Postoperative analgesic effects of intravenous dexamethasone for patients undergoing cesarean delivery under spinal anesthesia at Dilla University Referral Hospital, Ethiopia, 2023: a double-blind randomized controlled trial

Background

The use of cesarean section (CS) worldwide has increased to unprecedented levels. In Ethiopia, the CS delivery rate is above the rate recommended by the WHO. The postoperative pain experience is moderate to severe in most patients during their postoperative period. The administration of intravenous dexamethasone is thought to have an analgesic effect after surgery even though the analgesic profile of preoperatively administered dexamethasone is less addressed.

Objective

This study aimed to assess the postoperative analgesic effect of preoperative intravenous dexamethasone for patients undergoing cesarean delivery under spinal anesthesia at Dilla University Referral Hospital, Southern Ethiopia.

Methodology

A double-blinded randomized controlled trial (RCT) was done on 112 patients undergoing elective CS under spinal anesthesia who were allocated randomly into normal saline and dexamethasone groups. Total analgesic consumption, time to first analgesic request, and postoperative pain score with the numerical rating scale (NRS) were followed for 24 h in both groups. Shapiro-Wilk tests were used to check normality. Independent samples t-test was used for the comparison of means between groups, Mann-Whitney U test for non-normally distributed data, and χ 2 test for categorical variables, and P-value <0.05 was considered statistically significant with a power of 80%.

Result

The finding of this study showed that the postoperative pain score of the dexamethasone group was significantly lower than the normal saline group at 2, 4, 6, 12, 18, and 24 h with a statistically significant P-value <0.05. There was also a significant difference in the time to the first rescue analgesic request between the two groups, with the dexamethasone group (median=347.5 min) and the normal saline group (median=230 min) with P=0.001.

Conclusion and recommendation

The authors conclude that preoperative administration of 8 mg of dexamethasone prolongs the first analgesic request time, decreases postoperative tramadol and diclofenac consumption, and decreases the postoperative pain score. The authors recommend that researchers conduct further RCTs with a different dose of dexamethasone and on a multicenter basis.

Evidence-based guideline on chronic postsurgical pain management in adult patients in resource-restricted setting, 2023: systematic review and guideline

Background

Chronic postsurgical pain (CPSP) after tissue trauma is frequent and may have a long-lasting impact on the functioning and quality of life. The development of CPSP increases the burden on both the patient and the community. This review aims to systematically review articles and, lastly, pull an evidence-based guideline for CPSP management in adult patients in resource-limited areas.

Methodology

The review was reported based on preferred reporting items for the systemic review and meta-analysis (PRISMA) protocol. A literature search was conducted from the Cochrane, PubMed/Medline, and Google Scholar databases, and other gray literature from 2010 to 2022. The conclusion was made based on the level of evidence.

Results

A total of 3521 articles were identified through the database by searching strategies. Finally, by filtering duplicates unrelated to the topics, 22 articles (9 meta-analyses and systematic reviews, 12 systematic reviews, and one cohort study) were selected on the management of CPSP in adult patients. Filtering was made based on the intervention, outcome data of the population, and methodological quality.

Conclusion

Given the complexity and multidimensional nature of chronic postsurgical pain, effective assessment, and management require a comprehensive, multiaxial approach. Adequate preoperative preparation and counseling, potential risk identification and optimization, and use of a multimodal approach, and noninvasive surgical techniques are crucial in reducing the development of chronic postsurgical pain.

Effects of Hyperbaric and Isobaric Bupivacaine on Hemodynamic Profiles and Block Characteristics Among Parturients Undergoing Elective Cesarean Section Under Spinal Anesthesia: A Randomized Controlled Trial

Background

Cesarean section (CS) is a surgical procedure where the baby is delivered through incisions made in the abdomen and uterus. Bupivacaine is a widely recognized local anesthetic available in different baricity and it is frequently used for spinal anesthesia. The baricity of bupivacaine impacts hemodynamic profiles and block characteristics.

Objective

To compare the effects of hyperbaric and isobaric bupivacaine on hemodynamic profiles and block characteristics among parturients undergoing elective cesarean section under spinal anesthesia at Dilla University Referral Hospital.

Methods

64 pregnant mothers scheduled for elective cesarean section under spinal anesthesia were randomly assigned to two groups: Group A received a dose of 12.5 mg of isobaric bupivacaine (n = 32), Group B received a dose of 12.5 mg of hyperbaric bupivacaine (n = 32). Prior to conducting the study, the necessary ethical approvals were obtained. For comparing numerical variables between the two groups, the independent Sample t-test or Mann-Whitney U-test was employed as needed. Repeated measurements were analyzed using mixed ANOVA. Categorical variables were assessed using either the chi-square test or Fisher's exact test. Statistical significance was set at P < 0.05, with a power of 90%.

Results

The mean Systolic Blood Pressure (SBP), Diastolic Blood pressure (DBP), and Mean Arterial Blood Pressure (MAP) showed significant decrement in the group receiving isobaric spinal anesthesia compared to those receiving hyperbaric bupivacaine. The decrement was observed from the 6th to 30th minute (p<0.05). Furthermore, the hyperbaric group had a faster onset time for achieving the maximum sensory block, with a median time of 3 (1) min compared to 4 (2) mins in the isobaric group (p<0.001).

Conclusion and Recommendation

We conclude that hyperbaric bupivacaine provides stable intraoperative hemodynamic parameters and an earlier onset of block than isobaric bupivacaine. Therefore, we recommend clinicians to use hyperbaric bupivacaine for cesarean delivery.

Proportion of births protected against neonatal tetanus and its associated factors among mothers who gave birth within the past 6 months in Gozamn district, Northwest Ethiopia, 2022

Today, neonatal tetanus accounts for a significant portion of newborn and under-5 mortality - 40% and 57%, respectively - and is the most prevalent cause of neonatal mortality and morbidity, particularly in developing nations. As a result, more study on birth protection against neonatal tetanus is required because it is such a terrible condition with such a high death rate and there is a need for more recent evidence on it. From April 1 to 30, 2022, a community-based cross-sectional survey was carried out in the Gozamn district of Northwest Ethiopia. A two-stage stratified sampling procedure was applied, with an overall sample size of 831. The data were gathered using a pre-tested, structured questionnaire. It was then checked, cleaned, and entered into Epidata software version 4.6 before being exported to Stata version 14 for analysis. The proportions of birth protected against neonatal tetanus were 58.57% (95% CI (55.15-61.89%) in the study. Mother who had radio (AOR = 3.09,95%CI: 2.09, 4.56), mother who travel less than one hour to reach nearest health facility (AOR = 1.96,95%CI: 1.23,3.10), mother who gave birth of their last child in the health institution (AOR = 4.17,95%CI:2.39,7.28), mothers who had information from health professional (AOR = 2.56,95%CI:1.56,4.19) and > 4 ANC visit (AOR = 2.57,95%CI:1.55,4.26) were positive predictors of birth protected against neonatal tetanus. Low levels of maternal protection against neonatal tetanus were seen in this study location. To enhance the percentage of births protected against neonatal tetanus, professional-based guidance regarding the TT vaccine are essential.

Evidence-based guideline on management of status epilepticus in adult intensive care unit in resource-limited settings: a review article

Status epilepticus (SE) is a life-threatening condition associated with at least 5 min of continuous seizures or repeated seizures without regaining consciousness between episodes. It is a medical emergency with significant morbidity and mortality. The most common causes of SE are previous seizures, stroke, trauma, metabolic disorders, and central nervous system tumor. The aim of this review was to systematically review articles and ultimately develop evidence-based guidelines for the management of SE in resource-limited settings.

Methods

This review was presented under the Protocol for Systematic Reviews and Meta-Analyses (PRISMA). A literature search was performed in PubMed, Google Scholar, Cochrane, and Medline databases from 2007 to 2021. The keywords for the literature search were (SE or controlled clinical trial) AND (SE or randomized controlled trial), (SE or multicenter trial) AND (SE or meta-analysis) AND (SE or crossover study).

Conclusion

SE is an urgent medical emergency that requires early recognition and aggressive treatment. Medical treatment is initiated when seizures continue for more than 5 min after all stabilization measures have been taken. Based on the available evidence, diazepam can be used as a substitute for lorazepam in the treatment of SE. Ketamine is effective when given before other anesthetics as a third-line treatment in refractory and very refractory epilepsy. Propofol reduced the number of days of mechanical ventilation in the treatment of SE and has better seizure control than thiopental. Music has been recommended as an adjunctive therapy for epilepsy medication.

Evidence-Based Guideline on Prevention and Management of Shivering After Spinal Anesthesia in Resource-Limited Settings: Review Article

Background

Perioperative shivering is a common problem faced in anesthesia practice. Unless it is properly managed and prevented, it causes discomfort and devastating problems, especially in patients with cardiorespiratory problems. Surgery, anesthesia, exposure of skin in a cool operating theater, and administration of unwarmed fluids are some of the major causes for the development of shivering among surgical patients. Currently, a variety of non-pharmacological and pharmacological techniques are available to prevent and manage this problem. The available options to prevent and treat shivering include but are not limited to pre-warming the patient for 15 minutes before anesthesia administration, administration of low dose ketamine, dexamethasone, pethidine, clonidine, dexmedetomidine, tramadol, and magnesium sulfate.

Objective

To develop evidence-based recommendations for the prevention and management of shivering after spinal anesthesia in a resource-limited settings.

Methods

The kinds of literature are searched from Google Scholar, PubMed, Cochrane library, and HINARI databases to get access to current and update evidence on the prevention and management of shivering after spinal anesthesia. The keywords for the literature search were (shivering or prevention) AND (shivering or management) AND (anesthesia or shivering).

Conclusion

Pre-warming the patient with cotton, blanket, gown warming, and administering warm IV fluid 15 minutes before spinal anesthesia are possible non-pharmacologic options for the prevention of shivering. Furthermore, pharmacological medications like low dose ketamine, dexamethasone, magnesium sulfate, ad tramadol can be used as alternative options for the prevention and management strategies for shivering of different degrees in resource-limited areas.

Sustaining tuberculosis preventive therapy scale-up through direct supportive supervision

Background

Tuberculosis preventive therapy (TPT) is recommended for tuberculosis (TB) prevention among people living with HIV (PLHIV) and other high-risk groups. The Nigerian Military HIV Program embarked on TPT-specific 'direct supportive supervision' (DSS) in May 2018 to increase TPT initiation and completion rates.

Methods

Interventional approaches included site visits to conduct root cause analysis, didactic teaching approach on the concepts of quality improvement and mentorship to address barriers. The DSS introduced TPT monitoring tools, sticker reminders on clients' folders, and bi-weekly data collection and review for decision making.

Results

TPT initiation increased from a monthly pre-intervention median of 323 clients to monthly medians of 2611 during the 'surge' and 1212 clients during the 'sustained' phases. Due to an isoniazid stock-out, a 'dip phase', with a median of 559 clients was recorded. Overall, 10 463 clients were started on TPT in fiscal year (FY) 2018 and 12 596 in FY2019, with an overall initiation rate of 79%. Completion rates were respectively 73% and 70% for FY2018 and FY2019.

Conclusion

With the implementation of a tailored DSS, programmatic barriers to TPT were easily identified and quickly addressed to increase initiation and completion rates.

Predictors and Barriers to Condom Use in the African Cohort Study

Consistent condom use is an inexpensive and efficacious HIV prevention strategy. Understanding factors associated with condom use and barriers to use can inform strategies to increase condom uptake. The ongoing African Cohort Study prospectively enrolls adults at 12 clinical sites in Uganda, Kenya, Tanzania, and Nigeria. At enrollment, participants are asked about condom use at last sex with a regular partner. Robust Poisson regression models were used to evaluate predictors of self-reported condom use. Participants who reported not using condoms were asked to provide reasons. From January 2013 to September 2019, 2482 participants reported having at least one regular sexual partner in the preceding 6 months. Of those, 1577 (63.5%) reported using a condom at last sex. Condom use was more common among older participants, males, HIV-infected participants, and those with an HIV-infected partner. Married participants, those with a partner of unknown HIV status, and those reporting alcohol use were less likely to report condom use at last sex. Condom use at last sex also varied significantly by clinical site. Partner disapproval or refusal to use a condom was a consistent driver of disparities in condom use among participants who were HIV infected, female, and aged 18-24 years. Effective HIV prevention programs should integrate condom education with the tools necessary to negotiate condom use with regular partners.

Taking tuberculosis preventive therapy implementation to national scale: the Nigerian PEPFAR Program experience

Background

Tuberculosis (TB) preventive therapy (TPT), including isoniazid preventive therapy (IPT), has been implemented within the Nigerian human immunodeficiency virus (HIV) programme since 2014. However, drug procurement and logistic support has remained the responsibility of the National Tuberculosis and Leprosy Control Programme. The US President's Emergency Plan for AIDS Relief-Nigeria (PEPFAR Nigeria) reviewed the key bottlenecks to TPT implementation in 2016.

Method

The logistics of delivery of isoniazid (INH) were integrated with the antiretroviral (ARV) logistics management and information system (LMIS). Drug order and requisition forms at the facility level were revised to include INH, along with training on appropriate quantification and requisition of INH with ARVs. Support was provided for last mile delivery of INH directly to every implementing site, alongside ARV.

Reults

We observed an increasing trend in TPT uptake between the pre-and-post intervention periods: 6% in fiscal year (FY) 2015, 7% in FY2016 and 12% in FY2017. Overall, the logistical changes in the LMIS to include INH in 2016 led to a 69% increase in TPT by the end of FY2017; this was statistically significant.

Conclusion

Addressing logistical challenges to TPT implementation will ensure that the TB and HIV programmes can tackle the increasing burden of TB infection in people living with HIV. We recommended that the provider-to-client stage of TPT implementation be driven by the HIV programme and that cross-communication between the two programmes be improved.

Improving indicators of tuberculosis program cascades by leveraging HIV program strategies

Background

To improve rates of human immunodeficiency virus (HIV) case detection and treatment, the Nigerian Ministry of Defense Health Implementation Program and the US Army Medical Research Directorate-Africa/Nigeria introduced a HIV standard of care (SOC) package. Given the integration of tuberculosis (TB) and HIV programs and evolving policies, we evaluated the impact of this strategy on TB program indicators.

Methods

Routine, de-identified program data from 27 Nigerian military hospitals were analyzed. Using Wilcoxon signed-rank test, bivariate analyses were performed to compare data from 12 months before and after implementation of the SOC package.

Results

Our data showed improvements post-implementation as follows: the number of individuals receiving antiretroviral therapy (ART) screened for TB increased from 14 530 to 29 467 (P < 0.001); the number of individuals with presumptive TB identified increased from 803 to 1800 (P < 0.001); the number of ART clients bacteriologically tested for TB increased from 746 to 1717 (P < 0.001); and the number of ART clients treated for TB increased from 152 to 282 (P < 0.001). Newly registered or relapsed TB cases increased from 436 to 906 (P < 0.001), the number of TB cases with known HIV status increased from 437 to 837 (P < 0.001), the number of TB-HIV co-infected cases increased from 182 to 301 (P = 0.006), and the number of TB-HIV co-infected clients who started ART increased from 101 to 176 (P = 0.003).

Conclusion

The implementation of the updated HIV SOC package led to the improvement in key TB diagnosis and treatment indicators. When emulated, this could help improve the performance of other TB programs in countries other than Nigeria.

Spatio-temporal analysis of land use dynamics and its potential indications on land surface temperature in Sokoto Metropolis, Nigeria

Land use change is the main driving force of global environmental change and is considered as most central to various debates on sustainable development. Even though a large volume of literature materials is available on land use/land cover change for many areas, very little work has been done on land use and its implications on land surface thermal characteristics over the Sokoto area of Nigeria, despite the strategic importance of the zone, including urbanization, increased population as well as the climate in the area, which is dominated by warm harmattan wind blowing Sahara dust inland. Thus, this study aimed at investigating the implications of urban growth on temporal variations of land surface temperature (LST) using remote sensing and geographic information system (GIS) techniques over Sokoto Metropolis, Nigeria between 1986 and 2016. The change detection of each land use class was carried out for each period using Landsat images obtained from the archives of the United States Geological Survey (USGS). The results revealed that the area has undergone a drastic transformation where built-up area witnessed changes at 10.77%, farmland and vegetation increased at the rate of 0.72% and 2.15%, respectively, for the period of study (1986-2016). While bare soil and water body decreased at the rate of 0.56% and 1.11%, respectively, during the study period. This shows that there exists a transformation from bare surface (desert) to vegetated surface especially between years 2009 and 2016. The LST of Sokoto Metropolis was calculated from the satellite data, and the land surface temperature of each land use class was assessed for the study period. The maximum LST of Sokoto was 30.6°C, 32.8°C and 34.6°C for 1986, 1999 and 2016, respectively. This study has revealed the existence of a positive relationship between built-up area and LST over the area. This development might be as a result of anthropogenic activities through urban growth coupled with its potential impacts on urban climate. These are intensified by constant changes of the space, causing imbalance in the interactions between surface and atmosphere which may be extensively influenced or modified by various forms of land use.

Cardiac surgical experience in northern Nigeria

Abstract

A pilot study was undertaken to determine the feasibility of establishing a heart surgery programme in northern Nigeria. During three medical missions by a visiting US team, in partnership with local physicians, 18 patients with heart diseases underwent surgery at two referral hospitals in the region. Sixteen (88.9%) patients underwent the planned operative procedure with an observed 30-day mortality of 12.5% (2/16) and 0% morbidity. Late complications were anticoagulant related in mechanical heart valve patients and included a first-trimester abortion one year postoperatively, and a death at two years from haemorrhage during pregnancy. This has prompted us to now consider bioprosthetics as the valve of choice in women of childbearing age in this patient population. This preliminary result has further stimulated the interest of all stakeholders on the urgency to establish open-heart surgery as part of the armamentarium to combat the ravages of heart diseases in northern Nigeria.

A study of extracranial aneurysms at UNTH in Enugu, Nigeria

BACKGROUND

Previous studies on aneurysms in Nigeria have either been case reports or studies of peripheral aneurysms. No study has comprehensively evaluated all aspects of this disease as an entity among Nigerians. The need therefore arises to re-evaluate this lesion so as to make deductions on incidence, sex ratio, aetiology and management.

STUDY DESIGN

This is a retrospective descriptive study of arterial aneurysms at the University of Nigeria Teaching Hospital (UNTH), Enugu. Those treated between January 1993 and December 2002 were included for the study. Data were obtained from medical records for all patients admitted with aneurysms over the study period.

RESULTS

Atotal of 26 patients were admitted during the period, but 24 case notes were analysed. The age range was 10-75 years with male: female ratio of 1.4:1. Traumatic pseudo aneurysms accounted for 16 cases (67.0%) while true aneurysms comprised the remaining. Of all the aneurysms, femoral artery with most of the pseudo aneurysms had 8 out of 24 (33.0%). This is followed by the infra-renal abdominal aorta (5/24, 21.0%) and other sites (11/24, 46.0%). Diagnoses were made clinically in most cases and by abdominal ultrasonography in abdominal aortic aneurysms. Twenty-one patients had surgical intervention with 9.5% operative mortality.

CONCLUSION

The incidence of aneurysm is low in our locality (2.6/year) based on the rate of diagnosis. Abdominal aorta harbours most of the true aneurysms with diameter ranging from 8.0-15.0 cm without rupture. Untreated, all will eventually rupture with catastrophic consequences. Treatment involved excision with graft interposition. This is not only expensive but the graft is often not readily available. As a solution, grafts should be stocked with drug revolving fund.