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Background Chronic Rheumatic Heart disease (RHD) continues to be a health problem in many low and middle income countries and especially in sub-Saharan Africa. Echocardiography has shown that the disease is far more widespread than may be detected by clinical assessment, but data are lacking on the prevalence and epidemiological features in rural Africa. Design Community-based prevalence survey Methods We used transthoracic echocardiography to carry out a population-based study of RHD in a rural area of Ethiopia. A total of 987 participants aged 6 to 25 were selected by cluster sampling. The prevalence of RHD was assessed by the current consensus World Heart Federation criteria. Results There were 37 definite cases of RHD and a further 19 borderline cases giving an overall prevalence of 37.5 cases per 1000 population (95% CI 26.9-51.8) rising to 56.7 (95% CI 43.9-73.5) if the borderline cases are included. The prevalence of definite disease rose to a peak of 60 cases per 1000 in those aged 16-20 years before falling to 11 cases per 1000 in subjects aged 21-25 years. Of the 37 with definite disease, 36 had evidence of mitral valve and seven evidence of aortic valve disease. Conclusions RHD has a high prevalence in rural Ethiopia. Although follow-up is needed to determine how the disease develops with advancing age, the data provide evidence that the disease is an important health problem in rural sub-Saharan Africa requiring urgent concerted action.

Aim: To audit levels of diabetes-related eye disease in Type 1 diabetes mellitus (T1DM) patients in northwest Ethiopia. In particular to establish whether, despite identical clinical goals, major differences between the physically demanding life-style of rural subsistence farmers and the sedentary life-style of urban dwellers would influence the prevalence of diabetes-related eye complications., Methods: A robust infrastructure for chronic disease management that comprehensively includes all rural dwellers was a pre-requisite for the investigation. A total of 544 T1DM were examined, representing 80% of all T1DM patients under regular review at both the urban and rural clinics and representative of patient age and gender (62.1% male, 37.9% female) of T1DM patients from this region; all were supervised by the same clinical team. Eye examinations were performed for visual acuity, cataract and retinal changes (retinal photography). HbA1c levels and the presence or absence of hypertension were recorded., Results/conclusions: Urban and rural groups had similar prevalences of severe visual impairment/blindness (7.0% urban, 5.2% rural) and cataract (7.3% urban, 7.1% rural). By contrast, urban dwellers had a significantly higher prevalence of retinopathy compared to rural patients, 16.1% and 5.0%, respectively (OR 2.9, p<0.02, after adjustment for duration, age, gender and hypertension). There was a 3-fold greater prevalence of hypertension in urban patients, whereas HbA1c levels were similar in the two groups. Since diabetic retinopathy is closely associated with microvascular disease and endothelial dysfunction, the possible influences of hypertension to increase and of sustained physical activity to reduce endothelial dysfunction are discussed., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The incidence of epilepsy in Ethiopia is high compared with industrialised countries, but in most cases the cause of epilepsy is unknown. Childhood malnutrition remains widespread. We performed a case-control study to determine whether epilepsy is associated with poverty and markers of early under-nutrition., Methods: Patients with epilepsy (n=112), aged 18-45years, were recruited from epilepsy clinics in and around two towns in Ethiopia. Controls with a similar age and gender distribution (n=149) were recruited from patients and relatives attending general outpatient clinics. We administered a questionnaire to define the medical and social history of cases and controls, and then performed a series of anthropometric measurements. Unconditional logistic regression was used to estimate multivariate adjusted odds ratios. Multiple linear regression was used to estimate adjusted case-control differences for continuously distributed outcomes., Results: Epilepsy was associated with illiteracy/low levels of education, odds ratio=3.0 (95% confidence interval: 1.7-5.6), subsistence farming, odds ratio=2.6 (1.2-5.6) and markers of poverty including poorer access to sanitation (p=0.009), greater overcrowding (p=0.008) and fewer possessions (p<0.001). Epilepsy was also associated with the father's death during childhood, odds ratio=2.2 (1.0-4.6). Body mass index was similar in cases and controls, but patients with epilepsy were shorter and lighter with reduced sitting height (p<0.001), bitrochanteric diameter (p=0.029) and hip size (p=0.003). Patients with epilepsy also had lower mid-upper arm circumference (p=0.011) and lean body mass (p=0.037)., Conclusion: Epilepsy in Ethiopia is strongly associated with poor education and markers of poverty. Patients with epilepsy also had evidence of stunting and disproportionate skeletal growth, raising the possibility of a link between early under-nutrition and epilepsy., (Copyright © 2012 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background/objectives: Most insulin-requiring diabetes patients in Ethiopia have an atypical form of the disease, which resembles previous descriptions of malnutrition-related diabetes. As so little is known about its aetiology, we have carried out a case-control study to evaluate its social and nutritional determinants., Subjects/methods: Men and women with insulin-requiring diabetes (n=107), aged 18-40 years, were recruited in two centres, Gondar and Jimma, 750 km northwest and 330 km southwest of the capital, Addis Ababa, respectively. Controls of similar age and sex (n=110) were recruited from patients attending other hospital clinics., Results: Diabetes was strongly associated with subsistence farming, odds ratio=3.5 (95% confidence interval: 1.5-7.8) and illiteracy/low levels of education, odds ratio=4.0 (2.0-8.0). Diabetes was also linked with a history of childhood malnutrition, odds ratio=5.5 (1.0-29.0) the mother's death during childhood, odds ratio=3.9 (1.0-14.8), and markers of poverty including poorer access to sanitation (P=0.004), clean water (P=0.009), greater overcrowding (P=0.04), increased distance from the clinic (P=0.01) and having fewer possessions (P=0.01). Compared with controls, people with diabetes had low mid upper arm circumference, body mass index (BMI) and fat/lean body mass (P<0.01). In addition, men with the disease tended to be shorter, were lighter (P=0.001), with reduced sitting height (P=0.015) and reduced biacromial (P=0.003) and bitrochanteric (P=0.008) diameters., Conclusions: Insulin-requiring diabetes in Ethiopia is strongly linked with poor education and markers of poverty. Men with the disease have associated disproportionate skeletal growth. These findings point towards a nutritional aetiology for this condition although the nature of the nutritional deficiency and its timing during growth and development remains obscure.

Aims/hypothesis: We evaluated the incidence of insulin-requiring diabetes in a rural area of sub-Saharan Africa., Methods: Health surveillance data from a chronic disease programme in two zones of Ethiopia, Gondar and Jimma, were studied. The two zones have a population of more than 5,000,000 people., Results: In Gondar Zone (1995-2008) and Jimma Zone (2002-2008) 2,280 patients presented with diabetes, of whom 1,029 (45%) required insulin for glycaemic control at diagnosis. The annual incidence of insulin-requiring diabetes was 2.1 (95% CI 2.0-2.2) per 100,000 and was twice as high in men (2.9 per 100,000) as in women (1.4 per 100,000). In both sexes incidence rates peaked at the age of 25 to 29 years. Incidence rates in the urban areas of Gondar and Jimma were five times higher than in the surrounding rural areas. Patients with insulin-requiring diabetes from rural and urban areas had a very low BMI and most were subsistence farmers or unemployed., Conclusions/interpretation: The typical patient with diabetes in rural Ethiopia is an impoverished, young adult male with severe symptoms requiring insulin for glycaemic control. The low incidence rates in rural compared with urban areas suggest that many cases of this disease remain undiagnosed. The disease phenotype encountered in this area of Africa is very different from the classical type 1 diabetes seen in the West and most closely resembles previous descriptions of malnutrition-related diabetes, a category not recognised in the current WHO Diabetes Classification. We believe that the case for this condition should be reopened.

Background: In 1998, we set up nurse-led epilepsy clinics in five rural health centres around Gondar in northern Ethiopia. Despite good treatment outcomes, two years after registration only 40% of patients were still under follow-up., Aim: The purpose of this study was to examine the causes of default and factors that might improve adherence to follow-up., Method: The study was carried out at one of the five health centres. Patients who had defaulted from follow-up were identified from the clinic register. Trained enumerators visited the patients' villages and administered a questionnaire to the patients, or relatives if the patient was not available., Results: 113 patients were traced. 28 (25%) had died and 21 (19%) had moved from the area. Of the remaining 64 patients, seven were accessing treatment from another source and 13 were in remission off treatment. 44 patients were still experiencing seizures and were on no treatment or had reverted to traditional remedies. The main reason given for default, in 44% of the patients, was difficulty in travelling to the health centre. 12% claimed that they preferred traditional remedies and 9% felt that they had not been improved by medical treatment., Conclusion: Despite decentralisation of care to rural health centres, the most common reason for default was the distance to travel to the health centre. Further decentralisation of care to a community level coupled with improved education may reduce default from follow-up.

Health services can respond to the needs of the poorest people in developing countries if those who work in the front line of health care are supported and motivated and if development needs in services and training programmes can be filled. This can be achieved when a Health Link between a southern hospital and/or training school and its northern counterpart is designed to build a disciplined and long-term programme of staff development including the needs of anaesthetic services, which meets the needs identified by the southern partner. Development of anaesthetic practice is best carried out in the context of an institution-wide Health Link where not only the staff and systems involved in anaesthesia but all the essential 'back office' or support services are also supported and developed.

Culture profoundly affects what those who come to the UK as migrants believe about disease and thus how they behave during illness. Their beliefs may be very different from the beliefs of healthcare professionals and so there can be difficulties in understanding and barriers which inhibit effective clinical management. The behaviour of healthcare professionals towards those of a different race can lead to feelings of discrimination and lack of sympathy, so that a gulf can be allowed to develop. This gulf can be bridged if simple measures are adopted: training in communication, culturally sensitive health-promotion programmes, specific programmes relevant for those of defined ethnic groups and, as a basic means to increase confidence and trust, elementary skills in the language of the migrants.

We have studied 227 women who had peripartum cardiac failure (PPCF) in Zaria, Nigeria, since 1969-72. This follow-up and review of survivors in 1993-95 depended chiefly on a Zaria woman (A. Abdullahi) and on her careful reporting. Overall, 31 (13.7%) were completely lost to follow-up, 17 (7.5%) were thought to be alive, and there were data on 179 others (78.8%). Of the 75 known deaths, 55 were cardiovascular--20 due to PPCF, 31 due to cardiac failure unrelated to pregnancy (CF), and four were due to a cerebrovascular accident. PPCF recurred in 13% of 551 subsequent pregnancies. Thirty-two women had a recurrence of PPCF only, and 27 an episode of CF only. Blood pressures rose steadily over the years. An enlarged left ventricle on discharge after the index admission predicted a poor prognosis. In 1993-5, we compared 100 survivors with 100 non-PPCF controls: 96 PPCF women but only 50 control women took extra salt (p = 0.0001). Significantly more PPCF women than controls had a diastolic pressure of 110 mm Hg (p = 0.011). The syndrome is probably provoked in potentially hypertensive women by the traditional practices of eating kanwa, which is rich in Na+, taking additional excess salt and heating the body after delivery. Evidence is presented that PPCF women are potentially hypertensive, and cannot handle the excess ingested sodium which therefore leads to hypervolaemia and thus PPCF.

A distance learning programme for medical officers and their assistants at the district level has produced some valuable lessons for future activities in continuing education. Besides correspondence and study materials, face-to-face contact between students and their tutors is a particularly important ingredient, as it provides the guidance, flexibility and motivation that are essential for an effective programme.

This review describes the qualities which those who are trainers in safe motherhood and other programs should display. The educational principles and objectives for maternal health workers, based on the tasks which they have to do and expressed in the skills and competences they must attain, are related to practical methods of training. Problem-based learning is advocated and the value of distance education for rural workers is discussed.

Plasma concentrations of atrial natriuretic peptide and aldosterone and plasma renin activity were measured in patients with peripartum heart failure and in age matched healthy women post partum. Both groups had carried out traditional postpartum practices of salt consumption and body heating. Plasma concentrations (mean (SEM)) of atrial natriuretic peptide were significantly higher in the seven patients with peripartum heart failure (146.9 (24.3) pg/ml) than in the seven controls (4.4 (0.8) pg/ml). Both plasma aldosterone and plasma renin activity were suppressed in the patients with peripartum heart failure. After treatment for the heart failure plasma atrial natriuretic peptide fell considerably and there were associated increases in plasma aldosterone and plasma renin activity. The high plasma concentrations of atrial natriuretic peptide may have been a compensatory response to salt and water retention as well as to the heart failure. These high concentrations could also, in part, have suppressed the release of aldosterone and renin in an attempt to correct for volume overload.

Medical education must be made relevant, and this implies that it must train its students towards the local health care system. If behavioural objectives are defined which must be attained before a student graduates, and before he can function effectively in a health unit, areas which need emphasis are revealed. Communication is a skill which can be left to clinical training: but it is best learned very early in the community, where the student is the supplicant, and not in the hospital where he is dominant. Early community experience can mould a student's attitudes fundamentally and can make him realise the need for work with members of a health team within a health care unit. If education is dogma-centred, and the student is not trained to ask questions early he will not be able to function effectively in any community: modern medical education should be problem-dominated, community-directed and learner-centered. If it is centred on the learner he will become equipped with the ability for independent study and a desire to learn, to improve himself and help other members of the health team throughout his professional career.

Providing primary care for the medically underserved is an international problem. In the developing world the problem is accentuated by the disparity between resources and needs. Although during the past few decades much has been accomplished worldwide to improve primary care, medical educators have not adequately responded to the challenge of preparing students to participate in community health services, education, and research. This paper describes a medical school program from the Department of Community Health, School of Medical Sciences, Ghana. It is a program designed to prepare medical students for primary care by making community health a curriculum component of all three years of medical education. The program has potential for replication in the industrial as well as the developing world.

The application of MCQ examination techniques, in the context of a new medical school in tropical Africa, is described. The pitfalls are noted, the composition of papers discussed, and a simple method of marking is described. Some examples of questions are given, and their individual values are simply assessed. From our experience, there is no doubt that objective testing has a real place in a young medical school, where it can actually save time, as well as reducing variation in standards of examination.

Ventricular function has been studied in 43 patients with the peripartum cardiac failure (PPCF) syndrome which occurs around Zaria. All patients had an echocardiogram on admission and 10 patients had right heart catheterization. Despite the gross edema, left ventricular function assessed by echocardiography and systolic time intervals was relatively good and the estimated cardiac output were high. At catheterization, although the pressures were high, the cardiac outputs were greater than normal in four out of six patients. No patient had a low cardiac output. These findings are not compatible with a severe heart muscle disorder, or cardiomyopathy. We suggest that the primary event in PPCF of Zaria is fluid retention which leads to a form of high output cardiac failure. The postpartum practices in this area (taking high sodium diets and lying on heated beds) almost certainly cause the fluid to accumulate initially, but the heart may be unable to meet the demands either because of preexisting heart muscle disease or, more likely, because of a rise of the peripheral resistance due to the volume expansion, overburdens such dilated hearts and leads to myocardial damage. Since there are similarities between this condition and PPCF in temperate climates, it is possible that there is a common mechanism which the traditional practices of this area have unveiled.

The subsequent course of 173 women with severe congestive heart failure hospitalized within 6 months of delivery has been analyzed after 4 to 7 year follow-up periods. Forty-seven normotensive women and 50 women hypertensive only during the initial 48 hours have little long term morbidity. Thirty-six women with hypertension initially improved, but many are now showing enlarging cardiac silhouettes. Morbidity is increasing in this group. A similar, less severe pattern is developing in 36 women with intermittent hypertension. The uniquely high incidence of this condition in Zaria is associated with several locale factors. These Hausa-Fulani women eat large quantities of a local lake salt, kanwa, for 40 days postpartum. The syndrome is markedly more common in the hot rainy season, when evaporative water loss is less, than in the dry season. The first postpartum days are spent confined to bed in a small heated room. Once or twice daily the new mother is given hot baths with branches which have been dipped in boiling water. The combination of excessive sodium intake and diminished evaporative water excretion seems to precipitate failure in both normotensive and hypertensive patients.

A cohort of patients with peripartum cardiac failure (PPCF) was followed for 10 years after the initial illness. The follow up rate was 78%. Fifty two per cent of patients improved without further episodes of heart failure. PPCF recurred in 26 per cent. Heart failure unrelated to pregnancy was seen in 13%, and 9% of the patients progressed to dilated cardiomyopathy. Transient hypertension was seen in 87% of patients on admission, and later hypertension was found in 45%. Late hypertension influenced heart size more when recurrent PPCF or progressive heart failure was present. Anaemia on admission had no effect on subsequent heart size. The electrocardiogram may continue to be abnormal for up to 10 years in normotensive patients who had no heart failure. The abnormal electrocardiogram in patients with persistent cardiomegaly may represent progressive myocardial damage. Mortality rate was highest (11%) in the first year and declined thereafter. Cardiac deaths were common in patients with recurrent PPCF or progressive heart failure.

The number of patients with cardiac failure admitted to hospital in Zaria, Nigeria, month by month during 1972-75 differed highly significantly between the cooler dry months and the hot wet months. The reasons are uncertain, but seasonal changes in blood-pressure and the effects of heat on the circulation and of humidity on the efficiency of sweating may be responsible.

The problem of default from follow-up prejudices the study of disease in Africa. During studies of 224 patients with pre-partum cardiac failure were found that 119 had defaulted from follow-up for six months or more, after an average period of 22 months from their admission. A sociologist tried to find all these patients at home and interviewed those who were found. If the patient was not found, information was sought from the village head and from friends and relatives. Thirteen patients had died. The 69 who were traced gave a total of 101 reasons for default. Domestic reasons prodominated, of which poverty, moving home and the difficulties of travel were the most important. Among personal reasons, feeling well was the commonest single reason, and was given by 19 patients. The results show that the problems of a subsistence agricultural economy dominate the reasons for default, and that such problem cannot be overcome without changes in society. Our findings are relevant in the care of all chronic diseases and throughout rural Africa.

The syndrome of peri-partum cardiac failure (PPCF) has been studied in 224 women seen in three years in Zaria, in northern Nigeria. A very high proportion were rural Hausa patients. There was a seasonal peak in July, and the incidence was about one per cent of deliveries. The risk increased with both age and parity. Symptoms began most commonly in the second week after delivery, and admission was commonest in the fourth. Typical signs of cardiac failure were found, and pulsus alternans, atrio-ventricular valvular incompetence, transient systemic hypertension and splenomegaly were common. The chest radiograph showed marked cardiomegaly, and extrasystoles and inverted T waves were often present in the electrocardiogram (ECG). Hypoalbuminaemia was common. Digoxin and diuretics were rapidly effective, causing a mean weight loss of 29 per cent in 15 days, resolution of hypertension, and a fall in the cardio-thoracic ratio (CTR) from 61 to 53 per cent. During the first year after diagnosis, the CTR became normal in 82 per cent of patients, and the ECG in 60 per cent. PPCF recurred, again with the same seasonal variation, after 19 per cent of subsequent pregnancies. During follow up for two to five years, 22 per cent of the women became hypertensive, and 11 per cent died. The prognosis was worst in those with an arrhythmia, hypertension, sustained cardiomegaly or aged 30 or more. Asymtomatic post-partum hypertension (PPHT) was found in 61 per cent of normal Hausa women, with a seasonal peak in May, especially in those with hypertension during pregnancy or labour, and twin pregnancies. Peri-partum cardiac failure may be due to the combined pressure load of PPHT, the volume load from eating the customary sodium-rich kanwa, and the cardiovascular demands of heat, both climatic and traditionally self-imposed.

The pattern of heart disease in 404 patients seen prospectively from the guinea savanna region of Africa is presented. Over 90% presented with cardiac failure. Hypertension, Peripartal Cardiac Failure (PPCF), Congestive Cardiomyopathy and Rheumatic Heart Disease are major problems. The highest incidence of PPCF in the world probably occurs in this area but the prognosis is good. The reasons for this and the possible interrelationship of hypertension with cardiomyopathy and PPCF are discussed. In contrast to the tropical rainforests, no case of endomyocardial fibrosis was seen. During the period of study, vascular thrombosis is uncommon and coronary heart disease is non-existent in Zaria.

Meningococcal antigen was measured by countercurrent immunoelectrophoresis in the blood and cerebrospinal fluid of 200 patients with group A meningococcal meningitis. Antigen was detected in the blood of 27 (13.5 per cent) patients. These patients had a worse prognosis and a higher incidence of allergic complications, such as arthritis and vasculitis, about 5 days after the start of antibiotic treatment. Antigen was found in the CSF of 129 (67.5 per cent) patients); antigen often persisted in the cerebrospinal fluid despite antibiotic treatment before admission. A combination of immunoelectrophoresis and routine bacteriologic study was used in the diagnosis of 162 (84.8 per cent) patients with meningococcal meningitis. High levels of antigen and a slow antigen disappearance were associated with neurologic damage. The antigen is stable and may be detected from specimens of cerebrospinal fluid dried on filter paper.

No large series of patients with cardiovascular disease has yet been reported from Ethiopia, where only limited means for investigation are at present available. The authors therefore studied the types of heart disease detected by mass miniature radiography in a largely self-selected population at the Addis Ababa Tuberculosis Centre, and examined the value of this method of cardiac case-finding. Rheumatic heart disease occurred in 34.8% of patients, but syphilitic aortitis, hypertension, "cardiomyopathy" and tuberculous pericarditis were also common. Endomyocardial fibrosis was not seen; this may be a further significant fact in the search for its cause. Mass miniature radiography is valuable for detecting symptomatic patients with the cardiovascular diseases mentioned above. The technique described in this paper could be used in other developing countries as it uses a single method of screening for 2 groups of diseases.