Joseph R. Egger

The Epidemiology of Chronic Kidney Disease in Northern Tanzania: A Population-Based Survey

Background In sub-Saharan Africa, kidney failure has a high morbidity and mortality. Despite this, population-based estimates of prevalence, potential etiologies, and awareness are not available. Methods Between January and June 2014, we conducted a household survey of randomly-selected adults in Northern Tanzania. To estimate prevalence we screened for CKD, which was defined as an estimated glomerular filtration rate ≤ 60 ml/min/1.73m2 and/or persistent albuminuria. We also screened for human immunodeficiency virus (HIV), diabetes, hypertension, obesity, and lifestyle practices including alcohol, tobacco, and traditional medicine use. Awareness was defined as a self-reported disease history and subsequently testing positive. We used population-based age- and gender-weights in estimating prevalence, and we used generalized linear models to explore potential risk factors associated with CKD, including living in an urban environment. Results We enrolled 481 adults from 346 households with a median age of 45 years. The community-based prevalence of CKD was 7.0% (95% CI 3.8-12.3), and awareness was low at 10.5% (4.7-22.0). The urban prevalence of CKD was 15.2% (9.6-23.3) while the rural prevalence was 2.0% (0.5-6.9). Half of the cases of CKD (49.1%) were not associated with any of the measured risk factors of hypertension, diabetes, or HIV. Living in an urban environment had the strongest crude (5.40; 95% CI 2.05-14.2) and adjusted prevalence risk ratio (4.80; 1.70-13.6) for CKD, and the majority (79%) of this increased risk was not explained by demographics, traditional medicine use, socioeconomic status, or co-morbid non-communicable diseases (NCDs). Conclusions We observed a high burden of CKD in Northern Tanzania that was associated with low awareness. Although demographic, lifestyle practices including traditional medicine use, socioeconomic factors, and NCDs accounted for some of the excess CKD risk observed with urban residence, much of the increased urban prevalence remained unexplained and will further study as demographic shifts reshape sub-Saharan Africa.

Baseline Health-Related Quality of Life and 10-Year All-Cause Mortality among 1739 Chinese Adults

Background and Purpose Health-related quality of life (HRQOL) may be associated with the longevity of patients; yet it is not clear whether this association holds in a general population, especially in low- and middle-income countries. The objective of this study was to determine whether baseline HRQOL was associated with 10-year all-cause mortality in a Chinese general population. Methods A prospective cohort study was conducted from 2002 to 2012 on 1739 participants in 11 villages of Beijing. Baseline data on six domains of HRQOL, chronic diseases and cardiovascular risk factors were collected in either 2002 (n = 1290) or 2005 (n = 449). Subjects were followed through the end of the study period, or until they were censored due to death or loss to follow-up, whichever came first. Results A multivariable Cox model estimated that Total HRQOL score (bottom 50% versus top 50%) was associated with a 44% increase in all-cause mortality (Hazard Ratio [HR] = 1.44; 95% confidence interval [CI]: 1.00-2.06), after adjusting for sex, age, education levels, occupation, marital status, smoking status, fruit intake, vegetable intake, physical exercise, hypertension, history of a stroke, myocardial infarction, chronic respiratory disease, and kidney disease. Among the six HRQOL domains, the Independence domain had the largest fully adjusted HR (HR = 1.66; 95% CI: 1.13-2.42), followed by Psychological (HR = 1.47; 95% CI: 1.03-2.09), Environmental (HR = 1.43, 95% CI: 1.003-2.03), Physical (HR = 1.38; 95% CI: 0.97-1.95), General (HR = 1.37; 95% CI: 0.97-1.94), and the Social domain (HR = 1.15; 95% CI: 0.81-1.65). Conclusion Lower HRQOL, especially the inability to live independently, was associated with a significantly increased risk of 10-year all-cause mortality. The inclusion of HRQOL measures in clinical assessment may improve diagnostic accuracy to improve clinical outcomes and better target public health promotions.

Improving Diabetes Management and Cardiovascular Risk Factors Through Peer-Led Self-management Support Groups in Western Kenya

In sub-Saharan Africa, projections anticipate a 110% rise in the number of people with diabetes mellitus (DM) from 19.8 million to 41.5 million by 2035 (1). This growth is attributed primarily to the multiple downstream ramifications of urbanization and westernization. Poor access to medications, finances, transportation, and skilled health care providers trained in DM management is a barrier that contributes to poor outcomes for patients with DM (2). As a result, patients are often forced to rely on self-management without guidance from the formal health care sector. To combat this barrier, diabetes self-management support (DSMS) programs sustain psychosocial support and education by incorporating lay DM patients as peer support group leaders at the community level (3,4). Limited data exist for DSMS outcomes in low- and middle-income countries (LMICs). The imminent rise of DM and the logistical challenges of health delivery in …

Neighborhood clustering of non-communicable diseases: results from a community-based study in Northern Tanzania.

BackgroundIn order to begin to address the burden of non-communicable diseases (NCDs) in sub-Saharan Africa, high quality community-based epidemiological studies from the region are urgently needed. Cluster-designed sampling methods may be most efficient, but designing such studies requires assumptions about the clustering of the outcomes of interest. Currently, few studies from Sub-Saharan Africa have been published that describe the clustering of NCDs. Therefore, we report the neighborhood clustering of several NCDs from a community-based study in Northern Tanzania.MethodsWe conducted a cluster-designed cross-sectional household survey between January and June 2014. We used a three-stage cluster probability sampling method to select thirty-seven sampling areas from twenty-nine neighborhood clusters, stratified by urban and rural. Households were then randomly selected from each of the sampling areas, and eligible participants were tested for chronic kidney disease (CKD), glucose impairment including diabetes, hypertension, and obesity as part of the CKD-AFRiKA study. We used linear mixed models to explore clustering across each of the samplings units, and we estimated absolute-agreement intra-cluster correlation (ICC) coefficients (ρ) for the neighborhood clusters.ResultsWe enrolled 481 participants from 346 urban and rural households. Neighborhood cluster sizes ranged from 6 to 49 participants (median: 13.0; 25th–75th percentiles: 9–21). Clustering varied across neighborhoods and differed by urban or rural setting. Among NCDs, hypertension (ρ = 0.075) exhibited the strongest clustering within neighborhoods followed by CKD (ρ = 0.440), obesity (ρ = 0.040), and glucose impairment (ρ = 0.039).ConclusionThe neighborhood clustering was substantial enough to contribute to a design effect for NCD outcomes including hypertension, CKD, obesity, and glucose impairment, and it may also highlight NCD risk factors that vary by setting. These results may help inform the design of future community-based studies or randomized controlled trials examining NCDs in the region particularly those that use cluster-sampling methods.

Knowledge, Attitudes, and Practices Associated with Chronic Kidney Disease in Northern Tanzania: A Community-Based Study.

Background Non-communicable diseases (NCDs) are a leading cause of death among adults in sub-Saharan Africa, and chronic kidney disease (CKD) is a growing public health threat. Understanding knowledge, attitudes, and practices associated with NCDs is vital to informing optimal policy and public health responses in the region, but few community-based assessments have been performed for CKD. To address this gap, we conducted a cross-sectional survey of adults in northern Tanzania using a validated instrument. Methods Between January and June 2014, we administered a structured survey to a random sample of adults from urban and rural communities. The validated instrument consisted of 25 items designed to measure knowledge, attitudes, and practices associated with kidney disease. Participants were also screened for CKD, diabetes, hypertension, and human immunodeficiency virus. Results We enrolled 606 participants from 431 urban and rural households. Knowledge of the etiologies, symptoms, and treatments for kidney disease was low (mean score 3.28 out of 10; 95% CI 2.94, 3.63). There were no significant differences by CKD status. Living in an urban setting and level of education had the strongest independent associations with knowledge score. Attitudes were characterized by frequent concern about the health (27.3%; 20.2, 36.0%), economic (73.1%; 68.2, 77.5%), and social impact (25.4%; 18.6, 33.6%) of kidney disease. Practices included the use of traditional healers (15.2%; 9.1, 24.5%) and traditional medicines (33.8%; 25.0, 43.9%) for treatment of kidney disease as well as a willingness to engage with mobile-phone technology in CKD care (94.3%; 90.1, 96.8%). Conclusions Community-based adults in northern Tanzania have limited knowledge of kidney disease. However, there is a modest knowledge base upon which to build public health programs to expand awareness and understanding of CKD, but these programs must also consider the variety of means by which adults in this population meet their healthcare needs. Finally, our assessment of local attitudes suggested that such public health efforts would be well-received.

Prevalence, Risk Factors, and Complications of Diabetes in the Kilimanjaro Region: A Population-Based Study from Tanzania

Background In sub-Saharan Africa, diabetes is a growing burden, yet little is known about its prevalence, risk factors, and complications. To address these gaps and help inform public health efforts aimed at prevention and treatment, we conducted a community-based study assessing diabetes epidemiology. Methods and Findings We conducted a stratified, cluster-designed, serial cross-sectional household study from 2014–2015 in the Kilimanjaro Region, Tanzania. We used a three-stage cluster probability sampling method to randomly select individuals. To estimate prevalence, we screened individuals for glucose impairment, including diabetes, using hemoglobin A1C. We also screened for hypertension and obesity, and to assess for potential complications, individuals with diabetes were assessed for retinopathy, neuropathy, and nephropathy. We enrolled 481 adults from 346 urban and rural households. The prevalence of glucose impairment was 21.7% (95% CI 15.2–29.8), which included diabetes (5.7%; 95% CI 3.37–9.47) and glucose impairment with increased risk for diabetes (16.0%; 95% CI 10.2–24.0). Overweight or obesity status had an independent prevalence risk ratio for glucose impairment (2.16; 95% CI 1.39–3.36). Diabetes awareness was low (35.6%), and few individuals with diabetes were receiving biomedical treatment (33.3%). Diabetes-associated complications were common (50.2%; 95% CI 33.7–66.7), including renal (12.0%; 95% CI 4.7–27.3), ophthalmic (49.6%; 95% CI 28.6–70.7), and neurological (28.8%; 95% CI 8.0–65.1) abnormalities. Conclusions In a northern region of Tanzania, diabetes is an under-recognized health condition, despite the fact that many people either have diabetes or are at increased risk for developing diabetes. Most individuals were undiagnosed or untreated, and the prevalence of diabetes-associated complications was high. Public health efforts in this region will need to focus on reducing modifiable risk factors, which appear to include obesity, as well as early detection that includes increasing awareness. These findings highlight a growing urgency of diabetes prevention in this region as well as the need for treatment, including management of complications.

Perioperative outcomes for pediatric neurosurgical procedures: analysis of the National Surgical Quality Improvement Program–Pediatrics

OBJECTIVE Existing studies have shown a high overall rate of adverse events (AEs) following pediatric neurosurgical procedures. However, little is known regarding the morbidity of specific procedures or the association with risk factors to help guide quality improvement (QI) initiatives. The goal of this study was to describe the 30-day mortality and AE rates for pediatric neurosurgical procedures by using the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatrics (NSQIP-Peds) database platform. METHODS Data on 9996 pediatric neurosurgical patients were acquired from the 2012-2014 NSQIP-Peds participant user file. Neurosurgical cases were analyzed by the NSQIP-Peds targeted procedure categories, including craniotomy/craniectomy, defect repair, laminectomy, shunts, and implants. The primary outcome measure was 30-day mortality, with secondary outcomes including individual AEs, composite morbidity (all AEs excluding mortality and unplanned reoperation), surgical-site infection, and unplanned reoperation. Univariate analysis was performed between individual AEs and patient characteristics using Fischers exact test. Associations between individual AEs and continuous variables (duration from admission to operation, work relative value unit, and operation time) were examined using the Student t-test. Patient characteristics and continuous variables associated with any AE by univariate analysis were used to develop category-specific multivariable models through backward stepwise logistic regression. RESULTS The authors analyzed 3383 craniotomy/craniectomy, 242 defect repair, 1811 laminectomy, and 4560 shunt and implant cases and found a composite overall morbidity of 30.2%, 38.8%, 10.2%, and 10.7%, respectively. Unplanned reoperation rates were highest for defect repair (29.8%). The mortality rate ranged from 0.1% to 1.2%. Preoperative ventilator dependence was a significant predictor of any AE for all procedure groups, whereas admission from outside hospital transfer was a significant predictor of any AE for all procedure groups except craniotomy/craniectomy. CONCLUSIONS This analysis of NSQIP-Peds, a large risk-adjusted national data set, confirms low perioperative mortality but high morbidity for pediatric neurosurgical procedures. These data provide a baseline understanding of current expected clinical outcomes for pediatric neurosurgical procedures, identify the need for collecting neurosurgery-specific risk factors and complications, and should support targeted QI programs and clinical management interventions to improve care of children.

Exploring the HIV continuum of care among young black MSM

Background HIV disproportionately impacts young, black men who have sex with men (YBMSM) who experience disparities across the HIV care continuum. A more nuanced understanding of facilitators and barriers to engagement in care, missed visits, antiretroviral uptake, adherence and viral suppression could improve care and intervention design. Methods A randomized controlled trial of an online intervention, healthMpowerment, enrolled 465 YBMSM (18–30 years); 193 identified as HIV-positive. Bivariable and multivariable analyses of baseline data explored predictors of: engagement in care, missed visits, antiretroviral uptake, self-reported adherence, and viral suppression. Results Mean age was 24.9 years; most identified as gay (71.0%) and were receiving HIV care (89.1%). Among those in care, 52.1% reported no missed visits in the past 12 months, 41 (24.6%) reported one missed visit, and 39 (23.4%) reported two or more. Having insurance (prevalence odds ratio [POR] 4.5; 95% CI: 1.3, 15.8) and provider self-efficacy (POR 20.1; 95% CI: 6.1, 64.1) were associated with being in care. Those with a college degree (POR 9.1; 95% CI: 1.9, 45.2) and no recent marijuana (POR 2.6; 95% CI: 1.2, 5.6) or methamphetamine use (POR 5.4; 95% CI: 1.0, 28.5) were less likely to miss visits. Most (n = 153, 84.1%) had been prescribed antiretroviral therapy. A majority of participants (70.8%) reported ≥90% adherence; those with depressive symptoms had 4.7 times the odds of reporting adherence <90% (95% CI: 1.65, 13.37). Of participants who reported viral load testing in the past six months, 65% (n = 102) reported an undetectable viral load. Disclosure to sex partners was associated with viral suppression (POR 6.0; 95% CI: 1.6, 22.4). Conclusions Multi-level facilitators and barriers to engagement across the continuum of care were identified in this sample of YBMSM. Understanding the distinct needs of YBMSM at each stage of the continuum and addressing them through tailored approaches is critical for long term success in care.

Epic Allies, a Gamified Mobile Phone App to Improve Engagement in Care, Antiretroviral Uptake, and Adherence Among Young Men Who Have Sex With Men and Young Transgender Women Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Background In the United States, young men who have sex with men (YMSM) and transgender women who have sex with men (YTWSM) bear a disproportionate burden of prevalent and incident HIV infections. Once diagnosed, many YMSM and YTWSM struggle to engage in HIV care, adhere to antiretroviral therapy (ART), and achieve viral suppression. Computer-based interventions, including those focused on behavior change, are recognized as effective tools for engaging youth. Objective The purpose of the study described in this protocol is to evaluate the efficacy of Epic Allies, a theory-based mobile phone app that utilizes game mechanics and social networking features to improve engagement in HIV care, ART uptake, ART adherence, and viral suppression among HIV-positive YMSM and YTWSM. The study also qualitatively assesses intervention acceptability, perceived impact, and sustainability. Methods This is a two-group, active-control randomized controlled trial of the Epic Allies app. YMSM and YTWSM aged 16 to 24 inclusive, with detectable HIV viral load are randomized 1:1 within strata of new to care (newly entered HIV medical care ≤12 months of baseline visit) or ART-nonadherent (first entered HIV medical care >12 months before baseline visit) to intervention or control conditions. The intervention condition addresses ART adherence barriers through medication reminders and adherence monitoring, tracking of select adherence-related behaviors (eg, alcohol and marijuana use), an interactive dashboard that displays the participant’s adherence-related behaviors and provides tailored feedback, encouragement messages from other users, daily HIV/ART educational articles, and gamification features (eg, mini-games, points, badges) to increase motivation for behavior change and app engagement. The control condition features weekly phone-based notifications to encourage participants to view educational information in the control app. Follow-up assessments are administered at 13, 26, and 39 weeks for each arm. The primary outcome measure is viral suppression. Secondary outcome measures include engagement in care, ART uptake, ART adherence, and psychosocial barriers to engagement in care and ART adherence, including psychological distress, stigma, and social support. Results Baseline enrollment began in September 2015 and was completed in September 2016 (n=146), and assessment of intervention outcomes continued through August 2017. Results for primary and secondary outcome measures are expected to be reported in ClinicalTrials.gov by April 30, 2018. Conclusions If successful, Epic Allies will represent a novel adherence intervention for a group disproportionately impacted by HIV in the United States. Adherent patients would require less frequent clinic visits and experience fewer HIV-related secondary infections, thereby reducing health care costs and HIV transmission. Epic Allies could easily be expanded and adopted for use among larger populations of YMSM and YTWSM, other HIV-positive populations, and for those diagnosed with other chronic diseases such as diabetes and hypertension. Trial Registration ClinicalTrials.gov NCT02782130; https://clinicaltrials.gov/ct2/show/NCT02782130 (Archived by Webcite at http://www.webcitation.org/6yGODyerk)

Validation of spirometry prediction equations in western Kenya

SETTING Community of Eldoret, Kenya. OBJECTIVE To test the performance of three commonly used spirometry prediction equations in a healthy Kenyan population. DESIGN Cross-sectional assessment of healthy adults in Eldoret. RESULTS Of the 331 subjects enrolled in the study, 282 subjects aged 18-85 years (45% males, 55% females) produced high-quality spirograms. Lung function predictions were made using the Global Lung Initiative 2012 (GLI 2012) prediction equations for African Americans, the National Health and Nutrition Examination Survey III (NHANES III) prediction equations for African Americans, and the Crapo prediction equation. Bland-Altman analyses were performed to measure the agreement between observed and predicted spirometry parameters. Overall, the GLI 2012 and NHANES equations for African Americans performed similarly for forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), significantly overestimating FVC while accurately predicting observed FEV1 values. CONCLUSION The study brings into question the utility of three major spirometry prediction equations in a Kenyan population. The significant overestimation of FVC by the best-performing equations despite accurate prediction of FEV1 suggests poor performance of these equations in our population.