Rheumatic fever and rheumatic heart disease among children presenting to two referral hospitals in Harare, Zimbabwe.

BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain significant causes of morbidity and mortality in resource-limited settings. In Zimbabwe ARF/RHD characteristics have not been systematically documented. OBJECTIVES: To document cases of ARF/RHD among children presenting at referral hospitals in Harare, Zimbabwe, determine their clinical and echocardiographic characteristics, and identify opportunities for improving care. METHODS: A cross-sectional survey was carried out in which consecutive children aged 1 - 12 years presenting with ARF/RHD according to the 2002/3 World Health Organization modified Jones criteria were enrolled. RESULTS: Out of 2 601 admissions and 1 026 outpatient visits over 10 months, 50 children were recruited, including 31 inpatients with ARF/RHD and 19 outpatients with chronic RHD. Among inpatients, 9 had ARF only, 7 recurrent ARF with RHD, and 15 RHD only. The commonest valve lesions were mitral regurgitation (26/31) and aortic regurgitation (11/31). The commonest reason for admission was cardiac failure (22/31). The proportion of ARF/RHD cases among inpatients aged 1 - 12 years was 11.9/1 000. Of the 22 with RHD, 14 (63.6%) presented de novo and 1 had bacterial endocarditis. Among the outpatients, 15 had cardiac failure while echocardiographic findings included mitral regurgitation (18/19) and aortic regurgitation (5/19). At presentation, 18/26 known cases were on oral penicillin prophylaxis and 7 on injectable penicillin. Of those on secondary prophylaxis, 68.0% reported taking it regularly. CONCLUSION: ARF/RHD remains a major problem and cause of hospital admissions in Harare, Zimbabwe. Children often present late with established RHD and cardiac failure. With the majority on oral penicillin, secondary prophylaxis was suboptimal in a resource-limited setting unable to offer valve replacement surgery.

Metabolic syndrome disorders in urban black Zimbabweans with type 2 Diabetes mellitus.

OBJECTIVE: The main aim of the study was to determine the prevalence of metabolic syndrome disorders and their interrelations in black Zimbabwean type 2 diabetic patients. STUDY DESIGN: Prospective cross sectional study. SETTING: Outpatient diabetic clinics at Harare and Parirenyatwa tertiary hospitals. MAIN OUTCOME MEASURES: We recruited 109 adult diabetic subjects attending a tertiary hospital Diabetic Clinic. Anthropometric and metabolic parameters were measured by standard methods. Eighty percent of the patients were hypertensive, 32% dyslipidaemic, 32% obese, 50% hyperinsulinaemic, 61% had poor glycaemic control and 43% of the participants had the metabolic syndrome. The means of BMI and triglycerides were significantly different in hyperinsulinaemic versus non-hyperinsulinaemic patients (p < 0.001 and 0.041 respectively), and diastolic blood pressure was significantly raised in the obese group (p = 0.043). The following significant associations were observed, hyperinsulinaemia with the metabolic syndrome (odds ratio = 3.9, p < 0.001) as well with obesity (odds ratio = 4.8, p < 0.001), however, only a weak association was observed between hypertension and hyperinsulinaemia (odds ratio = 2.5, p = 0.064). Patients exhibiting three metabolic disorders (dyslipidaemia, hypertension and obesity) were five times more likely to be hyperinsulinaemic (p = 0.025) and hypertensive patients were almost three times more likely to be hyperinsulinaemic. CONCLUSION: In comparison to their counterparts from certain ethnic groups, this urban diabetic population is also burdened with a variety of metabolic disorders which are risk factors for coronary artery disease. In this population, hyperinsulinaemia has a relatively weak association with hypertension and the relationship between obesity versus diastolic blood pressure as well as hypertriglyceridaemia versus serum insulin levels requires further investigation.

Correlates of blood pressure in an urban Zimbabwean population and comparison to other populations of African origin.

We have evaluated the relationship between systolic blood pressure (SBP) and age, body mass index (BMI), waist circumference, sodium to potassium ratio (Na/K), and tobacco use in an urban African population. We conducted a random, population-based, cross-sectional survey of people 25 years and older in Marondera, Zimbabwe, with over-sampling in older age groups (n = 775), using a method comparable to that used in International Collaborative Study on Hypertension in Blacks (ICSHIB). The age-adjusted prevalences of hypertension in Marondera (SBP >/=140/DBP >/=90/antihypertensive medication) were 30% for women and 21% for men. The average BMI was 26.3 kg/m2 for women and 21.4 kg/m2 for men. The prevalence of hypertension had a steep association with age and in women ranged from 15% (25-34 years) to 63% (55 years and over) and in men from 9% to 47%. No tobacco use in women and greater Na/K ratio in spot urines in men were significantly associated with an increased SBP. In both men and women the levels of hypertension and SBP were strongly positively associated with BMI, although the relationship appeared to plateau in women with a BMI greater than >/=25 kg/m2. At a given BMI, men and women had similar SBPs and prevalences of hypertension. There is a very high prevalence of hypertension among urban Zimbabweans, particularly among women. Under the assumption the studies are comparable, the prevalence of hypertension in Zimbabwean women (41%) and men (26%) after age adjustment to the ICSHIB populations, appeared higher than almost all of the ICSHIB populations, including those with higher average body mass indexes. Journal of Human Hypertension (2000) 14, 65-73.

Urinary iodine concentrations and thyroid function in adult Zimbabweans during a period of transition in iodine status.

BACKGROUND: In 1993 the compulsory iodization of salt was introduced in Zimbabwe, a country that was previously an area of severe iodine deficiency. OBJECTIVE: The objective of this study was to document urinary iodine excretion and biochemical thyroid function in seemingly healthy, community-dwelling adults after the introduction of iodization. DESIGN: A multistage, random sampling method was used in rural and urban settings to identify households from which the senior household member (aged >35 y) was recruited (alternating male and female recruits). Demographic data were collected for each subject and urinary and venous blood samples were taken. Urinary iodine excretion and serum thyroid hormone status (thyrotropin and total thyroxin) were evaluated according to age, sex, and area of residence. RESULTS: A total of 736 adults were recruited (253 men; mean age: 64 y). Urinary iodine concentrations were high [median (first and third quartiles): 4.41 (2.84, 6.78) micromol/L, or 560 (360, 860) microgram/L] and were significantly higher in rural areas than in urban areas [4.73 (3.07, 7.14) micromol/L, or 600 (390, 906) microgram/L, compared with 3.47 (2.05, 4.73) micromol/L, or 440 (260, 600) microgram/L; P < 0.001]. Urinary iodine excretion declined significantly with increasing age (r = -0.29, P < 0.001). Serum thyroid status suggested that the prevalence of biochemical hyperthyroidism in the study was 3%, with 13 of 415 cases in rural and 3 of 149 cases in urban subjects. CONCLUSION: This study reaffirms the need to continuously monitor iodine replacement programs to ensure efficacy.

Variation in in-patient stroke management in ten centres in different countries: the INCLEN multicentre stroke collaboration.

BACKGROUND AND PURPOSE: Large within-country variations have been described in stroke management and there have been a few studies of between-country variation (in the USA and the UK). We designed a study to examine stroke management across a wide range of countries representing different stages of economic development. Large variations would suggest the need to explore methods of increasing the uptake of evidence-based stroke practice. METHODS: Members of the International Clinical Epidemiology Network (INCLEN) from 14 centres in ten countries agreed to review the records of the last 50 patients admitted to hospital with a clinical diagnosis of stroke. Information on demographic variables, the clinical diagnosis of stroke type, investigations performed and treatments given and the discharge destination of the patient were recorded and sent to the coordinating centre in Australia for analysis. RESULTS: There were statistically significant between-centre differences in the proportions of patients cared for by a neurologist, staying in hospital for at least ten days and having CT or MRI scans. Significant between-centre differences were also seen for treatment, for example, the use of aspirin in non-haemorrhagic stroke varied from 11 to 79%. The variation (for all interventions studied) was no longer statistically significant when examined within strata according to availability of facilities. CONCLUSIONS: The large variation between centres in the management of stroke is largely 'explained' by the availability of resources, even for interventions that do not depend on resource availability. It will be important to develop management guidelines that reflect evidence-based practice of relevance across a range of economic settings.

Cardiovascular reactivity in Zimbabwe.

OBJECTIVE: In this study, we examined the effects of residency and gender on cardiovascular reactivity to a speech stressor in 50 rural Zimbabweans (24 males, 26 females) and 47 urban Zimbabweans (25 males and 22 females). METHODS: Participants were engaged in 4 periods: pre-task rest period, speech preparatory period, speaking task period, and the final recovery period. During each period, systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were assessed. RESULTS: There was a significant interaction between area of residence and period for SBP and HR. Urban residents exhibited greater SBP and HR during the speaking phase of the speech task than did rural residents. However, rural residents displayed more exaggerated HR reactivity during the speech preparatory phase as compared to the urban residents. No gender differences were observed on blood pressure or heart rate reactivity. CONCLUSION: In conclusion, the more exaggerated SBP and HR reactivity to the speaking phase among urban residents as compared to rural residents may be influenced by factors associated with urbanization.

Effect of variation in environmental temperature on blood pressure: is it important?

OBJECTIVES: To study the effect of variation in environmental temperature on blood pressure and pulse. DESIGN: Repeated blood pressure and pulse measurements in volunteers on two days when environmental temperatures differed by 10 degrees C. SETTING: Part of an ongoing community based study. SUBJECTS: 25 Black subjects (23 males and two females) volunteered from a population cohort participating in an ongoing longitudinal study examining cardiovascular risk factors in an urban African Black environment. MAIN OUTCOME MEASURE: Mean systolic and diastolic blood pressures and pulse rates. RESULTS: The systolic and diastolic blood pressures were significantly higher when recorded at 15 degrees C than at 25 degrees C, mean difference 32.2 +/- 4.2, p < 0.001 and 19.5 +/- 3.0 p < 0.001) for systolic and diastolic blood pressures respectively. The pulse rate per minute at 15 degrees C was significantly lower than at 25 degrees C (mean difference 11.1 +/- 3.2 p = 0.002). CONCLUSIONS: A decrease in environmental temperature by 10 degrees C appears to increase blood pressure. Awareness of this phenomenon is important, especially when surprisingly high blood pressures are observed during low ambient temperatures, to avoid over diagnosis of hypertension. This phenomenon, together with that already established of the white coat hypertension, may lead to the erroneous diagnosis of hypertension.

Effects of parental history of hypertension and urbanization on blood pressure in Zimbabweans.

The increasing prevalence of essential hypertension is a growing public health concern for Zimbabwe and other African countries. Two important risk factors for hypertension are urbanization and parental history of hypertension. The relations among parental history of hypertension, urbanization, and blood pressures (BPs) are poorly understood. The objective of this study is to clarify these relations in a population of urbanized, African, young adults. The relation between parental history of hypertension and urbanization on resting BP's and Bp responses to a mental arithmetic stressor was examined in a group of normotensive, Black medical students with (n = 36) and without (n = 34) a parental history of high BP, and with (n = 49) and without (n = 19) a parental history of urbanization. Results indicate that those with a positive parental history counterparts. Further, those with parents residing in urban areas had higher resting SBPs than those with parents residing in rural areas. However, no reactivity differences were apparent between the urban and rural parent groups. These data suggest that although parental history for hypertension influences both resting and reactivity BP's parental history of urbanization may influence only resting BP.

Stroke incidence rates among black residents of Harare--a prospective community-based study.

OBJECTIVE: To estimate the crude incidence rates of cerebrovascular accidents among the black residents of Harare. DESIGN: Prospective community-based study. SETTING: Black residents of Harare, Zimbabwe. PARTICIPANTS: Two hundred and seventy-three 'first-ever' strokes prospectively identified over a 12-month period. MAIN OUTCOME STUDY FACTORS: Cerebrovascular accident first-week fatality rate; age- and sex-related incidence. RESULTS: The crude incidence rate was estimated to be 30.7 per 100000 (95% confidence interval 27.1-34.4) and the standardised rate was 68 per 100000. Fifty-one per cent of stroke victims were below the age of 54 years. Thirty-five per cent of patients died within 1 week of the stroke. Overall, the age-specific rates for both sexes rose with age, with the rates for women being higher at all age strata except for the group 45-54 years. CONCLUSION: With a standardised rate of 68 per 100000 and a first-week mortality rate of 35%, stroke must now be considered an important cause of morbidity and mortality in the population.

Morbidity and disability in elderly Zimbabweans.

BACKGROUND: the population aged over 60 years in Zimbabwe is expanding. Despite the likely increased demand on medical services that this will bring, little is known about the health needs of this elderly population. OBJECTIVE: to record the prevalence of disability (impairment of activities of daily living), subjective morbidity (symptoms), the social circumstances and the utilization of health services in a group of elderly Zimbabweans. DESIGN: cross-sectional community survey. SETTING: a remote rural area in North Eastern Zimbabwe and two urban townships located approximately 80 km from Harare. SUBJECTS: 278 subjects (154 women, 174 rural), aged > 60 years (range 60-92) living at home. METHOD: subjects were selected by random cluster sampling. They were assessed in a structured interview and underwent physical examination including visual acuity, inspection for cataracts and assessment of mobility. RESULTS: less than 4% experienced difficulty with self-maintenance activities of daily living, but 30% had difficulty with instrumental activities. The former were all visually impaired and both visual and mobility problems contributed to the latter. Elderly people experienced many symptoms but had inadequate access to health services and used medication infrequently. Subjects were mainly self-sufficient for financial income and 60% still worked. They had declining resources with age and received little help from the social welfare department. Their health and functional abilities deteriorated with age but it was older subjects who had most difficulty getting to the clinic. Simple measures such as cataract surgery and analgesics were available only to the minority or not at all. CONCLUSIONS: this study highlights problem areas where simple, low-cost measures could make a difference to the morbidity and disability of elderly Zimbabweans.

Anaemia, macrocytosis, vitamin B12 and folate levels in elderly Zimbabweans.

OBJECTIVES: To establish the ranges of full blood count (FBC), vitamin B12 and folate levels and to determine the prevalence of occult haematological abnormalities in older Zimbabweans. STUDY DESIGN: Community based cross sectional survey. SUBJECTS: 278 randomly selected healthy Zimbabweans aged > 65 years. INTERVENTIONS/STUDY FACTORS: Haemoglobin level, MCV, folate, B12 alcohol consumption. RESULTS: The median Hb was males 14.0 (range 8 to 18.3), females 13.1 g/dl (7.9 to 18.1). 23% were anaemic (Hb < 13 g/dl in males, < 12 g/dl in females), 3% with microcytic and 20% with macrocytic indices. Overall 13% had low vitamin B12 and 30% had low folate levels. Folate levels were significantly lower in urban subjects and B12 levels were significantly lower in rural subjects. Fifty four subjects (21%) had an MCV > 100 fl. In this group, low folate levels were found in 22, low B12 levels in nine, excessive alcohol in eight and two subjects had elevated TSH. The MCV was higher in urban subjects. CONCLUSIONS: This study has revealed a large amount of occult haematological abnormality and interesting differences between rural and urban subjects. It focuses attention on low levels of folate, which should be preventable by simple nutritional education, as an extensive problem in the community.

Hypertension management in Zimbabwe--awareness, treatment and blood pressure control. A community-based study.

OBJECTIVE: To evaluate the level of awareness of hypertension, treatment and blood pressure control in rural and urban communities in Zimbabwe. DESIGN: Community-based cross-sectional survey. SUBJECTS AND SETTING: 749 male and female heads of households aged > 34 years recruited from alternate households of randomly selected villages in two adjacent rural areas and randomly selected streets in an urban area. MAIN OUTCOME MEASURES: Blood pressure, awareness of hypertension, treatment and control for those on drug therapy. RESULTS: 250 subjects were found to have a diastolic blood pressure (DBP) > 94 mmHg or were on treatment with a DBP < 95 mmHg. Only 56 (22.4%) were on treatment. Of those not on treatment, 73.9% were not aware that they were hypertensive, while only 26.1% were aware but were untreated. Of those on treatment, control was inadequate in 24 (52.2%). CONCLUSION: Awareness is low and treatment and control of hypertension are inadequate in this population. There is an urgent need to set up a national policy for the prevention and control of hypertension in Zimbabwe. The main focus should be on prevention, as this may be more cost-effective for a developing country with limited resources.

Diet and nutritional status in elderly Zimbabweans.

BACKGROUND: nutritional studies in developing countries tend to focus on women of reproductive age and children. Little is known about the diet or nutritional status of elderly Africans. OBJECTIVE: to record the diet, anthropometric, haematological and biochemical measurements which might reflect nutrition and social factors in a group of elderly Zimbabweans. DESIGN: cross-sectional community survey. SETTING: a remote rural area in north-eastern Zimbabwe and two urban townships located approximately 80 km from Harare. SUBJECTS: 278 subjects (154 women, 174 rural), aged >60 years (range 60-92), living at home. METHOD: subjects were selected by random cluster sampling. Diet was assessed by a food frequency questionnaire. Anthropometric measurements were body mass index (BMI), waist : hip ratio (WHR), triceps and subscapular skinfold thickness (SFT). Laboratory analysis included serum albumin, calcium, haemoglobin, alkaline phosphatase (ALP), cholesterol, triglycerides, vitamin B12 and red blood cell folate levels. RESULTS: the staple diet was maize meal and vegetables; 74 (27%) ate a protein-containing meal less than once a week; 135 (49%) took milk less than once a week and 27% had serum Ca2+ < 2 mmol/l. The frequency of eating meat, milk, bread and fried food varied with income and education and declined with age. For all anthropometric measurements median values were higher in the urban area (BMI 21.1 vs 18.3, WHR 0.98 vs 0.9, triceps SFT 10 vs 6.7 mm; P < 0.001 for all) and related to the frequency of eating meat and fried food. The BMI was higher in those with more years of education. Within the rural area physical measurements were higher in a more prosperous area. Serum lipid concentrations were higher in urban residents (median cholesterol 4.4 vs 3.9 mmol/l, triglycerides 1.8 vs 1.5 mmol/l; P < 0.001 for both) and correlated with BMI, WHR and triceps SFT. Vitamin B12 concentrations were higher in urban residents, whereas folate concentrations were higher in rural residents. CONCLUSIONS: dietary patterns, anthropometric measurements and biochemical values in a group of randomly-selected elderly Zimbabweans are influenced by area of residence, age, income and educational level.

Determinants of happiness and life satisfaction in elderly Zimbabweans.

OBJECTIVE: To assess determinants of happiness and life satisfaction in elderly Zimbabweans. DESIGN: Community based cross sectional survey. SETTING: Randomly selected villages and two urban areas in north eastern Zimbabwe. SUBJECTS: 278 subjects aged 60 to 92 years (124 male, 154 female). METHOD: One subject per randomly selected household was interviewed, at home, by a trained interviewer to complete a questionnaire. RESULTS: Independent determinants of happiness were: rural residence, whether children gave material support and satisfaction with financial circumstances. [Adjusted odds ratios and confidence intervals 0.25 (0.13 to 0.49), 0.45 (0.22 to 0.94) and 0.11 (0.01 to 0.87) respectively]. Independent determinants of life satisfaction were: feeling better off than their neighbours, receiving adequate respect from their children and satisfaction with financial circumstances. [Adjusted odds ratios and confidence intervals 0.73 (0.59 to 0.91), 0.13 (0.03 to 0.59) and 0.24 (0.1 to 0.61) respectively]. CONCLUSIONS: We have demonstrated that, despite physical hardship, the majority of Zimbabwean elders are happy and 50% are satisfied with their lives and we have identified independent determinants of happiness and life satisfaction in this group. Characterization of these determinants allows us to predict that social changes such as rural/urban migration, declining family support and diminishing respect from children will have a negative effect on happiness and life satisfaction in our elders. It is important that, when planning intervention programmes for the elderly, these facets of wellbeing are not neglected.

Endomyocardial fibrosis in Zimbabwe--how rare is it? A report of two cases.

In Africa endomyocardial fibrosis (EMF) is rare outside countries where it is endemic, such as Uganda, Mozambique and Ivory Coast. The only published case in Zimbabwe was in 1957. We describe two female patients aged 22 and 19 years who presented within seven months of each other with typical clinical, electrocardiographic and echocardiogaphic features of right ventricular EMF. We would like to suggest that EMF exists in Zimbabwe and needs to be considered in the differential diagnosis of patients presenting with suggestive clinical features.

Myocardial dysfunction in human immunodeficiency virus infection: an echocardiographic study of 157 patients in hospital in Zimbabwe.

OBJECTIVE: To determine the prevalence and characteristics of myocardial dysfunction and other cardiac manifestations in acutely ill hospital patients infected with human immunodeficiency virus (HIV) in Zimbabwe. DESIGN: A prospective echocardiographic survey of acutely ill HIV seropositive patients. SETTING: General medical ward, Harare Central Hospital, Zimbabwe. PATIENTS: One hundred and fifty seven HIV seropositive patients admitted with various acute medical conditions over a 12 month period, January to December 1994. MAIN OUTCOME MEASURES: Detection of myocardial dysfunction and other cardiac abnormalities by cross sectional echocardiography. RESULTS: Eighty (51%) men and 77 women were studied (mean (SD) age 34.4 (8.5), range 15-60 years for males and 31.6 (9.0), range 16-65 years for females). They were all heterosexual. None was haemophiliac or an intravenous drug user. Echocardiographic abnormalities were found in 79 (50%) patients: 14/151 (9%) had dilated cardiomyopathy, 33/151 (22%) left ventricular dysfunction, 9/151 isolated right ventricular dilatation, and 30/157 (19%) pericardial disease (28 with effusions, three having tamponade). There were two cases of constrictive pericarditis and one of ascending aortic aneurysm. CONCLUSIONS: There is a high prevalence of echocardiographically detected myocardial and pericardial disease in this group of acutely ill HIV infected patients. Left ventricular dysfunction without dilatation was common, but its significance was not ascertained.

Comparison of the Omron HEM-713C automated blood pressure monitor with a standard ausculatory method using a mercury manometer.

OBJECTIVES: To compare the Omron HEM-713C automated blood pressure machine with the standard ausculatory method using a mercury manometer. DESIGN: Blood pressures of randomly selected subjects were measured using both the Omron HEM-713C and the mercury manometer. SETTING: Dombotombo surburb in Marondera, Zimbabwe. SUBJECTS: One hundred and sixteen subjects 25 years and above (47 males and 69 females) randomly selected in Marondera. MAIN OUTCOME MEASURE: Systolic blood pressure and diastolic blood pressure. RESULTS: The Omron HEM-713C passed with a grade B for both systolic and diastolic blood pressures when using the British Hypertension Society protocol. It also passed both systolic and diastolic criteria for Association of the Advancement of Medical Instrumentation. CONCLUSION: The Omron HEM-713C compares well with the standard mercury manometer, we therefore recommend its use in both research and clinical applications which require blood pressure measurements.

Abbreviated Mental Test (AMT) in the elderly: shortcoming of an adapted AMT in Zimbabwe.

OBJECTIVE: To measure the abbreviated mental test (AMT)-and to determine factors which might influence this in a group of Zimbabwean elders. DESIGN: Community based cross sectional survey. SETTING: Randomly selected households within randomly selected villages and two high-density urban areas in north eastern Zimbabwe. SUBJECTS: 278 subjects aged 60 to 92 years (124 male, 154 female). INTERVENTIONS: A questionnaire, including the AMT, was administered, at home, by trained research nurses. MAIN OUTCOME MEASURES: AMT-literacy rates, visual acuity, social and demographic information. RESULTS: 128 (46pc) scored less than seven, a level normally associated with significant mental impairment. Only one subject was actually disoriented in time and place. Multiple regression analysis confirmed that increasing age, female sex, rural evidence, lack of formal education, reduced visual acquity and not currently living with a spouse were all independent factors associated with low AMT score. CONCLUSION: It was apparent that the AMT was not a valid tool for screening for confusion in Zimbabwean elderly, since the prevalence of senile-dementia is increasing in the developing world. It is important to develop a screening test for use in Zimbabwe which is sensitive but is independent of these confounding variables.