Incorporating point-of-care ultrasound into daily intensive care unit rounds: Another source of interruptions?

Point-of-care ultrasound (POCUS) is the use of bedside ultrasonography by the treating clinician, incorporating those images into direct clinical decisions. While there are a number of different techniques and training pathways in this relatively new modality, there has been little discussion around the logistics of integrating POCUS into the standard critical care "business day" of ward rounds, procedures and meetings. This article explores some of these aspects and presents data from an online survey of POCUS practitioners.

Inappropriate Intensive Care Unit admissions: Nigerian doctors' perception and attitude

BACKGROUND

Nonclinical factors are said to influence decisions to admit patients into the Intensive Care Unit (ICU). We therefore assessed the perception and attitude of Nigerian doctors working in the ICU about inappropriate admissions and request for admission in the setting of a full ICU.

METHODS

An anonymous, self-administered questionnaire survey was carried out among doctors working in the ICU of 17 University Teaching Hospitals, in Nigeria. A score of 0 (least usual reason) to 5 (most usual reason) was ascribed to some factors that can influence ICU admission. In addition, each of the 4 possible actions in the setting of a full ICU was graded from 0 (least likely) to 5 (most likely). The result was analyzed as appropriate.

RESULTS

Sixty-four doctors participated in the survey. Inappropriate admissions were acknowledged by 96% of respondents. Perceived reasons included pressure from superiors (93.7%), referring clinicians (89.1%), and hospital management (87.5%). If confronted with request for admission in the setting of a full ICU, respondents will arrange for the discharge of fit ICU patients to the ward (95.3%), transfer patients not receiving acute care to high dependency unit or recovery room (70.3%), or create additional ICU beds (42.2%). Chi-square test showed a significant difference between single and married respondents with regard to clinical doubt (P = 0.01) and pressure from referring clinician (P = 0.02) as reasons for inappropriate admission. Respondents' gender, marital status, professional activity, and number of ICU admissions per year did not affect possible steps in the setting of a full ICU.

CONCLUSION

Inappropriate ICU admissions were perceived as a common event and were mainly attributed to pressure from seniors, referring clinicians, and hospital management. Further work is necessary to determine the impact of such admissions on ICU efficiency.

Patterns of sexually transmitted infections in patients presenting in special treatment clinic in Ibadan south western Nigeria

INTRODUCTION

Sexually transmitted infections (STIs) are infections that are often transferred from one person to another during sexual activity. In developing countries, an increase in the incidence of STIs is attributed to increasing urbanization, modernization, travel, education and exposure to Western media which has led to increased sexual activity, especially among young people.

METHODS

This is a retrospective study carried out in the University College Hospital (UCH) Ibadan, Nigeria. The records of a total of 506 patients who attended the clinic between Jan 2010-Dec 2011 were retrieved. The records of the patients' complaints were taken. Detailed demographic data and history of genital symptoms was taken.

RESULTS

The records of 506 patients were used 43.7% (221) were males and 56.3% (285) were females. The patient's age ranged from one to eighty, the 1-10 age groups and the 71-80 ages were the least represented age group. Age, sex, level of education, presenting complaints, presence of yeast cells, VDRL positivity were variables that were looked at. Of these only sex and occupation were risk factors for transmission of STI.

CONCLUSION

Good clinical care for patients with STIs should extend beyond therapy and include help to avoid future infections. Control activities should focus on the primary prevention of infection through safer sexual practices. Strategies for improving secondary prevention (health care-seeking behavior and case management) should include identification of people at risk and targeting them for intervention.

Regulation of clathrin-coated vesicle formation

The formation of clathrin-coated pits at the plasma membrane requires the concerted action of many different molecules. The real challenge lies in determining the hierarchy of these interactions. We are using assays in both intact and permeabilized cells to dissect the temporal requirements for clathrin-coated vesicle formation, and also to examine the role of phosphorylation of the coat proteins.

Phosphorylation of threonine 156 of the mu2 subunit of the AP2 complex is essential for endocytosis in vitro and in vivo

The clathrin-coated pit is the major port of entry for many receptors and pathogens and is the paradigm for membrane-based sorting events in higher cells [1]. Recently, it has been possible to reconstitute in vitro the events leading to assembly, invagination, and budding off of clathrin-coated vesicles, allowing dissection of the machinery required for sequestration of receptors into these structures [2-6]. The AP2 adaptor complex is a key element of this machinery linking receptors to the coat lattice, and it has previously been reported that AP2 can be phosphorylated both in vitro and in vivo [7-10]. However, the physiological significance of this has never been established. Here, we show that phosphorylation of a single threonine residue (Thr156) of the mu2 subunit of the AP2 complex is essential for efficient endocytosis of transferrin both in an in vitro coated-pit budding assay and in living cells.

Studies on the effectiveness, safety and acceptability of fluids from local foodstuffs in the prevention and management of dehydration caused by diarrhoea in children

Two fluids derived from local staple food, Manioc Salt Solution (MSS) and Pap Salt Solution (PSS) were assessed and compared with the World Health Organization/Oral Rehydration Solution (WHO/ORS) in 333 children aged between 6 and 60 months in a clinical trial. All the children had some dehydration after episodes of acute watery diarrhoea using WHO criteria. All the children who were placed on MSS and PSS, as well as ORS were satisfactorily rehydrated. There was no significant difference in pre- and postserum electrolytes of the children on the three types of fluids. The fluids were found to be acceptable, readily available, easy to prepare and cheaper than the ORS fluid. There was no taboo against the fluid. It is noteworthy that there was no significant difference in the sugar and electrolyte contents of the different varieties of the manioc and pap available in this environment, thus making the MSS and PSS effective and readily available substitutes to ORS. The two fluids are therefore recommended as rehydrating fluids for children with some dehydration in the absence of WHO/ORS fluid.

The purification and characterization of intracellular invertase obtained from pathogenic Escherichia coli

All the non-pathogenic strains of Escherichia coli tested failed to synthesize invertase. However, among the pathogenic E. coli, only 11% of them synthesized the enzyme. Invertase synthesis was best at pH 8.0, when the sole nitrogen source was peptone. The enzyme was induced by sucrose but repressed by glucose and fructose. The enzyme was partially purified by ammonium sulphate precipitation, followed by dialysis and gel permeation chromatography. The partially purified invertase possessed a molecular weight of 125,000 KD and an apparent km of approximately 2.94mM for sucrose. The enzyme was stimulated by Ca++ and Mg++, inhibited by Cu++, U++, IAA and exhibited optimum activity at pH 6.5 at 40 degrees C.

Asymptomatic significant bacteriuria among pregnant and non-pregnant women in Sagamu, Nigeria

In a study carried out among 510 pregnant and 304 non-pregnant women at Ogun State University Teaching Hospital, Sagamu, 122 (23.9%) of the pregnant women and 37 (12.2%) of the non-pregnant women had significant bacteriuria. The rate amongst the pregnant women was significantly higher than in non-pregnant women (P < 0.001). There was a correlation between pyuria and significant bacteriuria in 45 (8.8%) of the pregnant women and in 11 (3.6%) of the non-pregnant women. Significant bacteriuria was closely associated with nulliparae. Most of the pregnant women with significant bacteriuria belonged to the low socioeconomic group. Unlike in previous studies in this country, the most prevalent organism in this study was the Staphylococcus aureus. In view of the high incidence of the problem in this environment, it is important that routine screening of urine for significant bacteriuria should be part of our ante-natal clinic services at least on the first visit of pregnant women to ante-natal clinics.

Nutrient intakes of children in a rural Nigerian community

The nutrient intakes of 30 children in a rural Nigerian community were assessed by measuring their food intakes for four consecutive days by direct weighing method. The contents of the following six nutrients were calculated: energy, protein, calcium, iron, riboflavin, and vitamin C. The mean (SD) daily energy intakes for the various ages groups were: 1-5 years 801 (317) kcal; 6-10 years 1123 (214) kcal; and 11-15 years 903 (134) kcal, while the mean (SD) daily protein intakes for the same group of children were 21 (11) g; 35 (10) g, and 27 (7) g. These figures show a wide departure from the FAO/WHO/UNU reference values and a worsening of the nutritional status of rural Nigerian children.

Asymptomatic significant bacteriuria among pregnant and non-pregnant women in Sagam, Nigeria

In a study carried out among 510 pregnant and 304 non-pregnant women at Ogun State University Teaching Hospital, Sagamu, 122 (23.9 pc) of the pregnant women and 37 (2.2 pc) of the non-pregnant women had significant bacteriuria. The rate amongst the pregnant women was significantly higher than in non-pregnant women (P < 0.001). There was a correlation between pyuria and significant bacteriuria in 45 (8.8 pc) of the pregnant women and in 11 (3.6 pc) of the non-pregnant women. Significant bacteriuria was closely associated with nulliparae. Most of the pregnant women with significant bacteriuria belonged to the low socio-economic group. Unlike in previous studies in this country, the most prevalent organism in this study was the Staphylococcus aureus.

Surface properties, connective tissue protein binding and Shiga-like toxin production of Escherichia coli isolated from patients with ulcerative colitis

Escherichia coli strains isolated from intestinal biopsies of patients with ulcerative colitis (n 146), Crohn's disease and colonic polyposis (n 41) were analysed for binding of collagen I, collagen IV, fibronectin and laminin. Strains expressed varying degrees of binding of one or more of the four connective tissue proteins. Only 32 strains did not express binding of any of the proteins. The strains expressed low or moderate cell surface hydrophobicity. There was no correlation between protein binding and expression of cell surface hydrophobicity. E. coli isolated from inflamed rectal mucosa were slightly less negatively charged than strains isolated from healthy intestinal mucosa. Shiga-like toxins I and II were detected in 32 strains from 28 patients. Of these, 5 strains had been isolated from normal or healed tissue. In patients with inflammatory bowel disease, connective tissue proteins are exposed in intestinal ulcerations. Strains expressing binding of one or several of these proteins may have a selective advantage to colonize these lesions.

Occurrence of toxic shock syndrome toxin-1 producing Staphylococcus aureus and the anti TSST-1 serostatus of hospital personnel in Nigeria

Of the 56 S. aureus strains tested, five (8.9%) isolates (four from asymptomatic nasal carriage and one from a non TSS staphylococcal disease) demonstrated TSST-1 production in vitro. Among the toxin positive strains the clinical isolate belonged to phage group I, 29/52 and the nasal carriage isolates were either non typable or ungroupable. Eighty-nine percent of isolates including all TSST-1 positive strains showed binding to crystal violet and were traced to S. aureus var. hominis (CV type C/D). A. aureus var. bovis (CV type A/B) were found only in nasal carriage group (10.7%) and did not bind crystal violet. During the sero-surveillance 101 out of 220 hospital personnel (48.1%) showed TSST-1 antibodies of IgG class at 1:1000 sera dilution. The four individuals with asymptomatic nasal carriage of TSST-1 positive staphylococci showed no antibody to the toxin. Anti TSST-1 levels persisted in 58 (57.4%) and 10 (9.9%) individuals at higher sera dilutions of 10(-4) and 10(-5) respectively.

Influence of mucin on serum and connective tissue protein binding to Staphylococcus aureus isolated from nasal carriage and clinical sources

A total of 89 Staphylococcus aureus strains were tested for [125I]-labelled fibronectin (Fn), type I (Cn-I), type II (Cn-II), type IV (Cn-IV) collagens and laminin (Lm) binding, and nasal carriage isolates (54 strains) demonstrated higher degree of interaction than clinical isolates (35 strains). Strains belonging to nasal carriage group, after preincubation with mucin demonstrated a significant decline in binding to Fn (39.4%), Cn-I (44.7%), Cn-IV (42.0%) and Lm (43.5%) compared with inhibition of binding of clinical isolates to Fn (13.3%), Cn-I (8.0%), Cn-IV (9.8%) and Lm (11.2%). S. aureus strain Nig-6 demonstrated a mucin concentration (in the range 0.01 to 100 mg/ml) dependent decrease of [125I]-labelled serum and connective tissue protein binding. Mucin concentrations of 100, 150, 175 and 250 micrograms/ml when incubated with 10(9) cells, caused 50% displacement of [125I]-labelled Lm, Cn-I, Cn-IV and Fn uptake respectively. Mucin interaction with bacterial cells seems probably important in the pathomechanism of staphylococcal adhesion and colonization.

Carriage of Staphylococcus aureus among hospital personnel in a Nigerian hospital environment

Among the 395 hospital staff examined during this study, 35.2pc of them were found to carry S. aureus in their anterior nares. The carriage was slightly higher in females (35.8pc) compared with 34.4pc in males, although it was not statistically significant. When the different age groups and professions were considered, the carriage was highest among the age group of 21-30 years and with the Nursing staff, who incidentally, are closest to the patients and had the highest number among the staff members examined. The carrier rate was also significantly higher (P less than 0.05) among staff members who had worked in the hospital for 7-10 months compared with other staff. There was a good correlation (97pc) between coagulase positivity and mannitol fermentation, while Methicillin, Claforan and Gentamycin were found to be very effective against most of the isolates. On re-examination of those staff members who ar closely associated with the patients two years after the initial exercise in 1987, it was evident that a significant number (P less than 0.05) of those carriers of Staph aureus in our hospital are not persistent ones.

Acute bacterial meningitis in children

A retrospective study of 48 children with pyogenic meningitis who were admitted between January 1986 and December, 1987 at the Ogun State University Teaching Hospital, Sagamu has shown that childhood meningitis is an important health problem in the community as it accounted for 2.8% of 1,724 admissions into the paediatric ward. The ages of the patients ranged from three weeks to twelve years with a mean of 2 1/2 years. The commonest causative organism was Streptococcus pneumoniae which accounted for 67.5% of all isolates. The mortality rate was 26.1% while significant morbidity occurred in 23.5% of survivors. Important prognostic factors included the presence of coma or persistent convulsions, low CSF glucose and low serum sodium levels as well as the interval between symptoms and treatment.

Immunological response to Helicobacter pylori among Nigerians

Among 420 Nigerians examined, 39% had antibodies to Helicobacter pylori. The prevalence was significantly higher in males (55%) than in females (29%). The prevalence tended to rise with age in both sexes and was significantly higher in the 30-34 years age group. Socio-economic class and rural dwellage did not affect the prevalence. The study may indicate that H. pylori is endemic in Nigeria. It also shows that the detection of antibodies to H. pylori may be a rapid and cheap method for diagnosing H. pylori infection in developing countries where sophisticated equipment for detecting this organism is not available.

Antibody prevalence against rubella among hospital personnel in Nigeria: implications for health care system and immunisation policy

Among 385 sera from Nigerian hospital personnel aged 15-39 years, 289 (75%) had an antibody titer corresponding to immunity against rubella, compared with 346 (90%) of the sera from Swedish women of the same age group. The frequency of high immune level against rubella did not change with age among Nigerians compared with a decrease in immunity with increasing age in the Swedish individuals. This probably is due to the differences between the dynamics of the development of natural immunity and immunity acquired through vaccination. In Nigeria, socio-economic factors were related with the degree of immune responses while sex was not. The results highlight the importance of immunization among hospital personnel and eventual vaccination of the whole population in Nigeria and the continuous surveillance of rubella immunity and periodic re-evaluation of immunization policies.

The risk of neonatal septicaemia after prolonged rupture of the membranes in Nigeria

In a study of 80 babies delivered after prolonged rupture of membranes in Wesley Guild Hospital (WGH), Ilesha, over a 16-month period, 18 (22.5%) were found to have a positive blood culture. Babies with a positive blood culture were more ill (p less than 0.02) and males were significantly more affected by culture proven infection (p less than 0.02). The mortality rate was significantly higher in babies with a positive blood culture (p less than 0.01). The high incidence of septicaemia in this group of babies in our environment may be due to the unhygienic environment from which mothers and babies were referred and delay in presentation. Improved obstetric and neonatal care will therefore reduce the morbidity and mortality due to septicaemia in such babies in Nigeria. Such babies should continue to be treated routinely for presumed infection till facilities for prompt diagnosis of neonatal septicaemia are more readily available.

Childhood carriers of Salmonella and Shigella species in the rural area of Ile-Ife, Nigeria

Four hundred and eight apparently healthy school children from rural primary schools in Ile-Ife were examined for the prevalence of Salmonella and Shigella species, which were found respectively in 2% and 3.2% of these children. The prevalence of the organisms decreased as the age of the children increased. Salmonella species were found only in specimens from boys while Shigella species occurred in both sexes and were more prevalent among females. No specimen contained both organisms. Only one of the 12 different sources of well and rain water used for domestic purposes in the rural areas where the children examined lived contained Salmonella species, and none contained any species of Shigella or faecal E. coli.

Seroepidemiology of human retroviruses in Ogun State of Nigeria

We analyzed sera collected during 1987 and 1988 from 385 healthy business employees of both sexes, of Ogun state in Nigeria, for antibodies to the 3 human retroviruses HIV-1, HIV-2 and HTLV-I. No serum was HIV-1 positive, 1 was HIV-2 positive and 2 were HTLV-I positive. A few sera were false-positive in the antibody screening tests which preceded the confirmatory antibody tests. In the confirmatory tests, we found that in the HIV-1 Western blot test 1 serum reacted only with the HIV-1 gag protein p17, and 2 sera reacted only with the HIV-1 pol proteins p64, p53 and p31. None of these reactivities fulfill internationally accepted criteria for HIV-1 seropositivity. We conclude that HIV-1 was rare in the study population and that HIV-2 and HTLV-I are present at a low frequency. The false positive serological reactions observed are similar to those described previously from Africa and elsewhere. The findings emphasize the importance of routinely testing blood donations for antibodies to these retroviruses in Nigeria.

Properties of lactase produced by enteropathogenic Escherichia coli from diarrhoeic children

The quantity of lactase produced by enteropathogenic Escherichia coli (EPEC) was significantly higher (P less than 0.01) than that produced by non-EPEC. The enzyme production was induced by lactose but repressed by glucose and galactose. The lactase from EPEC which was partially purified by ammonium sulphate precipitation and gel permeation chromatography had a molecular weight of 56 kD and apparent Km of approximately 2.78 mM for lactose. The lactase exhibited optimum activity at pH 7.0 at 40 degree C and was stimulated by Mg2+, Mn2+, Na+ and inhibited by Ba2+, Ca+, Cu2+, EDTA, iodo acetic acid (IAA) and Hg2+ and U2+ ions. The higher production of lactase by EPEC may be linked to its pathogenic role in childhood diarrhoea.

Biosocial factors in maternal mortality--a study from a Nigerian mission hospital

A survey of deaths occurring in women in association with pregnancy and childbirth was carried out in a large mission hospital in Benin City, Nigeria, with a view to identifying the underlying biosocial factors that influence such deaths. Age, parity, booking status, level of educational attainment and socio-economic status were all found to be important variables statistically affecting maternal death risks. No significant association was found in the study between maternal death risks and other social variables such as marital status, distance of home from hospital and ethnic origin of pregnant women. Maternal deaths were shown to be an index of the socio-economic standards in any society, and measures to lower the present high rates of maternal mortality in Nigeria and other developing countries through a manipulation of these biosocial factors were highlighted.

Rotavirus as an aetiological agent of acute childhood diarrhoea in Ile-Ife, Nigeria

Of the 456 urban children aged 14 days and 4 years examined for rotavirus in this study, 376 had diarrhoea while 80 were without diarrhoea and serve as control. Among the 376 diarrhoeic children, 57 (15.2%) had rotavirus while none of the 80 control children had the virus. Rotavirus was significantly higher (p less than 0.05) among the in-patients (19.8%) than in the out-patients (10.3%) and among children of 7-12 months compared with other aged groups. The majority of the children that had the rotavirus lived in areas without pipe-borne water and similarly belonged to the low-socio-economic level. It is therefore possible to deduce from this work that rotavirus is still a major aetiology of acute childhood diarrhoea in Nigeria and its incidence can be affected by hygienic practices, the environment and socio-economic level.

The prevalence of bacteriuria among high risk neonates in Nigeria

Among the 446 high risk neonates studied for significant bacteriuria and pyuria in the neonatal wards of the Obafemi Awolowo University teaching hospital Complex, Ile-Ife, 7.6% and 5.8% were positive for significant bacteriuria and pyuria respectively, while none of the 81 infants in the control group were positive. Males and females were similarly affected and there was no seasonal variation in the prevalence of pyuria or bacteriuria. It is noteworthy that 25 (96%) of the 26 pyuria neonates also had bacteriuria emphazising the significance of pyuria as a possible screening method for urinary tract infections in neonates. The clinical problems in the neonates studied included prematurity, low birthweight, neonatal jaundice, fever, CNS symptoms, ophthalmia neonatorum, prolonged rupture of the membranes (PROM), respiratory distress, septic cord/skin, diarrhoea, vomiting and feeding problems. Only prematurity and low birthweight were significantly associated with bacteriuria in the neonates studied. The organisms encountered in this study were Escherichia coli (58.4%), Klebsiella species (35.3%) and Proteus species (5.9%). Of the bacterial isolates, 67% were sensitive to Ampicillin and 97% to Gentamycin. The combination of these antibiotics was effective in all cases in the present study. The study has highlighted the need for routine urine culture in our high risk neonates.

Neonatal bacteraemia in Wesley Guild Hospital, Ilesha, Nigeria

In a study on neonatal bacteraemia among the high-risk neonates admitted into our neonatal unit at Wesley Guild Hospital, Ilesha, the incidence of bacteraemia in babies born in the hospital was 17/1000 live births and 71.6/1000 total admissions into the unit. Gram-negative bacteria accounted for about 58.1% of bacteria isolated and Staphylococcus aureus for 62% of the isolated Gram-positive bacteria. Among the commonly used antibiotics, gentamicin is the most favoured by the sensitivity test. S. aureus appeared more sensitive to erythromycin than to cloxacillin or ampicillin. The present policy of using the combination of gentamicin and cloxacillin and/or ampicillin is adequate for most agents encountered and therefore should continue. It is suggested that proper antenatal care, adequate supervision of delivery, better neonatal care and provision of better laboratory facilities will help to reduce the incidence of neonatal bacterial infection, improve the management of neonatal infection and reduce the morbidity and mortality from bacterial infection.

The pattern of rape in Benin City, Nigeria

A retrospective study of 330 female victims of alleged rape seen over a 3-year period [1981-1983] in Benin City, Nigeria revealed that children of elementary school age (6-12 years) and adolescent girls (13-19 years) were the major victims; 48.2 percent of the reported cases occurred in children below 13 years of age. Major differences were noted in the pattern and clinical presentation of rape between the child and adult victims. Group rape involving multiple assailants was encountered mostly in adult victims amongst whom the incidence was 47%. Physical injuries following rape were seen in 33% of the alleged victims; injuries to the genital area occurred in 45% of the child rape victims and in 16% of the adult victims while injuries to extragenital areas of the body were found mostly in the adult victims.

Role of hepatitis Bs antigen in chronic glomerulonephritides in Nigerians

Using enzyme-linked immunosorbent assay technique (Boehring Institute Laboratory), eighty-one adult patients were studied for hepatitis Bs antigenaemia. Nine of the patients had asymptomatic persistent proteinuria, thirty-nine, nephrotic syndrome, and thirty-three had profuse proteinuria, azotoaemia and hypertension. The histopathology obtained in forty showed twenty-two with MCGN, four with focal glomerulosclerosis, three with proliferative glomerulonephritis, one with minimal change glomerulonephritis and ten with end-stage kidney disease. None of the patients had apparent clinical evidence of liver disease nor a past history of jaundice. One hundred and eighty apparently normal adults served as controls; 33.3% of the patients had positive hepatitis Bs antigenaemia, in contrast to 6% (P less than 0.001) in the normal controls. Hepatitis Bs antigenaemia was more prevalent in the groups with nephrotic syndrome and persistent asymptomatic proteinuria than in the group with advanced renal failure. Hepatitis Bs antigenaemia was detected in all histopathologic forms but was most prevalent in the MCGN (P less than 0.001) which is also the more commonly encountered lesion. The implications of these findings are discussed.

Campylobacter jejuni as a bacterial cause of diarrhoea in Ile-Ife, NIgeria

A total of 495 diarrhoea and non-diarrhoea patients whose ages ranged between 5 and 39 years were examined for the presence of Campylobacter jejuni, Salmonella and Shigella species. About 12% of the specimens from diarrhoea patients were positive for Campylobacter jejuni compared with 6% and 10% for Salmonella and Shigella species. In contrast 2%, 0% and 1% of the samples from non-diarrhoea patients were positive for Campylobacter jejuni, Salmonella and Shigella species respectively. Most (62%) of the Campylobacter jejuni from diarrhoea patients were isolated from children under the age of 10 years. This compared with 26% and 37% for Salmonella and Shigella species in this age group. The frequency of isolation of Campylobacter jejuni in diarrhoea patients was highest during the dry months of the year. This study demonstrates the importance of Campylobacter jejuni as a major bacterial cause of diarrhoea in this part of the world.