Molecular testing for clinical diagnosis and epidemiological investigations of intestinal parasitic infections

Over the past few decades, nucleic acid-based methods have been developed for the diagnosis of intestinal parasitic infections. Advantages of nucleic acid-based methods are numerous; typically, these include increased sensitivity and specificity and simpler standardization of diagnostic procedures. DNA samples can also be stored and used for genetic characterization and molecular typing, providing a valuable tool for surveys and surveillance studies. A variety of technologies have been applied, and some specific and general pitfalls and limitations have been identified. This review provides an overview of the multitude of methods that have been reported for the detection of intestinal parasites and offers some guidance in applying these methods in the clinical laboratory and in epidemiological studies.

Female genital schistosomiasis (FGS): from case reports to a call for concerted action against this neglected gynaecological disease

In recent years, control of neglected tropical diseases has been increasingly gaining momentum and interventions against schistosomiasis are being progressively scaled-up through expansion of donated praziquantel and preventive chemotherapy campaigns. However, the public health importance of female genital schistosomiasis is not fully recognised nor its control is adequately addressed. Taking a clinical and anatomopathological perspective, we evaluated the available literature to highlight the importance of female genital schistosomiasis and its connections with two sexually transmitted infections of global importance, Human Immunodeficiency Virus (HIV) and Human Papilloma Virus. Outside the long list of clinical descriptive reports beginning in 1899, there is presently a shocking gap in epidemiological assessment and a significant underestimation of the burden of FGS remains. The scarcity of integrated approaches to address female genital schistosomiasis calls for more concerted action in its detection, treatment and prevention alongside other concomitant women's health issues, otherwise female genital schistosomiasis will remain a neglected gynaecological disease.

Surgery for Peptic Ulcer Disease in sub-Saharan Africa: Systematic Review of Published Data

INTRODUCTION

Peptic ulcer disease is a significant cause of morbidity and mortality worldwide, with a significant burden in low- and middle-income countries. However, there is limited information regarding management of peptic ulcer disease in these countries. This study describes surgical interventions for peptic ulcer disease in sub-Saharan Africa.

MATERIALS AND METHODS

A systematic review was performed using PubMed, EMBASE, and African Index Medicus for studies describing surgical management of peptic ulcer disease in sub-Saharan Africa.

RESULTS

From 55 published reports, 6594 patients underwent surgery for peptic ulcer disease. Most ulcers (86%) were duodenal with the remainder gastric (14%). Thirty-five percent of operations were performed for perforation, 7% for bleeding, 30% for obstruction, and 28% for chronic disease. Common operations included vagotomy (60%) and primary repair (31%). The overall case fatality rate for peptic ulcer disease was 5.7% and varied with indication for operation: 13.6% for perforation, 11.5% for bleeding, 0.5% for obstruction, and 0.3% for chronic disease.

CONCLUSION

Peptic ulcer disease remains a significant indication for surgery in sub-Saharan Africa. Recognizing the continued role of surgery for peptic ulcer disease in sub-Saharan Africa is important for strengthening surgical training programs and optimizing allocation of resources.

Nucleic acid detection in the diagnosis and prevention of schistosomiasis

Schistosomiasis is an important zoonotic parasitic disease that causes serious harms to humans and animals. Surveillance and diagnosis play key roles in schistosomiasis control, however, current techniques for surveillance and diagnosis of the disease have limitations. As genome data for parasites are increasing, novel techniques for detection incorporating nucleotide sequences are receiving widespread attention. These sensitive, specific, and rapid detection methods are particularly important in the diagnosis of low-grade and early infections, and may prove to have clinical significance. This paper reviews the progress of nucleic acid detection in the diagnosis and prevention of schistosomiasis, including such aspects as the selection of target genes, and development and application of nucleic acid detection methods.

Abdominal tuberculosis in a low prevalence country

OBJECTIVE

Abdominal tuberculosis is a rare disease. The clinical and radiological manifestations are non-specific and the diagnosis is difficult. Our objective was to describe the characteristics and treatment of patients presenting with abdominal tuberculosis in a low-incidence country.

PATIENTS AND METHODS

We reviewed the clinical, diagnostic, treatment, and outcome features of patients presenting with abdominal tuberculosis diagnosed by bacteriological and/or histological results and managed in five French university hospitals from January 2000 to December 2009.

RESULTS

We included 21 patients. The mean diagnostic delay was 13 months. Twelve patients (57%) came from a low-incidence area and only two had a known immunosuppressed condition. Eighteen patients (86%) presented with abdominal symptoms. The main organs involved were the peritoneum (n=14, 66%), the mesenteric lymph nodes (n=13, 62%), and the bowel (n=7, 33%). Sixteen patients (76%) underwent surgery, including two in an emergency setting. Seventeen patients (81%) received six months or more of anti-tuberculosis treatment. Finally, 16 patients (76%) had a positive outcome.

CONCLUSION

New diagnostic procedures, and especially molecular biology, may help diagnose unusual clinical presentations of tuberculosis. Invasive procedures are frequently necessary to obtain samples but also for the treatment of digestive involvement.

Clinical and epidemiologic variations of esophageal cancer in Tanzania

AIM

To estimate the incidence of esophageal cancer (EC) in Kilimanjaro in comparison to other regions in Tanzania.

METHODS

We also examined the clinical, epidemiologic, and geographic distribution of the 1332 EC patients diagnosed and/or treated at Ocean Road Cancer Institute (ORCI) during the period 2006-2013. Medical records were used to abstract patient information on age, sex, residence, smoking status, alcohol consumption, tumor site, histopathologic type of tumor, date and place of diagnosis, and type and date of treatment at ORCI. Regional variation of EC patients was investigated at the level of the 26 administrative regions of Tanzania. Total, age- and sex-specific incidence rates were calculated.

RESULTS

Male patients 55 years and older had higher incidence of EC than female and younger patients. Of histopathologically-confirmed cases, squamous-cell carcinoma represented 90.9% of histopathologic types of tumors. The administrative regions in the central and eastern parts of Tanzania had higher incidence rates than western regions, specifically administrative regions of Kilimanjaro, Dar es Salaam, and Tanga had the highest rates.

CONCLUSION

Further research should focus on investigating possible etiologic factors for EC in regions with high incidence in Tanzania.

Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis

This article aims to provide an update on the prevention of mother-to-child transmission of syphilis by drawing upon some important basic concepts and reviewing the most recent literature on the diagnosis and treatment of syphilis in pregnancy. New technologies, such as automated and point-of-care immunologic tests, are shifting some paradigms, which will certainly be further investigated in the forthcoming years. This is the time to carefully evaluate traditional as well as new strategies to prevent congenital syphilis. Adverse outcomes of mother-to-child transmission of syphilis can be prevented with antenatal screening and penicillin therapy, which proved to have an excellent cost-benefit ratio even in populations with a low prevalence of syphilis. However, syphilis epidemiology is influenced by socioeconomic and cultural factors, and major challenges are faced by poor and developing countries in which the severity of the problem is extremely alarming. On the other hand, the emergence of new technologies has raised doubts about the best algorithm to be used when proper laboratory resources are available. Conditions are quite heterogeneous across populations, and some procedures should not be generalized while there is no evidence that supports some changes and while in-depth studies about local conditions are not conducted. Official organizations need to be alert in order to avoid isolated decisions and ensure that evidence-based guidelines be used in the management of syphilis in pregnancy.

Clinical profile and surgical management of diabetic foot in Benghazi, Libya

BACKGROUND

The aim of this study was to outline the patterns and management of diabetic foot ulcer (DFU) and compare our experience with other published data.

PATIENTS AND METHODS

All consecutive patients admitted to Al-Jala Hospital with diabetic foot from June, 2008 to May, 2013 were reviewed retrospectively.

RESULTS

A total of 542 patients were studied, Wagner's grade III ulcers were the most prevalent (31%), followed by grade II (25%). About 10% of patients underwent major amputations and 24.2% underwent minor amputations. The amputation rate was 34%, and the mortality rate was 2%.

CONCLUSION

Diabetic foot infections cause significant morbidity and mortality among patients with diabetes in Benghazi. There is a need to establish a diabetic foot clinic in Benghazi with a multidisciplinary team to reduce the rates of hospital admission and amputation, as well as hospital stay duration.

The functional results of radical rectal cancer surgery: review of the literature

Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME. Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria. Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called "low anterior resection syndrome" (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation. Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.

Postoperative Morbidity and Mortality of Perforated Peptic Ulcer: Retrospective Cohort Study of Risk Factors among Black Africans in Côte d'Ivoire

Introduction. Surgical treatment of perforated peptic ulcer (PPU) is a challenge for surgeons in Africa. Aim. To determine risk factors of postoperative complications or mortality among black Ivoirian patients with PPU. Methods. All 161 patients (median age = 34 years, 90.7 male) operated on for PPU in the visceral and general surgery unit were enrolled in a retrospective cohort study. Variables were studied with Kaplan Meier and Cox proportional hazard models. Results. Among 161 patients operated on for PPU, 36 (27.5%) experienced complications and 31 (19.3%) died. Follow-up results were the incidence of complications and mortality of 6.4 (95% CI: 4.9–8.0) per 100 person-days and 3.0 (95% CI: 1.9–4.0) per 100 person-days for incidence of mortality. In multivariate analysis, risk factors of postoperative complications or mortality were comorbidities (HR = 2.1, P = 0.03), tachycardia (pulse rate > 100/minutes) (HR = 2.4, P = 0.02), purulent intra-abdominal fluid collection (HR = 2.1, P = 0.04), hyponatremia (median value ≤ 134 mEq/L) (HR = 2.3, P = 0.01), delayed time of hospital admission > 72 hours (HR = 2.6, P < 0.0001), and delayed time of surgical intervention between 24 and 48 hours (HR = 3.8, P < 0.0001). Conclusion. The delayed hospital admission or surgical intervention and hyponatremia may be considered as additional risk of postoperative complications or mortality in Black African patients with PPU.

Aetiological spectrum of benign gastric outlet obstruction in India: new trends

There is a paucity of data on the spectrum of benign gastric outlet obstruction in India. Our aim was to evaluate its spectrum and to identify the subgroup which would be most amenable to endoscopic therapy. We studied 64 patients whose aetiology revealed in approximately equal proportions: corrosive injury; gastroduodenal tuberculosis (TB); and peptic ulcer disease. The median number of endoscopic dilations required was two for TB, four for peptic ulcer disease and five for corrosive injury. Gastroduodenal TB and corrosive injury appear now to be more, or at least as, common as peptic ulcer disease as causes of benign gastric outlet obstruction in India. Gastroduodenal TB responds best to endoscopic therapy.

Array-in-well platform-based multiplex assay for the simultaneous detection of anti-HIV- and treponemal-antibodies, and Hepatitis B surface antigen

Multiplex assays detecting sets of related clinical analytes simultaneously can save considerable amount of time and resources. Array-in-well (AIW) is a powerful platform for the multiplex detection of different analytes where microarrays can be printed at the bottom of microtiter wells, thus combining the potential of microarrays with the ease of handling microtiter wells. We have developed a single-step AIW assay for the simultaneous screening of HIV, Treponema pallidum subspecies pallidum (causing syphilis) and Hepatitis B virus infections targeting the specific detection of anti-HIV- and treponemal-antibodies and Hepatitis B surface antigen (HBsAg), respectively, using two different fluorescent label technologies i.e. DyLight 633 and europium nanoparticle. Double-antigen assay formats were used for anti-HIV- and treponemal-antibody detection that can simultaneously detect both IgG and IgM, and thus reduce the window period of detection. AIW assay was evaluated with well characterized serum/plasma samples (n=111), and the qualitative results were in near complete agreement with those of the reference assays. The AIW assay exhibited 100% sensitivities for all three analytes, and 100% specificities for anti-HIV antibodies and HBsAg, and 98.6% specificity for treponemal antibodies. The limit of detection of HBsAg in AIW assay was 0.18 ng/ml. This high performing AIW assay has the potential to be used as a multiplex screening test for these three infections.

Kaposi sarcoma can also involve the heart

Kaposi sarcoma (KS) is a low-grade angioproliferative tumor associated with infection with human herpes virus 8 (HHV-8). The disease was named after Moritz Kaposi, a Hungarian dermatologist who first described it in 1872 as 'idiopathic multiple pigmented sarcoma of the skin.' HHV-8 infection is required for the development of KS, but not all infected persons develop the disease. KS is also considered an acquired immune deficiency syndrome (AIDS)-defining illness by the Centers for Disease Control and Prevention guidelines. According to data from the United States AIDS and cancer registries, both KS and non-Hodgkin lymphoma are the most common malignancies associated with human immunodeficiency virus (HIV) infection. However, the incidence of both malignancies has decreased dramatically since 1996 following the widespread utilization of highly active antiretroviral therapies. HIV-associated KS can involve virtually any site in the body including lymph nodes, gastrointestinal tract, respiratory system, heart, pericardium, bone marrow, and other visceral organs. However, cutaneous disease is the most common and is the usual initial presentation for KS. KS-related pericardial effusion can be a life-threatening emergency and should be considered in HIV/AIDS patients who present with signs and symptoms of pericardial effusion. The importance of diagnosing and differentiating KS-related pericardial effusion from other causes of pericardial effusion lies in the differences in the treatment and management in comparison to other etiologies of pericardial effusion. We report a case of a 54-year old man who presented to our hospital with a large pericardial effusion and was subsequently diagnosed to have HIV-related KS pericardial effusion. A brief review of the literature on the diagnosis and management is also presented.

A systematic review of published literature describing factors associated with tuberculosis recurrence in people living with HIV in Africa

BACKGROUND

A summary of factors associated with recurrent tuberculosis (TB) in the African HIV-infected population is lacking. We performed a systematic review to address this.

METHODS

We performed a literature search within PubMed and The WHO Global Library with specific inclusion and exclusion criteria to identify manuscripts emanating from the African continent which potentially described factors associated with recurrent TB in persons living with HIV.

RESULTS

The literature search yielded 52 unique manuscripts, of which only 4 manuscripts were included in the final systematic review following application of the inclusion and exclusion criteria. Baseline CD4 count, baseline HIV viral load, a positive tuberculin skin test, prior active TB disease, cutaneous hypersensitivity reaction to treatment, having < 3 lung zones affected by prior TB disease, and anaemia were associated with recurrent TB in HIV-infected individuals, whilst age and antiretroviral status were not.

CONCLUSION

The lack of studies describing recurrent TB in Africa which stratify results by HIV-status is a hindrance to understanding risk factors for recurrent TB in this population. This might be overcome by implementing guidelines related to the publishing of data from observational studies in peer-reviewed medical journals reporting recurrent TB in populations with a high-burden of HIV infection.

CLINICAL CHARACTERISTICS AND OUTCOME OF PATIENTS WITH UPPER GASTROINTESTINAL BLEEDING AT THE EMERGENCY DEPARTMENT OF A TERTIARY HOSPITAL IN NIGERIA

BACKGROUND

Upper gastrointestinal bleeding is a potentially life threatening condition with multiple causes. There is scarcity of health data depicting the clinical characteristics of the condition in African countries. This study was designed to describe the demographic, clinical characteristics and outcome of the patients who presented to our Emergency Department.

METHOD

The records of cohort of all patients admitted with upper gastrointestinal tract bleeding from 1 January 2011 to 31 December 2012 were retrospectively reviewed from admission to discharge or death.

RESULTS

There were 169 patients with median age of 44.0 years (range 13-89); 25 (15.0%) of them were known peptic ulcer disease patients. Most (69.2%) of the patients were males. The most common presenting symptom was haematemesis (34.9%) followed by melaena (16.6%). There was a history of NSAIDs use in 16.8% and alcohol ingestion in 12%. Upper Gastrointestinal Endoscopy was performed in 6.8% cases. Twenty-three (13.6%) patients died. There was association between mortality and diastolic blood pressure; more deaths (1/7; 14.3%) occurred in those with diastolic blood pressure > 90mmHg compared with ≤90mmHg (5/70; 7.1%) (P = 0.002). There were more deaths among patients who did not receive blood transfusion (4/40; 10.0%) compared with those who had blood transfusion (2/37; 5.4%) (P=0.008).

CONCLUSION

The common presentations were haematemesis and melaena, mainly in middle aged men with mortality in one out of seven patients. The high mortality may be due to co-morbidities and poor support services.

Demographic and Etiological Patterns of Gastric Outlet Obstruction in Kerala, South India

Background:

In the modern era, the major cause of gastric outlet obstruction (GOO) is known to be a malignancy, especially in the developed world. Many books and articles do suggest that the benign causes continue to be the major cause of GOO in the developing world however, there is growing evidence proving the contrary. Males were (more commonly) affected females and individuals in their fifth and sixth decade have been the predominant age group in the majority of studies. There is a minimal data of GOO from South India.

Aims:

A retrospective analysis of the endoscopic findings of patients presenting with features of GOO to determine the demographic and etiological patterns.

Materials and Methods:

A retrospective study of the endoscopic findings of patients with GOO from January 2005 to January 2014 was done. The diagnosis of GOO was based on clinical presentation, and an inability during the upper endoscopy to enter the second portion of the duodenum as documented in the endoscopy registers. Patients who have already been diagnosed with malignancy prior to the endoscopy were excluded from the study; so were the patients with gastroparesis.

Results:

A total of 342 patients with GOO underwent the endoscopy during the study period. The causes for benign obstruction were predominantly peptic ulcer disease. The major cause for malignant obstruction was carcinoma of stomach involving the distal stomach. The male to female ratio was 3.2:1. The patients with malignancy were older than patients with benign disorders. Most of the patients were in the sixth and seventh decade. The risk of malignancy was higher with increasing age, especially in women. A fourth of all carcinoma stomach presented with GOO.

Conclusion:

The study demonstrates that the cause for GOO in Kerala, South India is predominantly malignancy. The etiological and demographic patterns were similar to the studies conducted in the developed nations.

Burden of typhoid fever in low-income and middle-income countries: a systematic, literature-based update with risk-factor adjustment

BACKGROUND

No access to safe water is an important risk factor for typhoid fever, yet risk-level heterogeneity is unaccounted for in previous global burden estimates. Since WHO has recommended risk-based use of typhoid polysaccharide vaccine, we revisited the burden of typhoid fever in low-income and middle-income countries (LMICs) after adjusting for water-related risk.

METHODS

We estimated the typhoid disease burden from studies done in LMICs based on blood-culture-confirmed incidence rates applied to the 2010 population, after correcting for operational issues related to surveillance, limitations of diagnostic tests, and water-related risk. We derived incidence estimates, correction factors, and mortality estimates from systematic literature reviews. We did scenario analyses for risk factors, diagnostic sensitivity, and case fatality rates, accounting for the uncertainty in these estimates and we compared them with previous disease burden estimates.

FINDINGS

The estimated number of typhoid fever cases in LMICs in 2010 after adjusting for water-related risk was 11·9 million (95% CI 9·9-14·7) cases with 129 000 (75 000-208 000) deaths. By comparison, the estimated risk-unadjusted burden was 20·6 million (17·5-24·2) cases and 223 000 (131 000-344 000) deaths. Scenario analyses indicated that the risk-factor adjustment and updated diagnostic test correction factor derived from systematic literature reviews were the drivers of differences between the current estimate and past estimates.

INTERPRETATION

The risk-adjusted typhoid fever burden estimate was more conservative than previous estimates. However, by distinguishing the risk differences, it will allow assessment of the effect at the population level and will facilitate cost-effectiveness calculations for risk-based vaccination strategies for future typhoid conjugate vaccine.

Hookworm infestation is not an uncommon cause of obscure occult and overt gastrointestinal bleeding in an endemic area: A study using capsule endoscopy

Obscure gastrointestinal bleeding (OGIB), particularly occult, has been reported to be caused by hookworm infestation rarely from tropical countries, particularly India. Hence, we undertook a retrospective study evaluating frequency, clinical spectrum, and outcome of patients with OGIB associated with worm infestation. Data of consecutive patients with OGIB undergoing capsule endoscopy in a multilevel university hospital in northern India were retrospectively analyzed. Twenty-one out of 163 (13 %) patients with OGIB had hookworm infestation detected on capsule endoscopy. Of 21 patients (median age 65 years [range 19-82], 17 [81 %] male), 16 had overt and 5 had occult OGIB. Another lesion that could explain OGIB was present in 8/21 patients, 3/5 with OGIB occult, and 5/16 overt (p = ns). All the patients received treatment with albendazole and appropriate measures for the associated lesion, if any. Patients with hookworm infestation with another lesion experienced recurrent bleeding more often than those with worm infestation only. Hookworm infestation is an important cause of occult as well as overt OGIB and may be present even in association with another lesion. Those with additional lesion had recurrent bleeding more often than those with worm infestation alone.

Etiology, treatment outcome and prognostic factors among patients with secondary peritonitis at Bugando Medical Centre, Mwanza, Tanzania

INTRODUCTION

Secondary peritonitis due to perforation of the gastrointestinal tract is one of the most common surgical emergencies all over the world and is associated with significantly morbidity and mortality. Previous studies conducted at Bugando Medical Centre (BMC) were retrospective and each was focused on single etiology; therefore there was an obvious need to evaluate the etiologies, treatment outcome and their prognostic factors altogether.

METHODS

This was a descriptive cross-sectional study involving patients with secondary peritonitis admitted at BMC from May 2014 to April 2015. Sociodemographic and clinical characteristics among consented patients were collected using questionnaires. Peritoneal aspirate, biopsy and blood were collected perioperatively and processed using standard operating procedures. Analysis was done using STATA version 11 software.

RESULTS

The study enrolled 97 patients with the female to male ratio of 1:1.8 and approximately 41.2 % (40/97) were in their third and fourth decades of life. Only 3 (3.09 %) patients arrived to the hospital within 24 hours of onset of illness, 26 (26.80 %) patients presented with shock and HIV seropositivity among all patients was 13.40 % (13/97). The common etiologies of secondary peritonitis were perforated appendicitis 23 (23.71 %), peptic ulcer disease 18 (18.56 %), ischemia 18 (18.56 %) and typhoidal perforation 15 (15.46 %). Of the 97 patients, 35 (36.08 %) had complications and 15 (15.46 %) died. Presence of premorbid illness and post-operative complication were found to be associated with death (p values = 0.004 and <0.001 respectively).

CONCLUSIONS

The most common etiologies of secondary peritonitis at BMC are perforated appendicitis, peptic ulcer disease, ischemia and typhoidal perforation. Premorbid illness and postoperative complications in this setting are associated with death and as the matter of fact proper screening on admission should be done to identify patients with premorbid illness and confer prompt management.

Trends in upper gastrointestinal diagnosis over four decades in Lusaka, Zambia: a retrospective analysis of endoscopic findings

Background and aims

There a shortage of robust information about profiles of gastrointestinal disease in sub-Saharan Africa. The endoscopy unit of the University Teaching Hospital in Lusaka has been running without interruption since 1977 and this 38-year record is largely intact. We report an analysis of endoscopic findings over this period.

Methods

Written endoscopy records from 29th September 1977 to 16th December 2014 were recovered, computerised, coded by two experienced endoscopists and analysed. Temporal trends were analysed using tables, graphs, and unconditional logistic regression, with age, sex of patient, decade, and endoscopist as independent variables to adjust for inter-observer variation.

Results

Sixteen thousand nine hundred fifty-three records were identified and analysed. Diagnosis of gastric ulcer rose by 22 %, and that of duodenal ulcer fell by 14 % per decade. Endoscopically diagnosed oesophageal cancer increased by 32 % per decade, but gastric cancer rose only in patients under 60 years of age (21 % per decade). Oesophageal varices were the commonest finding in patients presenting with haematemesis, increasing by 14 % per decade in that patient group. Two HIV-related diagnoses, oesophageal candidiasis and Kaposi’s sarcoma, rose from almost zero to very high levels in the 1990s but fell substantially after 2005 when anti-retroviral therapy became widely available.

Conclusions

This useful dataset suggests that there are important trends in some endoscopic findings over four decades. These trends are not explained by inter-observer variation. Reasons for the divergent trends in incidence of peptic ulceration and apparent trends in diagnosis of upper gastrointestinal cancers merit further exploration.

Balloon dilatation in patients with gastric outlet obstruction related to peptic ulcer disease

BACKGROUND AND STUDY AIMS

Gastric outlet obstruction (GOO) is a rare complication of peptic ulcer disease (PUD). The endoscopic balloon dilatation (EBD) associated with medical treatment of Helicobacter pylori is a successful method in the management of pyloric stenosis. The aim of this study was to describe epidemiological, clinical, and endoscopic characteristics of GOO related to PUD and to evaluate the effectiveness, safety, and outcome of EBD.

PATIENTS AND METHODS

In a retrospective study of patients seen between 1999 and 2009 with symptoms of GOO secondary to PUD, pyloro-bulbar stenosis was confirmed by endoscopic examination. Balloon dilatation was performed when obstruction persisted after treatment with double-dose proton-pump inhibitor (PPI) intravenously for 7-10days. The H. pylori status was assessed with histology, and eradication therapy was prescribed for infection.

RESULTS

A total of 45 consecutive patients (38 males, 7 females median age, 51.9years; range, 20-58years) with symptoms of GOO secondary to PUD underwent EBD. Median follow-up time of the 45 patients was 32months (range, 4-126months). The immediate success rate of the procedure was 95.5%. Clinical remission was noted in 84.4% of the patients. Remission without relapse was observed in 55.8%, 30months after the dilatation. Pyloric stenosis relapsed in 15 patients (39.5%) after a median period of 22.9months. The dilatation was complicated in three patients (6.7%, two perforations and one bleeding). A total of 13 patients (29%) underwent surgery. H. pylori was found to be positive in 97.7% of the patients, and was eradicated in 78.4% of them. Smoking and failure of H. pylori eradication were associated with the relapse of the stenosis.

CONCLUSION

EBD is a simple, effective, and safe therapy for the GOO related to PUD, producing short- and long-term remission.

Perforated peptic ulcer

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

Overexpression of osteopontin promotes resistance to cisplatin treatment in HCC

Osteopontin (OPN) is a multi-functional cytokine involved in cell survival, migration and adhesion. Increasing evidence has elucidated its role in tumorigenesis, progression and metastasis. However, the role of OPN in chemoresistance of human hepatocellular carcinoma (HCC) has not yet been clarified. In the present study, we examined the expression of OPN in human HCC samples before and after cisplatin-treatment, the results showed that OPN was significantly increased in cisplatin-resistant specimens. We then studied the effect of cisplatin on OPN expression in HCC cells, after exposure to cisplatin, the expression of OPN in HCC cells was elevated compared to control cells. We also found that PI3K/AKT signaling pathway was also activated by cisplatin and this effect was induced by the OPN pathway. To study the effect of OPN on chemoresistance, HCC cells were treated with cisplatin along with OPN. Incubation with OPN enchanced the chemoresistance of HCC cells to cisplatin. In contrast, blockage of OPN pathway promoted the chemosensitivity of HCC cells to cisplatin. Our results suggest that OPN enhanced chemoresistance of cisplatin in HCC cells by activating PI3K/AKT signaling pathway, blocking the OPN pathway might be a novel way to overcome the disease.

Oculocutaneous Albinism and Squamous Cell Carcinoma of the Skin of the Head and Neck in Sub-Saharan Africa

Oculocutaneous albinism which is characterised by impaired melanin biosynthesis is the most common inherited pigmentary disorder of the skin and it is common among Blacks in sub-Saharan Africa. All albinos are at great risk of developing squamous cell carcinoma of sun-exposed skin, and Black albinos in sub-Saharan Africa are at about a 1000-fold higher risk of developing squamous cell carcinoma of the skin than the general population. In Black albinos, skin carcinoma tends to run an aggressive course and is likely to recur after treatment, very probably because the aetiology and predisposing factors have not changed. Prevention or reduction of occurrence of squamous cell carcinoma of the skin in Black albinos might be achieved through educating the population to increase awareness of the harmful effects of exposure to sunlight and at the same time making available effective screening programs for early detection of premalignant and malignant skin lesions in schools and communities and for early treatment.

Typhoid Intestinal Perforations: Has the Clinical Importance Decreased in Eastern Anatolia for 36 Years?

OBJECTIVE

Typhoid fever (TF) is an important health problem in developing countries, and typhoid intestinal perforation (TIP) is a serious complication of TF. The present report aims to determine the clinical importance of TIPs for the last 36 years in our region, eastern Anatolia.

MATERIALS AND METHODS

The clinical records of 84 surgically treated cases with TIPs were reviewed retrospectively.

RESULTS

When the last 36-year period was sectioned by 6-year periods, the distribution of TIPs was found as 39 (46.4% of total), 31 (36.9%), 7 (8.3%), 4 (4.8%), 2 (2.4%) and 1 (1.2%), respectively. The mean age of the patients was 37.1 years (range: 7-68 years), and 66 patients (78.6%) were male. As a surgical procedure, 34 patients (40.5%) had primary repair, 9 (10.7%) had wedge resection with primary repair, 9 (10.7%) had resection with primary anastomosis, 28 (33.3%) had resection with ileostomy, and 4 (4.8%) had exteriorization. Complications were seen in 71 patients (84.5%), while the mortality rate was 10.7% (9 patients).

CONCLUSION

Although eastern Anatolia is an endemic region for TF, a certain decrease in the incidence of TIPs was found for the last 36 years. Keeping in mind the TIP, patients with TF may improve the prognosis of this serious disease.

PRESENTATION AND MANAGEMENT OF PERFORATED PEPTIC ULCER DISEASE IN A TERTIARY CENTRE IN SOUTH SOUTH NIGERIA

BACKGROUND

Perforations of the stomach and duodenum are common complications of peptic ulcer disease (PUD), abuse of non steroidal anti inflammatory drugs (NSAIDS) and gastric cancer. Being a life threatening complication of PUD, it needs special attention with prompt resuscitation and appropriate surgical management if morbidity and mortality are to be avoided.

AIM

To determine the pattern and management outcome of perforated peptic ulcer disease PUD as seen in University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Rivers State, Nigeria).

METHODOLOGY

All the patients with perforated PUD that were managed at UPTH between January 2006 and December 2014 were studied. Relevant data were extracted from the case notes and analysed using the Statistical Package for Social Sciences (SPSS) version 17.

RESULTS

Thirty six patients with perforated PUD were evaluated consisting of 28 males and 8 females with a male to female ratio of 3.5:1. Their ages ranged from 24 to 65 years with a mean of 42.1± 12.3 years and the peak age was at the third decade. After adequate resuscitation, all the patients had exploratory laparotomy. In 26 (72.2%) patients, the perforation was in the duodenum while in 10 (27.8%), it was in the stomach. Thirty two (88.9%) patients had Graham's omental patch repair of the perforation while simple closure only was done in 4 (11.1%) patients. Surgical site infection was the commonest post operative complication which was seen in 7 (19.4%) patients while 4 patients died giving a mortality rate of 11.1%.

CONCLUSION

Perforated peptic ulcer predominantly affected young males and Graham's omental patch followed by Helicobacter pylori eradication was an effective treatment modality.

Gastric Schwannoma: Case report from Tanzania and brief review of literature

Upper gastrointestinal bleeding causes significant morbidity and mortality worldwide. We report a rare case of hematemesis secondary to a gastric schwannoma in a Tanzanian female. Gastric schwannomas should be considered in the differential diagnosis of gastric masses and distinguished from other etiologies, given their excellent postresection prognosis.

Protective Effects of Turbinaria ornata and Padina pavonia against Azoxymethane-Induced Colon Carcinogenesis through Modulation of PPAR Gamma, NF-κB and Oxidative Stress

The aim of this study was to investigate the antiproliferative and protective effects of the brown seaweeds, Turbinaria ornata and Padina pavonia, against azoxymethane (AOM)-induced colon carcinogenesis in mice. Both algal extracts showed anti-proliferative effects on the human carcinoma cell line HCT-116 in vitro, with T. ornata demonstrating a more potent effect. Male albino Swiss mice received intraperitoneal injections of AOM (10 mg/kg) once a week for two consecutive weeks and 100 mg/kg of either T. ornata or P. pavonia extracts. AOM-induced mice exhibited alterations in the histological structure of the colon, elevated lipid peroxidation and nitric oxide, declined glutathione content and reduced activity of superoxide dismutase and glutathione peroxidase. In addition, AOM induced downregulation of peroxisome proliferator activated receptor gamma (PPARγ) and p53 mRNA expression, with concomitant upregulation of nuclear factor-kappa B (NF-κB) in colon tissue. Administration of either algal extract markedly alleviated the recorded alterations. In conclusion, the current study suggests that T. ornata and P. pavonia, through their antioxidant and anti-inflammatory effects, are able to attenuate colon inflammation by downregulating NF-κB expression. Furthermore, the protective effects of both algae against AOM-initiated carcinogenesis were attributed, at least in part, to their ability to upregulate colonic PPARγ and p53 expression.

Assessment of the impact of rapid syphilis tests on syphilis screening and treatment of pregnant women in Zambia

OBJECTIVE

To evaluate the impact of rapid syphilis tests (RSTs) on syphilis testing and treatment in pregnant women in Kalomo District, Zambia.

METHODS

In March 2012, health workers at all 35 health facilities in Kalomo Distract were trained in RST use and penicillin treatment. In March 2013, data were retrospectively abstracted from 18 randomly selected health facilities and stratified into three time intervals: baseline (6months prior to RST introduction), midline (0-6 months after RST introduction), and endline (7-12 months after RST introduction).

RESULTS

Data collected on 4154 pregnant women showed a syphilis-reactive seroprevalence of 2.7%. The proportion of women screened improved from baseline (140/1365, 10.6%) to midline (976/1446, 67.5%), finally decreasing at endline (752/1337, 56.3%) (P<0.001). There was no significant difference in the proportion of syphilis-seroreactive pregnant women who received 1 dose of penicillin before (1/2, 50%) or after (5/48, 10.4%; P=0.199) RST introduction with low treatment rates throughout.

CONCLUSION

With RST scale-up in Zambia and other resource-limited settings, same-day test and treatment with penicillin should be prioritized to achieve the goal of eliminating congenital syphilis.

Strongyloidiasis with emphasis on human infections and its different clinical forms

Strongyloidiasis (caused by Strongyloides stercoralis, and to a lesser extent by Strongyloides fuelleborni) is one of the most neglected tropical diseases with endemic areas and affecting more than 100 million people worldwide. Chronic infections in endemic areas can be maintained for decades through the autoinfective cycle with the L3 filariform larvae. In these endemic areas, misdiagnosis, inadequate treatment and the facilitation of the hyperinfection syndrome by immunosuppression are frequent and contribute to a high mortality rate. Despite the serious health impact of strongyloidiasis, it is a neglected disease and very little is known about this parasite and the disease when compared to other helminth infections. Control of the disease is difficult because of the many gaps in our knowledge of strongyloidiasis. We examine the recent literature on different aspects of strongyloidiasis with emphasis in those aspects that need further research.

The effects of focal adhesion kinase on the motility, proliferation and apoptosis of Caco2 and SMMC-7721 cells

Focal adhesion kinase (FAK) plays important roles in cancer development. However, the significance of FAK expression in colorectal carcinoma and hepatocellular carcinoma has not been clarified. This study aims to explore the roles FAK played in the progression of colorectal carcinoma and hepatocellular carcinoma. RNAi method was used to inhibit the expression of FAK in Caco2 and SMMC-7721 cells. Reverse transcriptase polymerase chain reaction analysis and Western blot analysis were used to examine mRNA and protein expression of FAK. Then, the proliferation, motility and apoptosis of both types of cells were detected using MTT assay, wound healing/transwell assay and nuclear staining assay. The microstructure changes (F-actin, β-tubulin and lamin B1) of SMMC-7721 cells were visualized by immunofluorescence. FAK was overexpressed in both cell lines and down-regulation of FAK resulted in suppression of cell proliferation, inhibition of cell migration and invasion. The apoptosis of cells was increased significantly following the FAK expression inhibition. Moreover, actin polymerization, β-tubulin and lamin B1 expression of cells were significantly decreased. The results highlight the role of FAK in the progression of cancers. These findings suggest FAK serve as a potential therapeutic target for cancer therapy.

Severe liver fibrosis caused by Schistosoma mansoni: management and treatment with a transjugular intrahepatic portosystemic shunt

Liver diseases are common in inhabitants and migrants of tropical countries, where the liver can be exposed not only to toxins but also to many viral, bacterial, fungal, and parasitic infections. Schistosomiasis--a common parasitic infection that affects at least 240 million people worldwide, mostly in Africa--is regarded as the most frequent cause of liver fibrosis worldwide. We present a case of a 19-year-old male refugee from Guinea with recurrent oesophageal variceal bleeding due to schistosomal liver fibrosis refractory to endoscopic therapy. This case was an indication for portosystemic surgery, which is a highly invasive non-reversible intervention. An alternative, less invasive, reversible radiological procedure, used in liver cirrhosis, is the placement of a transjugular intrahepatic portosystemic shunt (TIPS). After thorough considerations of all therapeutic options we placed a TIPS in our patient. In more than 3 years of observation, he is clinically well apart from one episode of hepatic encephalopathy related to an acute episode of viral gastroenteritis. Bleeding from oesophageal varices has not recurred. In this Grand Round, we review the diagnostic approaches and treatment options for portal hypertension due to schistosomal liver fibrosis.

Superior vena cava syndrome revealing a Behçet's disease

Introduction

Behçet’s disease (BD) is a rare vasculitis in sub-Saharan Africa. Vascular thrombosis, especially venous, is common in this condition and also constitutes a basic diagnostic criterion. Its affection of the superior vena cava is rather rare with only a few cases described in the literature.

Case report

A 42-year-old male patient was seen at consultation presenting with a pulsatile, warm and slightly painful right latero-cervical swelling extending to the supraclavicular fossa with the presence of collateral venous circulation for three weeks prior to presentation associated with a mild headache. There were oral and genital ulcerations and erythematous skin lesions associated with a history of inflammatory recurrent arthralgia. Chest computed tomo-angiography showed cruoric internal jugular vein thrombosis extending to the superior vena cava with significant venous collateral circulation. The patient was treated with prednisolone (1 mg/kg/day) and colchicine (2 mg/day), as well as anticoagulation with heparin and vitamin K antagonist (Acenocoumarol) with regular INR monitoring. Clinical evolution was favorable during hospitalization, with residual discrete right supraclavicular swelling. There was no bleeding associated with anticoagulants use.

Conclusion

The case stresses the importance of maintaining a high degree of suspicion for Behçet’s disease in all cases of venous thrombosis.

Management of overt upper gastrointestinal bleeding in a low resource setting: a real world report from Nigeria

Background

Upper gastrointestinal bleeding (UGIB) remains a common medical problem worldwide that has significant associated morbidity, mortality, and health care resource use. This study outlines the aetiology, clinical presentation, and treatment outcomes of patients with UGIB in a Nigerian low resource health facility.

Methods

This was a descriptive study of consecutive patients who underwent upper gastrointestinal (GI) endoscopy for upper GI bleeding in the endoscopy unit of the Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria from January 2007 to December 2013.

Results

During the study period, 287 (12.4%) of 2,320 patients who underwent upper GI endoscopies had UGIB. Of these, 206 (72.0%) patients were males and their ages ranged from 3 to 100 years with a median age of 49 years. The main clinical presentation included passage of melaena stool in 268 (93.4%) of individuals, 173 (60.3%) had haematemesis, 110 (38.3%) had haematochezia, and 161 (56.1%) were dizzy at presentation. Observed in 88 (30.6%) of UGIB patients, duodenal ulcer was the most common cause, followed by varices [52 (18.1%)] and gastritis [51 (17.1%)]. For variceal bleeding, 15 (28.8%) and 21 (40.4%) of patients had injection sclerotherapy and variceal band ligation, respectively. The overall rebleeding rate for endoscopic therapy for varices was 16.7%. For patients with ulcers, only 42 of 55 who had Forrest grade Ia to IIb ulcers were offered endoscopic therapy. Endoscopic therapy was áin 90.5% of the cases. No rebleeding followed endoscopic therapy for the ulcers. The obtained Rockall scores ranged from 2 to 10 and the median was 5.0. Of all patients, 92.7% had medium or high risk scores. An increase in Rockall score was significantly associated with length of hospital stay and mortality (p < 0.001). The overall mortality rate was 5.9% (17 patients).

Conclusion

Endoscopic therapy for UGIB in a resource-poor setting such as Nigeria is feasible, significantly reduces morbidity and mortality, and is cost effective. Efforts should be made to improve the accessibility of these therapeutic procedure for patients with UGIB in Nigeria.

Intra-abdominal sepsis--epidemiology, aetiology and management

Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.

Evaluation of Diabetic Foot Complications According to Amit Jain's Classification

Background : Wagners classification has been one of the commonly used grading system for diabetic foot lesions. Amit Jain's classification is a new classification which includes almost all the common problems affecting diabetic foot. The aim of our study was to include the patients with Diabetic foot in different sub groups as per the new classification and to evaluate the outcome.

MATERIALS AND METHODS

This retrospective study was conducted by analyzing the records of the inpatients in the Department of Surgery in a tertiary care teaching institute at Bangalore, India, between June 2013 to December 2013. Results : Males (82.11%) were more commonly affected than females, the ratio being 4.6:1. Type 1 diabetic foot complications (91.06%) were the most common type of diabetic foot complication seen at our centre. Wet gangrene (35.7%) was the most common type of type 1 diabetic foot complication. Twenty (16.26%) patients underwent major amputations out of which 12.2% belonged to type 1 complications.

CONCLUSION

Majority of the diabetic foot patients in a tertiary care hospital belonged to type 1 complication. Most of the major amputations in a diabetic occurred in type 1 diabetic foot complication. This classification was found to be very easy and almost all the diabetic foot complications were placed effectively and appropriately in this classification.

Evidence-based nursing in infants with congenital megacolon

AIM: To investigate the clinical significance of evidence-based nursing in infantile patients with congenital megacolon.

METHODS: Fifty infantile patients with congenital megacolon hospitalized at our hospital from January 2008 to December 2013 were retrospectively analyzed. According to the measure of nursing intervention after admission, the patients were divided into either a conventional nursing group or an evidence-based nursing group. The nursing effects were compared between the two groups.

RESULTS: Complications occurred only in 3 cases in the evidence-based nursing group, and none of them had multiple simultaneous complications. In contrast, complications occurred in 61 children in the conventional nursing group, of whom 6 developed only one complication, 17 had two concurrent complications, and 7 had three complications (χ² = 41.667, P = 0.000). The incidences of water and electrolyte imbalance, malnutrition, and hemodynamic instability were significantly lower in the evidence-based nursing group than in the conventional nursing group (P < 0.05). The length of hospital stay and the incidence of anastomotic obstruction were also significantly lower in the evidence-based nursing group than in the conventional nursing group (P < 0.05).

CONCLUSION: Evidence-based nursing may be helpful to reduce the incidence of complications and shorten the length of hospital stays in patients with congenital megacolon.

Oculocutaneous albinism in sub-Saharan Africa: adverse sun-associated health effects and photoprotection

Oculocutaneous albinism (OCA) is a genetically inherited autosomal recessive condition. Individuals with OCA lack melanin and therefore are susceptible to the harmful effects of solar ultraviolet radiation, including extreme sun sensitivity, photophobia and skin cancer. OCA is a grave public health issue in sub-Saharan Africa with a prevalence as high as 1 in 1000 in some tribes. This article considers the characteristics and prevalence of OCA in sub-Saharan African countries. Sun-induced adverse health effects in the skin and eyes of OCA individuals are reviewed. Sun exposure behavior and the use of photoprotection for the skin and eyes are discussed to highlight the major challenges experienced by these at-risk individuals and how these might be best resolved.

Predictors of mortality in children with typhoid ileal perforation in a Nigerian tertiary hospital

PURPOSE

Childhood typhoid ileal perforation is associated with high morbidity and mortality. Our aim was to ascertain the predictors of survival in children.

MATERIALS AND METHODS

This is a tertiary hospital-based retrospective review of patients aged ≤15 years managed for typhoid ileal perforations between January 2005 and December 2013. The details of their biodata, potential risk factors and outcome were evaluated.

RESULTS

Forty-five children out of a total of 97 with typhoid fever had typhoid ileal perforation. The age range was 2-15 years, mean (±SD) = 9.3 (±3.31) years, median = 10 years. There were more males than females (26:19). Thirty-nine (86.7%) patients were >5 years old. There were nine deaths (20% mortality). The mean (±SD) age of survivors was 9.8 (±2.9) years and 7.1 (±4.2) for non-survivors (p = 0.026). The duration of illness at presentation, gender, admission temperature, nutritional status and packed cell volume, perforation-operation interval, number of perforations, surgical procedure, and the duration of surgery did not statistically influence survival (p > 0.05). The age of the patients and burst abdomen attained statistical significance (p < 0.05).

CONCLUSION

The patients' age and postoperative burst abdomen were significant determinants of survival in children with typhoid ileal perforation.

Quality of life and treatment satisfaction observed among Indians with diabetes foot ulcers undergoing ayurvedic adjunct therapy

The purpose of the study was to assess the health-related quality of life and treatment satisfaction of diabetes patients (n = 36) with foot ulcers undergoing insulin and ayurvedic adjunct therapy. Retrospective hospital based cross-sectional design considered patients with diabetes foot ulcers undergoing 4-week treatment with insulin and ayurvedic combinatorial therapy. The Audit of Diabetes Dependent Quality of Life Questionnaire and Diabetes Treatment Satisfaction Questionnaire were completed for the assessment. The mean duration of diabetes among participants was 9.32 ± 5.3 years. Assessment of Diabetes Treatment Satisfaction Questionnaire (total treatment satisfaction) score was found to be 26.0139 ± 5.20369, and Audit of Diabetes Dependent Quality of Life Questionnaire (average weighted impact) score was -3.0819 ± 1.83003. Relationship with diabetes complications showed that Audit of Diabetes Dependent Quality of Life Questionnaire score (P = .383) had no relationship, but Diabetes Treatment Satisfaction Questionnaire score (P = .039) showed significance. Integrated approaches for diabetes foot ulcer management with insulin and ayurvedic management have a favorable impact on patient-perceived quality of life.