Anticoagulation control among patients on vitamin K antagonists in nine countries in Sub-Saharan Africa.

Vitamin K antagonists (VKA) is the primary anticoagulant in most settings of Sub-Saharan Africa. Understanding the quality of anticoagulation services in the continent is vital in optimising the intended benefits. This study assessed the quality of anticoagulation and associated factors among VKA-treated patients in nine SSA countries. We conducted a retrospective cohort study of randomly selected patients on anticoagulation from 20 clinics in Botswana, the Democratic Republic of Congo, Ethiopia, Gambia, Ghana, Mozambique, Nigeria, Tanzania, and South Africa. Eligible participants were those on VKAs for at least three months and with at least four international normalised ratios (INR) results in 2019-2021. We report the proportion of INR values in the therapeutic range, time-in-therapeutic range (TTR) using the Rosendaal method, and the proportion of patients with TTR ≥ 65% (optimal anticoagulation). The mean age was 51.1(16.1) years, and 64.2% were women. The most common indications for VKA included venous thromboembolism (29.6%), prosthetic valves (26.7%) and atrial fibrillation/flutter (30.1%). We analysed 6743 INR tests from 1011 participants, and of these, 48.5% were sub-therapeutic, 34.1% therapeutic, and 17.4% were supratherapeutic relative to disease-specific reference ranges. TTR was calculated for 660 patients using 4927 INR measurements. The median (interquartile range [IQR]) TTR was 35.8(15.9,57.2) %. Optimal anticoagulation control was evident in 19.2% of participants, varying from 2.7% in Tanzania to 23.1% in Ethiopia. The proportion of patients with TTR ≥ 65% was 15,4% for prosthetic heart valves, 21.1% for venous thromboembolism and 23.7% for atrial fibrillation or flutter. Countries with universal health coverage had higher odds of optimal anticoagulation control (adjusted odds ratio (aOR) 1.79, 95% confidence interval [CI], 1.15- 2.81, p = 0.01). Patients on VKAs for different therapeutic indications in SSA had suboptimal TTR. Universal health coverage increased the odds of achieving TTR by 79%. The evidence calls for more intensive warfarin management strategies in SSA, including providing VKA services without out-of-pocket payments.

Renal echotextural changes in Nigerian workers chronically exposed to petroleum-based liquid fuels.

Background: Exposure to hydrocarbon is associated with an increased risk of development of chronic kidney disease. Ultrasound, which is a non-invasive imaging modality, provides very important information about kidney morphology. Objective: The aim of this study was to evaluate the effects of chronic exposure to some petroleum products on the kidney of exposed workers using sonography. Materials and methods: This was a prospective cross-sectional study involving 415 workers with chronic workplace exposure to petroleum fuel in Enugu metropolis. The study population comprised 164 petrol station attendants, 175 automobile mechanics and 76 petrol tanker drivers aged between 20 and 65 years. Abdominal ultrasound was performed, as well as serum urea and creatinine were measured to assess the kidneys of these workers chronically exposed to petroleum fuels, and the findings were compared to findings in an aged-matched, non-exposed control group. Results: Increased echogenicity of the kidneys was observed in 21 subjects from the study group and this differed significantly (p <0.05) from the findings in the control group. Conclusions: The study has shown that chronic exposure to petroleum fuel affects renal echotexture and that ultrasound may serve as a useful non-invasive tool for routine use in the assessment of petroleum-induced nephropathy.Background: Exposure to hydrocarbon is associated with an increased risk of development of chronic kidney disease. Ultrasound, which is a non-invasive imaging modality, provides very important information about kidney morphology. Objective: The aim of this study was to evaluate the effects of chronic exposure to some petroleum products on the kidney of exposed workers using sonography. Materials and methods: This was a prospective cross-sectional study involving 415 workers with chronic workplace exposure to petroleum fuel in Enugu metropolis. The study population comprised 164 petrol station attendants, 175 automobile mechanics and 76 petrol tanker drivers aged between 20 and 65 years. Abdominal ultrasound was performed, as well as serum urea and creatinine were measured to assess the kidneys of these workers chronically exposed to petroleum fuels, and the findings were compared to findings in an aged-matched, non-exposed control group. Results: Increased echogenicity of the kidneys was observed in 21 subjects from the study group and this differed significantly (p <0.05) from the findings in the control group. Conclusions: The study has shown that chronic exposure to petroleum fuel affects renal echotexture and that ultrasound may serve as a useful non-invasive tool for routine use in the assessment of petroleum-induced nephropathy.

Cytotoxic-induced heart failure among breast cancer patients in Nigeria: A call to prevent today's cancer patients from being tomorrow's cardiac patients.

We report three cases of heart failure (HF) associated with the use of cytotoxic drugs such as anthracycline, cyclophosphamide, and 5-fluorouracil in the treatment of breast cancer in Nigerians. The patients had systolic and diastolic HF: HF with reduced ejection fraction and preserved ejection fraction. The prevalence of breast cancer is increasing across Africa, and cytotoxics are some of the most common and best drugs used during management. The cardiotoxicity caused by these drugs limits their use as chemotherapeutic agents. Cytotoxic-induced HF is a preventable and manageable cause of cardiovascular disease (CVD) in Nigeria and Africa. This article discusses the pathophysiology of cytotoxic-induced HF and presents the risk factors that impair cardiovascular function. The importance of proper assessment and the prophylactic and therapeutic measures in the management of cytotoxic-induced HF are emphasized. The peculiar challenges in the management of cytotoxic-induced HF in Nigeria were also discussed. The need for early involvement of cardiologists by oncologists to improve on the chemotherapeutic and cardiovascular outcome in the management of patients with breast cancer was stressed. Perhaps, it is time to birth a new discipline of cardiooncology in Nigeria.

Résumé Nous rapportons trois cas d'insuffisance cardiaque (IC) associés à l'utilisation de médicaments cytotoxiques tels que l'anthracycline, le cyclophosphamide et le 5-fluorouracile dans le traitement du cancer du sein chez les Nigérians. Les patients avaient une HF systolique et diastolique: HF avec une fraction d'éjection réduite et une fraction d'éjection préservée. La prévalence du cancer du sein augmente à travers l'Afrique et les cytotoxiques sont parmi les médicaments les plus courants et les meilleurs utilisés pendant la prise en charge. La cardiotoxicité causée par ces médicaments limite leur utilisation comme agents chimiothérapeutiques. L'IC induite par les cytotoxiques est une cause évitable et gérable de maladies cardiovasculaires (MCV) au Nigéria et en Afrique. Cet article traite de la physiopathologie de l'IC induite par cytotoxique et présente les facteurs de risque qui altèrent la fonction cardiovasculaire. L'importance d'une évaluation appropriée et des mesures prophylactiques et thérapeutiques dans la gestion de l'IC induite par les cytotoxiques est soulignée. Les défis particuliers de la gestion de l'IC induit par des cytotoxiques au Nigeria ont également été discutés. La nécessité d'une implication précoce des cardiologues par les oncologues pour améliorer les résultats chimiothérapeutiques et cardiovasculaires dans la prise en charge des patientes atteintes d'un cancer du sein a été soulignée. Peut-être est-il temps de donner naissance à une nouvelle discipline de cardiooncologie au Nigeria.

Cardiotoxicity of Pesticides: Are Africans at Risk?

Cardiovascular disease has maintained the unenviable position as the number one cause of death in the world. It is now clear that the traditional risk factors of cardiovascular disease are driven by primary factors like globalisation, urbanisation, industrialisation and agricultural practices. Pesticide use is an integral component of modern and improved agriculture. The abuse and misuse of these chemicals has caused significant poisoning worldwide and particularly in low- and middle-income countries where Africa belongs. This review surveys the widening population of people poisoned by pesticides in Africa and examines the possibility of pesticide-induced cardiotoxicity. The exposed group includes workers in pesticide industries, transporters of these chemicals, farmers, farm workers who apply these pesticides, vendors and sellers of farm produce and consumers of foodstuffs that are treated with pesticides as well as persons who consume water and inhale air filled with pesticides. There are numerous animal model studies that employ electrocardiography, echocardiography, enzyme studies and histopathology to demonstrate pesticide-induced cardiotoxicity in many parts of the world. There are also case reports and epidemiological data of pesticide-induced cardiovascular intoxication in man. With the increasing reports of pesticide-induced central system nervous toxicity in Africa, there are enough reasons to suspect cardiovascular system poisoning as well. The poorly developed clinical toxicology specialty may explain the low index of suspicion of pesticide-induced cardiovascular diseases. With the pervading ignorance, indiscriminate sale, unguarded use, lack of adequate legislation, inadequate enforcement of legal institutes associated with pesticide use in Africa, there is no doubt that the increasing prevalence and incidence of cardiovascular diseases may partly be due to exposure to these chemicals. Africans may after all be at risk of pesticide-induced cardiotoxicity, but more studies will be required to examine the pattern of cardiotoxicity as well as factors that modulate its occurence.

Clinicians-related determinants of anticoagulation therapy and prophylaxis in Nigeria.

BACKGROUND: Thromboembolic and hypercoagulable diseases are common life-threatening but treatable problems in hospital practice. Fortunately, anticoagulation is an efficacious management practice indicated for arterial, venous, and intracardiac thromboembolism. Clinicians in developing countries may have gaps in their knowledge of anticoagulation therapy/prophylaxis which could affect their clinical decision. OBJECTIVES: The study examined the knowledge and attitude of clinicians to anticoagulation therapy/prophylaxis in some tertiary hospitals in Nigeria. METHODOLOGY: The study was a multicenter survey. A pretested questionnaire was administered to clinicians in six tertiary hospitals in Southeast Nigeria. RESULTS: A total of 528 questionnaires were returned by 419 (79.4%) residents and 109 (20.6%) consultants. We observed significant abysmal knowledge and lack of awareness of direct oral anticoagulants (DOACs) among most respondents irrespective of their job grades (P = 0.02, odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.90). Their knowledge of anti-Xa assay as laboratory monitoring tool was also significantly inadequate (P = 0.001, OR 0.23, 95% CI 0.10-0.51). On statement analysis on their attitude to anticoagulation therapy/prophylaxis, "Do you think anticoagulation therapy/prophylaxis is clinically relevant" had the highest mean of 4.60, P = 0.01, and a high degree of agreement; while "Should hospital inpatient with > 3 days admission routinely receive anticoagulation/prophylaxis?" had the lowest mean of 2.27, P = 0.02, and a low degree of agreement. CONCLUSION: There is the need to upscale knowledge of anticoagulation agents and an attitude change to anticoagulation therapy/prophylaxis, especially on the DOACs through continuing medical education activities in emerging countries such as Nigeria.

Sonographic assessment of petroleum-induced hepatotoxicity in Nigerians: does biochemical assessment underestimate liver damage?

BACKGROUND: Exposure to petroleum products has been shown to have significant adverse effects on the liver which can manifest either as morphological or physiological changes. OBJECTIVES: The aim of the study was to assess the effects of chronic exposure to some petroleum products on the liver of exposed workers using sonography and to determine whether biochemical assessments underestimated hepatotoxicity. METHODS: Abdominal ultrasound was performed on 415 exposed workers in order to evaluate liver echogenicity and size. Also, biochemical assessment of the liver was done to evaluate its function. RESULTS: Statistically significant increase in the liver parenchymal echogenicity and the liver size was seen in the exposed workers compared with control (p ≤ 0.05). These increased as the exposure duration increased. It was also noted that out of 16.87% (N=70) exposed workers with abnormal liver echopattern, only 2.65% (N=11) had alanine aminotransferase above the reference range. CONCLUSION: The study revealed evidence of ultrasound detectable hepatotoxicity among the exposed subjects. Sonography appeared to detect petroleum products-induced hepatic toxicity more than biochemical assays suggesting that biochemical assessment may have underestimated toxicity.

Awareness, Treatment, and Control of Hypertension in Primary Health Care and Secondary Referral Medical Outpatient Clinic Settings at Enugu, Southeast Nigeria.

Essential hypertension is the most common noncommunicable disease (NCD), affecting more than half the adult population in many countries and being the major NCD contributor to the double burden of disease in developing countries. We undertook a survey of the hypertension awareness, treatment, and control in primary and secondary referral health care clinics in Enugu, Nigeria, and compared these data with those obtained in local community surveys. The prevalence of hypertension in the primary care clinic (9.2%) was lower than in a previously reported community survey (42.2%), while, in the referral clinic, 70.3% of patients attending were hypertensive. Hypertension awareness rates were 91.9%, 29.4%, and 93.2% in these respective health care settings. Treatment and control rates (89.9% and 72.9%) were better in the secondary care clinic than in the primary care centre (87.7% and 46.0%). (Chi-square analysis confirmed statistically significant differences between these rates (p < 0.05).) These data may form a useful index of health care system effectiveness in Nigeria. Possible reasons for the differences observed and effective strategies to address the waxing pandemic of hypertension are discussed.

Echocardiographic assessment of left ventricular function in thyrotoxicosis and implications for the therapeutics of thyrotoxic cardiac disease.

INTRODUCTION: Thyrotoxicosis is an endocrine disorder with prominent cardiovascular manifestations. Thyroid hormone acts through genomic and non-genomic mechanisms to regulate cardiac function. Echocardiography is a useful, non-invasive, easily accessible, and affordable tool for studying the structural and physiological function of the heart. AIM: We studied thyrotoxicosis patients in a Nigerian Teaching Hospital and employed trans-thoracic echocardiography to find out if there were abnormalities in the hearts of these patients. METHODS: Fifty adult thyrotoxicosis patients diagnosed with clinical and thyroid function tests in the medical out-patient unit of the hospital were recruited and we performed transthoracic echocardiography with a Sonos 2000 HP machine. RESULTS: We documented the presence of abnormalities in the following proportion of thyrotoxicosis patients: left ventricular enhanced systolic function in 30%, enhanced diastolic function in 34%, diastolic dysfunction in 34%, heart failure with preserved ejection fraction in10%, heart failure with reduced ejection fraction in 6%, and left ventricular hypertrophy in 34%. CONCLUSION: Echocardiography was useful in the stratification of cardiac function abnormalities and is indispensable as a guide in the choice of therapeutic options in patients with thyrocardiac disease. The finding of left ventricular enhanced systolic and diastolic functions signify early echocardiographic detectable cardiac abnormalities in thyrotoxicosis, and the clinical management includes the use of anti-thyroid drugs and ß-adrenoceptor blockade. Diastolic dysfunction in thyrotoxicosis patients asymptomatic for cardiac disease should be treated with anti-thyroid drugs, and ß-adrenoceptor blockade. The judicious application of clinical therapeutics will guide the use of anti-thyroid drugs, diuretics, digoxin, angiotensin inhibitors, and ß-adrenoceptor blockade in the successful management of thyrotoxicosis patients with heart failure and reduced, preserved, or increased ejection fraction: parameters which are derived from echocardiography.

Antiphospholipid syndrome in a young Nigerian girl presenting with gangrenous toes.

We report on a 21-year-old Nigerian girl with toe gangrene, which is one of the most unlikely forms of presentation of antiphospholipid syndrome among Africans. The essence of this case report is to raise awareness that, although antiphospholipid syndrome typically presents in Africans in association with a pregnancy-related event or a neuropathology, it should be considered as a differential diagnosis in all African patients with unexplained vasculitis. A high index of suspicion and early treatment will prevent toe amputations and reduce mortality rates.

A rare case of cor pulmonale secondary to idiopathic pulmonary fibrosis in Nigeria.

Idiopathic pulmonary fibrosis (IPF) is a rarely reported disease in Nigeria. Cor pulmonale, one of the complications of this type of diffuse parenchymal lung disease is even rarer. The authors present a Nigerian patient with IPF with a classical high-resolution CT features, managed in our centre together with associated problems.