Body mass index, proteinuria and total lymphocyte counts in predicting treatment responses among ART naïve individuals with HIV initiated on antiretroviral treatment in Dar es Salaam, Tanzania, 2019: a cohort study.

OBJECTIVES: To explore the potential use of body mass index (BMI), proteinuria and total lymphocyte count changes in predicting immunological and virological response in individuals with HIV initiated on antiretroviral treatment (ART). DESIGN: Prospective cohort study. SETTING: Three urban HIV care and treatment centres in Dar es Salaam. PARTICIPANTS: Individuals with HIV initiating ART. OUTCOME MEASURES: HIV viral load ≥1000 copies/mL (viral non-suppression) at 6 months after ART initiation. RESULTS: Of 215 (out of 220 enrolled) participants who returned for evaluation at 6 months, 147 (66.8%) were women. At 6 months of follow-up, 89.4% (76/85) of participants with sustained weight gain were virally suppressed compared with 31.8% (7/22) with sustained loss, p<0.001. In participants who were lymphopaenic at baseline, an increase to normal total lymphocyte counts at 6 months was associated with an increase in CD4 count compared with participants who remained lymphopaenic, 96.2% (50/52) versus 54.8% (17/31), p<0.001. At baseline, 50.0% (110/220) had proteinuria. In participants without proteinuria from baseline to 6 months, 89.8% (79/88) were virally suppressed compared with participants with proteinuria at baseline and/or 3 months, 85.6% (77/90), those with persistent proteinuria, 30.8% (8/26), and proteinuria at 6 months only, 45.5% (5/11), p<0.001. In modified Poisson regression, the independent predictors other than CD4 cell counts for viral non-suppression at 6 months among individuals with HIV initiating on ART were BMI loss >5% from baseline to 6 months (adjusted RR 2.73, 95% CI (1.36 to 5.47)), lymphopaenia at 6 months (adjusted RR=4.54, 95% CI (2.19 to 9.39)) and proteinuria at 6 months (adjusted RR=2.63, 95% CI (1.25 to 5.54)). CONCLUSIONS: Change in BMI, total lymphocyte count and presence of proteinuria can monitor and predict ART response and may be particularly helpful in settings when CD4 counts and viral load monitoring are unavailable.

Predictors of 30-day mortality among patients with stroke admitted at a tertiary teaching hospital in Northwestern Tanzania: A prospective cohort study.

Background: Stroke is the second leading cause of death worldwide, with the highest mortality rates in low- to middle-income countries, particularly in sub-Saharan Africa. We aimed to investigate the predictors of 30-day mortality among patients with stroke admitted at a tertiary teaching hospital in Northwestern Tanzania. Methods: This cohort study recruited patients with the World Health Organization's clinical definition of stroke. Data were collected on baseline characteristics, the degree of neurological impairment at admission (measured using the National Institutes of Health Stroke Scale), imaging and electrocardiogram (ECG) findings, and post-stroke complications. The modified Rankin scale (mRS) was used to assess stroke outcomes. Kaplan-Meier analysis was used to describe survival, and the Cox proportional hazards model was used to examine predictors of mortality. Results: A total of 135 patients were enrolled, with a mean age of 64.5 years. Hypertension was observed in 76%, and 20% were on regular anti-hypertensive medications. The overall 30-day mortality rate was 37%. Comparing patients with hemorrhagic and ischemic stroke, 25% had died by day 5 [25th percentile survival time (in days): 5 (95% CI: 2-14)] versus day 23 [25th percentile survival time (in days): 23 (95% CI: 11-30) (log-rank p < 0.001)], respectively. Aspiration pneumonia was the most common medical complication, occurring in 41.3% of patients. ECG abnormalities were observed in 54.6 and 46.9% of patients with hemorrhagic and ischemic stroke, respectively. The most common patterns were as follows: ST changes 29.6 vs. 30.9%, T-wave inversion 34.1 vs. 38.3%, and U-waves 18.2 vs. 1.2% in hemorrhagic and ischemic stroke, respectively. Independent predictors for case mortality were as follows: mRS score at presentation (4-5) [aHR 5.50 (95% CI: 2.02-15.04)], aspiration pneumonia [aHR 3.69 (95% CI: 1.71-13.69)], ECG abnormalities [aHR 2.28 (95% CI: 1.86-5.86)], and baseline stroke severity [aHR 1.09 (95% CI: 1.02-1.17)]. Conclusion: Stroke is associated with a high 30-day mortality rate in Northwestern Tanzania. Concerted efforts are warranted in managing patients with stroke, with particular attention to individuals with severe strokes, ECG abnormalities, and swallowing difficulties to reduce early morbidity and mortality.

A comparison of AAIR versus DDDR pacing for patients with sinus node dysfunction: a long-term follow-up study.

OBJECTIVES: The aim of the study was to compare the clinical outcomes [atrial fibrillation (AF), atrio-ventricular (AV) block, device sepsis and lead revision] of patients with sinus node dysfunction (SND) between atrial-pacing atrial-sensing inhibited-response rate-adaptive (AAIR) versus dual-chamber rate-adaptive (DDDR) pacing. The choice of AAIR pacing versus DDDR pacing was determined by AV nodal functional testing at implant. METHODS: We conducted a retrospective review of consecutive patients who underwent AAIR and DDDR pacing over a 10-year period. RESULTS: One hundred and sixteen patients required pacing for symptomatic SND. Fifty-four (46.6%) patients received AAIR pacemakers and 62 (53.4%) received DDDR pacemakers based on AV nodal functional testing at implant. Patients who had AV Wenkebach with atrial pacing at 120 beats per minute received DDDR pacing. Overall the mean age of patients with SND was 65 years and 66.4% were females, 30% were diabetics and 71% were hypertensives. Pre-syncope/syncope (84%) and dizziness (69%) were the most common symptoms. Sinus pauses and sinus bradycardia were the most common ECG manifestations. Over a median follow up of five (IQR: 2-11) years, four patients (7.4%) developed AF in the AAIR group compared to three (4.8%) in the DDDR group (p = 0.70). AV block occurred in one patient in the AAIR group, who required an upgrade to a DDDR pacemaker. There was no difference in device sepsis or need for lead revision between the two groups. CONCLUSIONS: We found that AV nodal functional testing with atrial pacing at the time of pacemaker implantation was a useful tool to help guide the implanter between AAIR or DDDR pacing. Patients who underwent AAIR pacing had a low risk of AF, AV block or lead revision. In resource-limited settings, AAIR pacing guided by AV nodal functional testing should be considered as an alternative to DDDR pacing.

Prevalence of non-communicable diseases among individuals with HIV infection by antiretroviral therapy status in Dar es Salaam, Tanzania.

BACKGROUND: Long-term antiretroviral therapy has modified the clinical course of HIV infection to a chronic condition associated with increased risk of developing non-communicable diseases (NCDs). Information is scant, from sub-Saharan Africa, on the prevalence of NCDs and associated factors among individuals on ART. METHODOLOGY: We consecutively enrolled individuals with HIV infection who were ART naïve and those on ART for ≥5 years (LTART) attending health facilities in Dar es Salaam. Participant's blood pressure, anthropometric measurements, and fasting blood glucose were recorded. Participants with impaired fasting blood glucose underwent an oral glucose tolerance test. A venous blood sample was sent to the lab for biochemical tests. Chi-square test was used to compare proportions, Poisson regression with robust standard errors was used to determine associations between variables. RESULTS: Overall, 612 individuals with HIV infection were enrolled, half of whom were ART naïve. Females comprised 71.9% and 68.0% of participants in the LTART and ART naïve study arms, respectively, p = 0.290. The mean age (±SD) was 44.9 ± 12.7 years and 37.5 ± 11.8 years among LTART and ART naïve participants, respectively, p<0.001. Hypertension was documented in 25.2% in those on LTART compared to 6.9% among ART naïve subjects, p<0.001. Impaired glucose tolerance was found in 22.9% and 4.6% among LTART compared to ART naïve subjects, p<0.001. Diabetes mellitus was detected in 17.0% of those on LTART compared to 3.9% ART naïve participants, p<0.001. Hypercholesterolemia was found in 30.4% of individuals on LTART compared to 16.7% of ART naïve subjects, p<0.001, and hypertriglyceridemia was found in 16.0% of participants on LTART compared to 9.5% of ART naïve, p = 0.015. LTART use, age ≥40 years, history of smoking, and body mass index were independently associated with NCDs. CONCLUSION: Hypertension, impaired glucose tolerance, diabetes mellitus, hypercholesterolemia, and hypertriglyceridemia were associated with long-term use of antiretroviral drugs.

Disease spectrum and outcomes among elderly patients in two tertiary hospitals in Dar es Salaam, Tanzania.

BACKGROUND: There has been an increase in the number of individuals aged ≥60 years in Tanzania and in sub Saharan Africa in general due to improved survival. However, data is scarce on the disease burden and outcomes following admission in this population. We herein describe the pattern of diagnoses, outcomes and factors associated with the outcomes among elderly patients admitted at Muhimbili National Hospital (MNH) and Jakaya Kikwete Cardiac Institute (JKCI) medical wards. METHODOLOGY: From October to December 2017, we consecutively enrolled patients aged ≥60 years (elderly) admitted to the MNH and JKCI medical wards. The ICD 10 was used to code for disease diagnosis at discharge or death. The Modified Barthel index was used to assess for functional activity on admission and at discharge. RESULTS: We enrolled 336 (30.1%) elderly participants out of 1301 medical admissions. The mean age ± SD was 70.6 ± 8.9 years; 169 (50%) were female and the average number of diagnoses was 2 per participant. The most common diagnoses were: hypertension 151 (44.9%), stroke 106 (31.5%), heart failure 62 (18.5%), pneumonia 60 (17.9%), diabetes mellitus 58 (17.3%) and chronic kidney disease 55 (16.4%). The median duration of hospital stay was 5 (IQR 3-10) days and in-hospital mortality was 86 (25.6%), 56 (65%) deaths were due to non-communicable diseases and 48 (55.8%) deaths occurred within 72 hours of hospitalization. A modified Barthel score ≤20 on admission was associated with an OR 15.43 (95% CI: 7.5-31.7, p<0.001) for death. CONCLUSION: Elderly patients constituted a significant proportion of medical admissions at MNH and JKCI with high in-hospital mortality. A modified Barthel index score ≤20 during admission is associated with mortality and can be used to identify patients requiring special attention.