Preparing Institutions to Implement Harmonized Medicine and Nursing Curricula Through the Use of Cross-Institutional Faculty Developers.

Background: Effective implementation of new curricula requires faculty to be knowledgeable about curriculum goals and have the appropriate pedagogical skills to implement the curriculum, even more so if the new curriculum is being deployed at multiple institutions. In this paper, we describe the process of creating a common faculty development program to train cross-institutional faculty developers to support the implementation of national harmonized medicine and nursing curricula. Methods: A five-step approach was used, including a cross-institutional needs assessment survey for faculty development needs, the development of a generic faculty development program, the identification and training of cross-institutional faculty educators, and the implementation of cross-institutional faculty capacity-building workshops. Results: A list of common cross-cutting faculty development needs for teaching and learning was identified from the needs assessment survey and used to develop an accredited, cross-institutional faculty development program for competency-based learning and assessment. A total of 24 cross-institutional faculty developers were identified and trained in 8 core learning and assessment workshops. A total of 18 cross-institutional and 71 institutional workshops were conducted, of which 1292 faculty members and 412 residents were trained, and three cross-institutional educational research projects were implemented. Conclusion: The success attained in this study shows that the use of cross-institutional faculty developers is a viable model and sustainable resource that can be used to support the implementation of harmonized national curricula.

A rare case of pulmonary embolism in a Mt. Kilimanjaro recreational hiker: A case report with review of literature.

Pulmonary embolism is one of the rarest complications of high-altitude sickness that can coexist with high altitude pulmonary edema. The risk of developing this phenomenon increases significantly with prolonged stay in high altitudes especially above 5000 m. Given the fatality of the condition, early screening and management is crucial; however, there is no gold standard approach in diagnosis. A 44-year-old male, a Tanzanian tourist first time hiking Mt. Kilimanjaro developed difficulty in breathing on the 4th day of ascending on a route that takes 6 days to summit whereby he was saturating at 38% on room air at the height of 4775 m. He was admitted with the clinical diagnosis of high altitude pulmonary edema. However, in the course of treatment for 72 h with no improvement, further investigations including computed tomography scan were suggestive of pulmonary embolism whereby he was treated with full recovery. Pulmonary embolism case reports are increasingly rising with the difficult to notice among high altitude pulmonary edema patients given their presentation similarities. A high index of suspicion based on clinical examination and investigations should prompt a clinician to include or exclude it.

Characteristics and outcomes of patients with symptomatic chronic myocardial injury in a Tanzanian emergency department: A prospective observational study.

BACKGROUND: Chronic myocardial injury is a condition defined by stably elevated cardiac biomarkers without acute myocardial ischemia. Although studies from high-income countries have reported that chronic myocardial injury predicts adverse prognosis, there are no published data about the condition in sub-Saharan Africa. METHODS: Between November 2020 and January 2023, adult patients with chest pain or shortness of breath were recruited from an emergency department in Moshi, Tanzania. Medical history and point-of-care troponin T (cTnT) assays were obtained from participants; those whose initial and three-hour repeat cTnT values were abnormally elevated but within 11% of each other were defined as having chronic myocardial injury. Mortality was assessed thirty days following enrollment. RESULTS: Of 568 enrolled participants, 81 (14.3%) had chronic myocardial injury, 73 (12.9%) had acute myocardial injury, and 412 (72.5%) had undetectable cTnT values. Of participants with chronic myocardial injury, the mean (± sd) age was 61.5 (± 17.2) years, and the most common comorbidities were CKD (n = 65, 80%) and hypertension (n = 60, 74%). After adjusting for CKD, thirty-day mortality rates (38% vs. 36%, aOR 1.03, 95% CI: 0.52-2.03, p = 0.931) were similar between participants with chronic myocardial injury and those with acute myocardial injury, but significantly greater (38% vs. 13.6%, aOR 3.63, 95% CI: 1.98-6.65, p<0.001) among participants with chronic myocardial injury than those with undetectable cTnT values. CONCLUSION: In Tanzania, chronic myocardial injury is a poor prognostic indicator associated with high risk of short-term mortality. Clinicians practicing in this region should triage patients with stably elevated cTn levels in light of their increased risk.

Provider attitudes towards quality improvement for myocardial infarction care in northern Tanzania.

INTRODUCTION: Myocardial Infarction (MI) is a leading cause of death worldwide. In high income countries, quality improvement strategies have played an important role in increasing uptake of evidence-based MI care and improving MI outcomes. The incidence of MI in sub-Saharan Africa is rising, but uptake of evidence-based care in northern Tanzania is low. There are currently no published quality improvement interventions from the region. The objective of this study was to determine provider attitudes towards a planned quality improvement intervention for MI care in northern Tanzania. METHODS: This study was conducted at a zonal referral hospital in northern Tanzania. A 41-question survey, informed by the Theoretical Framework for Acceptability, was developed by an interdisciplinary team from Tanzania and the United States. The survey, which explored provider attitudes towards MI care improvement, was administered to key provider stakeholders (physicians, nurses, and hospital administrators) using convenience sampling. RESULTS: A total of 140 providers were enrolled, including 82 (58.6%) nurses, 56 (40.0%) physicians, and 2 (1.4%) hospital administrators. Most participants worked in the Emergency Department or inpatient medical ward. Providers were interested in participating in a quality improvement project to improve MI care at their facility, with 139 (99.3%) strongly agreeing or agreeing with this statement. All participants agreed or strongly agreed that improvements were needed to MI care pathways at their facility. Though their facility has an MI care protocol, only 88 (62.9%) providers were aware of it. When asked which intervention would be the single-most effective strategy to improve MI care, the two most common responses were provider training (n = 66, 47.1%) and patient education (n = 41, 29.3%). CONCLUSION: Providers in northern Tanzania reported strongly positive attitudes towards quality improvement interventions for MI care. Locally-tailored interventions to improve MI should include provider training and patient education strategies.

Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention.

Background: Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa. Objectives: Co-design a quality improvement intervention for AMI care tailored to local contextual factors. Methods: An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context. Findings: The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education. Conclusion: MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.

Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping.

BACKGROUND: Evidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa. METHODS: Purposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies. RESULTS: Thirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials. CONCLUSIONS: Multiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.

Evaluating the performance of the HEART score in a Tanzanian emergency department.

OBJECTIVE: The HEART score successfully risk stratifies emergency department (ED) patients with chest pain in high-income settings. However, this tool has not been validated in low-income countries. METHODS: This is a secondary analysis of a prospective observational study that was conducted in a Tanzanian ED from January 2019 through January 2023. Adult patients with chest pain were consecutively enrolled, and their presenting symptoms and medical history were recorded. Electrocardiograms and point-of-care troponin assays were obtained for all participants. Thirty-day follow-up was conducted, assessing for major adverse cardiac events (MACEs), defined as death, myocardial infarction, or coronary revascularization (coronary artery bypass grafting or percutaneous coronary intervention). HEART scores were calculated for all participants. Likelihood ratios, sensitivity, specificity, and negative predictive values (NPVs) were calculated for each HEART cutoff score to predict 30-day MACEs, and area under the curve (AUC) was calculated from the receiver operating characteristic curve. RESULTS: Of 927 participants with chest pain, the median (IQR) age was 61 (45.5-74.0) years. Of participants, 216 (23.3%) patients experienced 30-day MACEs, including 163 (17.6%) who died, 48 (5.2%) with myocardial infarction, and 23 (2.5%) with coronary revascularization. The positive likelihood ratio for each cutoff score ranged from 1.023 (95% CI 1.004-1.042; cutoff ≥ 1) to 3.556 (95% CI 1.929-6.555; cutoff ≥ 7). The recommended cutoff of ≥4 to identify patients at high risk of MACEs yielded a sensitivity of 59.4%, specificity of 52.8%, and NPV of 74.7%. The AUC was 0.61. CONCLUSIONS: Among patients with chest pain in a Tanzanian ED, the HEART score did not perform as well as in high-income settings. Locally validated risk stratification tools are needed for ED patients with chest pain in low-income countries.

Patient and provider perspectives on barriers to myocardial infarction care among persons with human immunodeficiency virus in Tanzania: A qualitative study.

INTRODUCTION: People with HIV (PLWH) have an increased risk myocardial infarction (MI), and evidence suggests that MI is under-diagnosed in Tanzania. However, little is known about barriers to MI care among PLWH in the region. METHODS: In this qualitative study grounded in phenomenology, semi-structured interviews were conducted in northern Tanzania. Purposive sampling was used to recruit a diverse group of providers who care for PLWH and patients with HIV and electrocardiographic evidence of prior MI. Emergent themes were identified via inductive thematic analysis. RESULTS: 24 physician and patient participants were interviewed. Most participants explained MI as caused by emotional shock and were unaware of the association between HIV and increased MI risk. Providers described poor provider training regarding MI, high out-of-pocket costs, and lack of diagnostic equipment and medications. Patients reported little engagement with and limited knowledge of cardiovascular care, despite high engagement with HIV care. Most provider and patient participants indicated that they would prefer to integrate cardiovascular care with routine HIV care. CONCLUSIONS: PLWH face many barriers to MI care in Tanzania. There is a need for multifaceted interventions to educate providers and patients, improve access to MI diagnosis, and increase engagement with cardiovascular care among this population.

Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania.

BACKGROUND: Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge. OBJECTIVE: The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania. METHODS: This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis. RESULTS: Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up. CONCLUSION: Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.

Healthcare provider perspective on barriers and facilitators in the care of pediatric injury patients at a tertiary hospital in Northern Tanzania: A qualitative study.

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). The recovery of injured children in LMICs is often impeded by barriers in accessing and receiving timely and quality care at healthcare facilities. The purpose of this study was to identify the barriers and the facilitators in pediatric injury care at Kilimanjaro Christian Medical Center (KCMC), a tertiary zonal referral hospital in Northern Tanzania. In this study, focus group discussions (FGDs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the barriers and facilitators in pediatric injury care. Five FGDs were completed from February 2021 to July 2021. Participants (n = 30) were healthcare providers from the emergency department, burn ward, surgical ward, and pediatric ward. De-identified transcripts were analyzed with team-based, applied thematic analysis using qualitative memo writing and consensus discussions. Our study found barriers that impeded pediatric injury care were: lack of pediatric-specific injury training and care guidelines, lack of appropriate pediatric-specific equipment, staffing shortages, lack of specialist care, and complexity of cases due to pre-hospital delays in patients presenting for care due to cultural and financial barriers. Facilitators that improved pediatric injury care were: team cooperation and commitment, strong priority and triage processes, benefits of a tertiary care facility, and flexibility of healthcare providers to provide specialized care if needed. The data highlights barriers and facilitators that could inform interventions to improve the care of pediatric injury patients in Northern Tanzania such as: increasing specialized provider training in pediatric injury management, the development of pediatric injury care guidelines, and improving access to pediatric-specific technologies and equipment.

Clinical evaluation of the alcohol use disorders identification test (AUDIT) in Moshi, Tanzania.

BACKGROUND: Alcohol use disorder is a major cause of morbidity and mortality in low- and middle-income countries. Alcohol screening using a validated tool is a useful way to capture high-risk patients and engage them in early harm reduction interventions. Our objectives were to 1) evaluate the psychometric evidence the Alcohol Use Disorders Identification Test (AUDIT) and its subscales in the general population of Moshi, Tanzania, and 2) evaluate the usefulness of the tool at predicting alcohol-related harms. METHODS: Two hundred and fifty-nine adults living in Moshi, Tanzania were included in the study. We used the AUDIT and its subscales to determine the classification of harmful and hazardous drinking. To analyze the internal structure of AUDIT and the model adequacy we used Confirmatory Factor Analysis (CFA). The reliability of AUDIT was analyzed for Cronbach's alpha, Omega 6 and Composite Reliability. The optimal cut off point for the AUDIT was determined by the receiver operating characteristic (ROC) curve, using the Youden approach to maximize sensitivity and specificity. RESULTS: The median score of the AUDIT was 1 (inter-quartile range: 0-7). The internal structure of the AUDIT showed factor loadings ranging from 0.420 to 0.873. Cronbach's alpha, Omega and Composite Reliability produced values above 0.70. The Average Variance Extracted was 0.530. For the AUDIT, a score of 8 was identified as the ideal cut-off value in our population. CONCLUSIONS: This study validates AUDIT in the general population of Moshi and is one of the only studies in Africa to include measures of the internal structure of the AUDIT and its subscales.

Alcohol use among emergency medicine department patients in Tanzania: A comparative analysis of injury versus non-injury patients.

BACKGROUND: Alcohol is a leading behavioral risk factor for death and disability worldwide. Tanzania has few trained personnel and resources for treating unhealthy alcohol use. In Emergency Medicine Departments (EMDs), alcohol is a well-known risk factor for injury patients. At Kilimanjaro Christian Medical Center (KCMC) in Moshi, Tanzania, 30% of EMD injury patients (IP) test positive for alcohol upon arrival to the ED. While the IP population is prime for EMD-based interventions, there is limited data on if non-injury patients (NIP) have similar alcohol use behavior and potentially benefit from screening and intervention as well. METHODS: This was a secondary analysis of a systematic random sampling of adult (≥18 years old), KiSwahili speaking, KCMC EMD patients surveyed between October 2021 and May 2022. When medically stable and clinically sober, participants provided informed consent. Information on demographics (sex, age, years of education, type of employment, income, marital status, tribe, and religion), injury status, self-reported alcohol use, and Alcohol Use Disorder (AUD) Identification Test (AUDIT) scores were collected. Descriptive statistics were analyzed in RStudio using frequencies and proportions. RESULTS: Of the 376 patients enrolled, 59 (15.7%) presented with an injury. The IP and NIP groups did not differ in any demographics except sex, an expected difference as females were intentionally oversampled in the original study design. The mean [SD] AUDIT score (IP: 5.8 [6.6]; NIP: 3.9 [6.1]), drinks per week, and proportion of AUDIT ≥8 was higher for IP (IP:37%; NIP: 21%). However, alcohol preferences, drinking quantity, weekly expenditure on alcohol, perceptions of unhealthy alcohol use, attempts and reasons to quit, and treatment seeking were comparable between IPs and NIPs. CONCLUSION: Our data suggests 37% of injury and 20% of non-injury patients screen positive for harmful or hazardous drinking in our setting. An EMD-based alcohol treatment and referral process could be beneficial to reduce this growing behavioral risk factor in non-injury as well as injury populations.

Six month incidence of major adverse cardiovascular events among adults with HIV in northern Tanzania: a prospective observational study.

OBJECTIVES: We aimed to prospectively describe incident cardiovascular events among people living with HIV (PLWH) in northern Tanzania. Secondary aims of this study were to understand non-communicable disease care-seeking behaviour and patient preferences for cardiovascular care and education. DESIGN: A prospective observational study. SETTING: This study was conducted at the Majengo HIV Care and Treatment Clinic, an outpatient government-funded clinic in Moshi, Tanzania PARTICIPANTS: Adult patients presenting to an HIV clinic for routine care in northern Tanzania were enrolled from 1 September 2020 to 1 March 2021. INTERVENTIONS: At enrolment, participants completed a survey and a resting 12-lead ECG was obtained. At 6 month follow-up, a repeat survey regarding interim health events and repeat ECG was obtained. PRIMARY AND SECONDARY OUTCOME MEASURES: Interim major adverse cardiovascular events (MACE) were defined by: self-reported interim stroke, self-reported hospitalisation for heart failure, self-reported interim myocardial infarction, interim myocardial infarction by ECG criteria (new pathologic Q waves in two contiguous leads) or death due to cardiovascular disease (CVD). RESULTS: Of 500 enrolled participants, 477 (95.4%) completed 6 month follow-up and 3 (0.6%) died. Over the 6 month follow-up period, 11 MACE occurred (3 strokes, 6 myocardial infarctions, 1 heart failure hospitalisation and 1 cardiovascular death), resulting in an incidence rate of 4.58 MACE per 100 person-years. Of participants completing 6 month follow-up, 31 (6.5%) reported a new non-communicable disease diagnosis, including 23 (4.8%) with a new hypertension diagnosis. CONCLUSIONS: The incidence of MACE among PLWH in Tanzania is high. These findings are an important preliminary step in understanding the landscape of CVD among PLWH in Tanzania and highlight the need for interventions to reduce cardiovascular risk in this population.

A feasibility assessment of a traumatic brain injury predictive modelling tool at Kilimanjaro Christian Medical Center and Duke University Hospital.

Traumatic brain injury (TBI) is the most common cause of death and disability globally. TBI, which disproportionately affects low middle-income countries (LMIC), uses significant amounts of health system resources in costly care and management. Innovative solutions are required to address this high burden of TBI. One possible solution is prognostic models which enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a TBI prognostic model developed in Tanzania for use by Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke-affiliated healthcare providers using human centered design methodology. Duke participants were included to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows, co-design interviews were conducted with emergency physicians and nursing staff at KCMC and Duke. Qualitatively, the TBI tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Our knowledge translation method was guided using the knowledge-to-action framework. Of the 21 participants interviewed, 12 were associated with Duke Hospital, and 9 from Kilimanjaro Christian Medical Centre. Emerging from the data were 6 themes that impacted the implementation of the TBI tool: access, barriers, facilitators, use of the TBI tool, outer setting, and inner setting. To our knowledge, this is the first study to investigate the pre-implementation of a sub-Saharan Africa (SSA) data- based TBI prediction tool using human centered design methodology. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC.

Longitudinal ECG changes among adults with HIV in Tanzania: A prospective cohort study.

The prevalence of cardiovascular disease (CVD) is rising among people with HIV (PWH) in sub-Saharan Africa (SSA). Despite the utility of the electrocardiogram (ECG) in screening for CVD, there is limited data regarding longitudinal ECG changes among PWH in SSA. In this study, we aimed to describe ECG changes over a 6-month period in a cohort of PWH in northern Tanzania. Between September 2020 and March 2021, adult PWH were recruited from Majengo HIV Care and Treatment Clinic (MCTC) in Moshi, Tanzania. Trained research assistants surveyed participants and obtained a baseline ECG. Participants then returned to MCTC for a 6-month follow-up, where another ECG was obtained. Two independent physician adjudicators interpreted baseline and follow-up ECGs for rhythm, left ventricular hypertrophy (LVH), bundle branch blocks, ST-segment changes, and T-wave inversion, using standardized criteria. New ECG abnormalities were defined as those that were absent in a patient's baseline ECG but present in their 6-month follow-up ECG. Of 500 enrolled participants, 476 (95.2%) completed follow-up. The mean (± SD) age of participants was 45.7 (± 11.0) years, 351 (73.7%) were female, and 495 (99.8%) were taking antiretroviral therapy. At baseline, 248 (52.1%) participants had one or more ECG abnormalities, the most common of which were LVH (n = 108, 22.7%) and T-wave inversion (n = 89, 18.7%). At six months, 112 (23.5%) participants developed new ECG abnormalities, including 40 (8.0%) cases of new T-wave inversion, 22 (4.6%) cases of new LVH, 12 (2.5%) cases of new ST elevation, and 11 (2.3%) cases of new prolonged QTc. Therefore, new ECG changes were common over a relatively short 6-month period, which suggests that subclinical CVD may develop rapidly in PWH in Tanzania. These data highlight the need for additional studies on CVD in PWH in SSA and the importance of routine CVD screening in this high-risk population.

Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors.

Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.

Six-month incidence of hypertension and diabetes among adults with HIV in Tanzania: A prospective cohort study.

Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.

Feasibility of a pragmatic randomized adaptive clinical trial to evaluate a brief negotiational interview for harmful and hazardous alcohol use in Moshi, Tanzania.

INTRODUCTION: Low-resourced settings often lack personnel and infrastructure for alcohol use disorder treatment. We culturally adapted a Brief Negotiational Interview (BNI) for Emergency Department injury patients, the "Punguza Pombe Kwa Afya Yako (PPKAY)" ("Reduce Alcohol For Your Health") in Tanzania. This study aimed to evaluate the feasibility of a pragmatic randomized adaptive controlled trial of the PPKAY intervention. MATERIALS AND METHODS: This feasibility trial piloted a single-blind, parallel, adaptive, and multi-stage, block-randomized controlled trial, which will subsequently be used to determine the most effective intervention, with or without text message booster, to reduce alcohol use among injury patients. We reported our feasibility pilot study using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, with recruitment and retention rates being our primary and secondary outcomes. We enrolled adult patients seeking care for an acute injury at the Kilimanjaro Christian Medical Center in Tanzania if they (1) exhibited an Alcohol Use Disorder Identification Test (AUDIT) ≥8, (2) disclosed alcohol use prior to injury, or (3) had a breathalyzer ≥0.0 on arrival. Intervention arms were usual care (UC), PPKAY, PPKAY with standard text booster, or a PPKAY with a personalized text booster. RESULTS: Overall, 181 patients were screened and 75 enrolled with 80% 6-week, 82.7% 3-month and 84% 6-month follow-up rates showing appropriate Reach and retention. Adoption measures showed an overwhelmingly positive patient acceptance with 100% of patients perceiving a positive impact on their behavior. The Implementation and trial processes were performed with high rates of PPKAY fidelity (76%) and SMS delivery (74%). Intervention nurses believed Maintenance and sustainability of this 30-minute, low-cost intervention and adaptive clinical trial were feasible. CONCLUSIONS: Our intervention and trial design are feasible and acceptable, have evidence of good fidelity, and did not show problematic deviations in protocol. Results suggest support for undertaking a full trial to evaluate the effectiveness of the PPKAY, a nurse-driven BNI in a low-income country. TRIAL REGISTRATION: Trial registration number NCT02828267. https://classic.clinicaltrials.gov/ct2/show/NCT02828267.

Pattern, Management, and Outcomes of Chest Injury At Kilimanjaro Christian Medical Centre.

Background: Chest trauma is a major cause of morbidity and mortality in the region. Lacking data in our environment has been a challenging part of knowing the burden of the problem. Long hospital stays and associated injuries are an essential measure of morbidity. The study results will provide a basis for planning prevention strategies and establishment of treatment protocols. Objectives: To determine the prevalence, pattern, and management outcomes of chest injury patients at Kilimanjaro Christian Medical Center (KCMC), a Tertiary Hospital in Northern zone Tanzania from October 2021 to April 2022. Methodology: A hospital-based cross-sectional study was conducted among patients with chest injuries who were admitted and managed at Tertiary Hospital Northern Zone (Kilimanjaro Christian Medical Center-KCMC) in the Emergency medicine and General Surgery departments. Using a designated data collection tool, details of the mechanism of injury, radiological and laboratory investigations, management, and outcomes were recorded. Results: A total of 114 chest injury patients were studied. Males outnumbered females by a ratio of 7.14:1. Their ages ranged from 2 to 83 years (mean = 36.18 years). The Majority of patients (95.58%) sustained blunt injuries. Road traffic crush was the most common cause of injuries affecting 65.79% of patients. Lung contusion, hemothorax, and rib fractures were the most common type of injuries accounting for 54.4%, 27.2%, and 21.1%, respectively. Associated injuries were noted in 85.7% of patients, and head injury (60.5%) was found in most patients. The Majority of patients (60.5%) were treated successfully with a non-operative approach. Underwater seal drainage was performed at (38.9%). One Patient (0.9%) underwent a thoracotomy. 14% of patients had complications of surgical site infection, and 69% were found in the Majority of patients. The median length of hospital stay was 4.5 days. The mortality rate was 21. Conclusion: Motor traffic crash was the principal cause of chest trauma. Young male patients were most affected by chest trauma and the majority of patients were treated conservatively. Chest X-ray remains to be the main imaging modality for diagnosing thoracic trauma lesions. Associated injuries such as head injuries, were found to contribute to a high mortality rate.

A qualitative assessment of stakeholder perspectives on barriers and facilitators to emergency care delays in Northern Tanzania through the Three Delays.

Introduction: Emergency conditions cause a significant burden of death and disability, particularly in developing countries. Prehospital and Emergency Medical Services (EMS) are largely nonexistent throughout Tanzania and little is known about the community's barriers to accessing emergency care. The objective of this study was to better understand local community stakeholder perspectives on barriers, facilitators, and potential solutions surrounding emergency care in the Kilimanjaro region through the Three Delays Model framework. Methods: A qualitative assessment of local stakeholders was conducted through semi-structured focus group discussions (FGDs) from February to June 2021 with five separate groups: hospital administrators, emergency hospital workers, police personnel, fire brigade personnel, and community health workers. FGDs were conducted in Kiswahili, audio recorded, and translated to English verbatim. Two research analysts separately coded the first two FGDs using both inductive and deductive thematic analysis. A final codebook was then created to analyze the remaining FGDs. Results: A total of 24 participants were interviewed. Thematic analysis revealed that participants identified significant barriers within the Three Delays Model as well as identified an additional delay centered on community members and first aid provision. Perceived delays in the decision to seek care, the first delay, were financial constraints and the lack of community education on emergency conditions. Limited infrastructure and reduced transportation access were thought to contribute to the second delay. Potential barriers to receiving timely appropriate care, the third delay, included upfront payments required by hospitals and emergency department intake delays. Suggested solutions focused on increasing education and improving communication and infrastructure. Conclusion: The findings outline barriers to accessing emergency care from a stakeholder perspective. These themes can support recommendations for further strengthening of the prehospital and emergency care system. Due to logistical constraints, emergency care workers interviewed were all from one hospital and patients were not included.