The relationship between trust, belief and adherence among patients who complain of hypertension in Ghana

AIM

We determined the relationship between trust, belief and adherence among patients who complain of hypertension in Ghana.

DESIGN

A cross-sectional design was used.

METHOD

We sampled 447 Ghanaians with hypertension receiving care at the Korle Bu Teaching Hospital. Data were collected using a pre-tested self-administered questionnaire. Data analyses were conducted with the aid of Stata 15.0.

RESULTS

There is low belief and trust in the biomedical treatment for hypertension. Only 36.9% of the respondents said they adhered to treatment with females expressing higher level of adherence. Trust and belief in allopathic care were associated with adherence to treatment. It is recommended that health workers identify effective ways of improving patients' trust in the allopathic care for hypertension through teaching and re-enforcement models to enhance treatment adherence and reduce the complications of hypertension. Patient or Public Contribution.

Adamantinoma-like Ewing sarcoma of thyroid gland-An unfamiliar mimicker of epithelial and mesenchymal neoplasms of the head and neck

INTRODUCTION

Adamantinoma-like Ewing Sarcoma (ALES) is a rare variant of the Ewing family of tumours (EFT) harbouring the EWSR1-FLI1 translocation and with complex epithelial differentiation. Very few cases of ALES involving thyroid have been reported in literature.

CASE REPORT

We report a case of ALES involving the thyroid in a 61-year-old male who presented with an enlarging nodule in the left lobe of the thyroid and underwent hemithyroidectomy.

DISCUSSION

ALES demonstrates morphologic similarity to a multitude of epithelial and mesenchymal tumours, creating a potential diagnostic pitfall in thyroid and head and neck pathology. Given the rarity of this tumour, there is also a lack of accepted guidelines regarding further surgical management of these cases following hemithyroidectomy.

Factors associated with pregnancy uptake decisions among seropositive HIV people receiving antiretroviral therapy in sub‐Saharan Africa: A systematic review

Aim

This study determined the factors associated with pregnancy uptake decision among seropositive HIV people receiving antiretroviral therapy in sub‐Saharan Africa.

Design

Systematic review.

Methods

The population, intervention, comparison and outcomes framework was adopted to search for literature after a scoping review using the preferred reporting items for systematic reviews and meta‐analyses guidelines adopted in searching, and screening articles from four databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google scholar) to find 12 articles suitable for this study.

Results

Motivators of pregnancy uptake among HIV‐positive women include desire to have children, knowledge about PMTCT, cultural duty for married women to have children, and household income. Demotivating factors included the modern method of contraception and burden associated with pregnancy.

Conclusion

There is a need to improve on services that reduce conception‐related risks especially for women who choose to conceive and to incorporate fertility‐related counselling into HIV treatment services.

Influence of nurse-patient relationship on hospital attendance. A qualitative study of patients in the Kwahu Government Hospital, Ghana

Background

The relationship of nurses and patients in healthcare settings has been central in ensuring good and efficient healthcare delivery. The total hospital attendance in the Kwahu Government Hospital have reduced in recent years. The study explored patients’ perceptions of the nurse-patient relationship and its influence on hospital attendance at the Kwahu Government Hospital.

Methods

A phenomenological qualitative study design, with a purposive sampling technique, was used to interview ten participants from the various wards in the hospital on their perceptions of the nurse patient relationship and its influence on hospital attendance. The data were transcribed and analysed using a thematic content analysis approach that embraces three interrelated stages, namely data reduction, data display, and data conclusion drawing.

Results

Many of the participants had positive perceptions regarding the attitude of nurses, and that influenced hospital attendance while others opined that nurses’ attitudes towards them made them attend a private facility. Almost all the participants suggested that patients should exhibit an equally good attitude and behaviour towards nurses, and better communication between patients and nurses as vital ways of improving the nurse-patient relationship. Nurses in the Kwahu Government Hospital are described as friendly, respectful and attend promptly to patient health care needs adequately. The range of perceived respect differed from patient to patient and include the nurse called patient by name, respond promptly to patient needs, helped “helpless patients” to feed and also assisted them change diapers, listen to patient concerns, linked patient to other professionals, work within the cultural context of hierarchy and that the nurse is sociable and interacted with patient positively.

Conclusion

Hospital management should conduct regular evaluations of patients' experiences as well as nurses’ experiences to address deficiencies in communication and nurse-patient interactions.

Factors influencing the utilization of Focused antenatal care services during pregnancy, a study among postnatal women in a tertiary healthcare facility, Ghana

Aim

To assess the factors that influence the utilization of FANC services among pregnant women.

Methodology

A cross-sectional quantitative study conducted among 210 postnatal women in Ho Teaching Hospital. Data were entered into Microsoft excel, cleaned and transported to SPSS and analysed. Cross tabulations were used to explore associations between variables.

Results

The respondents indicated that FANC would enable them to receive comprehensive ANC (74.8%). Higher parity was significantly associated with low utilization of FANC (p = .028). Long distance to the health facility, seeking permission to use FANC was significantly associated with low utilization of FANC (p < .001). Fear associated with witchcraft was associated with low FANC utilization (p < .001).

Effect of preoperative injection of superparamagnetic iron oxide particles on rates of sentinel lymph node dissection in women undergoing surgery for ductal carcinoma in situ (SentiNot study)

Background

One-fifth of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) have invasive breast cancer (IBC) on definitive histology. Sentinel lymph node dissection (SLND) is performed in almost half of women having surgery for DCIS in Sweden. The aim of the present study was to try to minimize unnecessary SLND by injecting superparamagnetic iron oxide (SPIO) nanoparticles at the time of primary breast surgery, enabling SLND to be performed later, if IBC is found in the primary specimen.

Methods

Women with DCIS at high risk for the presence of invasion undergoing breast conservation, and patients with DCIS undergoing mastectomy were included. The primary outcome was whether this technique could reduce SLND. Secondary outcomes were number of SLNDs avoided, detection rate and procedure-related costs.

Results

This was a preplanned interim analysis of 189 procedures. IBC was found in 47 and a secondary SLND was performed in 41 women. Thus, 78·3 per cent of patients avoided SLND (P &lt; 0·001). At reoperation, SPIO plus blue dye outperformed isotope and blue dye in detection of the sentinel node (40 of 40 versus 26 of 40 women; P &lt; 0·001). Costs were reduced by a mean of 24·5 per cent in women without IBC (€3990 versus 5286; P &lt; 0·001).

Conclusion

Marking the sentinel node with SPIO in women having surgery for DCIS was effective at avoiding unnecessary SLND in this study. Registration number: ISRCTN18430240 (http://www.isrctn.com).

Abstract P3-03-12: SentiDose interim analysis. A dose optimizing study with a super paramagnetic iron oxide for sentinel node detection

Background

Superparamagnetic iron oxide nanoparticles (SPIO) is a novel tracer for axillary mapping in breast cancer with comparable performance to the dual standard of isotope and blue dye. The earlier SPIO (Sienna+®) required 2 ml of SPIO diluted in 3 ml NaCl and was injected retro-areolarly. This was considered to be associated with the discoloration observed in 40% of breast conservation cases. Subsequently, a new form was developed (SiennaXPTM) in a volume of 2 ml without dilution. The aim of the ongoing SentiDose study is to compare smaller doses of SiennaXPTM injected in different time-frames (1.5 ml periareolarly on the operation day vs 1 ml peritumourally 1-7 days preoperatively) and compare it to the performance of the original SPIO (Sienna+®). A background mapping with isotope and blue dye was performed for assessment of concordance.

Method

In all, 330 patients will be recruited from six sites in Sweden, divided in two isonumerical cohorts injected as described above. Results from the 1.5 ml cohort are presented and compared on a patient-level analysis to the SentiMag Nordic trial that used Sienna+®, on a 2-sided non-inferiority margin of 5%. Study endpoints are detection rate per patient, number of sentinel nodes (SN) retrieved and discoloration at 3 weeks postoperatively.

Results

Detection rate for SiennaXPTM, 1.5 ml, was comparable with Sienna+® (96.9 vs 97.6%, p=0.76), even in multivariate analysis adjusting for age and metastasis rate (Exp(B)=0.68; 95% CI; 0.18-2.60, p=0.58). with a high concordance between isotope and SiennaXPTM. The number of SNs were similar (1.91 vs. 1.83, p=0.08) for Sienna+® and SiennaXPTM. Discoloration rate was lower for SiennaXPTM compared to Sienna+® (14.3% vs. 38.2%, p&lt;0.001) after breast conserving surgery. Furthermore, two patients were excluded in the SentiDose cohort due to protocol violation.

Demographics and outcomes are illustrated in

Table 1 Nordic SentiMag Trial (n=206)SentiDose 1.5ml Cohort (n=163)p-valueAge (yrs)61.864.30.03BMI (kg/m2)26.927.20.84Size (mm)19.220.00.64Type of Surgery (BCS/Mx)154 (74.8%) / 52 (25.2%)130 (79.8%) / 33 (20.2%)0.26SPIO Detection Rate (per patient)97.6%96.9%0.76SPIO-Tc Concordance97.5%97.5%0.42Mean SPIO detected SN1,831,910.08Metastasis Rate26.2%16.0%0.01SPIO nodal rate in malignancy91.2%81.6%0.21Discoloration in BCS38.2%14.3%&lt;0.001

Conclusion

The periareolar injection of 1.5 ml SiennaXPTM on the day of the operation provides comparable detection rates with much less skin discoloration, providing effectivity and flexibility. The completion of the SentiDose study will allow for more definitive results on the dose, timeframe and injection site of SPIO.

Citation Format: Hersi A-F, Obondo C, Pistioli L, Abdsaleh S, Nilsson F, Mohammed I, Eriksson S, Wärnberg F, Karakatsanis A. SentiDose interim analysis. A dose optimizing study with a super paramagnetic iron oxide for sentinel node detection [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-12.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Air pressure changes in the creation and bursting of the type-1 big bubble in deep anterior lamellar keratoplasty: an ex vivo study

PurposeTo measure the pressure and volume of air required to create a big bubble (BB) in simulated deep anterior lamellar keratoplasty (DALK) in donor eyes and ascertain the bursting pressure of the BB.Patients and methodsTwenty-two human sclera-corneal discs were used. Air was injected into the corneal stroma to create a BB and the pressure measured by means of a pressure converter attached to the system via a side port. A special clamp was designed to prevent air leak from the periphery of the discs. The pressure at which air emerged in the corneal tissue; the bursting pressure measured after advancing the needle into the bubble cavity and injecting more air; the volume of air required to create a BB and the volume of the BB were ascertained.ResultsType-1 BB were achieved in 19 and type-2 BB in 3 eyes. The maximum pressure reached to create a BB was 96.25+/- 21.61 kpa; the mean type-1 intrabubble pressure was 10.16 +/- 3.65 kpa. The mean bursting pressure of a type-1 BB was 66.65 +/- 18.65 kpa, while that of a type-2 BB was 14.77 +/- 2.44 kpa. The volume of air required to create a type-1 BB was 0.54 ml and the volume of a type-1 BB was consistently 0.1 ml.ConclusionsDua's layer baring DALK can withstand high intraoperative pressures compared to Descemet's membrane baring DALK. The study suggests that it could be safe to undertake procedures such as DALK-triple with a type-1 BB but not with a type-2 BB.

Elevated Heart-Type Fatty Acid-Binding Protein Predicts Early Myocardial Injury and Aids in the Diagnosis of Non-St Elevation Myocardial Infarction

Background

Biomarkers play an important role in the early diagnosis, risk stratification and management of patients with the acute coronary syndrome.

Objective

The objective of this study was to evaluate the clinical reliability of heart-type fatty acid-binding protein (h-FABP) in identifying patients with the acute coronary syndrome in the early hours of chest pain.

Methods

Creatine kinase (CK-MB) (in laboratory), troponin T (in laboratory) and h-FABP (with point-of-care test CardioDetect®) were performed on 791 patients who presented with chest pain with duration since onset ranging from 20 minutes to 12 hours.

Results

Data of the 791 patients were analysed. h-FABP had a higher sensitivity of 75.76% and a specificity of 96.97% compared with 58.59% and 98.84% for troponin T and 68.69% and 97.54% for CK-MB respectively (in the first 6 hours). Conclusion: h-FABP was found to be a better biomarker of cardiac necrosis in the early hours in the diagnosis of non-conclusive ECG in patients with acute myocardial infarction. (Hong Kong j.emerg.med. 2009;16:141–147)

Looking back and moving forward: 50 years of soil and soil fertility management research in sub-Saharan Africa

Low and declining soil fertility has been recognized for a long time as a major impediment to intensifying agriculture in sub-Saharan Africa (SSA). Consequently, from the inception of international agricultural research, centres operating in SSA have had a research programme focusing on soil and soil fertility management, including the International Institute of Tropical Agriculture (IITA). The scope, content, and approaches of soil and soil fertility management research have changed over the past decades in response to lessons learnt and internal and external drivers and this paper uses IITA as a case study to document and analyse the consequences of strategic decisions taken on technology development, validation, and ultimately uptake by smallholder farmers in SSA. After an initial section describing the external environment within which soil and soil fertility management research is operating, various dimensions of this research area are covered: (i) 'strategic research', 'Research for Development', partnerships, and balancing acts, (ii) changing role of characterization due to the expansion in geographical scope and shift from soils to farms and livelihoods, (iii) technology development: changes in vision, content, and scale of intervention, (iv) technology validation and delivery to farming communities, and (v) impact and feedback to the technology development and validation process. Each of the above sections follows a chronological approach, covering the last five decades (from the late 1960s till today). The paper ends with a number of lessons learnt which could be considered for future initiatives aiming at developing and delivering improved soil and soil fertility management practices to smallholder farming communities in SSA.

The 67P/Churyumov-Gerasimenko observation campaign in support of the Rosetta mission

We present a summary of the campaign of remote observations that supported the European Space Agency's Rosetta mission. Telescopes across the globe (and in space) followed comet 67P/Churyumov-Gerasimenko from before Rosetta's arrival until nearly the end of the mission in September 2016. These provided essential data for mission planning, large-scale context information for the coma and tails beyond the spacecraft and a way to directly compare 67P with other comets. The observations revealed 67P to be a relatively 'well-behaved' comet, typical of Jupiter family comets and with activity patterns that repeat from orbit to orbit. Comparison between this large collection of telescopic observations and the in situ results from Rosetta will allow us to better understand comet coma chemistry and structure. This work is just beginning as the mission ends-in this paper, we present a summary of the ground-based observations and early results, and point to many questions that will be addressed in future studies.This article is part of the themed issue 'Cometary science after Rosetta'.

Dupuytren's contracture in Ethiopia

Dupuytren's contracture is believed to be rare in Africa. We have observed the disease in many patients coming to our hospital. This study aimed to provide information concerning the occurrence of the disease and risk factors in these patients. All 75 patients who were referred to the hospital during a 2-year period because of a hand problem that was diagnosed as Dupuytren's contracture were included. The demographic data of the patients and possible risk factors were recorded and compared with a control group. The male to female ratio was 18:1. The little and ring fingers were most commonly affected. A total of 43 had bilateral hand involvement. The condition affected only the left hand in one patient. Six men also had fibromatosis of the soles of the feet and three of the penis. There was a statistically significant association with hypertension and alcohol consumption, but not with diabetes mellitus. We conclude that there are more cases of Dupuytren's contracture in Ethiopia than previously thought.

LEVEL OF EVIDENCE

III.

A study of pathophysiological factors associated with gastro-esophageal reflux disease in twins discordant for gastro-esophageal reflux symptoms

BACKGROUND

Differences in lower esophageal sphincter (LES) and peristaltic function and in transient LES relaxations (TLESR) have been described in patients with gastro-esophageal reflux disease (GERD). However, some of these differences may be the result of chronic GERD rather than being an underlying contributory factor.

METHODS

Twins discordant for GERD symptoms, i.e., only one twin had GERD symptoms, underwent standard LES and esophageal body manometry, and then using a sleeve sensor prolonged LES and pH monitoring, 30 min before and 60 min after a 250 mL 1200 kcal lipid meal.

KEY RESULTS

Eight monozygotic and 24 dizygotic female twins were studied. Although there was no difference in preprandial LES pressure (symptomatic 13.2 ± 7.1 mmHg vs asymptomatic 15.1 ± 6.2 mmHg, P = 0.4), LES pressure fell further postprandially in symptomatic twins (LES pressure area under the curve 465 ± 126 vs 331 ± 141 mmHg h, P < 0.01). 12/37 (32%) of acid reflux episodes in symptomatic twins occurred due to low LES pressure or deep inspiration/strain and 0/17 in asymptomatic twins (P = 0.01). There was no difference between symptomatic and asymptomatic twins in: peristaltic amplitude, ineffective esophageal body motility, hiatus hernia prevalence, or LES length. There was also no difference in TLESR frequency preprandially (symptomatic median 1(range 0-2) vs asymptomatic 0(0-2), P = 0.08) or postprandially (2.5(1-8) vs 3(1-6), P = 0.81).

CONCLUSIONS & INFERENCES

Twins with GERD symptoms had lower postprandial LES pressure and given the close genetic link between the twins, it is possible that such differences are caused by GERD. Acid reflux episodes associated with a hypotensive LES were seen in symptomatic, but not in asymptomatic twins.

Osteoid osteoma associated with the teeth: unusual presentation

Osteoid osteoma is a rare benign osseous neoplasm which rarely affects the jaws. It is more common in long bones which can lead to postural scoliosis. The clinical characteristic feature of this tumour is the unexplained pain that is relieved by the intake of analgesics. Histologically it is characterized by the formation of central nidus with surrounding sclerotic bone. The diagnostic dilemma in this case report is aggravated by its unusual association with the teeth. The use of CT scanning is advised to distinguish from other odontogenic tumours. Treatment for this tumour is surgical removal or excisional biopsy to avoid recurrence and progression to malignant changes.

Effects of chickpea flour on wheat pasting properties and bread making quality

Pulses (pea, chickpea, lentil, bean) are an important source of food proteins. They contain high amounts of lysine, leucine, aspartic acid, glutamic acid and arginine and provide well balanced essential amino acid profiles when consumed with cereals. The influence of partial substitution of wheat flour with chickpea flour at the levels of 10, 20 and 30 % was carried out to study their pasting properties and bread making quality. Pasting properties were determined using Micro Visco-Amylo-Graph Analyser and Farinograph. The pasting temperature increased with increase chickpea flour concentration and the temperature of pasting ranged between 62 to 66.5 °C. No peak of viscosity curve was found for pure chickpea flour and have higher pasting temperature than pure wheat flour. Chickpea flour addition increased the water absorption and dough development time (p < 0.05), Regarding dough stability, it appears that 10 % chickpea exhibited higher stability and resistance to mechanical mixing values than the control, while it decreased as the substitute level increases from 20 % to 30 %. The dough surface of the wheat dough and the blend with 10 % was classified as "normal", however the blend with 20 % and 30 % produced "sticky" dough surface. The presence of chickpea flour in dough affected bread quality in terms of volume, internal structure and texture. The color of crust and crumb got progressively darker as the level of chickpea flour substitution increased. While the substitution of wheat flour with 10 % chickpea flour gave loaves as similar as control.

P3-07-33: Are Single Node Metastases More Common in Patients with Breast Cancer in the Sentinel Node Era?

Background: The axillary recurrence rate after axillary lymph node dissection has been reported as approximately 3%. Since the introduction of sentinel node biopsy (SNB), it has become apparent that, there is a significant decrease in axillary recurrence, ranging from 0.26% to 0.9% in published literature. One of the concerns that arises from this data is that, the sentinel node may have been missed when routine axillary node clearance were being performed. The aim of this study was to compare the results of a cohort of patients who had an axillary staging procedure prior to the introduction of SNB (axillary clearance) with patients after the introduction of SNB in relation to the number who had only one positive node in the axilla.

Methods: From June 2003 to November 2010 data was collected on demographics, histopathology and procedure performed. All patients with invasive breast cancer prior to April 2005 had an axillary node clearance (ANC) with either wide local excision or mastectomy. Since April 2005 all patients with invasive breast cancer had a SNB and patients with a positive sentinel node (SN) underwent ANC. Patients with a negative SNB had no further axillary surgery.

Results: 702 patients had axillary node surgery between June 2003 and November 2010. 251 patients had axillary node clearance (pre SN period) and 451 had SNB (SN period). Average age was 57 years. 509 patients (156 in pre SNB period and 353 in post SNB period) had no nodal metastases. Amongst the 193 node positive patients, 100 had single node involvement. In the pre SNB period 33 (34.7%) patients had single node involvement, compared to 67 (68.3%) in SNB period. The histopathological type of cancer did not vary significantly between the one node positive, multiple node positive and node negative groups.

Conclusion: Our study confirms a significant rise in patients with a single node positive in the sentinel node period. This could be due to the SLN being “missed” during surgery when an axillary node clearance was performed, which would explain the reported higher axillary recurrence rates in the pre sentinel node period compared to the sentinel node period. Another possibility is that the SN is undergoing more detailed histopathological assessment as there are fewer number of lymph nodes to be examined.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-33.

Drain site hernia in an adult: a case report

BACKGROUND

Surgical drains, as useful as they are, have been noted not to be without complications. Small bowel herniation through a previous drain site is a rare complication of abdominal drain insertion.

OBJECTIVE

To report a case of strangulated hernia through a drain site.

METHODS

A 46-year-old civil servant was referred to our hospital from a general hospital with a two-week history of progressive abdominal pain and bulge in the right lower quadrant. She was evaluated clinically as with an ultrasonography. Results of tests indicated a laparatomy.

RESULTS

She had a previous abdominal drain insertion when she had an emergency exploratory laparatomy for perforated typhoid enteritis in the same hospital 20 years prior to presentation. Exploratory laparatomy done revealed gangrenous loops of small bowel that herniated through a previous drain site with interstitial spread. Resection and end-to-end anastomosis was effected and internal end was closed with non absorbable suture (Nylon 1).

CONCLUSION

Careful insertion and management of surgical drains are necessary so as to prevent hernia complications.

Antimicrobial peptides expression by ocular surface cells in response to Acanthamoeba castellanii: an in vitro study

AIMS

Antimicrobial peptides (AMPs) are natural effectors of the innate immune response. Much work has been done to study their response and effects on bacterial and viral infection. Little if any information is available in relation to protozoal infections. The aim of the study was to comprehensively study the gene expression of the ocular AMPs in human corneal limbal epithelial cells stimulated with Acanthamoeba castellanii (AC).

METHODS

Human corneal limbal epithelial cells were exposed to AC at different time points, up to 9 h, the genomic profile of the AMPs were analysed at these time point using real time PCR. corneal limbal epithelial cells not infected with AC were used as controls.

RESULTS

Seven of the eight studied AMPs showed statistically significant upregulation in gene expression. Human beta Defensin 3 (hBD3) showed a very significant 10-fold upregulation in the exposed cells and Ribonuclease-7 (RNase-7) showed a very early and consistent increase. Human beta Defensin 1 (hBD1) was the only downregulated AMP.

CONCLUSIONS

The study data suggests a possible role of the AMPs in combating the amoebic infection at the ocular surface. Using AMPs singly or in combination is a promising avenue for further exploration in the treatment of the sight threatening Acanthamoeba keratitis.

Epidemic yellow fever in Borno State of Nigeria: characterisation of hospitalised patients

BACKGROUND

In 1990, an outbreak of a febrile illness with high mortality was reported in border villages, later spreading to other areas of Borno State of Nigeria.

OBJECTIVE

To present a report of the investigation of that outbreak, with emphasis on the characterisation of hospitalised patients.

METHODS

Selected centres reporting cases of acute febrile illness during the months of August to December, 1990 were visited, to establish surveillance. Case investigation forms were used to obtain clinical and demographic data; and blood samples were obtained from patients for analyses. Only hospitalised patients with adequate clinical information from three centres were included in the analysis.

RESULTS

The outbreak, which involved five of the six health zones in the state, and spread into adjoining Gongola state and the Cameroun Republic, was caused by the yellow fever virus. Fever, central nervous system (CNS) involvement, jaundice and haemorrhage were the most common clinical manifestations of 102 hospitalised patients. Eighty -three (81%) of hospitalised patients died and most within two days of admission. CNS manifestations were more common in dying patients than in survivors.

CONCLUSION

The reasons for this rare outbreak of yellow fever in the dry Savannah belt of Borno State remain unclear. Improved surveillance and more effective prevention strategies are needed to avert the recurrence of such outbreaks.

Mobile caecum and ascending colon syndrome in a Nigerian adult

A mobile caecum and ascending colon is a rare congenital abnormality. Its presentation as a cause of right lower abdominal pain in an adult is usually mis-diagnosed as acute appendicitis. A 42-year-old civil servant presented with a 2-year history of recurrent right lower quadrant pain of the abdomen. The pain was sharp in nature and persistent in the last 2 weeks and centered mainly in the right side of the abdomen. No other associated symptoms were noted. Laboratory investigations did not reveal obvious abnormality. A diagnosis of acute on chronic lower quadrant pain of unknown etiology was made. The patient was resuscitated and had exploratory laparatomy. No abnormalities were found other than the caecum and the whole ascending colon, which were unattached to the posterior peritoneum. Appendectomy and caecopexy, using a lateral peritoneal flap were performed. The diagnosis of mobile caecal syndrome should be considered in patients with chronic right lower quadrant pain, and appendectomy and caecopexy offers a great relief.

Malarial retinopathy in northern Nigerian children

This is a prospective study involving two centres. Children younger than 16 years old who had severe malaria underwent funduscopy. In one centre, direct ophthalmoscopy was performed by both an ophthalmologist and a non-ophthalmologist physician. At the other, two ophthalmologists performed a funduscopy on each patient using different methods (one using direct and the other indirect ophthalmoscopy). The objective was to determine the frequency of retinopathy and evaluate the effectiveness of direct ophthalmoscopy in detecting retinopathy in constantly dilated eyes. Of 62 children seen at both centres, 37% were found to have malarial retinopathy. Macula whitening was the most common finding. There was substantial agreement between the ophthalmologists using either the direct or indirect ophthalmoscopy techniques (Kappa value 0.604). However, at the centre using only direct ophthalmoscopy, there was poor agreement between the ophthalmologist and the non-ophthalmologist (kappa value -0.244). Direct ophthalmoscopy seemed to be effective in detecting malarial retinopathy, but only when performed by experienced personnel.

Relevance of moldy fungi as agents of chronic lower respiratory tract infection in patients seen in Maiduguri, Nigeria

BACKGROUND

In Maiduguri, Nigeria in the 1990's, we had available to us only the direct Acid Fast Bacilli (AFB) smear method to diagnose tuberculosis (TB), and no facility for TB culture. Because the clinical and radiologic manifestations of lower respiratory tract (LRT) fungal infections are difficult to differentiate from those of LRT TB, it was not clear how many of the direct AFB smear negative patients had fungal infections, or were true negatives for TB.

OBJECTIVE

To assess sputum samples from patients with suspected lower respiratory tract infection for non-candidal fungal isolates as well as Mycobacterium tuberculosis.

METHODS

Smears of sputum samples were examined microscopically for fungal hyphae and AFB. Sputum samples were also plated onto different fungal culture media. Isolation data were correlated with clinical and radiological data, to determine their clinical significance.

RESULTS

Of the 274 patients seen, 41(15%) had positive sputum for AFB, while 61(22.3%) had positive sputum for fungal isolates. The most common fungal isolates were Aspergillus spp (42.9%), Scopulariopsis (14.3%), Chrysosporium (8.9%), Penicillium (7.1%), Fusarium (7.1%) and Acremonium (5.4%). No patient with mold isolate had cavitary lung disease, while 62.5% of TB patients had cavitary disease. Extensive disease (54.2%) and abnormal chest x-ray (91.7 %) were characteristic of patients with TB but very rare in patients with fungal infection.

CONCLUSION

We therefore conclude that serious lower respiratory tract fungal infection was rare and that extensive or cavitary disease was usually due to pulmonary TB. The clinical diagnosis of TB under defined conditions, as in our setting, still has great utility.

Risk factors for gastro-oesophageal reflux disease symptoms: a community study

AIM

To examine the prevalence of gastro-oesophageal reflux disease symptoms and potential risk factors among community subjects.

METHODS

A questionnaire was sent to 4000 subjects, stratified by age, gender and ethnicity to be representative of the local population. Gastro-oesophageal reflux disease symptoms were defined as at least weekly heartburn or acid regurgitation.

RESULTS

2231 responded (59%), 691 refused to participate and seven were incomplete. 1533 (41%) were evaluable (637 male, mean age 51 years, range: 20-80). The prevalence of gastro-oesophageal reflux disease symptoms was 21%. Smoking, excess alcohol, irritable bowel syndrome, increasing body mass index, a family history of upper gastrointestinal disease, increasing Townsend deprivation index, anticholinergic drugs (all P < 0.0001), weight gain, antidepressant drugs, inhaled bronchodilators, no educational attainment (all P < 0.01), south Asian origin (P = 0.02) and manual work (P < 0.05) were associated with gastro-oesophageal reflux disease symptoms. Multivariate logistic regression revealed increasing body mass index, a family history of upper gastrointestinal disease, irritable bowel syndrome, south Asian origin (all P < 0.0001), smoking, excess alcohol, no educational attainment and anticholinergic drugs (all P < 0.01) were independently associated with gastro-oesophageal reflux disease symptoms.

CONCLUSIONS

Frequent gastro-oesophageal reflux disease symptoms affect 21% of the population. Increasing body mass index, a family history of upper gastrointestinal disease, irritable bowel syndrome, south Asian origin, smoking, excess alcohol, social deprivation and anticholinergic drugs are independently associated with gastro-oesophageal reflux disease symptoms.

Genetic influences in gastro-oesophageal reflux disease: a twin study

BACKGROUND

A number of families have been described which include multiple members with symptomatic, endoscopic, or complicated gastro-oesophageal reflux disease (GORD). First degree relatives of patients with GORD are more likely to suffer with GORD symptoms. These observations raise the possibility of a genetic contribution to the aetiology of GORD.

AIMS

To determine the relative contribution of genetic factors to GORD by evaluating GORD symptoms in monozygotic (MZ) and dizygotic (DZ) twins.

METHODS

A total of 4480 unselected twin pairs, identified from a national volunteer twin register, were asked to complete a validated symptom questionnaire. GORD was defined as symptoms of heartburn or acid regurgitation at least weekly during the past year.

RESULTS

Replies were obtained from 5032 subjects (56% response rate). A total of 1960 twin pairs were evaluable: 928 MZ pairs (86 male pairs, mean (SD) age 52 (13) (range 19-81) years) and 1032 DZ pairs (71 male pairs, mean age 52 (13) (20-82) years). The prevalence of GORD among both groups of twins was 18%. Casewise concordance rates were significantly higher for MZ than DZ twins (42% v 26%; p<0.001). Multifactorial liability threshold modelling suggests that additive genetic effects combined with unique environmental factors provide the best model for GORD. Heritability estimates suggest that 43% (95% confidence interval 32-55%) of the variance in liability to GORD is due to additive genetic factors.

CONCLUSIONS

There is a substantial genetic contribution to the aetiology of GORD.

Tuberculosis myocarditis: a case report

A 35-year old man presented with fever, weight loss, drenching night sweats and symptoms of cardiac failure for three months. Examination revealed wasting, peripheral oedema, bilateral pleural effusion and constrictive pericarditis. A diagnosis of constrictive pericarditis with bilateral pleural effusion probably due to tuberculosis was made. Human immunodeficiency virus antibodies and six sputum for acidfast bacilli were negative. Electrocardiograph revealed low voltages globally and echocardiography showed global myocardial hypokinesia. He had pericardiectomy, pericardial and pleural histology was non-specific inflammatory reaction but myocardial histology showed granulomatous changes of tuberculous myocarditis. We suggest that in experienced hands myocardial biopsy could be useful in making the diagnosis.

Multiple endocrine neoplasia type iia: report of a family with a study of three generations in qatar

OBJECTIVE

To study the pattern of multiple endocrine neoplasia type IIA (MEN IIA) and describe the clinical features and results of genetic testing and treatment in 21 members of the first reported family with MEN IIA in Qatar.

METHODS

After identification of the proband, we screened all her family members (21 members) with genetic testing for the RET proto-oncogene mutation. Those subjects with the mutation were further assessed for pheochromocytoma by measurement of the 24-hour urinary vanillylmandelic acid, metanephrines, and catecholamines, and those with high levels underwent a metaiodobenzylguanidine scan and adrenalectomy. The serum calcium was measured in a effort to detect hyperparathyroidism. Those family members who had the mutation and were eligible for surgical treatment underwent total thyroidectomy and central compartment dissection. In those patients with high postoperative calcitonin levels, residual disease was sought with radiologic imaging, and follow-up was done with pentagastrin stimulation tests.

RESULTS

Of the 21 family members screened, 10 had the RET proto-oncogene mutation (codon 634, TGC->GGC) (5 females and 5 males; 6 adults and 4 children). All the adults had bilateral medullary thyroid carcinoma (MTC); four of them had lymph node metastatic lesions, and one had metastatic involvement of the liver. Two adults had pheochromocytomas. Two family members were reported to have parathyroid hyperplasia, although both were normocalcemic.

CONCLUSION

This family with MEN IIA showed classic mendelian autosomal dominant inheritance. All adult patients had MTC, two had pheochromocytomas, and two had parathyroid hyperplasia. Although one child had a high stimulated calcitonin level, the histopathologic findings were normal; another child with high stimulated calcitonin levels showed C-cell hyperplasia on histopathologic examination.

Pseudomyxoma peritonei manifesting as intestinal obstruction

Pseudomyxoma peritonei is an appendiceal tumor with distinct clinical and pathologic features. It frequently presents a problem in diagnosis and management. We report a case of pseudomyxoma peritonei, which initially appeared with intestinal obstruction. This is a rare initial manifestation in patients who have not had multiple surgical procedures. We review the literature and discuss the unique clinical features and misconceptions surrounding pseudomyxoma peritonei.

A severe epidemic of meningococcal meningitis in Nigeria, 1996

A particularly severe epidemic of meningococcal meningitis (cerebrospinal meningitis, CSM) occurred in Nigeria between January and June 1996. There were 109,580 recorded cases and 11,717 deaths, giving a case fatality rate of 10.7% overall. This is the most serious epidemic of CSM ever recorded in Nigeria, and may be the largest in Africa this century. It took over 3 months and the combined efforts of a National Task Force set up by the Federal Ministry of Health, the WHO, UNICEF, UNDP, Médecins Sans Frontières, the International Red Cross and several other non-governmental organizations to bring the epidemic under control. The main control measures centred on active treatment of infected persons, mass vaccination and health education. The exact number of persons treated cannot be ascertained, but there were treatment centres in almost every Local Government Area in the affected States. A study of 1577 patients admitted at the Infectious Diseases Hospital, Kano, showed that 84% of those infected were aged < or = 20 years and that, for the first time, infants aged < or = 2 months were affected. Despite intervention, the case fatality rate of 9.1% among this group of patients was similar to the nationwide figure of 10.7%. Long-acting oily chloramphenicol proved highly effective in the treatment of patients, and its routine use in epidemic CSM is recommended. Over 13 million persons were vaccinated in the course of the epidemic. For the first time, cases of CSM were reported from States south of the 'African meningitis belt', suggesting an extension of the belt. The severity of this epidemic yet again underscores the need for a clear policy regarding control measures aimed at forestalling future epidemics. The availability of the recently developed polysaccharide-protein conjugate vaccine should facilitate a decision on mass vaccination for the prevention of epidemic CSM in Africa.

Retinoblastoma in an adult: a case report

A case of retinoblastoma in an adult with a family history of retinoblatoma is presented. To our knowledge, this is presumably the first case of retinoblastoma recorded in an adult in Northern Nigeria. The differential diagnosis, genetics, and importance of counselling and early presentation are discussed.

Clostridium difficile colitis associated with treatment of Helicobacter pylori infection

Helicobacter pylori infection of the stomach is being detected and treated more often now than ever before. This is likely to result in an increase in complications such as antibiotic-associated diarrhea. However, there is no literature on the incidence of such diarrhea, particularly Clostridium difficile colitis, in patients treated for Helicobacter pylori infection. We report the case of a patient who developed Clostridium difficile colitis after treatment for Helicobacter pylori infection with metronidazole, amoxicillin, H2 blockers, and bismuth subsalicylate. This patient presented with severe diarrhea that responded to a course of metronidazole with rapid disappearance of symptoms. The incidence of Clostridium difficile colitis in patients treated for Helicobacter pylori infection has not been studied. This unique association, although not unexpected, has not yet been reported in the literature. The increasing number of patients being diagnosed and treated for this infection requires a heightened awareness on the part of physicians, to assure early diagnosis and treatment of this treatable, yet potentially dangerous, complication.

Prognostic scores for use in African meningococcal epidemics

Current WHO guidelines for the case management of meningococcal infections during epidemics in developing countries often cannot be applied, largely because of the limited health resources in such countries. Several scoring scales based on clinical and laboratory features in numerous combinations have been developed for the management of meningococcal infections in developed countries, and these have facilitated early identification of patients with fulminant disease and thus early intervention and reduction in mortality. Unfortunately such scoring scales are not appropriate for use in developing countries. We identified hypotension, tachycardia, tachypnoea, delay in capillary refill time, coma, absence of neck stiffness and petechiae and/or purpura as simple prognostic factors of meningococcal disease. Two scores were developed: score I, which includes all seven prognostic factors, had a sensitivity and specificity of 80% and 94%, respectively. Score II, which excluded hypotension, had a sensitivity and specificity of 73.3% and 89.7%, respectively. Quick and simple scoring scales are therefore not only applicable but useful for the case management of patients in meningococcal epidemics in developing countries.

Prevalence of transmissible blood infections among blood donors at the University of Maiducuri Teaching Hospital, Maiduguri, Nigeria

Before the advent of the Acquired Immune Deficiency Syndrome (AIDS), many countries of the world transfused blood without seriously considering the potential risks of transmission of infectious agents. Even after it was shown that the Human Immunodeficiency virus(HIV) could be transmitted through blood and blood products, many hospitals and clinics in Nigeria still continue to transfuse unscreened blood. This study was therefore initiated to highlight the risks of transmitting infectious agents through blood transfusion and the category of infectious agents which could be transfused in blood in this area. A total of 364 healthy blood donors were counselled, bled and screened for HIV-1, HIV-2, HBsAg, Treponema pallidum, Plasmodium falciparum and microfilaria. The results show that the three most common infections transmissible through blood transfusion are Hepatitis B(14.9%), HIV-1 (5.8%) and P.falciparum (4.1%). Thirteen of the 364 blood donors (3.6%) and antibodies to T. pallidum. There were no donors with HIV-2 or filarial infection. Infection of donors by hepatitis B virus (HBV), T. pallidum and HIV-1 was not significant dependent on promiscuity, polygamy, previous blood transfusion or local surgery. However, there was a significant difference between donors with no risk factors and those with risk factors with regard to seroprevalence to HBV, T. pallidum and HIV-1 (p = 0.0053). The results confirm that transfusion of unscreened blood carries severe risks of transmitting serious infectious agents and that is a need to enforce laws for transfusing blood in Nigeria. Meanwhile, in the absence of screening facilities, proper counselling of blood donors in order to ascertain their risk behaviour should be used to select donors and reduce this risk.

IgG2 associated hypergammaglobulinaemia in some Nigerians with HIV infection

Concentrations of immunoglobulins (IgA, IgG and IgM) were measured in Nigerians with (HIV) infection. Considerable elevations up to two-fold the reference values were observed for IgG and IgM in the patient group as a whole but elevations in IgA concentration were least marked albeit significantly different from the healthy subjects. Elevation of a particular isotype was not always concomitant with elevation of the other major classes in the same patient. Overall, these elevations were observed in both symptomatic and asymptomatic infected subjects. Further analysis of IgG hyperglobulinemia showed that increases in this major class may be due to increased IgG2 subclass concentrations. It is suggested that elevation of IgG2 subclass in Nigerians with HIV infection and not IgG1 or IgG3 may be due to genetic and environmental factors rather than variation in the strain of the virus.

Meningioma resembling an epidermoid tumor

A case of retro-orbital meningioma who presented to the Department of Surgery, Neuro-surgery Unit of Tikur Anbessa Hospital in June 1993 with a progressive right eye proptosis is described. Exploration through a right frontal craniotomy showed a well circumscribed and encapsulated thickened bony tumor that had a cavity containing a cheesy-yellowish oily material. The lesion was successfully shelled-out. The preoperative diagnosis was meningioma. However, based on its intraoperative macroscopic appearance, mode of presentation, and location of the lesion an impression of an epidermoid tumor (cholesteatoma) was made. The result of histologic examination turned out to be meningioma (psammomatous type). Literature review on both conditions, the pathologic characteristics and clinical features are discussed briefly.

Seroepidemiology of human immunodeficiency virus infection in Borno State of Nigeria by sentinel surveillance

A serosurvey for human immunodeficiency virus (HIV) infection was carried out in three well-separated population centers in Borno State of Nigeria in 1989-1990. The study subjects were 1,259 made up of sexually transmitted disease (STD) clinic attenders, pregnant women, female prostitutes, and blood donors. Sera were screened by enzyme-linked immunosorbent assay and confirmation was done by Western blotting. The overall seroprevalence was 1.67% (21/1,259), with no significant differences from one population center to another. There were, however, significant differences among the population groups studied: prostitutes, 4.24%; STD clinic attenders, 1.67%; blood donors, 0.71%; and pregnant women, 0.24%. Of the 21 seropositives, 18 were positive for HIV-1 only; 1 was positive for HIV-2 only; and 2 were positive for both HIV-1 and HIV-2. All three HIV-2-positive sera were from prostitutes. Prevalence rates found in this study showed marked increases from 2 to 3 years earlier. There is therefore the need for a vigorous and sustained intervention program.

Determination by Widal agglutination of the baseline titre for the diagnosis of typhoid fever in two Nigerian states

This study was carried out in Borno and Plateau States of Nigeria to determine the baseline titre for the diagnosis of typhoid fever using a single Widal test. Of 172 patients with symptoms and signs of typhoid fever, 92.4% and 90.7% had reciprocal O and H antibody titres respectively of 160 or above. On the other hand, 95.3% and 66.3% of the 937 healthy control subjects had reciprocal O and H antibody titres respectively of 80 or less. The results of this study suggest that in Borno and Plateau States of Nigeria a reciprocal O antibody titre of 160 and above in persons with illness whose symptoms and signs are compatible with typhoid fever could be considered diagnostic using the single Widal test.