Introduction: Little is known about the burden of hypertension and diabetes on emergency department (ED) utilization and hospitalizations in sub-Saharan Africa. Methods: A retrospective review of adult ED patients in northern Tanzania was performed from September 2017 through March 2018. Hypertension was defined as documented diagnosis of hypertension or blood pressure ≥ 140/90 mm Hg. Diabetes was defined as documented diagnosis of diabetes mellitus or random glucose ≥ 200 mg/dL. Results: Of 3961 adult ED patients, 1359 (34.3%) had hypertension, 518 (13.1%) had diabetes, and 273 (6.9%) had both. Both hypertension (OR 1.42, 95% CI 1.23-1.63, P<.001) and diabetes (OR 2.05, 95% CI 1.66-2.54, P<.001) were associated with increased odds of admission. Of 2418 hospital admissions, 694 (28.7%) were for complications of hypertension or diabetes. Of 499 patients admitted for hypertensive complications, the most common admission diagnoses were: heart failure (163 patients, 32.7%); stroke (147 patients, 29.5%); and severe hypertension (139 patients, 27.9%). Of 278 patients admitted for diabetic com­plications, the most common admission di­agnoses were: hyperglycemia (158 patients, 56.9%); infection (60 patients, 21.6%); and stroke (28 patients, 10.1%). Conclusions: The burden of hypertension and diabetes in a Tanzanian ED is high, and the ED may serve as an opportune location for case identification and linkage-to-care interventions. Given the large proportion of Africans with undiagnosed hyperten­sion and diabetes, an ED-based screening program would likely identify many new cases of these diseases. The high burden of hypertension- and diabetes-related hos­pitalizations highlights the urgent need for improvements in primary preventative care in Tanzania. Ethn Dis. 2019;29(4):559-566; doi:10.18865/ed.29.4.559

The Burden of Hypertension and Diabetes in an Emergency Department in Northern Tanzania

Objective The objective of this review was to examine the best available evidence on the risk factors for hypertensive crisis in adult patients with hypertension Introduction Hypertensive crisis is an acute severe elevation in blood pressure, which can present as hypertensive urgency or emergency In contrast to hypertensive urgency, which is a markedly elevated blood pressure without acute target organ damage, hypertensive emergency is associated with equally high blood pressure in the presence of potentially life-threatening target organ damage, such as myocardial infarction, stroke, pulmonary edema, or acute kidney injury Hypertensive crisis results in adverse clinical outcomes and high utilization of health care Inclusion criteria This review considered studies of non-modifiable factors (age, sex, ethnicity) and modifiable factors such as socioeconomic factors (lack of medical insurance, lack of access to medical care), adherence to medical therapies, presence of comorbidities (diabetes, hyperlipidemia, coronary artery disease, history of stroke, chronic kidney disease, congestive heart failure), and substance abuse in persons of either sex, older than 18 years with a diagnosis of hypertension Methods A search of four databases, seven gray literature sites, and relevant organizational websites revealed 11,387 titles After duplicates were removed, 9183 studies were screened by the title and abstract for eligibility Forty full-text articles were retrieved, and each was assessed for eligibility Twenty-one articles were excluded The remaining 19 full-text studies were critically appraised and included in this review Results The risk of hypertensive crisis was higher in patients with a history of comorbid cardiovascular conditions, such as chronic kidney disease (odds ratio [OR] 2899, 95% confidence interval [CI] 132, 6364), coronary artery disease (OR 1654, 95% CI 1232, 2222), or stroke (OR 1769, 95% CI 1218, 2571) Patients with hypertensive emergency had higher mean systolic blood pressure (mean difference [MD] 2413, 95% CI 0477, 4350) and diastolic blood pressure (MD 2043, 95% CI 0624, 3461) Hypertensive emergency was more common in men (OR 1390, 95% CI 1207,1601), older patients (MD 5282, 95% CI 3229, 7335), and those with diabetes (OR 1723, 95% CI 1485, 2000) and hyperlipidemia (OR 2028, 95% CI 1642, 2505) Non-adherence to antihypertensive medications (OR 0939, 95% CI 0647,1363) and hypertensive diagnosis unawareness (OR 0807, 95% CI 0564, 1154) did not increase the risk of hypertensive emergency Conclusions Comorbid cardiac, renal, and cerebral comorbidities (coronary artery disease, congestive heart failure, cerebrovascular disease, and chronic kidney disease) increase the risk of hypertensive crisis The risk of hypertensive crisis is higher in patients with unhealthy alcohol and recreational drug use Systolic and diastolic blood pressure are marginally higher in patients with hypertensive emergency compared to patients with hypertensive urgency Since these differences are small and not clinically significant, clinicians should rely on other symptoms and signs to differentiate between hypertensive urgency and hypertensive emergency The risk of hypertensive emergency is higher in older adults The coexistence of diabetes, hyperlipidemia, and chronic kidney disease increases the risk of hypertensive emergency Systematic review registration number PROSPERO (CRD42019140093)

Risk factors for hypertensive crisis in adult patients: a systematic review.

Hypertensive crisis (HC) includes hypertensive urgency (HU) and hypertensive emergency (HE). There is scarcity of data on the epidemiology of patients presenting with HC in Cameroon. The aim of this study was to determine the prevalence, clinical characteristics, and outcome of HU and HE. We conducted a cross-sectional study from June 2018 until June 2019. The criteria to define a hypertensive crisis were systolic and/or diastolic blood pressure ≥180/110 mm Hg. We compared HU vs HE. Out of the 1536 patients admitted, 95(6.2%) had a HC. There were 49(51.6%) men and 56 (58.9%) had a HE. The mean age was 51.1 ± 14.9 years. A history of hypertension was found in 75.3% of the patients but only 24.2% were on treatment. 33.7% consumed alcohol and 24.2% had chronic kidney disease. Headache (34.7%), dyspnea (34.7%), and neurological deficit (23.2%) were the most common symptoms. Patients with HE had higher systolic and diastolic blood pressures though the difference was not significant. The most frequent forms of HE were acute left ventricular failure with pulmonary edema (44.6%), intracerebral hemorrhage (21.4%), and cerebral infarction (16.1%). The most commonly prescribed medication was labetalol (44.2%). Mean length of hospital stay was 8.4 days. Patients with HE had a longer hospital stay (9.8 vs 6.3 days, P < .001). In-hospital case fatality was 6.3%. Hypertensive crisis accounted for 6.2% of admissions in the medical unit with HE being more common than HU. Acute left ventricular failure with pulmonary edema and stroke were the most frequent target organ lesions in HE.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/jch.14035

Epidemiology of hypertensive crisis in the Buea Regional Hospital, Cameroon

Background Hypertensive emergency (HE) is an acute stage of uncontrolled blood pressure which poses a substantial cardiovascular morbidity and mortality in developing countries. In our setting, the prevalence of HE and the characteristics of patients with a hypertensive crisis are not certainly known yet. Objective The study assessed the prevalence of hypertensive emergency and associated factors among hospitalized patients with hypertensive crisis. Methods A retrospective cross-sectional study was conducted by reviewing records of patients having a diagnosis of hypertensive crisis with systolic/diastolic blood pressure raised to more than 180/120 mmHg admitted to Ayder Comprehensive Specialized Hospital (ACSH) from September 2018 to August 2019. Patients' medical records with complete information were enrolled consecutively. Socio-demographic, clinical characteristics, and other related variables were collected using a structured data collection tool from patient medical records. Data were entered and analyzed using SPSS version 20. Logistic regression was employed to determine factors associated with HE. Results A total of 141 patients' records with a diagnosis of a hypertensive crisis were enrolled in the study; the majority were females 77 (54.6%) and residing in the urban setting 104 (73.8%). The mean age of the participants was 58.8 years. HE was found in 42 (29.8%) of patients. Intravenous Hydralazine 39 (27.7%) and oral calcium channel blocker 102 (72.3%) were the prescribed drugs for acute blood pressure reduction in the emergency setting. Surprisingly, patients who had no history of hypertension (adjusted odds ratio (AOR)=2.469; 95% confidence interval (CI): 0.176‒0.933) and female sex (AOR=2.494; 95% CI: 1.111‒5.596) were found to be independently associated factors with HE. Conclusion The prevalence of HE was found to account a significant proportion of patients. Hence, hypertensive patients should be strictly managed accordingly, and promoting screening programs could reduce the risk of target organ damage.

/pdf/prevalence-of-hypertensive-emergency-and-associated-factors-2luc5qnkf5.pdf

Prevalence of Hypertensive Emergency and Associated Factors Among Hospitalized Patients with Hypertensive Crisis: A Retrospective Cross-Sectional Study.

Background Trauma contributes significantly to the burden of disease and mortality in sub-Saharan Africa (SSA). Like most of SSA, Tanzania lacks prospective trauma registries (TRs), resulting in poor and inconsistent availability of injury data. A model TR was implemented at five representative regional hospitals in Tanzania; the TR incorporates the variables recommended by the World Health Organisation (WHO) Data Set for Injury. This study characterises the burden of trauma seen at five regional hospital Emergency Units (EUs) in Tanzania using data from this new TR. Methods This prospective descriptive study used TR data from EUs of five regional Hospitals in Tanzania between February 2019 to September 2019. Descriptive statistics were calculated for mechanism of injury, injury severity, disposition and mortality. Injury severity scores were calculated. We determined relative risk for mortality by injury type. Results Over a seven-month period, 6,302 (9.6%) patients presented to these EUs with trauma-related complaints. They had a median age of 27 (IQR: 19–37) years and 71.3% were male. Most patients (76.6%) were self-referred and presented to EU on motorized (two or three-wheeler) vehicle (55.9%). Road traffic accidents (RTAs) 3786 (60.3%) were the most common mechanism of injury. Most patients (63.3%) presented with injuries to the upper and lower extremities, while few (2.0%) had injuries to the chest. The overall mean Injury Severity Score (ISS) was 9 (Interquartile Range (IQR): 4–13], and varied by hospital. Total 24-hour mortality was 3.3% and 126 (2.1%) patients died while receiving care at the EU. Among those who died, 156 (81.7%) had an intracranial injury; relative risk of death was [13.3 (CI95%: 9.3 -19.1), p Conclusions TR from these five Tanzanian regional hospitals has provided an opportunity to more accurately describe the country's burden of injury. Having sufficient data for ISS and other key trauma variables allows us to compare the burden and outcomes of trauma in Tanzania with other countries, which will help to quantify an accurate burden of injury, inform quality improvement initiatives, and suggest where to focus preventative measures.

The burden of trauma in Tanzania: analysis of prospective trauma registry data at regional hospitals in Tanzania

Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania. This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency. We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45–67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively. In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.

/pdf/profile-of-patients-with-hypertensive-urgency-and-emergency-5g1wlrshmo.pdf

Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania.

Background. Tanzania has no formal prehospital system. The Tanzania Ministry of Health launched a formal prehospital system to address this gap. The Muhimbili University of Health and Allied Sciences (MUHAS) was tasked by the Ministry of Health to develop and implement a multicadre/provider prehospital curriculum so as to produce necessary healthcare providers to support the prehospital system. We aim to describe the process of designing and implementing the multicadre/provider prehospital short courses. The lessons learned can help inform similar initiatives in low- and middle-income countries. Methods. MUHAS collaborated with local and international Emergency Medicine and Emergency Medical Services (EMS) specialists to form the Emergency Medical Systems Team (EMST) that developed and implemented four short courses on prehospital care. The EMST used a six-step approach to develop and implement the curriculum: problem identification, general needs assessment, targeted needs assessment, goals and objectives, educational strategies, and implementation. The EMST modified current best EMS practices, protocols, and curricula to be context and resource appropriate in Tanzania. Results. We developed four prehospital short courses: Basic Ambulance Provider (BAP), Basic Ambulance Attendant (BAAT), Community First Aid (CFA), and EMS Dispatcher courses. The curriculum was vetted and approved by MUHAS, and courses were launched in November 2018. By the end of July 2019, a total of 63 BAPs, 104 BAATs, 25 EMS Dispatchers, and 287 CFAs had graduated from the programs. The main lessons learned are the importance of a practical approach to EMS development and working with the existing government cadre/provider scheme to ensure sustainability of the project; clearly defining scope of practice of EMS providers before curriculum development; and concurrent development of a multicadre/provider curriculum to better address the logistical barriers of implementation. Conclusion. We have provided an overview of the process of designing and implementing four short courses to train multiple cadres/providers of prehospital system providers in Tanzania. We believe this model of curricula development and implementation can be replicated in other countries across Africa.

/pdf/development-and-implementation-of-short-courses-to-support-2ldfe1d4zr.pdf

Development and Implementation of Short Courses to Support the Establishment of a Prehospital System in Sub-Saharan Africa: Lessons Learned from Tanzania.

Patrick J. Shao

Papers

Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania.

Development and Implementation of Short Courses to Support the Establishment of a Prehospital System in Sub-Saharan Africa: Lessons Learned from Tanzania.