Mortality and associated factors among children admitted to an intensive care unit in muhimbili national hospital, from the time of admission to three months after discharge: a prospective cohort study

BACKGROUND

Mortality of children admitted to Intensive Care Units (ICU) is higher in low-to-middle-income countries (LMICs) as compared to high-income countries (HICs). There is paucity of information on outcomes following discharge from ICU, especially from sub-Saharan Africa region. This study was conducted to determine mortality and its associated factors among children admitted to Pediatric ICU (PICU) at Muhimbili National Hospital, from admission to three months after discharge.

METHODOLOGY

This was a hospital-based prospective cohort study conducted between July 2021 and May 2022, among children admitted to PICU who were followed up for 3-month after discharge. Structured questionnaires were used to collect data from their medical charts. Telephone interviews were made after discharge. Medical records and verbal autopsy were used to determine the cause of death after discharge. Cox regression analysis was performed to assess the association between variables. A p-value of < 0.05 was considered statistically significant. Survival after PICU discharge was estimated by Kaplan - Meier curve.

RESULTS

Of 323 children recruited, 177(54.8%) were male, with a median age of 17 months (1-168). The leading cause of PICU admission was severe sepsis 90/323(27.9%). A total of 161/323 children died, yielding an overall mortality of 49.8%. Of 173 children discharged from PICU, 33(19.1%) died. The leading cause of death among children who died in the general ward or as readmission into PICU was sepsis 4/17(23.5%). Respiratory diseases 4/16(25.0%) were the commonest cause of death among those who died after hospital discharge. Independent predictors of overall mortality included single organ dysfunction with hazard ratio(HR):5.97, 95% confidence interval (CI)(3.05-12.26)] and multiple organ dysfunction [HR:2.77,95%CI(1.03-2.21)]. Chronic illness[HR:8.13,95%CI(2.45-27.02)], thrombocytosis [HR:3.39,95%CI(1.32-8.73)], single[HR:3.57,95%CI(1.42-9.03)] and multiple organ dysfunction[HR:3.11,95%CI(1.01-9.61)] independently predicted post-PICU discharge mortality.

CONCLUSION

Overall mortality and post- PICU discharge mortality were high and more likely to affect children with organ dysfunction, chronic illness, and thrombocytosis. The leading causes of mortality post- PICU discharge were sepsis and respiratory diseases. There is a need for a focused follow up plan of children post- PICU discharge, further research on the long term survival and strategies to improve it.

Xpert® MTB/RIF assay testing on stool for the diagnosis of paediatric pulmonary TB in Tanzania

SETTING

Six health facilities in Dar es Salaam, Tanzania.

OBJECTIVE

To evaluate the use of stool specimens in the diagnostic workup of paediatric TB using the Xpert^® MTB/RIF assay.

DESIGN

Between December 2018 and May 2019, we performed a cross-sectional diagnostic study of children aged between 1 month and 14 years with presumptive TB. A single stool specimen was tested using Xpert. The result was compared with the reference microbiological standard for respiratory or gastric specimens tested using Xpert and/or solid culture. The sensitivity, specificity and predictive values of stool Xpert assay were assessed.

RESULTS

A total of 225 children with a median age of 2.17 years (IQR 1.16-5.19) were enrolled; 165/225 (73.3%) were aged <5 years. Of 225 children, 8 (3.6%) were diagnosed with TB as they were culture- or Xpert-positive on sputum/gastric aspirate. The stool Xpert assay showed a sensitivity of 62.5% (95% CI 25-92) and specificity of 100% (95% CI 98-100) against the reference standard.

CONCLUSION

Use of the Xpert assay on stool specimens had a moderate sensitivity and high specificity in the diagnosis of pulmonary TB in children. Our data adds to the body of evidence for the use of Xpert assay on stool as a non-respiratory specimen to complement conventional methods used to diagnose the disease.

Pattern and risk factors for childhood injuries in Dar es Salaam, Tanzania

Background

Injuries contribute to morbidity and mortality in children. This study was carried out to describe the pattern of childhood injuries and associated risk factors in Dar es Salaam, Tanzania.

Methods

This case control study was conducted in six selected health facilities in Dar es Salaam, Tanzania. Data were collected using a structured questionnaire. Cases and controls were children below 18 years who had suffered injuries and those without injury associated condition respectively.

Results

A total of 492 cases and 492 controls were included in the study, falls (32%), burns (26%), Road Traffic Injuries (14%) and cuts (10%) were the major types of injuries identified. Younger parents/guardians {Adjusted odds ratio (AOR)= 1.4; 95% CI: 1.4 -3.6}, more than six people in the same house (AOR= 1.8; 95% CI: 1.3–2.6), more than three children in the house {AOR= 1.4; 95% CI (1.0–2.0)}, absence of parent/guardian at time of injury occurrence (AOR= 1.6; 95% CI: 1.1–2.3), middle socio-economic (AOR=1.6; 95%CI: 1.1–2.4) and low socio-economic status (AOR= 1.5; 95% CI: 1.0–2.1) were independent risk factors for childhood injury.

Conclusion

Falls, burns and road traffic injuries were the main injury types in this study. Inadequate supervision, overcrowding, lower socio-economic status and low maternal age were significant risk factors for childhood injuries.

Shared decision-making between health care providers and patients at a tertiary hospital diabetic Clinic in Tanzania

Background

Patients’ participation in decision making regarding their treatment is defined in ethical, legal and human rights standards in the provision of care that concerns health providers and the entire community. This study was conducted to document experiences of patients and health care providers on shared decision making.

Methods

This study employed a phenomenological study design using in-depth interview technique. Study participants were diabetic patients visiting the clinic and healthcare providers working at Muhimbili National Hospital. Data was collected using the semi-structured interview guide with open-ended questions using an audio digital recorder. Content analysis method was used during analysis whereby categories were reached through the process of coding assisted by Nvivo 12 software.

Results

Participants in this study expressed the role of shared decision-making in the care of patients with diabetes, with report of engagement of patients by health care providers in making treatment decisions. Participants reported no use of decision-making aids; however, health education tools were reported by participants to be used for educating patients. Limited time, patient beliefs and literacy were documented as barriers of effective engagement of patients in decision making by their healthcare providers.

Conclusion

Engagement of patients in decision-making was noted in this study as experienced by participants of this study. Time, patient beliefs and patient literacy were documented as barriers for patients engagement, therefore diabetic clinic at Muhimbili National Hospital need to devise mechanisms for ensuring patients involvement in treatment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06041-4.

Prevalence of malnutrition inflammation complex syndrome among patients on maintenance haemodialysis at Muhimbili National Hospital in Tanzania: a cross-sectional study

Background

Malnutrition, inflammation, and the combination thereof are predictors of poor outcomes in haemodialysis patients. Malnutrition Inflammation Complex Syndrome (MICS) is an accelerator of atherosclerosis and portends high mortality. Early recognition and treatment of MICS may help to improve the clinical outlook of such patients. This study investigated the prevalence of MICS and its associated factors among patients on maintenance haemodialysis at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania.

Methods

This was a prospective cross-sectional observational study done among 160 adult patients on maintenance haemodialysis at MNH in 2019. All participants provided written informed consent. Questionnaires were used to collect data and patients’ blood was tested for complete blood count (CBC), C-reactive protein (CRP), ferritin, transferrin, creatinine, urea, total cholesterol, and albumin. The Malnutrition Inflammation Score was used to assess MICS and its severity. Data analysis was done using the SPSS 20 software.

Results

Of the 160 patients included in the study, 111 (69.4%) were male. The mean age (±SD) of patients and mean duration (±SD) on haemodialysis were 52.2(13.3) years and 22(18) months respectively. MICS was prevalent in 46.3% (mild in 24.4% and moderate to severe in 21.9%).

Long-term haemodialysis (> 4 years) was an independent predictor of MICS [Adjusted Odds Ratio, AOR 5.04 (95% CI: 1.33–19.2), p < 0.05]. Hypercholesterolaemia was a negative predictor of MICS [AOR 0.11 (95% CI: 0.01–0.97), p < 0.05]. Patients with MICS had significantly lower mean body mass index, serum albumin, total cholesterol, transferrin, haemoglobin, and creatinine levels. The presence of MICS was higher in underweight patients and those who had inflammation. Haemodialysis adequacy did not correlate with MICS.

Conclusion

Malnutrition Inflammation Complex Syndrome is relatively common among patients on haemodialysis in Dar es Salaam, Tanzania. Our study has shown a longer duration on haemodialysis to be associated with the occurrence of MICS; on the contrary, having hypercholesterolaemia seems to be protective against MICS consistent with the concept of reverse epidemiology. Patients on haemodialysis should be assessed regularly for malnutrition and inflammation and should receive appropriate and timely treatment to reduce the burden of associated morbidity, and mortality to these patients.

Electrolytes supplementation can decrease the risk of nephrotoxicity in patients with solid tumors undergoing chemotherapy with cisplatin

Background

Cisplatin is an important drug in the treatment of various Cancers. However, this drug causes nephrotoxicity that is linked to electrolyte derangement. The aim of this study was to evaluate the effect of electrolyte supplementation in reducing kidney injury in patients receiving cisplatin-based regimen.

Methods

This was non-randomized interventional study conducted at Ocean Road Cancer Institute (ORCI) among patients with confirmed solid tumors. Patients who received cisplatin-based chemotherapy at a dose of ≥50 mg with intravenous normal saline supplemented with Magnesium, Calcium and Potassium (triple electrolyte supplementation) were compared with those who received cisplatin-based chemotherapy with normal saline alone. The patients were followed up for 4 weeks and serum creatinine was measured at every visit. Nephrotoxicity was defined as serum creatinine elevation > 1.5 times that at baseline.

Results

A total of 99 patients were recruited, whereby 49 patients (49.5%) received electrolyte supplementation (treatment group) and 50 patients (51.5%) did not receive electrolyte supplementation (control group). The incidence risk of nephrotoxicity was 20.41% (n = 10) in the treatment group and 54% (n = 27) in the control group. Patients in the control group were 2.6 times more likely to experience nephrotoxicity as compared to treatment group [Relative Risks (RR); 2.6, 95%CI; 1.5–4.9, P < 0.0001]. The most common malignancy was cervical cancer, n = 43 (87.8%) in treatment group and n = 45 (90.0%) in the control group (P = 0.590). The Kaplan-Meier analysis and the log-rank test revealed that electrolytes supplementation was associated with extended survival with less nephrotoxicity incidences [P = 0.0004; Hazard ratio (HR) 0.3149; 95% CI 0.165 to 0.6011].

Conclusions

Electrolytes supplementation decreases the risk of nephrotoxicity after chemotherapy with cisplatin. A randomized controlled trial with a larger sample size is recommended to evaluate the robustness of these findings.

Skin disorders among children living in orphanage centres in Dar es Salaam, Tanzania

Background

Skin conditions contribute significantly to the global burden of diseases and are among the leading causes of non-fatal disease burden. Children living in orphanage centres are vulnerable to several conditions including dermatological disorders, and there is limited data on the burden of these conditions among orphans in Tanzania. This study was carried out to determine the pattern of dermatological conditions and contributing factors among orphans in Dar es Salaam, Tanzania.

Methodology

A cross-sectional study was conducted among 420 children aged less than 18 years from 12 orphanage centres in Dar es Salaam. Guided interviews using structured questionnaires were carried out to obtain socio-demographic and clinical data from participants. Clinical examination was performed for each participant and whenever indicated skin scrapings and biopsy were obtained.

Results

Four hundred and twenty participants were recruited out of which 281 (66.9%) were male, mean and median ages of participants were 11 ± 3.7 and 12 years, respectively. Two hundred and twenty-five (53.6%) participants were aged between 6 and12 years. Proportion of children with dermatological manifestations among participants was 57.4%. Two hundred and ninety-six diagnoses were made comprising of 192 (64.9%) infections and 104 (35.1%) non-infectious conditions. Tinea capitis was the commonest infection while acne vulgaris was the most common non-infectious condition. Proportionately more male children were affected as compared to female ones, p = 0.006.

Conclusion

Skin conditions are common among children living in orphanage centres in Dar es Salaam. Infectious conditions were predominant conditions and male children were more affected than female children. Reducing crowding and improving hygienic practices in these centres will be important in reducing the burden of these conditions.

Spectrum of paediatric rheumatic disorders at a tertiary hospital in Tanzania

BACKGROUND

Paediatric rheumatic disorders are common in children and result in significant impairment in quality of life, morbidity and mortality. There is limited information on the burden of these disorders in lower income countries especially in sub-Saharan Africa. Few case reports have documented presence of paediatric rheumatic disorders in Tanzania. This study was conducted to determine the spectrum of rheumatic disorders among children at Muhimbili National Hospital (MNH).

METHODS

This was a retrospective study conducted among children who were attended at MNH between January 2012 and August 2019. Paediatric patients seen in the out-patient clinics and those admitted in the wards were eligible. All patients with diagnosis of rheumatic disorders were identified from admission books and outpatient clinic logbooks, and later data were collected from their case notes and were recorded in clinical research forms. Collected information included age, sex, clinical features and laboratory tests results.

RESULTS

A total of 52 children with mean age of 9.5 ± 4.3 years, 12 (40.4%) participants were aged above 10 years and 32 (61.5%) were females. Frequently reported clinical presentations were joint pain 44 (84.6%), joint swelling 34 (65.4%), fever 24 (46.2%) and skin rashes 21(40.4%). Juvenile idiopathic arthritis (JIA) was the predominant diagnosis reported in 28 (53.8%) participants followed by juvenile systemic lupus erythematosus 8 (15.4%), mixed connective tissue diseases 4 (7.7%) and juvenile dermatomyositis 4 (7.7%). Antinuclear antibody test was performed in 16 participants it was positive in 9 (56.2%). Nine participants were tested for anti-double stranded DNA test and 5 (55.6%) were positive for this test. C-reactive protein was tested in 46 participants out of which 32 (69.6%) had elevated levels. HIV was tested in 24 (46.2%) participants and results were negative. Thirty-five out of 52 (67.3%) participants had anaemia. Predominant drugs used for treatment of JIA include prednisolone and methotrexate.

CONCLUSIONS

Paediatric rheumatic disorders are not uncommon in Tanzania-and were noted to affect more female children in this study. Predominant conditions included juvenile idiopathic arthritis (JIA), juvenile systemic lupus erythematosus (JSLE) and juvenile dermatomyositis (JDM).

Acute kidney injury among critically ill neonates in a tertiary hospital in Tanzania; Prevalence, risk factors and outcome

Background

Neonatal acute kidney injury contributes to high mortality in developing countries. The burden of neonatal AKI is not known in Tanzania despite having high neonatal mortality. This study was conducted to determine the burden of AKI among critically ill neonates admitted at Muhimbili National Hospital.

Methods

This was a cross-sectional study conducted in the neonatal ward at the MNH. Eligible critically ill neonates were recruited consecutively between October 2017 and March 2018. Data was collected using a standardized structured questionnaire. Blood specimen was drawn to measure baseline creatinine at admission, 48^th hour, 72^nd hour and 14^th day. Data was analysed using SPSS version 20.0 Univariate analysis was done using chi-square to determine the association between categorical variables and multivariate logistic regression was performed to determine predictors of AKI.

Results

A total of 378 critically ill neonates were recruited, 31.5% had AKI and independent predictors of AKI were noted to be neonatal sepsis (aOR 2.237, 95%CI 1.3–3.6, P = 0.001), severe pneumonia (aOR3.0, 95%CI 1.0–9.3, P = 0.047) and use of gentamycin (aOR6.8, 95%CI 1.3–9.3, P = 0.02). Complete resolution of renal dysfunction at the fourteenth day was seen in 83.1% of the neonates while 16.9% had persistence of renal dysfunction. Ultrasound scan were performed among 105 participants with AKI revealed increased echogenicity, mild hydronephrosis and ectopic kidneys in 25 (23.8%), 4 (3.8%) and 2 (1.9%) respectively. In-hospital mortality was significantly higher among neonates with AKI (70.6%) as compared to those without (29.4%) p< 0.001.

Conclusions

AKI was noted in a third of critically ill neonates, with neonatal sepsis, severe pneumonia and use of gentamycin as independent predictors of AKI. Neonates who suffered AKI had twice as much mortality as compared to those without.

Developing nephrology services in low income countries: a case of Tanzania

BACKGROUND

The burden of kidney diseases is reported to be higher in lower- and middle-income countries as compared to developed countries, and countries in sub-Saharan Africa are reported to be most affected. Health systems in most sub-Sahara African countries have limited capacity in the form of trained and skilled health care providers, diagnostic support, equipment and policies to provide nephrology services. Several initiatives have been implemented to support establishment of these services.

METHODS

This is a situation analysis to examine the nephrology services in Tanzania. It was conducted by interviewing key personnel in institutions providing nephrology services aiming at describing available services and international collaborators supporting nephrology services.

RESULTS

Tanzania is a low-income country in Sub-Saharan Africa with a population of more than 55 million that has seen remarkable improvement in the provision of nephrology services and these include increase in the number of nephrologists to 14 in 2018 from one in 2006, increase in number of dialysis units from one unit (0.03 unit per million) before 2007 to 28 units (0.5 units per million) in 2018 and improved diagnostic services with introduction of nephropathology services. Government of Tanzania has been providing kidney transplantation services by funding referral of donor and recipients abroad and has now introduced local transplantation services in two hospitals. There have been strong international collaborators who have supported nephrology services and establishment of nephrology training in Tanzania.

CONCLUSION

Tanzania has seen remarkable achievement in provision of nephrology services and provides an interesting model to be used in supporting nephrology services in low income countries.

Prevalence and factors associated with renal dysfunction in children admitted to two hospitals in northwestern Tanzania

BACKGROUND

It is evident that renal dysfunction (RD) is associated with unique infectious and non-infectious causes in African children. However, little data exists about the prevalence and factors associated with RD in children admitted to African hospitals.

METHODS

In this cross-sectional study, we enrolled all children admitted to pediatric wards of Bugando Medical Centre (BMC) and Sekou-Toure Regional Referral hospital (SRRH) during a 6 month time period. Socio-demographical, clinical and laboratory data were collected using a structured questionnaire. Estimated glomerular filtration rate (eGFR) was calculated using modified Schwartz equation and those with < 60 ml/min/1.73m2were considered to have RD. Data analysis was done using STATA version 13 and considered significant when p-value was < 0.05.

RESULTS

A total of 513 children were enrolled, of which 297 (57.9%) were males. Median age of children with and without RD was 34 months (27-60) and 46.5 (29-72) respectively. Prevalence of RD was 16.2%. Factors associated with RD were herbal medication use (p = 0.007), history of sore throat or skin infection (p = 0.024), sickle cell disease (SCD) (p = 0.006), dehydration (p = 0.001), malaria (p = 0.01) and proteinuria (p = < 0.001).

CONCLUSIONS

High prevalence of RD was observed among children admitted to referral hospitals in Mwanza. Screening for RD should be performed on admitted children, particularly those with history of herbal medication use, sore throat/skin infection, SCD, dehydration and malaria. Where creatinine measurement is not possible, screening for proteinuria is a reasonable alternative.