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Comparison of CD4+ T-Cell changes in response to highly active antiviral therapy (HAART) in adolescents and children enrolled at Parirenyatwa Hospital Family Care Centre (2005-2010) - Secondary Data Analysis
No full textBackground
In general, there is an increase in CD4 cell count after initiating on HAART. Despite an increasing trend of access to HAART there is a paucity of studies examining the changes in CD4 count over time in Zimbabwe and also no study has been done at PHFCC specifically comparing children and adolescents at the clinic. The PAP study data has not been analyzed to compare how CD4 count changes over time between different age groups and to find out the factors which predicts CD4 count response after initiating on HAART. The study aims to determine the factors associated with changes in CD4 count in adolescents and children and to compare the changes between these two age groups over time.
Methodology
Out of 2200 HIV infected children and adolescents who have been enrolled into HIV/AIDS care between January 2004 and December 2012, a total of 512 subjects who met the inclusion criteria were selected for this secondary data analysis study. Differences between groups in CD4 cell response at different time points was assessed using Wilcoxon rank-sum test. Mixed effects model was used to compare the pattern of changes in CD4 count over time between adolescents and children and to identify the factors which are associated with changes in CD4 count after HAART initiation.
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Results
A total of 512 subjects were selected for the study. More (59.6 %) of the subjects were adolescents and the female gender (52.3%) was mostly represented. The change in CD4 count in response to HAART between adolescents and children was different. The median (IQR) baseline CD4 count for children was 171.5 (51-298) cells/mm3 and 145 (50-254) cells/mm3 for adolescents (p=0.087). The response in children was significantly higher after 18 months on treatment compared to adolescents (p=0.004). Baseline CD4 counts and age group was found to predict the changes in the square root of CD4 count over time in the multivariate analysis. The increase in the square root of CD4 count over time for those who initiate HAART at adolescence stage were 0.0853 times less when compared to those initiated whilst they were still children (p=0.037) adjusting for other variables. Adjusting for other baseline variables, subjects with CD4 cell count less than 100cells/mm3 had a greater increases (beta=0.501, p<0.001) in the square root of CD4 cell count when compared to those with baseline CD4 count of more than 300cells/mm3. Subjects with baseline CD4 count of 100 to 200 cells/mm3 had a greater increase in the square root of CD4 count over time as compared to those with baseline CD4 count above 300cells/mm3 adjusting for other variables ( beta=0.340, p<0.001).
Conclusion
The change in CD4 count in response to HAART between adolescents and children was different. The baseline variables which were significantly associated with an increase in CD4 count over time were baseline CD4 cell count and age group after controlling for other independent variables
A critical incident reporting system in anaesthesia
No full textObjective: To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department.
Design: Cross sectional study. A critical incident was defined as ‘any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient’. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis.
Setting: The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals.
Subjects: Between May and October 2000, 62 completed critical incident forms were collected.
Main Outcome Measures: The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms.
Results: A total of 14165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14 165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, lary ngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57 %, oxymetry 90 % and ECG 100 %. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15 % died, 23 % were unplanned admissions to HDU while 62 % were discharged to the ward with little or no adverse outcome. Conclusion: Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change of practice and improvement in the safety features of the service provided by the hospital and staff
Fournier's Gangrene: outcome analysis at three tertiary hospitals in Harare Zimbabwe
No full textBackground: Fournier’s gangrene is a potentially life threatening, infective necrotizing fasciitis of the external genitalia and perineum. The average world mortality rate is between 20 – 30%. The factors associated with mortality are not universally accepted and have not been described in our environment.
Main objective: To determine the disease related mortality rate and factors associated with mortality among patients admitted with a clinical diagnosis of Fournier’s gangrene at 3 tertiary hospitals in Harare, Zimbabwe. .
Study Design: A prospective observational descriptive study on 51 consecutive patients with a clinical diagnosis of Fournier’s gangrene managed at 3 tertiary hospitals in Harare, Zimbabwe over a 2 year period.
Materials and Methods: The study was done after approval by the relevant regulatory boards and after obtaining informed consent from the patients. Data on demographics, clinical history and physical examination, vital signs and laboratory values on admission were recorded on a designed data collection sheet. All patients received intravenous broad spectrum antibiotics and fluid resuscitation and surgical debridement. The number and time to first surgical debridement and any additional surgical procedures
performed were recorded. The patients were followed up from admission till discharge from hospital or death. The patients were stratified according to outcome, whether dead or alive and comparison between survivors and non survivors was done to determine factors associated with mortality using chi squared or Fischer exact test for categorical variables and student t test for comparison of the means. Binary multiple regression analysis was performed to determine independent factors associated with mortality.
Results: The disease related hospital mortality rate was 27% (14/51). The median hospital stay was 15 days. The median age of the 51 patients was 43 years. The patients that did not survive were significantly older than those that survived (58.36 + 21.04 vs 42.76 + 14.40 years)(p=0.021). The presence of at least one comorbity was associated with an increased mortality (p=0.007).HIV was the commonest risk factor
accounting for 36% of the cases Neither the presence of HIV nor diabetes mellitus was assocaited with mortality. Renal failure at presentation was signficantly associated with mortality, with a rate of 70% among patients.(p=0.001). The urogenital tract source of infection was associated with increased mortality (p=0.01) while a cutaneous source was associted with survival. (p=0.003). E coli and staphylococcus aures were the commonest pathogens isolated. A delay in first surgical debridement beyond 24 hours from time of admision was signficantly associated with an increased mortality (p=0.04).The number of debridement did not differ significantly between survivors and non survivors. A body surface area involvement of > 5% and abdominal involvement was also signficantly associated with higher mortality. The admitting clinal and biochemical parameters signficantly associated with non survivors were a high respiratory rate, low haemoglobin, hyperkalemia, elevated blood urea nitrogen and elevated creatinine. There was no factor that was independently associated with mortality after multiple
logistic regression analysis.
Conclusion: Fournier’s gangrene remains a potentially fatal condition in our enviroment with a mortality rate of 27%. On univariate analysis an older age, presence of renal failure on admission, a urogenital source of infection, severe sepsis, abdominal involvement, anemia, hyperkalemia and delay in surgical debridement is associated with mortality in our enviroment. The presence of HIV and diabetes mellitus and number of surgical debridement does not seem to affect mortality in our enviroment
Health related quality of life (HRQoL) of people living with HIV: A comparison with biomedical markers of HIV
No full textBackground: Health related quality of life (HRQoL) in HIV patients has become an important indicator of impact of disease and treatment outcomes. Linking CD4 count to HRQoL measures is necessary to determine if HRQoL can be predicted from CD4 count.
Methods: A cross sectional study was carried out at Chitungwiza Opportunistic Infections Clinic among HIV patients on ART. The HAT-QoL and EQ-5D-3L were used to measure HRQoL. Internal consistency of HAT-QoL and EQ-5D-3L was evaluated. Univariate and multivariable linear regression was used to identify predictors of HRQoL in HIV/AIDS patients.
Results: A total of 257 participants (mean age 39.7±8.9, 72% female) out of 351(73.4% response rate) consented to take part in the study. The overall mean HAT-QoL score was 69.3±16.9. The mean EQ-5D-3L index and VAS scores were 68.7± 29.4 and 73.3 ±18.9 respectively. The overall Cronbach‟s alpha for HAT-QoL and EQ-5D-3L was 0.76 (p<0.001) and 0.68 (p<0.001). The Cronbach‟s alpha between EQ-VAS and EQ-5D index was 0.68 (p=0.004). Income was a significant predictor of HRQoL scores [(HAT-QoL: β=0.37, p<.001), (EQ-5D index: β=0.18, p=0.05), (EQ-VAS :β=0.19, p=0.04)] . CD4 count was not correlated with HRQoL scores. Unadjusted coefficients and p-values were: (β=0.09, p=0.26), (β=0.05, p=0.59) and (β=0.16, p=0.06) for HAT-QoL, EQ-5D index and EQ-VAS respectively. Adjusted coefficients and p-values were (β=0.02, p=0.82),(β= 0.07, p=0.48) and (β=0.12, p=0.19) for HAT-QoL, EQ-5D index and EQ-VAS respectively.
Conclusion: There was no correlation between CD4 count and HRQoL scores. HAT-QoL and EQ-5D-3L have good psychometric properties and potential for use in clinical settings.
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Incorporation of HRQoL in the management of HIV/AIDS patients is essential to provide clinicians with accurate estimates of the quality of life patients.NECTAR Mentored Research Scholars Programme under the NIH grant
Relationship between knowledge and self-care practices regarding tuberculosis treatment among clients aged 20 – 40 years at Beatrice Road Infectious Hospital outpatient clinic
No full textTuberculosis is a worldwide public health problem with a continued increase in both morbidity and mortality. It has been compounded by HIV/AIDS pandermic. Tuberculosis is widely known to affect the most economically active group, with 99% of all TB death occurring in the developing countries. Directly Observed Treatment Short Course is an internationally recommended approach adopted to improve self care practices as adherence among the clients on tuberculosis treatment. In Zimbabwe over 40,000 cases were reported in 2007 at a rate of 302 per 100 000 population, compared to 402 per 100 000 in 2000. The purpose of the study is to examine the relationship between self-care practices and knowledge among 20-40 year old clients on tuberculosis therapeutic management at Beatrice Road Infectious Disease Hospital Outpatient Clinic. Orem’s self-care nursing model was used as a conceptual framework. The study used descriptive correlation design. The study included a random sample of 80 subjects comprising 48 females and 32 males aged between 22 to 40 years. The interview schedule contained closed ended structured questions on the demographic data open ended and closed ended questions on dependent and independent variables. Data was collected and analyzed using descriptive and inferential statistics. The results of the study showed a significant low positive Pearson correlation coefficient of (r = .354, p* < 0.01) implying that as knowledge increases self-care increases. Regression analysis R2 = .125 expressed as percentage 12.5. This implies that knowledge accounts for 12.5% of the variance in the self-care practice. F Statistics = 11. 140; p = .001). Therefore there is need to reinforce individualized health education and counseling of clients. For self-care to be effective, the clients should have knowledge skills to do self-care (Orem, 1991)
Survival and risk factors for mortality among HIV/Tuberculosis co-infected patients on antiretroviral therapy in a resource limited setting
No full textBackground: Tuberculosis is the most common opportunistic infection and most frequent cause of mortality among HIV-infected persons in resource constrained settings and the number of patients with co-infection continues to grow rapidly.
Objective: To determine the survival and predictors of mortality among HIV/Tuberculosis co-infected patients on antiretroviral therapy at Wilkins Infectious Disease Hospital (WIDH), Harare.
Methods: A retrospective study in a cohort of 207 HIV/TB co-infected patients who presented to WIDH and started ART between 1 December 2004 and 1 March 2010 was carried out. A retrospective review of patient medical records was done. Kaplan-Meier method was used to construct survival functions, the log rank test was used to test equality of survivor functions across strata; we performed univariate and multivariate analysis and constructed a Cox-proportional hazards model to determine factors that determine survival in HIV/TB co-infected patients on ART.
Results: There were 45 (21.7%) deaths at the end of the study among whom 18 (40%) died in those who had extra-pulmonary tuberculosis and 27 (60%) in patients with pulmonary tuberculosis. The mortality rate was 9.8 deaths/100person years of follow-up. The cumulative mortality at 3, 6 and 12 months was 1%, 5% and15% respectively. Independent predictors of mortality were CD4 count<50cells/ul adjusted Hazard ratio [AHR] 2.37, 95% CI (1.158-4.856)], WHO stage four at baseline [AHR=2.69 95%CI (1.35-5.34)], cotrimoxazole use [AHR=0.29 95%CI (0.86-0.89)]. Haemoglobin was not found to be a risk factor.
Conclusion: Mortality was high in the first year relative to subsequent years. There was increased risk of death in patients co infected with HIV and TB who presented to the clinic with late stage disease as indicated by the WHO clinical stage criterion and low CD4 count at baseline and these were strong predictors of mortality. Collaboration of HIV/TB activities should be reemphasized and scale up of patients to access ART or effective treatment and control of TB among co infected patients. Increasing access of cotrimoxazole by patients on ART and interventions to identify patients before they develop these clinical markers will improve survival and increase benefits of therapy
A survey of anaesthetic drug availability: Impact on practice of anaesthesia and patient care in Harare
No full textObjectives:
To investigate how common anaesthetic drug shortages are, how they affect the practice of anaesthesia and patient care in Harare.
Methodology:
A multicentre prospective observational study of anaesthetic drug availability was carried out involving a self-administered questionnaire completed by anaesthetists working in 3 Public hospitals and 6 Private hospitals in Harare daily over the period; 1 August 2014 to 31 October 2014. A total of 422 completed questionnaires were collected out of 619 that had been distributed. In the last week of October 2014, a once off survey of the hospitals’ chief pharmacists was done using a different questionnaire.
Results:
The incidence of reporting at least an anaesthetic drug shortage by anaesthetists was 79.86% and 100% for pharmacist. There is a statistically significant difference in the availability of drugs between private and public hospitals, p < 0.001. Private hospitals tend to have less drug shortages compared to public hospitals. Anaesthetic drug shortages are associated with a high frequency of negative adverse effects on the practice of anaesthesia and patient care.
Conclusion:
Anaesthetic drug shortages are common in Harare and they are associated with high incidences of adverse effects on anaesthesia practice and patient care
Occurrence of diabetogenic changes in pregnancy among black women in an urban setting
No full textObjective: To find out if pregnancy in black Zimbabwean women is a diabetogenic state using basal blood levels of cortisol, insulin, C-peptide and glucose.
Methods: 111 women (28 non-pregnant, 29 first trimester, 26 second trimester and 28 third trimester) aged between 18 and 35 years were recruited for the study. Fasting plasma cortisol, insulin, C-peptide and glucose were determined by standard methods. The glucose/insulin ratio was used as an index of insulin sensitivity and the C-peptide/glucose ratio as well as the homeostasis assessment model (HOMA) as an index of insulin resistance.
Results: The means of fasting plasma cortisol levels were significantly elevated, p <0.0001 among the four groups (non-pregnant, first, second and third trimester women). Fasting plasma insulin levels peaked during the third trimester and significant differences were noted among all women, p <0.05. Similar data was obtained for C-peptide levels (a better indicator of beta-cell insulin secretory activity) among the groups, p <0.01. The means of fasting plasma glucose levels were significantly decreased with advancing gestation, p <0.0001. Significantly lower glucose/insulin ratios, a measure of insulin sensitivity and elevated C-peptide/glucose ratios, an index of insulin resistance, were demonstrated among the women, (p <0.05 and <0.01 respectively). Conclusion: The basal data presented in this paper clearly demonstrates that the diabetogenic effects of pregnancy are also expressed by Zimbabwean black women, especially in late gestatio
Attitude of medical practitioners to antibiotic prescribing in Zimbabwe
No full textThe findings indicate that a majority (91%) of medical practitioners are aware of the dangers of antibiotic abuse and consider patient variables in the choice of drug, the dose, and duration of therapy. Combinations of antimicrobial agents are reserved for severe and refractory infections. The major problem area appears to be patient pressure on medical practitioners to prescribe antibiotics unnecessarily. Other potential areas of concern are that some practitioners appear to use a broad-spectrum antibiotic as a first choice and/or prescribe an antibiotic for a shorter time than that usually recommended
Assessment of the absorption profile of ascorbic acid as a biomarker for moringa oleifera lam absorption after a bolus oral dose
No full textMoringa oleifera Lam is a medicinal plant used in the management of various ailments in many countries. Despite being used widely, the rate and extent of absorption of these
compounds from the ingested Moringa leaf powder is unknown. As a result there is no a
standard dosing regimen for Moringa oleifera Lam leaf powder. There is also potential for herb-drug interactions if Moringa is taken concomitantly with conventional medicines.
Aim. The aim of the study was to estimate the absorption profile of Moringa oleifera Lam
leaf extract after oral dosing using ascorbic acid as a bio-marker.
Methods:
Extract preparation. Harvested Moringa oleifera Lam leaves were dried under shade and
kept away from direct sun light before being ground into powder and macerated with a water and methanol mixture followed by drying.
Experimental animals. Six male rabbits of about 6 months were used.
Feeding and blood sample collection. The rabbits were fasted overnight preceding dosing. Three rabbits receiveda weighed amount of the Moringa oleifera Lam extract at a dose of 300mg/kg body weight. Three rabbits received de-ionised water only, and were used to obtain control plasma. Blood samples were collected at 0, 0.25, 0.5, 1, 2, 4 and 8 hrs after dosing. Plasma was taken and assayed by uv/visible spectrophotometry.
Results. The Moringa extract percentage yield was 16%. The content of vitamin C in the
extract was 1.371g per 100g of extract. The average bioavailability was 33%.The average
Cmax was 0.91mg/ml.This occurred at an average Tmax of 1.04 hours. The average time to reach plasma was 0.37 hours.
Conclusion. Moringa oleifera Lam is a good source of vitamin C. Usingthe absorption
profile of the vitamin C it was estimated that Moringa compounds may reach the systemic circulation after37.33 minutes and reaches maximum concentration in plasma after about one hour following oral ingestion. It was also estimated that by the end of eight hours following oral ingestion all the accessible vitamin C in Moringa will have been absorbed