alcohol and tobacco intake and were collected with questionnaires. Blood pressure and anthropometric parameters were measured using standard methods. Fasting lipids, blood glucose, and insulin were measured. IR was calculated with homeostasis model assessment of IR formula. The ratios; triglyceride/high-density lipoprotein (TG/HDL), total cholesterol (TC)/HDL, and atherogenic index of plasma; log (TG/HDL) were calculated and compared with IR. Metabolic syndrome was sought for using both the WHO and the harmonized joint criteria. RESULTS: The mean age was 44.4 (13.1) years. Hypertension, obesity/overweight, and abdominal obesity were present in 31.5%, 81.1%, and 92.2%, respectively. There was elevated TC (62.2%), elevated low-density lipoprotein (45.6%), low HDL (40%), and elevated TG (14.4%) levels. IR was present in 39 (45.3%). Metabolic syndrome was present in 25 (29.1%) and 17 (19.8%) using the joint criteria and the WHO criteria, respectively. The sensitivity and specificity of the joint revised criteria in identifying IR individuals were 48.7% and 87.2%, respectively, and for the WHO criteria, were 38.5% and 95.7%, respectively. The only significant predictor of IR was the presence of diabetes; P = 0.03, odds ratio = 7.2 (95% confidence interval = 1.19-41.88). CONCLUSION: IR and metabolic syndrome were common. They were not related to any of the lipoprotein ratios. Metabolic syndrome had a low sensitivity in detecting IR.

Disparities in the Magnitude of Human Immunodeficiency Virus-related Opportunistic Infections Between High and Low/Middle-income Countries: Is Highly Active Antiretroviral Therapy Changing the Trend?

Opportunistic infections (OIs) cause significant morbidity/mortality in human immunodeficiency virus (HIV)-infected individuals globally. Disparities between high-income countries (HICs) and low/middle-income countries (LMICs) in the magnitude of HIV-related OIs in pre-highly active antiretroviral therapy (HAART) populations was reviewed, and HAART-induced decline in OIs was further compared between the two settings. Studies published in English from onset of HIV epidemic up to December 2013 were searched in PubMed, Google, Google Scholar, and African Journal online. An article was included if (a) the study was conducted in HIC or LMIC, (b) the age of the participants was ≥12 years, (c) the HAART status of the participants was stated, and (d) various types of OIs were investigated. In predominantly pre-HAART populations, the incidence and prevalence of overall HIV-related OIs in HIC ranged from 5.5 to 50.0 per 100 person-years (PY) and 27.4-56.7%, respectively. In LMIC, the respective overall incidence and prevalence of OIs were 12.2-93.9 per 100 PY and 32.0-77.7%. Pneumocystis jirovecii pneumonia, candidiasis, Cytomegalovirus disease, Mycobacterium avium complex disease, and Kaposi's sarcoma were the most frequent OIs in HICs while tuberculosis, candidiasis, chronic diarrhea, and cryptococcosis were predominant in LMICs. The introduction of HAART led to substantial reduction in the incidence of OIs with more impressive percentage decline in HICs (43-97%) compared to 30-79% in LMICs. Disparities in the magnitude of HIV-related OIs between HICs and LMICs are evident both in the pre-HAART and post-HAART era. Efforts to optimize HAART-induced decline in HIV-related OIs should become a global health priority irrespective of prevailing socioeconomic circumstances.

Factors Associated with Prevalent Tuberculosis Among Patients Receiving Highly Active Antiretroviral Therapy in a Nigerian Tertiary Hospital.

BACKGROUND: Tuberculosis (TB) causes significant morbidity/mortality among human immunodeficiency virus-infected individuals in Africa. Reducing TB burden in the era of highly active antiretroviral therapy (HAART) is a public health priority. AIM: We determined the factors associated with prevalent TB among patients receiving HAART. SUBJECTS AND METHODS: We conducted a cross-sectional study of adult patients who had received HAART for ≥12 weeks in a Nigerian tertiary hospital. Patients whose TB diagnosis predated HAART were excluded from the study. Pre-HAART data were collected from the clinic records, whereas post-HAART data were obtained through medical history, physical examination, and laboratory investigations. Standard TB screening/diagnostic algorithms as applicable in Nigeria were used. Logistic regression analysis was used to determine factors independently associated with prevalent TB. RESULTS: about 65.8% (222/339) were women. The mean age was 41.1 (10.0) years and 23.6% (73/339) had past history of TB. The prevalence of active TB was 7.7% (26/339). Among these patients, 42.3% (11/26) had pulmonary TB, 34.6% (9/26) had disseminated TB, whereas 23.1% (6/26) had only extra-pulmonary disease. Only 45% (9/20) of patients with pulmonary involvement had positive sputum smear. Factors independently associated with prevalent TB were lower social class (adjusted odds ratio [aOR]: 31.7; 95% confidence interval [CI]: 1.1-1417.3), HAART non-adherence (aOR125.5; 95% CI: 9.6-1636.3), baseline CD4 <200cells/µl (aOR31.0; 95%CI: 1.6-590.6), previous TB (aOR13.8; 95% CI: 2.0-94.1), and current hemoglobin <10 g/dl (aOR10.3; 95% CI: 1.1-99.2). CONCLUSION: Factors associated with prevalent TB were a lower social class, HAART non-adherence, severe immunosuppression before HAART initiation, previous TB, and anemia post-HAART. TB case finding should be intensified in these high-risk groups.

Factors Associated with Prevalent Tuberculosis Among Patients Receiving Highly Active Antiretroviral Therapy in a Nigerian Tertiary Hospital

Background: Tuberculosis (TB) causes significant morbidity/mortality among human immunodeficiency virus­infected individuals in Africa. Reducing TB burden in the era of highly active antiretroviral therapy (HAART) is a public health priority.Aim: We determined the factors associated with prevalent TB among patients receiving HAART.Subjects and Methods: We conducted a cross­sectional study of adult patients who had received HAART for ≥12 weeks in a Nigerian tertiary hospital. Patients whose TB diagnosis predated HAART were excluded from the study. Pre­HAART data were collected from the clinic records, whereas post­HAART data were obtained through medical history, physical examination, and laboratinvestigations.StandardTBscreening/diagnostic algorithms as applicable in Nigeria were used. Logistic regression analysis was used to determine factors independently associated with prevalent TB.Results: about 65.8% (222/339) were women. The mean age was 41.1 (10.0) years and 23.6% (73/339) had past history of TB. The prevalence of active TB was 7.7% (26/339). Among these patients, 42.3% (11/26) had pulmonary TB, 34.6% (9/26) had disseminated TB, whereas 23.1% (6/26) had only extra­pulmonary disease. Only 45% (9/20) of patients with pulmonary involvement had positive sputum smear. Factors independently associated with prevalent TB were lower social class (adjusted odds ratio [aOR]: 31.7; 95% confidence interval [CI]: 1.1­1417.3), HAART non­adherence (aOR125.5; 95% CI: 9.6­1636.3), baseline CD4 <200cells/µl (aOR31.0; 95%CI: 1.6­590.6), previous TB (aOR13.8; 95% CI: 2.0­94.1), and current hemoglobin <10 g/dl (aOR10.3; 95% CI: 1.1­99.2).Conclusion: Factors associated with prevalent TB were a lower social class, HAART non­adherence, severe immunosuppression before HAART initiation, previous TB, and anemia post­HAART. TB case finding should be intensified in these high­risk groups

Relationship between Six-Minute Walk Test and Left Ventricular Systolic Function in Nigerian Patients with Heart Failure.

BACKGROUND: Heart failure (HF) is a major public health problem. The six-minute walk test (6MWT) is a submaximal exercise test performed even by HF patients not tolerating maximal exercise testing. The left ventricular ejection fraction is one of the strongest indicators of mortality in HF. Literature reports that relationship between 6MWT and (Left Ventricular Systolic Function (LVSF) were not homogenous, hence the need for this study. METHODS: One hundred and forty consenting HF patients in NYHA II and III were consecutively recruited after obtaining ethical clearance. The patients were made to walk on a level ground at their own convenient pace while attempting to cover as much ground as possible in six minutes. Echocardiography was also performed on all the patients. RESULTS: Eighty-five (60.7%) were women. The population mean age was 48.2 ± 14.5 years. The average distance walked was 272.2 ± 114.0 meters and the mean ejection fraction (EF) was 36.73 ± 15.04. Patients in NYHA II significantly walked longer than those in NYHA III (334.81 ± 98.80m vs 204.05 ± 87.66m; p<0.001). There was no correlation between the distance walked and LVSF; EF(r = -0.402, P = 0.534), SF (r = -0.128, P = 0.878).The independent predictors of distance walked were sex (p=0.021) and NYHA stage(p<0.0001). CONCLUSION: NYHA stage and sex independently predicted the distance walked in our HF patients. There was an inverse relationship between 6MWT and NYHA, with no correlation between 6MWT and LVSF. 6MWT therefore, appears not to be a good measure of LVSF as assessed by M-mode derived EF, in our HF patients.

REVIEW OF CONTROL OF HUMAN IMMUNODEFICIENCY VIRUS INFECTION IN NIGERIA.

The global scourge of human immunodeficiency virus (HIV) infection is inundating, especially in sub-Saharan Africa and in particular Nigeria which is home to 10% of the world's HIV-infected persons. The target of the millennium development goal 6 is to halt and reverse the spread of HIV/AIDS by 2015. HIV control in Nigeria was initially shrouded in denial and apathy. Subsequently, a more pragmatic approach was launched during the tenure of President Olusegun Obasanjo. Several policies were formulated. The national prevalence of HIV witnessed some progressive decline and is currently 4.1%. There is now improvement in both HIV awareness and counselling and testing. Greater access to antiretroviral therapy and other support services have also been witnessed with over 300,000 persons currently on drugs. Notable achievements have been recorded in prevention of mother to child transmission (PMTC). However, with increased access to antiretroviral therapy, antiretroviral drug resistance has become inevitable. Acquired drug resistance is high-82% and transmitted drug resistance ranges between 0.7 and 4.5%. The achievements were largely facilitated by international partnerships which have become more streamlined in recent years. A sustained shift to indigenously sourced financial and manpower resource has become imperative. It is also important to integrate HIV facilities with other existing health care facilities for sustainability and cost-effectiveness. In an attempt to strengthen the national response, President Goodluck Ebele Jonathan launched the President's Comprehensive Response Plan for HIV/AIDS in Nigeria. It is hoped that this well-articulated policy would be well implemented to significantly reverse the epidemic.

An audit of diagnosis and treatment of sepsis in north-central Nigeria.

BACKGROUND: We audited the diagnosis and antibiotic therapy of patients admitted with sepsis in a resource-limited Nigerian hospital setting in order to improve the quality of sepsis care. METHOD: We conducted a retrospective analysis of the records of medical patients admitted for sepsis at the Jos University Teaching Hospital between September 2011 and August 2012. Data analysis included age, sex, appropriateness of sepsis diagnosis/severity, comorbidities, utility/yield of sample cultures, antibiotic therapy, duration of hospital stay and treatment outcome. RESULT: Only 94 out of 142 cases (66.2%) were judged to meet the diagnostic criteria for sepsis. Out of the 94 patients, 77 (82%) were appropriately classified for sepsis severity. Nineteen patients (20%) met criteria for severe sepsis/septic shock. The commonest comorbidity was HIV/AIDS (57.3%). All the patients received empirical antibiotic therapy but in 23 cases (24.5%), the empirical prescriptions were judged inappropriate and none was administered within one hour of diagnosis. Blood cultures were available to guide definitive antibiotic therapy in only 12.5% of cases. The median (range) duration of hospital stay was 12 (1-70) days while the in-hospital mortality rate was 53%. CONCLUSION: The management of sepsis was suboptimal in our setting and mortality was high. We recommend adoption of standard sepsis guidelines to ensure optimal management and improved outcome.

Liver function test abnormalities in Nigerian patients with human immunodeficiency virus and hepatitis B virus co-infection.

Data on baseline hepatic function of HIV and hepatitis B virus (HBV) co-infected patients are limited in sub-Saharan Africa. We assessed liver function test (LFT) abnormalities in Nigerian patients with HIV/HBV co-infection to highlight the impact of HIV on HBV-related liver disease in sub-Saharan Africa. A cross-sectional study involving 100 HIV/HBV co-infected patients and 100 age- and sex-matched HBV mono-infected controls. Blood testing for HIV antibodies, CD4+ cell count, hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), LFTs, platelet count, fasting blood glucose and lipid profile were carried out. Non-invasive hepatic fibrosis scores (aspartate aminotransferase-platelet ratio index [APRI] and FIB-4) were also calculated. Co-infected patients had deranged liver enzymes more than the controls (77% versus 64%, P = 0.04). The predominant patterns of enzyme derangement in co-infected patients were either predominantly ↑ALP (30% versus 4%, P < 0.0001) or mixed (30% versus 15%, P = 0.01) but predominantly ↑AST/ALT in the controls (25% versus 9%, P = 0.003). Co-infected patients had higher fibrosis scores for both APRI (P = 0.002) and FIB-4 (P = 0.0001). On further analysis, LFT abnormalities and fibrosis scores were only significantly higher in co-infected patients in the immune clearance and HBeAg-negative chronic hepatitis phases. LFT abnormalities are common in Nigerians with HBV infection and co-infection with HIV negatively impacts on hepatic function.