Peripartum cardiomyopathy in low- and middle-income countries.

Peripartum cardiomyopathy (PPCM) causes pregnancy-associated heart failure, typically during the last month of pregnancy, and up to 6 months post-partum, in women without known cardiovascular disease. PPCM is a global disease, but with a significant geographical variability within and between countries. Its true incidence in Africa is still unknown because of the lack of a PPCM population-based study. The variability in the epidemiology of PPCM between and within countries could be due to differences in the prevalence of both genetic and non-genetic risk factors. Several risk factors have been implicated in the aetiopathogenesis of PPCM over the years. Majority of patients with PPCM present with symptoms and signs of congestive cardiac failure. Diagnostic work up in PPCM is prompted by strong clinical suspicion, but Echocardiography is the main imaging technique for diagnosis. The management of PPCM involves multiple disciplines - cardiologists, anaesthetists, intensivists, obstetricians, neonatologists, and the prognosis varies widely.

Adherence Clubs to Improve Hypertension Management in Nigeria: Clubmeds, a Feasibility Study.

Background: Hypertension control remains a significant challenge in reducing the cardiovascular disease burden worldwide. Community peer-support groups have been identified as a promising strategy to improve medication adherence and blood pressure (BP) control. Objectives: The study aimed to evaluate the feasibility and impact of adherence clubs to improve BP control in Southeast Nigeria. Methods: This was a mixed-methods research involving a formative (pre-implementation) research, pilot study and process evaluation. Hypertensive patients in two communities were recruited into peer-support adherence clubs under the leadership of role-model patients to motivate and facilitate medication adherence, BP monitoring, and monthly medication delivery for six months. The primary outcome was medication adherence measured using visual analogue scale (VAS), with BP level at six months as a key secondary outcome. Results: We recruited a total of 104 participants. The mean age was 56.8 (SD-10.7) years, 72 (69.2%) were women, mean BP was 146.7 (SD-20.1)/86.9 (SD-11.2) mmHg, and the mean percentage of medication adherence on the VAS was 41.4% (SD-11.9%). At six months, 67 patients were assessed; self-reported adherence on the VAS increased to 57.3% (SD-25.3%) (mean difference between baseline and follow-up of 15.5%, p < 0.0001), while the mean BP decreased to 132.3 (SD-22.0)/82.9 (SD-12.2) mmHg (mean difference of 13.0 mmHg in systolic BP, p < 0.0001 and of 3.6 mmHg in diastolic BP, p = 0.02). Five in-depth interviews and four focus groups discussions were conducted as part of the qualitative analyses of the study. The participants saw hypertension as a big issue, with many unaware of the diagnosis, and they accepted the CLUBMEDS differential service delivery (DSD) model concept in hypertension. Conclusions: The study demonstrates that the implementation of adherence clubs for hypertension control is feasible and led to a statistically significant and clinically meaningful improvement in self-reported medication adherence, resulting in BP reduction. Upscaling the intervention may be needed to confirm these findings.

Prevalence and Determinants of Masked Hypertension in Nigeria: The REMAH Study.

BACKGROUND: Estimating the burden of hypertension in Nigeria hitherto relied on clinic blood pressure (BP) measurement alone. This excludes individuals with masked hypertension (MH), i.e., normotensive clinic but hypertensive out-of-clinic BP. METHODS: In a nationally representative sample of adult Nigerians, we obtained clinic BP using auscultatory method and out-of-clinic BP by self-measured home BP with semi-automated oscillometric device. Clinic BP was average of 5 consecutive measurements and home BP was average of 3 days duplicate morning and evening readings. MH was clinic BP <140 mm Hg systolic and 90 mm Hg diastolic and home BP ≥135 mm Hg systolic and/or 85 mm Hg diastolic. RESULTS: Among 933 participants, the prevalence of sustained hypertension, MH, and white-coat hypertension was 28.3%, 7.9%, and 11.9%, respectively. Among subjects whose clinic BP were in the normotensive range (n = 558), the prevalence of MH was 13%; 12% among untreated and 27% among treated individuals. The mutually adjusted odds ratios of having MH among all participants with normotensive clinic BP were 1.33 (95% confidence interval, 1.10-1.60) for a 10-year higher age, 1.59 (1.09-2.40) for a 10 mm Hg increment in systolic clinic BP, and 1.16 (1.08-1.28) for a 10 mg/dl higher random blood glucose. The corresponding estimates in the untreated population were 1.24 (1.03-1.51), 1.56 (1.04-2.44), and 1.16 (1.08-1.29), respectively. CONCLUSIONS: MH is common in Nigeria and increasing age, clinic systolic BP, and random blood glucose are the risk factors.

Urinary sodium excretion and its association with blood pressure in Nigeria: A nationwide population survey.

Assessment of level of salt intake in a population is the first step toward planning strategies aimed at salt reduction. As a surrogate of salt intake, we measured a single 24-hour urine sodium (uNa) of free-living 2503 adults in a nationally representative sample of Nigerians drawn from 12 rural and urban communities; and evaluated the community-level association of uNa with blood pressure (BP). Overall, the median (interquartile range (IQR)) of uNa was 99 (105) mmol, ranging from 23.8 (32.4) in rural north-central to 172.8 (131.0) mmol in urban northwestern region. Daily uNa was significantly higher (p < .001) in men compared to women (107.1 vs 93.9 mmol); and urban compared to rural dwellers (114.9 vs 86.0mmol). About one-half of participants excreted uNa in excess of recommended daily maximum value (86mmol). In a model adjusted for age, sex, body mass index (BMI), level of education, place of residence, and use of antihypertensive medication; being a man (odds ratio, OR 1.69, 95% confidence Interval CI, 1.21-2.37, p = .002) and being < 60 years of age (OR 1.74, 95% CI 1.23-2.45, p = .002), were associated with excreting higher than recommended uNa. In a fully adjusted model of the community-level analysis, urinary sodium, potassium, and sodium-to-potassium ratio each showed no significant independent association with both systolic and diastolic BPs. Among adult Nigerians, the median daily uNa excretion was 99 mmol and it had no significant association with blood pressure indices.

Prevalence, Awareness, Treatment and Control of Hypertension in Nigeria: Data from a Nationwide Survey 2017.

Background: Previous studies that evaluated the prevalence, awareness and treatment of hypertension in Nigeria were either localized to some specific regions of the country or non-standardized thereby making evaluation of trend in hypertension care difficult. Methods: We used the World Health Organization (WHO) STEPwise approach to chronic disease risk factor surveillance to evaluate in a nationally representative sample of 4192 adult Nigerians selected from a rural and an urban community in one state in each of the six geo-political zones of the country. Results: The overall age-standardized prevalence of hypertension was 38.1% and this varied across the geo-political zones as follows: North-Central, 20.9%; North-East, 27.5%; North-West, 26.8%; South-East, 52.8%; South-South, 44.6%; and South-West, 42.1%. Prevalence rate did not differ significantly (p > 0.05) according to place of residence; 39.2% versus 37.5 %; urban vs rural. Prevalence of hypertension increased from 6.8% among subjects less than 30 years to 63.0% among those aged 70 years and above. Awareness was better (62.2% vs. 56.6%; P = 0.0272); treatment rate significantly higher (40.9 % vs. 30.8%; P < 0.0001) and control similar (14 vs. 10.8%) among urban compared to rural residents. Women were more aware of (63.3% vs. 52.8%; P < 0.0001); had similar (P > 0.05) treatment (36.7 vs. 34.3%) and control (33.9% vs. 35.5%) rates of hypertension compared to men. Conclusion: Our results suggest a large burden of hypertension in Nigeria and a closing up of the rural-urban gap previously reported. This calls for a change in public health policies anchored on a primary health care system to address the emerging disease burden occasioned by hypertension.

Adapting a club-based medication delivery strategy to a hypertension context: the CLUBMEDS Study in Nigeria.

INTRODUCTION: The prevalence of hypertension in sub-Saharan Africa is among the world's highest; however, awareness, treatment and control of hypertension in this region are suboptimal. Among other barriers, the overburdened healthcare system poses a great challenge for hypertension control. Community peer-support groups are an alternative and promising strategy to improve adherence and blood pressure (BP) control. The CLUBMEDS study aims to evaluate the feasibility and impact of adherence clubs to improve hypertension control in Nigeria. METHODS AND ANALYSIS: The CLUBMEDS study will include a formative (pre-implementation) qualitative evaluation, a pilot study and a process (postimplementation) qualitative evaluation. At the formative stages, focus group discussions with patient groups and in-depth interviews with healthcare providers, managers and key decision makers will be conducted to understand the feasibility, barriers and facilitators, opportunities and challenges for the successful implementation of the CLUBMEDS strategy. The CLUBMEDS pilot study will be implemented in two primary healthcare facilities, one urban and one rural, in Southeast Nigeria. Each adherence club, which consists of a group of 10-15 patients with hypertension under the leadership of a role-model patient, serves as a support group to encourage and facilitate adherence, BP self-monitoring and medication delivery on a monthly basis. A process evaluation will be conducted at the end of the pilot study to evaluate the acceptability and engagement with the CLUBMEDS strategy. To date, 104 patients were recruited and grouped into nine clubs, in which patients will be followed-up for 6 months. ETHICS AND DISSEMINATION: The study was approved by the University of Abuja Teaching Hospital and the Federal Teaching Hospital Abakaliki Human Research Ethics Committees and all patients provided informed consent. Our findings will provide preliminary data on the potential effectiveness and acceptance of this strategy in a hypertension context. Study findings will be disseminated via scientific forums.

Quality of pilot trial abstracts in heart failure is suboptimal: a systematic survey.

BACKGROUND: Pilot trials are miniature researches carried out with the sole aim of acting as the precursor for larger more definitive studies. Abstracts are used to summarize and introduce the findings to the reading audience. There is substantive empirical evidence showing that abstracts, despite their important roles, are not informative enough, lacking the necessary details. This systematic survey was designed to assess the quality of reporting of heart failure pilot trial abstracts. The quality of reporting was defined as the completeness of reporting based on adherence to the CONSORT extension for reporting of pilot trial abstracts. We also identified factors associated with reporting quality. METHODS: We searched MEDLINE (PubMed), Cochrane Controlled Trials Register, Scopus, and African-wide information databases for abstracts from heart failure pilot trials in humans published from 1 January 1990 to 30 November 2016. These were assessed to determine the extent of adherence to CONSORT extension checklist for reporting of abstracts of pilot trials. We screened identified studies for inclusion based on title and abstract. Data were independently extracted by two reviewers using the checklist. We used regression analysis to assess the association between completeness of reporting (measured as the number of items in the CONSORT extension checklist for reporting of abstracts in pilot trials contained in each abstract) and factors influencing the quality of the reports. RESULTS: Two hundred and twenty-eight (228) articles were retrieved, of which 92 met the inclusion criteria. The mean CONSORT extension score was 8.3/16 (standard deviation 1.7); the least reported items were the source of funding (1% [1/92]), trial registration (13% [12/92]), randomization sequence (13% [12/92]), number randomized to each arm (16% [15/92]), and number analyzed in each arm (16% [15/92]). Multivariable regression analysis showed that pharmacological intervention pilot trials [incidence rate ratio (IRR) = 0.88; 95% confidence interval (CI), 0.81-0.97] were significantly associated with better reporting. Other factors such as structured abstract (IRR = 1.10; 95% CI, 0.99-1.23) and CONSORT endorsement (IRR = 1.10; 95% CI, 0.99-1.23) only showed minimal relationship with better reporting quality. CONCLUSION: The quality of reporting of abstracts of heart failure pilot trials was suboptimal. Pharmacological intervention was significantly associated with better reporting. These findings are consistent with previous research on reporting of trials.

Domestic solid fuel combustion in an adult population in Nigeria: A cross sectional analysis of association with respiratory symptoms, quality of life and lung function.

BACKGROUND AND OBJECTIVES: We examined the association of respiratory symptoms, health status, and lung function with the use of solid fuel (wood, charcoal, coal or crop residue) for cooking or heating in a predominantly non-smoking population. METHODS: Using the protocol of the Burden of Obstructive Lung Diseases (BOLD) initiative, we collected representative population data using questionnaires and spirometry tests. We categorized solid fuel use into 'never user', 'ex user' and 'current user' based on responses to the survey. We developed regression models to evaluate the relation between use of solid fuel and the prevalence of respiratory symptoms, quality of life and lung function adjusting for confounding variables. RESULTS: Out of 1147 respondents with complete information on domestic fuel type, 33% were 'never-users', 19% were 'ex-users' while 48% reported current use of solid fuel for domestic cooking and/or indoor heating. Compared with never-users, current solid fuel users were more likely to report cough (OR: 1.7, 95% CI: 1.0, 2.9), cough or phlegm (OR: 1.6, 95% CI: 1.0, 2.5) and the association was stronger among women (OR: 3.0, 95% CI: 1.3, 7.1 and OR: 2.3, 95% CI: 1.1, 5.2, respectively). Current solid fuel users also had lower mental health status (coefficient: ?1.5, 95% CI: ?2.8, - 0.2) compared with the group of never-users. Current or previous domestic use of solid fuels for cooking or heating was not associated with higher prevalence of chronic airflow obstruction (FEV1/FVC < LLN). CONCLUSIONS: Using solid fuel for domestic cooking or heating was associated with a higher risk of cough or phlegm and a lower mental quality of life. However we found no significant effect in the prevalence of chronic airflow obstruction in Ife, Nigeria.

Predictors of in-hospital mortality and length of stay in community-acquired pneumonia: a 5-year multi-centre case control study of adults in a developing country.

BACKGROUND: We investigated predictors of in-hospital mortality and length of hospital stay among adults with community-acquired pneumonia (CAP) in Nigeria in order to provide recommendations to improve CAP outcomes in developing countries. METHODS: This was a multi-centre case control study of patients ≥18 years who were admitted with CAP between 2008 and 2012. Case notes of 100 consecutive patients who died (cases) and random sample of 300 patients discharged (controls) were selected. RESULTS: Mean ages were 55.4±19.6 (cases) and 49.3±19.2 (controls). Independent predictors of mortality were CURB-65 score ≥3: adjusted odds ratio (aOR) 24.3, late presentation: aOR 8.6, co-morbidity: aOR 3.9, delayed first dose antibiotics (>4 hours): aOR 3.5, need for supplemental oxygen: aOR 4.9, multilobar pneumonia: aOR 4.0, non-pneumococcal aetiology: aOR 6.5, anaemia: aOR 3.8 and hyperglycemia: aOR 8.6. CURB-65 ≥3 predicted mortality with a high specificity (96.1%) but low sensitivity (75%); positive predictive value of 88.2% and negative predictive value of 90.8%. Care in hospital A and B: aOR 3.3 and 2.2 respectively, male gender aOR 2.1, co-morbidity aOR 3.0, anaemia aOR 2.1 and elevated serum creatinine aOR 6.3 independently predicted length of hospital stay >10 days among survivors. CONCLUSIONS: Several modifiable patient-related and process-of-care factors predicted in-hospital mortality, and length of hospital stay among survivors. Our findings should be used to improve CAP outcomes in developing countries.

Sputum bacteriology and antibiotic sensitivity patterns of community-acquired pneumonia in hospitalized adult patients in Nigeria: a 5-year multicentre retrospective study.

BACKGROUND: A clear knowledge of the pathogens responsible for community-acquired pneumonia (CAP) in a given region and their antibiotic sensitivity patterns is necessary for optimal treatment. We determined the common bacterial pathogens causing CAP in Nigeria and further reviewed their antibiotic senstivity patterns with a view to providing recommendations to improve antibiotic management of CAP. METHODS: Case notes of all adult patients who were 18 years or more admitted to four major tertiary hospitals in South East Nigeria with a diagnosis of CAP between 2008 and 2012 were retrospectively studied. To be eligible, patients were required to have sputum culture and sensitivity results available. Socio-demographic, clinical, pre-admission and in-hospital treatment data were also obtained. RESULTS: Of 400 patients with a radiologically confirmed diagnosis of CAP, 232 fulfilled the study criteria; 122 (52.6%) were women and the mean age was 50.6 ± 18.8 years. Aetiological agents were identified from sputum in 189 (81.5%) patients. Streptococcus pneumoniae (n = 90, 47.6%) was the most frequent isolate followed by Klebsiella pneumoniae (n = 62, 32.8%), Staphylococcus aureus (n = 24, 12.7%) and Streptococcus pyogenes (n = 13, 6.9%). The pathogens were most sensitive to levofloxacin (77%), ceftazidime (75.5%) and ofloxacin (55.8%). The susceptibility of the isolates to antibiotics most frequently presecribed for empirical therapy was low (co-amoxiclav, 47.6%; ciprofloxacin, 45.9% and ceftriaxone, 47.6%) and this was associated with higher mortality and/or longer duration of hospital stay in survivors. CONCLUSION: Strep. pneumoniae and K. pneumoniae were the most common causes of CAP. The pathogens were most sensitive to levofloxacin and ceftazidime. We suggest that these antibiotics should increasingly be considered as superior options for empirical treatment of CAP in Nigeria.

Contributions of pulmonary hypertension to HIV-related cardiac dysfunction.

BACKGROUND/AIM: To evaluate the prevalence of pulmonary hypertension among patients living with HIV/AIDS and to determine its contribution to cardiac dysfunction. METHOD: A hospital based cross sectional study was carried out over a 6-month period at the Jos University Teaching Hospital. The subjects were 200 confirmed HIV positive patients, ≥18 years of age who consented to the study. Physical examination, laboratory investigations, 2 dimensional and Doppler echocardiography were conducted on the subjects. RESULTS: The mean age of the patients was 38 ± 9 years, and there were 142 females (71%). Females were younger, mean age 36 ± 8 years versus 41 ± 10 years for males (p-value <0.01). The median CD4 cell count was 312 cells/µl, there were no homosexual or intravenous drug user among the subjects. Eight of the subjects had pulmonary hypertension, with a case prevalence of 4%, and this had no relationship to CD4 cell count. Both systolic and diastolic functions were worse in subjects with pulmonary hypertension, with a negative correlation between mean pulmonary arterial systolic pressure (mPASP) and parameters like ejection fraction (r = -0.28, p-value 0.0003), fractional shortening (r = -0.21, p-value 0.003), deceleration time (r = -0.13. p-value 0.09). CONCLUSION: Immune-suppression affects the cardiac function adversely and coexisting pulmonary hypertension contributes to poor systolic and diastolic function in affected patients. The subtle nature of presentation of pulmonary hypertension and other cardiac dysfunctions in HIV/AIDS patients demand a high-index of suspicion and early intervention if detected, to ensure better care for these emerging threats to our patients.

Prevalence and predictors of impaired fasting glucose among Nigerian patients with hepatitis B virus infection.

AIM: Previous studies on the relationship between hepatitis B virus (HBV) infection and type 2 diabetes mellitus (DM) are conflicting. We aimed to elucidate the relationship by investigating the prevalence and predictors of impaired fasting glucose (IFG) in HBV-infected patients. METHODS: A total of 204 consecutive patients with hepatitis B surface antigen (HBsAg) seropositivity for ≥ 6 months were recruited in a cross-sectional study. Patients with DM were excluded. Information regarding age, gender, ethnicity, residence, family history of DM, alcohol use, and cigarette smoking were obtained using a structured questionnaire. Fasting plasma glucose, lipid profile, liver enzymes and hepatitis Be antigen (HBeAg) were tested. RESULTS: The participants had a mean age of 33.6 ± 8.4 years and included 123 (60.3%) females, 40 (19.6%) with HBeAg seropositivity, and 29 (14.2%) with family history of DM. The prevalence of IFG was 52 (25.5%). On multivariate analysis, the independent predictors of IFG were family history of DM (OR = 8.23, 95% CI = 2.78-24.31), male gender (OR = 2.83, 95% CI = 1.17-6.64), HBeAg seropositivity (OR = 4.97, 95% CI = 1.87-13.18) and elevated GGT (OR = 7.27, 95% C.I = 2.88-18.35). CONCLUSION: The prevalence of IFG among HBV-infected patients is high. Targeted screening and follow-up of HBV-infected patients for abnormalities of glucose metabolism is recommended.