The pattern of respiratory disease morbidity and mortality in a tertiary hospital in southern-eastern Nigeria

Critical illness at the emergency department of a Tanzanian national hospital in a three-year period 2019-2021

BACKGROUND

Critically ill patients have life-threatening conditions requiring immediate vital organ function intervention. But, critical illness in the emergency department (ED) has not been comprehensively described in resource-limited settings. Understanding the characteristics and dynamics of critical illness can help hospitals prepare for and ensure the continuum of care for critically ill patients. This study aimed to describe the pattern and outcomes of critically ill patients at the ED of the National Hospital in Tanzania from 2019 to 2021.

METHODOLOGY

This hospital-records-based retrospective cohort study analyzed records of all patients who attended the ED of Muhimbili National Hospital between January 2019 and December 2021. Data extracted from the ED electronic database included clinical and demographic information, diagnoses, and outcome status at the ED. Critical illness in this study was defined as either a severe derangement of one or more vital signs measured at triage or the provision of critical care intervention. Data were analyzed using Stata 17 to examine critical illnesses' burden, characteristics, first-listed diagnosis, and outcomes at the ED.

RESULTS

Among the 158,445 patients who visited the ED in the study period, 16,893 (10.7%) were critically ill. The burden of critical illness was 6,346 (10.3%) in 2019, 5,148 (10.9%) in 2020, and 5,400 (11.0%) in 2021. Respiratory (18.8%), cardiovascular (12.6%), infectious diseases (10.2%), and trauma (10.2%) were the leading causes of critical illness. Most (81.6%) of the critically ill patients presenting at the ED were admitted or transferred, of which 11% were admitted to the ICUs and 89% to general wards. Of the critically ill, 4.8% died at the ED.

CONCLUSION

More than one in ten patients attending the Tanzanian National Hospital emergency department was critically ill. The number of critically ill patients did not increase during the pandemic. The majority were admitted to general hospital wards, and about one in twenty died at the ED. This study highlights the burden of critical illness faced by hospitals and the need to ensure the availability and quality of emergency and critical care throughout hospitals.

Community‐acquired pneumonia and its predictors of mortality in rural southwestern Nigeria: A‐five year retrospective observational study

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Majority of people in sub-Sahara Africa reside in rural areas.

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Many hospitals in rural and sub-urban centres do not have adequate personnel and infrastructures.

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There are limited dataoncommunity-acquired pneumonia and its predictors of mortality and were largely restricted to urban and suburban centres.

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The results of the present study would guide the stakeholders on how to reduce community- acquired pneumonia mortality in rural centres.

Introduction

The predictors of community-acquired pneumonia (CAP) mortality are important outcome measures in epidemiological studies and clinical trials. There is an observed paucity of data regarding the predictors of mortality of CAP in Nigeria. Few studies from the urban centres have been reported in the literature, with none from the rural centres. The objective of this study is to ascertain the clinical presentations, risk factors, and predictors of mortality among patients admitted for CAP in rural Southwestern Nigeria.

Methods

A retrospective observational study using a data form and a standardised questionnaire reviewed the 176 patients admitted to Southwestern Nigeria hospital between January 2015 and December 2019. The data were analysed using SPSS Version 22.0. The results were presented in descriptive and tabular formats.

Results

A total of 176 patients were studied. Their mean age was 53.3±16.8 years. There were more males, 112 (63.6%), than females. The most common clinical presentations were cough, fever and sputum expectoration. The case fatality rate was 9.1% and its predictors were older aged patients [Adjusted Odds Ration (AOR), 4.135: 95% Confidence Interval (CI) (1.389-12.315); p =0.005], hypoxia [AOR, 11.118: 95% CI (2.607-47.405); p<0.001], tobacco smoking [AOR, 3.632: 95% CI (1.459-9.039); p=0.008], chronic obstructive pulmonary disease (COPD) [AOR, 10.111: 95%CI (2.370-43.139); p <0.001], and human immunodeficiency virus (HIV) [AOR, 9.444: 95% CI (4.304-20.725), p<0.001].

Conclusion

The case -fatality rate was 9.1%, and its predictors were older age patients, patients with hypoxia, tobacco smoking, COPD, and HIV. This study strengthens the argument on the higher prevalence of CAP and its mortality in rural Southwestern Nigeria. The findings may provide an impetus for prospective research on these outcomes.

Source profiling of air pollution and its association with acute respiratory infections in the Himalayan-bound region of India

The studies related to air pollutants and their association with human health over the mountainous region are of utmost importance and are sparse especially over the Himalayan region of India. The linkages between various atmospheric variables and clinically validated data have been done using various datasets procured from satellite, model reanalysis, and surface observations during 2013-2017. Aerosol optical depth, air temperature, and wind speed are significantly related (p < 0.001) to the incidence of acute respiratory infections with its peak during winter. Model-derived particulate matter (PM_2.5) shows high contributions of black carbon, organic carbon, and sulfate during winter. The wind roses show the passage of winds from the south-west and southern side of the region. Back trajectory density plot along with bivariate polar plot analyses have shown that most of the winds coming from the western side are taking a southward direction before reaching the study area and may be bringing pollutants from the Indo-Gangetic Plain and other surrounding regions. Our study shows that the accumulation of pollutants in the Himalayan valley is owing to the meteorological stability with significant local emissions from burning of biomass and biofuels along with long-range and mid-range transport during the winter season that significantly correlated with the incidence of acute respiratory infections in the region.

Identification of pediatric respiratory diseases using a fine-grained diagnosis system

Respiratory diseases, including asthma, bronchitis, pneumonia, and upper respiratory tract infection (RTI), are among the most common diseases in clinics. The similarities among the symptoms of these diseases precludes prompt diagnosis upon the patients' arrival. In pediatrics, the patients' limited ability in expressing their situation makes precise diagnosis even harder. This becomes worse in primary hospitals, where the lack of medical imaging devices and the doctors' limited experience further increase the difficulty of distinguishing among similar diseases. In this paper, a pediatric fine-grained diagnosis-assistant system is proposed to provide prompt and precise diagnosis using solely clinical notes upon admission, which would assist clinicians without changing the diagnostic process. The proposed system consists of two stages: a test result structuralization stage and a disease identification stage. The first stage structuralizes test results by extracting relevant numerical values from clinical notes, and the disease identification stage provides a diagnosis based on text-form clinical notes and the structured data obtained from the first stage. A novel deep learning algorithm was developed for the disease identification stage, where techniques including adaptive feature infusion and multi-modal attentive fusion were introduced to fuse structured and text data together. Clinical notes from over 12000 patients with respiratory diseases were used to train a deep learning model, and clinical notes from a non-overlapping set of about 1800 patients were used to evaluate the performance of the trained model. The average precisions (AP) for pneumonia, RTI, bronchitis and asthma are 0.878, 0.857, 0.714, and 0.825, respectively, achieving a mean AP (mAP) of 0.819. These results demonstrate that our proposed fine-grained diagnosis-assistant system provides precise identification of the diseases.

Pattern of Respiratory Diseases, Morbidities and Outcome in Patients Admitted in Respiratory Ward of a Tertiary Care Hospital: A Descriptive Cross-sectional Study

INTRODUCTION

Respiratory diseases are a leading cause of morbidity and mortality worldwide imposing a significant global health burden. The admission rate of patients is the indication of the overall workload in the ward. The aim of this study was to find the prevalence of admission of patients in the pulmonology ward among patients visiting the pulmonology department of a tertiary care hospital.

METHODS

A descriptive cross-sectional study was conducted at Tribhuvan University Teaching Hospital. Medical records of all patients visiting the pulmonology department and admitted to the pulmonology ward from May 2018 to April 2020 were retrospectively reviewed. Data entry and analysis was done in SPSS version 20.0. Descriptive statistics were performed.

RESULTS

A total of 30,480 patients visited the pulmonology department in the two-year study period. Out of them, 1296 (4.25%) patients were admitted to the pulmonology ward. Eleven respiratory diseases were identified as primary causes for admission. Acute exacerbation of chronic obstructive pulmonary disease (44.5%), pneumonia (26.3%), tuberculosis (11%), lung cancer (5%), and bronchiectasis (3.9%) ranked the top five causes for admission.

CONCLUSIONS

Respiratory diseases impose a tremendous burden in the health care setting. Acute exacerbation of the chronic obstructive pulmonary disease, pneumonia, and tuberculosis remains an important cause of respiratory admissions in our study.

Clinical and microbiological profile of adult inpatients with community acquired pneumonia in Ilorin, North Central, Nigeria

Background

The optimal management of community acquired pneumonia (CAP) depends on the clinical and microbiological profile in the locality.

Objectives

To determine the clinical and microbiological profile of patients admitted with CAP in Ilorin, Nigeria.

Methods

One hundred and two consenting consecutively selected patients with clinical and radiologic confirmation of CAP were recruited in 12 months. The socio-demographic, physical examination and laboratory/radiologic parameters were documented in a questionnaire. Microbiological evaluation of their sputum was done and blood samples were taken for complete blood count, culture, serum urea and serological evaluation for atypical bacteria and some viral pathogens.

Results

CAP constituted 5.9% of the total medical admissions during the one-year study period. The mean age of the patients was 49 ± 22 years with the largest frequency in those aged 65 years and above. The commonest symptoms were shortness of breath (96.1%) and cough (94.1%), with a median duration of 3 days from symptom onset to admission. Systemic hypertension was the commonest comorbid illness (25/102; 24.5%). Klebsiella pneumoniae was the predominant pathogen isolated (20/102; 28.1%). The susceptible antibiotics were Imipenem, Ceftazidime and Ceftriaxone. Intra-hospital mortality was 17.6%. CURB – 65 score of ≥ 2 and the presence of complications of CAP were the independent predictors of mortality.

Conclusion

CAP constitutes a significant disease burden in Ilorin, Nigeria. Typical bacteria accounted for over half of the pathogens isolated from the patients with gram negative agents predominating. This highlights a possible shift in the microbiological profile which could guide empirical treatment.

Burden and spectrum of paediatric respiratory diseases at a referral hospital in North-Central Nigeria - A five year review

Introduction

Globally respiratory diseases, comprising a broad range of disease conditions due to infectious and non-infectious causes, are a major cause of childhood morbidity and mortality. Thus, identification of the burden of respiratory illness will ensure appropriate interventions towards reducing its attendant morbidity and mortality. The study was conducted to identify the burden, spectrum and outcome of respiratory diseases in hospitalized children at University of Ilorin Teaching Hospital, North-Central Nigeria.

Methods

A retrospective descriptive cross-sectional study involving children admitted through the emergency paediatric unit over five years (January 2013-December 2017) was conducted. Data on demography, diagnosis, co-morbidities and complications, duration of admission, and outcome were collected and analyzed using SPSS 20.

Results

Of the total 7012 children admitted, 1939(27.7%) were due to respiratory diseases with a median age of 16 (interquartile range {IQR} 7-36) months. Males were 994(51.3%) and 945(48.7%) females. Infectious diseases were the most common cause of admission. Pneumonia (50.1%) and aspiration pneumonitis (5.1%) accounted for the highest admissions due to infective and non-infective respiratory diseases respectively. Overall, respiratory diseases accounted for 20.7% (119/574) of the overall mortality among all admissions while the all-respiratory disease mortality was 6.1% (119/1939). The major contributors to mortality were pneumonia, aspiration pneumonitis and tuberculosis accounting for 81(68.1%), 12(10.1%) and nine (7.6%) deaths respectively. The median duration of hospital stay was four days [IQR: 2 to 6 days]. A significantly higher proportion of the deaths occurred with four days of admission and 82.4% of the deaths occurred among those aged less than five years. A higher number of females (70, 58.8%) died compared to males (49, 41.2%), p=0.05.

Conclusion

Pneumonia and aspiration pneumonitis are major contributors to morbidity and mortality due to respiratory diseases for which interventions towards improving childhood health indices should be prioritized.

An integrative review on the positive expiratory pressure (PEP)-bottle therapy for patients with pulmonary diseases

BACKGROUND AND PURPOSE

Positive expiratory pressure (PEP)-bottle device delivers a PEP within a range of 10-20 cmH₂ O. PEP treatment is applied to different pathological conditions also in combination with other physiotherapeutic techniques. The primary aim of the present review was to investigate the effects of PEP-bottle therapy in patients with pulmonary diseases and, secondarily, to provide a physiological analysis of its use.

METHODS

The databases PubMed, Scopus, Web of Science, Cinahl, and Cochrane Library were searched for citations published from their inception until May 2019. Adult participants (>18 years) with pulmonary disease who underwent PEP-bottle treatment, with no restriction on gender, were included in the study. There were no restrictions about the therapeutic settings and the condition of the disease (either acute or chronic).

RESULTS

The literature review returned 97 citations. After duplicates removal, the remaining 77 articles have been screened: 66 have been assessed as not eligible at first because the abstract did not meet the inclusion criteria. Eleven articles were left after the first two steps of selection: four have been excluded after full-text reading.

CONCLUSION

PEP-bottle therapy has been proved to improve lung volume, to reduce hyperinflation, and to remove secretions. The device delivers a pressure equal to the water column only if the inner diameter of the tubing and the width of the air escape orifice are equal or greater than 8 mm, and the length of tubing ranges between 20 and 80 cm. The cost of a PEP-bottle device is significantly lower if compared with other commercially available devices having the same therapeutic purposes.

Trends, patterns and causes of respiratory disease mortality among inpatients in Tanzania, 2006-2015

OBJECTIVE

To determine the causes, patterns and trends of respiratory diseases-related deaths in hospitals of Tanzania 2006-2015.

METHODS

Retrospective study involving 39 hospitals. Medical records of patients who died in hospital were retrieved, reviewed and analysed. Sources of data were hospital admission registers, death registers and International Classification of Diseases report forms. Information on demographic characteristics, date of death, the immediate underlying cause of death and co-morbid conditions was collected.

RESULTS

Of the 247 976 deaths reported during the 10-year period, respiratory diseases accounted for 12.92% (n = 32 042). The majority of the respiratory mortality was reported among males (55.9%). Overall median age at death was 31 years with an interquartile range (IQR) of 1-47. Median age at death was significantly higher among males (35 years) than females (28 years) (P < 0.0001). Most deaths (37.8%) occurred in eastern Tanzania. About one-third (31.3%) of all respiratory mortality was reported among under-five children, being among girls than boys (34.3% vs. 28.9%, χ²  = 10.3, P < 0.0001). Adolescent and young adult females (15-29 years) had higher age-standardised mortality rates per 100 000 due respiratory diseases than males. Pneumonia (n = 16 639; 51.9%) and pulmonary tuberculosis (n = 9687; 30.2%) accounted for the majority of deaths due to respiratory diseases. Significantly more females (n = 7665; 54.5%) than males died from pneumonia (n = 8878; 49.8%; χ²  = 8.5, P < 0.0001). By contrast, significantly more males (n = 6024; 34%) than females (n = 3596; 26%; χ²  = 15.5, P < 0.0001) died of tuberculosis. The proportion of death due to tuberculosis declined from 32.8% in 2006-2010 to 7.9% in 2011-2015. However, there was a significant increase in the proportion of death due to pneumonia from 49.6% in 2006-2010 to 53.4% in 2011-2015. Co-morbid conditions contributed to 9.1% (2871/31 628) of all deaths due to respiratory diseases. The most common co-morbid condition was HIV which accounted for 1735 (60.4%) deaths and was more common among males (60.8%; n = 957) than among females (59.7%; n = 764).

CONCLUSIONS

Respiratory diseases account for a substantial proportion of all causes of hospital death in Tanzania. Pneumonia and tuberculosis contribute to more than three quarters of all deaths due to respiratory diseases. Since most major respiratory illnesses are avoidable, it is important to strengthen the capacity of the health delivery system in managing cases of respiratory diseases.

Bronchoscopy in Nigerian Clinical Practice: A Survey of Medical Doctors' Perception, Use and Associated Challenges

Background

Bronchoscopy is a vital diagnostic and therapeutic procedure in pulmonological practice. The aim of this study was to determine the perception, use and challenges encountered by Nigerian medical doctors involved in this procedure.

Materials and Methods

A cross-sectional study was conducted among 250 medical doctors recruited from three major tertiary institutions in Nigeria between September 2013 and June 2014. A semi-structured questionnaire was self-administered to adult physicians, paediatricians, and surgeons as well as their trainees to obtain their perception, use and associated challenges in the use of bronchoscopy in clinical practice.

Results

The majority (91.6%) of the respondents perceived bronchoscopy as a beneficial procedure to respiratory medicine. However, 59.2% of them were not aware of the low mortality rate associated with this procedure. The commonest indications for bronchoscopic use were foreign body aspiration (88.8%) and management of lung tumors (75.6%). Only 21 (8.4%) of the respondents had received formal training in bronchoscopy. Very few procedures (1–5 cases per month) were performed. The respondents identified the lack of formal training in the art of bronchoscopy as the foremost challenge facing its practice in Nigeria. In addition, availability of bronchoscopes, level of awareness, knowledge of the procedure among medical doctors and the cost of the procedure were the challenges faced by the medical doctors.

Conclusion

There is an urgent need to equip training centers with modern bronchoscopic facilities. In addition,well-structured bronchoscopic training programme is imperative to enhance the trainees' proficiency for the furtherance of bronchoscopic practice.

Predictors of in-hospital mortality and length of stay in community-acquired pneumonia: a 5-year multi-centre case control study of adults in a developing country

BACKGROUND

We investigated predictors of in-hospital mortality and length of hospital stay among adults with community-acquired pneumonia (CAP) in Nigeria in order to provide recommendations to improve CAP outcomes in developing countries.

METHODS

This was a multi-centre case control study of patients ≥18 years who were admitted with CAP between 2008 and 2012. Case notes of 100 consecutive patients who died (cases) and random sample of 300 patients discharged (controls) were selected.

RESULTS

Mean ages were 55.4±19.6 (cases) and 49.3±19.2 (controls). Independent predictors of mortality were CURB-65 score ≥3: adjusted odds ratio (aOR) 24.3, late presentation: aOR 8.6, co-morbidity: aOR 3.9, delayed first dose antibiotics (>4 hours): aOR 3.5, need for supplemental oxygen: aOR 4.9, multilobar pneumonia: aOR 4.0, non-pneumococcal aetiology: aOR 6.5, anaemia: aOR 3.8 and hyperglycemia: aOR 8.6. CURB-65 ≥3 predicted mortality with a high specificity (96.1%) but low sensitivity (75%); positive predictive value of 88.2% and negative predictive value of 90.8%. Care in hospital A and B: aOR 3.3 and 2.2 respectively, male gender aOR 2.1, co-morbidity aOR 3.0, anaemia aOR 2.1 and elevated serum creatinine aOR 6.3 independently predicted length of hospital stay >10 days among survivors.

CONCLUSIONS

Several modifiable patient-related and process-of-care factors predicted in-hospital mortality, and length of hospital stay among survivors. Our findings should be used to improve CAP outcomes in developing countries.

Depiction of Trends in Administrative Healthcare Data from Hospital Information System

Background:

administrative healthcare data are among main components of hospital information system. Such data can be analyzed and deployed for a variety of purposes. The principal aim of this research was to depict trends of administrative healthcare data from HIS in a general hospital from March 2011 to March 2014.

Methods:

data set used for this research was extracted from the SQL database of the hospital information system in Razi general hospital located in Marand. The data were saved as CSV (Comma Separated Values) in order to facilitate data cleaning and analysis. The variables of data set included patient’s age, gender, final diagnosis, final diagnosis code based on ICD-10 classification system, date of hospitalization, date of discharge, LOS(Length of Stay), ward, and survival status of the patient. Data were analyzed and visualized after applying appropriate cleansing and preparing techniques.

Results:

morbidity showed a constant trend over three years. Pregnancy, childbirth and the puerperium were the leading category of final diagnosis (about 32.8 %). The diseases of the circulatory system were the second class accounting for 13 percent of the hospitalization cases. The diseases of the digestive system had the third rank (10%). Patients aged between 14 and 44 constituted a higher proportion of total cases. Diseases of the circulatory system was the most common class of diseases among elderly patients (age≥65). The highest rate of mortality was observed among patients with final diagnosis of the circulatory system diseases followed by those with diseases of the respiratory system, and neoplasms. Mortality rate for the ICU and the CCU patients were 62% and 33% respectively. The longest average of LOS (7.3 days) was observed among patients hospitalized in the ICU while patients in the Obstetrics and Gynecology ward had the shortest average of LOS (2.4 days). Multiple regression analysis revealed that LOS was correlated with variables of surgery, gender, and type of payment, ward, the class of final diagnosis and age.

Conclusion:

this study presents trends in administrative health care data residing in hospital information system of a general public hospital. Patterns in morbidity, mortality and length of stay can inform decision making in health care management. Mining trends in administrative healthcare data can add value to the health care management.

Radiographers' performance in chest X-ray interpretation: the Nigerian experience

OBJECTIVE

To assess the performance of Nigerian radiographers in interpretation of plain chest radiographs and to assess whether age, years since qualification and sector of practice are associated with performance.

METHODS

A test set of 50 radiographs containing 23 cases with no pathology (normal) and 27 abnormal cases (cardiopulmonary conditions) independently confirmed by 3 radiologists were presented to 51 radiographers in a random order. Readers independently evaluated radiographs for absence or presence of disease and stated the location, radiographic features and diagnosis. Readers self-reported their age, years since qualification and sector of practice. Receiver operating characteristic was used to assess the performance. Mann-Whitney U test was used to assess whether age, years since qualification and sector of practice were associated with performance.

RESULTS

Mean location sensitivity was 88.9 [95% confidence interval (CI), 0.787-0.980]. Mean sensitivity and specificity were 76.9 (95% CI, 0.658-0.864) and 79.8 (95% CI, 0.658-0.864), respectively. Age was not associated with performance (p = 0.07). Number of years qualified as radiographer (p = 0.005) and private practice (p = 0.004) were positively associated with performance.

CONCLUSION

Nigerian radiographers can correctly report chest radiographs to a reasonable standard, and performance is associated with number of years since qualification and the sector of practice.

ADVANCES IN KNOWLEDGE

There are less than 300 radiologists serving a Nigerian population of about 170 million; therefore, X-ray interpretation by radiographers deserves consideration. Nigerian radiographers have potential to interpret chest X-ray in the clinical setting, and this may significantly improve radiology service delivery in this region.