Minimal Access Surgery

Is laparoscopic approach for wandering spleen in children an option? Gratiana Oana Alqadi, Amulya K Saxena Journal of Minimal Access Surgery 2019 15(2):93-97 Aim: Wandering spleen present generally as an acute abdomen after twisting of the splenic vascular pedicle. This study aimed to review the literature with regard to the management and outcomes of the laparoscopy in children with wandering spleen. Methods: The literature was reviewed for articles on PubMed with regard to the following search terms 'laparoscopy', 'wandering', 'spleen' and 'children'. The inclusion criteria included article only in the paediatric age group of 0–16. Articles that did not meet the inclusion criteria were excluded from the study. Results: The PubMed search from 1998 to 2016 identified 15 articles. There were 20 children with an age range from 2 to 16 years who underwent the laparoscopic procedure for wandering spleen. The median age was 8 years. Associated conditions were present in 45% of patients: gastric volvulus (n = 3), torsion of the distal pancreas (n = 3), splenic cyst (n = 2), mental retardation and myotonic dystrophy (n = 1). In two cases, the spleen was twisted around the pedicle and was non-viable, and therefore, a splenectomy was performed. Other 18 cases were managed by splenopexy using a 3–5-port technique. An extraperitoneal pocket was created using a balloon device in five patients. Fixation of the spleen was performed using a mesh in 10 cases and omentum in three cases. In one case, additional support was created by plicating the phrenicocolic ligament. Simultaneous gastropexy was performed in four patients. There were no post-operative complications. Conclusions: Wandering spleen is a rare entity and in the paediatric age group 10% cannot be salvaged for which splenectomy is the only option. Of the 90% that can be pexied, the literature has favoured the application of meshes followed by the extraperitoneal pockets and omental pouch. Laparoscopic splenopexy is feasible, with no reported conversions or complications.

The surgical outcome of minimally invasive pharyngo-laryngo-oesophagectomy in prone position Mariko Ogino, Yuma Ebihara, Akihiro Homma, Kimitaka Tanaka, Yoshitsugu Nakanishi, Toshimichi Asano, Takehiro Noji, Yo Kurashima, Soichi Murakami, Toru Nakamura, Takahiro Tsuchikawa, Keisuke Okamura, Toshiaki Shichinohe, Satoshi Hirano Journal of Minimal Access Surgery 2019 15(2):98-102 Purpose: Pharyngo-laryngo-oesophagectomy (PLE) which is mainly indicated for cervical oesophageal cancer or synchronous double cancer of the thoracic oesophagus and the pharynx or larynx, is extremely invasive. Since minimally invasive oesophagectomy (MIE) using video-assisted thoracic surgery has become popular recently, the procedure can be adopted to PLE. Moreover, the use of the prone position (PP) in MIEs has been increasing recently because technical advantages and fewer post-operative complications were reported. To assess the validity of PP, this study compared surgical outcomes of minimally invasive PLE (MIPLE) in PP with that in the left lateral decubitus position (LLDP). Patients and Methods: This study enrolled consecutive 15 patients that underwent MIPLE with LLDP (n = 7) or PP (n = 8) between January 1996 and October 2016. The patients' background characteristics, operative findings and post-operative complications were examined. Results: Eligible diseases are 5 cases of cervical oesophageal cancer, 9 cases of synchronous double cancer of the thoracic oesophagus and head and neck and 1 case of cervical oesophageal recurrence of the head-and-neck cancer. The patients' background characteristics were not significantly different. During surgery, thoracic blood loss was significantly lower in PP than in LLDP (P = 0.0487). Other operative findings and post-operative complications were not significantly different between the two groups. Conclusions: In MIPLE, the PP could reduce blood loss due to the two-lung ventilation under artificial pneumothorax and was associated with lower surgical stress than LLDP.

Laparoscopic ureterolithotomy: Experience of 60 cases from a developing world hospital Mudassir Maqbool Wani, Abdul Munnan Durrani Journal of Minimal Access Surgery 2019 15(2):103-108 Objective: Laparoscopic ureterolithotomy, which has been quoted to have a success rate equivalent to open ureterolithotomy for uretric stones, can be performed transperitoneally and retroperitoneally. The aim of the present study is to report our experience with laparoscopic retroperitoneal ureterolithotomy, its results and advantages in the current era of minimally invasive surgery in a developing country. Patients and Methods: It was a prospective study carried from May 2010 to December 2012. 60 patients diagnosed with upper and middle uretric calculi, with sizes more than 1 cm and with value of more than 1500 hu on CT Urography ,underwent laparoscopic retroperitoneal ureterolithotomy. Results: All patients underwent retroperitoneal laparoscopic ureterolithotomy successfully. The mean operative time was 64.53 min. The mean blood loss was 39.83 ml. 3 patients had minor intra-operative complications which were tackled on table. Post-operative complications developed in 3 patients, all minor. There were no major complications. The removal of drain was at (2.7 days). Mean hospital stay was of 3.3 days. Patients reported to their routine activities in 1.78 weeks. During follow-up 3 months later, CT urography revealed normal ureter in all cases. Conclusion: Laparoscopic retroperitoneal ureterolithotomy has low rate of conversion to open surgery and an acceptable overall complication rates. In selected patients with impacted, hard, large ureteral stones, which are likely to cause diffi-culty in endo-urological procedures, laparoscopic ureterolithotomy is a reason-able treatment option.

Short-term outcomes of minimally invasive surgery for patients presenting with suspected gallbladder cancer: Report of 8 cases Gerald Zeng, Nan Zun Teo, Brian K. P. Goh Journal of Minimal Access Surgery 2019 15(2):109-114 Introduction: Minimally invasive surgery (MIS) for gallbladder cancer (GBCa) has traditionally been discouraged, with limited studies reporting on its outcomes. The aim of this study was to evaluate the short-term outcomes of MIS for patients with GBCa or suspected GBCa. Methods: A retrospective study of 8 consecutive patients who underwent MIS for GBCa by a single surgeon over a 22-month period between 2015 and 2017. Results: Three patients underwent robotic surgery, while five underwent conventional laparoscopic surgery. Four patients presented with histologically proven GbCa detected incidentally after cholecystectomy. All 4 patients underwent resection of Segment 4b/5. Of these, 3 underwent hilar lymphadenectomy and 1 underwent hilar lymph node sampling. Four patients presenting with suspected GBCa underwent upfront extended cholecystectomy. Two patients who had malignancy on frozen section underwent hilar lymphadenectomy. The median operation time was 242.5 (range, 165–530) min, and the median blood loss was 175 (range, 50–700) ml. The median post-operative hospital stay was 3.5 (range, 2–8) days. There were no open conversion, post-operative morbidities and mortalities. Six had histologically proven GBCa. Five were T3 and one had T2 cancers. Conclusions: The results of the present study confirm the short-term safety and feasibility of MIS for patients with GBCa, as all eight patients underwent successful MIS with no major morbidity or mortality. Further studies with larger patient cohorts with long-term follow-up are needed to determine the oncologic outcomes and the definitive role of MIS in treating GBCa.

Changes of serum and peritoneal inflammatory mediators in laparoscopic radical resection for right colon carcinoma Pengcheng Zhu, Wenzhong Miao, Feng Gu, Chungen Xing Journal of Minimal Access Surgery 2019 15(2):115-118 Objective: The objective of this study is to investigate the effects of laparoscopic and open operation on serum and peritoneal inflammatory mediators in patients with right colon carcinoma. Patients and Methods: A total of 100 patients were randomly divided into laparoscopic group (n = 50) and open group (n = 50). The age, sex, operation time, operation blood loss, post-operative Dukes stage, time to first passage of flatus and post-operative hospital stay were recorded. The levels of hypersensitive C reactive protein (hsCRP) and tumour necrosis factor-α (TNF-α) in serum and abdominal exudate were measured by ELISA at the time of pre-operative 2 h and post-operative 6 h and 24 h. Results: There was no significant difference in age, sex, Dukes stage and pre-operative inflammatory mediators between the two groups (P > 0.05). The operation time, intraoperative blood loss, time to first passage of flatus and post-operative hospital stay were significantly better in laparoscopic group than those in open operation group. At 6 h and 24 h after operation, the levels of hsCRP and TNF-α in serum and abdominal exudate in laparoscopic group were significantly lower than those in open operation group. Conclusions: Laparoscopic surgery for the treatment of right colon carcinoma has the advantages of fewer traumas, less systemic and local inflammatory response, rapider post-operative recovery and shorter hospital stay. It is worthy of clinical application.

Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience P R K Bhargav, M Sabaretnam, V Amar, N Vimala Devi Journal of Minimal Access Surgery 2019 15(2):119-123 Introduction: Primary hyperparathyroidism is one of the most common endocrine disorders requiring surgical parathyroidectomy for its definitive treatment. Surgical exploration is traditionally performed through conventional open neck approach. A wide range of minimal access and minimally invasive endoscopic techniques (gas less and with gas) have been attempted in the past two decades. In this context, we evaluated the feasibility and safety of an innovative transoral endoscopic parathyroidectomy (EP) technique, which represents a paradigm shift in transluminal endocrine surgery. Materials and Methods: This is a prospective study conducted at a tertiary care Endocrine Surgery Department in South India between May 2016 and August 2017. We employed a novel transoral, lower vestibular route for EP. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled database. Statistical analysis was performed with SPSS 20.0 version. Operative Technique: Under inhalational general anaesthesia, access to the neck was obtained with 3 ports (central frenulotomy and two lateral port sites), dissected in subplatysmal plane and insufflated with 6 mm Hg CO2 for working space. Rest of surgical steps is similar to conventional open parathyroidectomy. Results: Out of the 38 hyperparathyroidism cases operated during the study, 12 (32%) were operated by this technique. Mean operative time was 112 ± 15 min (95–160). The post-operative course was uneventful with no major morbidity, hypocalcemia or recurrent laryngeal nerve palsy. Cure and diagnosis were confirmed by >50% fall in intraoperative parathyroid hormone levels and histopathology (all were benign solitary adenomas). Conclusions: Through this study, we opine that this novel transoral vestibular route parathyroidectomy is a feasibly applicable approach for primary sporadic hyperparathyroidism, especially with solitary benign adenomas.

Who profits from three-dimensional optics in endoscopic surgery? Analysis of manual tasks under two-dimensional/three-dimensional optic vision using a pelvic trainer model Cornelius Jacobs, Frank Alexander Schildberg, Dieter Christian Wirtz, Philip Peter Roessler Journal of Minimal Access Surgery 2019 15(2):124-129 Background: In endoscopic operations, direct binocular view, tissue sensation and depth perception get lost. It is still unclear whether the novel three-dimensional (3D) high-definition (HD) cameras are able to compensate the limited senses and how this affects the skill set of users with different endoscopic experience. This study aimed first to evaluate if the 3D technology improves depth perception, precision and space orientation as compared to conventional two-dimensional (2D) HD technology. The second aim was to determine the 3D influence on participants with different endoscopic experience. Methods: A total of 24 participants of different experience levels performed three different tasks on a pelvic trainer using the same thoracoscopic unit in 2D and 3D modes. Results were statistically analysed using Student's t-test and Pearson's product–moment correlation. Results: Across all the participants, we found that 3D optic vision significantly reduced the needed time to perform a defined difficult task in comparison to 2D. This difference was less pronounced in participants with higher experience level. Participants with eyeglasses performed slower in both 2D and 3D in comparison to participants with normal vision. Only participants with normal vision could significantly improve their completion times with 3D optic vision. Conclusions: By testing the novel generation of 3D HD cameras, we could demonstrate that the 3D optic of these systems improves depth perception and space orientation for novices and experienced users and especially inexperienced users benefit from 3D optic.

Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose? Oleh Yevhenovych Matsevych, Modise Zacharia Koto, Moses Balabyeki, Lehlogonolo David Mashego, Colleen Aldous Journal of Minimal Access Surgery 2019 15(2):130-136 Background: Selective non-operative management (NOM) and diagnostic laparoscopy (DL) are well-accepted approaches in the management of stable patients with penetrating abdominal trauma (PAT). The aim of this pilot study was to investigate the advantages and disadvantages of early DL in stable asymptomatic or minimally symptomatic patients with PAT as opposed to NOM, a standard of care in this scenario. The secondary aim was to suggest possible indications for DL. Methods: Patients managed with DL or NOM over a 12-month period were included in this study. The age, gender, mechanism and location of injuries, trauma scores, haemodynamic and metabolic parameters, intraoperative findings and length of hospital stay (LOS) were recorded and correlated with outcomes. Results: Thirty-six patients were in the NOM group and 35 in the DL group. Stab wounds were more common. The most common location of injury was the anterior abdominal wall in the NOM group and the lower chest in the DL group. Computed tomography (CT) scan was performed more often in the NOM group (75% vs. 17.1%). The injury severity score (ISS), New ISS and PAT Index were higher in the DL group. Nearly 23 (66%) patients in the DL group had a penetration of the peritoneum, but no significant abdominal injuries. LOS in the NOM group was 2 days versus 3.1 days in the DL group. There were no missed injuries, complications or mortality. Conclusion: NOM is a preferred modality for minimally symptomatic stable patients. However, there is a risk of missed injuries and delayed treatment. DL accurately visualizes injuries, decreases unnecessary CT scans and avoids nontherapeutic laparotomies.

End-stage renal disease is a risk factor for complex laparoscopic cholecystectomy in patients waiting for renal transplantation Sara Colozzi, Samuele Iesari, Giovanni Cianca, Quirino Lai, Luigi Bonanni, Francesco Pisani, Gianfranco Amicucci Journal of Minimal Access Surgery 2019 15(2):137-141 Introduction: To date, there are no studies investigating whether laparoscopic cholecystectomy (LC) is technically more complex in patients waiting for kidney transplant. The aim of this study is to create a user-friendly score to identify high-risk cases for complex LC integrating end-stage renal disease (ESRD). Materials and Methods: We retrospectively analysed 321 patients undergoing LC during the period 2014–2016. Two groups were compared: ESRD group (n = 25) versus control group (n = 296). Concerning statistical analysis, continuous variables were compared using Kruskal–Wallis' test, dummy variables with Chi-square test or Fisher's exact test when appropriate. A multivariable logistic regression analysis was performed to identify risk factors for complex LC. A backward conditional method was used to design the final model. Results: Seventy out of 321 (21.8%) cases were considered as complex, with a higher prevalence in the ESRD group (32.0 vs. 20.9%; P = 0.2). Using a multivariable logistic regression analysis, we formulated a score based on the independent risk factors for complex LC: 4×(previous cholecystitis) +5 × (previous ESRD) +1 × (age per decade) +2 × (previous open abdominal surgery). High-risk cases (score ≥ 10) were more commonly reported in the ESRD group (72.0 vs. 24.7%; P < 0.0001). Conclusion: Although several scores investigating the risk for complex LC have been proposed, none of them has focused on ESRD. This is the first series demonstrating that ESRD is an independent risk factor for technical complexity in LC. We developed a score to offer surgeons an extra tool for pre-operative evaluation of patients requiring LC.

Gastrointestinal stromal tumours of stomach: Robot-assisted excision with the da Vinci Surgical System regardless of size and location site Niccolò Furbetta, Matteo Palmeri, Simone Guadagni, Gregorio Di Franco, Desirée Gianardi, Saverio Latteri, Emanuele Marciano, Andrea Moglia, Alfred Cuschieri, Giulio Di Candio, Franco Mosca, Luca Morelli Journal of Minimal Access Surgery 2019 15(2):142-147 Aims: The role of minimally invasive surgery of gastrointestinal stromal tumours (GISTs) of the stomach remains uncertain especially for large and/or difficult located tumours. We are hereby presenting a single-centre series of robot-assisted resections using the da Vinci Surgical System (Si or Xi). Subjects and Methods: Data of patients undergoing robot-assisted treatment of gastric GIST were retrieved from the prospectively collected institutional database and a retrospective analysis was performed. Patients were stratified according to size and location of the tumour. Difficult cases (DCs) were considered for size if tumour was >50 mm and/or for location if the tumour was Type II, III or IV sec. Privette/Al-Thani classification. Results: Between May 2010 and February 2017, 12 consecutive patients underwent robot-assisted treatment of GIST at our institution. DCs were 10/12 cases (83.3%), of which 6/10 (50%) for location, 2/10 (25%) for size and 2/10 (25%) for both. The da Vinci Si was used in 8 patients, of which 6 (75%) were DC, and the da Vinci Xi in 4, all of which (100%) were DC. In all patients, excision was by wedge resection. All lesions had microscopically negative resection margins. There was no conversion to open surgery, no tumour ruptures or spillage and no intraoperative complications. Conclusion: Our experience suggests a positive role of the robot da Vinci in getting gastric GIST removal with a conservative approach, regardless of size and location site. Comparative studies with a greater number of patients are necessary for a more robust assessment.

Mycobacteriology

The unexplained increase of nontuberculous mycobacteriosis Octavio Miguel Rivero-Lezcano, Carolina González-Cortés, Mehdi Mirsaeidi International Journal of Mycobacteriology 2019 8(1):1-6 Epidemiological data show a worldwide increase in nontuberculous mycobacteriosis. Although it has been partially attributed to the improvement of microbiological methodologies that has allowed a better recovery and identification of nontuberculous mycobacteria (NTM), it is generally accepted that there is a genuine incidence augmentation. The reasons of the increase are likely multifactorial, depending on the nature of the pathogen, the host, and their interaction. Mycobacteria from the Mycobacterium tuberculosis complex has been regarded as pathogenic and NTM as opportunistic and nontransmissible. Nevertheless, few differences have been found in either their phenotypic or genotypic characteristics. The phenomenon of M. tuberculosis adaptation to the human host may be taking place again in NTM as a consequence of human environmental alterations that facilitate the interaction with the pathogen. The current worsening of the immunological status of increasing numbers of individuals, a result of factors such as malnutrition (obesity and diabetes), population aging or the widespread use of immunosuppressive medication, may be allowing the rapid evolution and person-to-person transmission of NTM. It is likely that mycobacteriosis incidence will keep escalating. New measures should be taken to deal with these diseases, including their reportability and the implementation of strain genotyping that would shed light on the NTM dissemination routes from the environment or human hosts.

Antimycobacterial strategies to evade antimicrobial resistance in the nontuberculous mycobacteria Beverley Cherie Millar, John Edmund Moore International Journal of Mycobacteriology 2019 8(1):7-21 The nontuberculous mycobacteria (NTM) have recently emerged as important bacterial pathogens of both animals and humans. Of particular, concern is the high level of antimicrobial resistance (AMR) displayed by these organisms, which complicates treatment and potential successful outcomes. This review, therefore, wishes to examine novel compounds and approaches to combatting AMR in the NTMs, specifically examining antimycobacterial (NTM) compounds from plants and venoms, as well as examining synergistic and combination effects with other antimicrobials. Novel and modified drugs including new inhaled drugs are examined, as well as the repurposing of existing drugs for antimycobacterial activity. Many of these novel interventions are at various stages of development, from initial concept through to licensed intervention. The challenge remains to translate these interventions from in vitro laboratory models to effective in vivo interactions. When these are realized, then we will have the opportunity of overcoming NTM AMR, to the benefit of medicine, society, and humanity.

Drug resistance profile of Mycobacterium tuberculosis isolates from patients referred to tuberculosis reference laboratory in Kosovo Rrezarta Bajrami, Gjyle Mulliqi, Arsim Kurti, Greta Lila, Lul Raka International Journal of Mycobacteriology 2019 8(1):22-24 Background: Drug-resistant tuberculosis (TB) continues to threaten TB control and remains a major global public health concern. The poor patient adherence in TB treatment is the cornerstone of emerging multidrug-resistant TB (MDR-TB). The aim of this study was to evaluate the resistance of Mycobacterium tuberculosis to the first-line TB drugs among isolates from clinical specimens. Methods: A laboratory-based study was conducted in the Department of Microbiology, within the National Institute of Public Health of Kosovo, from January 2017 to September 2018. Sputum and other clinical specimens were obtained from patients with pulmonary and extrapulmonary TB. The specimens were stained with Ziehl–Neelsen, inoculated on Löwenstein–Jensen media for 6–8 weeks, and tested for sensitivity against the first-line TB drugs (isoniazid [INH], rifampicin [RIF], ethambutol [EMB], and streptomycin [SM]). Results: Of the 316 M. tuberculosis isolates collected, 31.6% showed resistance to first-line TB drugs. Among these resistant isolates, 31% showed resistance to at least one of the first-line TB drugs and 0.3% showed MDR. Resistance to EMB, INH, RIF, and SM was seen in 17%, 8%, 3%, and 72% of isolates, respectively. Polyresistance was seen in 3% of the isolates. Conclusion: Our study confirms that resistance to streptomycin was the most common phenomenon. The resistance pattern identified in this study could assist clinicians in providing appropriate treatment regimen to TB patients and improve their clinical outcome.

Detection of multidrug resistant Mycobacterium tuberculosis in Tabuk, Saudi Arabia, using Genotype MTBDRplus Eltayib Hassan Ahmed-Abakur, Tarig Mohammed Saad Alnour International Journal of Mycobacteriology 2019 8(1):25-28 Background: The global increase in the rates of multidrug-resistant (MDR) tuberculosis (TB) has made the timely identification of resistant Mycobacterium tuberculosis complex strains an important emergence to achieve effective disease management and to prevent their spread in the community. The present study aimed to determine the MDR-TB in Tabuk province, north of the Kingdom of Saudi Arabia. Methods: The GenoType MTBDRplus assay was used to determine the mutations associated with isoniazid (INH) and rifampicin (RIF) resistances. A total number of 61 confirmed M. tuberculosis positive-sputum samples were scanned for the mutation in the rpoB, inhA, and katG genes. Results: The present study revealed that 67.2% of the samples were susceptible, 29.5% were monoresistant, and 3.3% were MDR. Conclusions: The monoresistant showed 26.2% for INH and 3.3% for RIF. The early detection of MDR could guide the starting of appropriate regimen of treatment.

A retrospective study of the severe and uncommon variants of erythema nodosum leprosum at a tertiary health center in central India Vaishali H Wankhade, Pritica Debnath, Rajesh Pratap Singh, Gitesh Sawatkar, Dharitri Mukund Bhat International Journal of Mycobacteriology 2019 8(1):29-34 Background: Erythema nodosum leprosum (ENL) classically presents with tender, coppery, evanescent nodules along with constitutional features and visceral involvement. However, uncommon morphological variants of ENL-like erythema nodosum necroticans, erythema multiforme (EM)-like ENL, Sweet's syndrome (SS)-like ENL, Lucio phenomenon, and reactive perforating type of ENL have also been described in the literature. The primary objective of this study was to describe the clinical features of the severe and uncommon morphological variants of ENL. Methods: This was an observational case series with retrospective review of records of all ENL patients with ulceronecrotic lesions admitted in the Department of Dermato-venereo-leprology of a tertiary health center of central India over a period of 2 years. Results: Eighteen patients were included, all of whom had ulceronecrotic lesions. Four out of them had EM like ENL, two had SS-like presentation, and one of them had annular bullous lesions over old infiltrated plaques of leprosy. Conclusions: Uncommon variants of ENL can be very commonly misdiagnosed in patients, especially in those who have not been previously diagnosed with leprosy. Hence, a high index of suspicion is required in such cases to avoid delay in the diagnosis and resulting morbidity.

Treatment outcomes and associated factors in tuberculosis patients at Jimma University Medical Center: A 5-year retrospective study Gemeda Abebe, Zegeye Bonsa, Wakjira Kebede International Journal of Mycobacteriology 2019 8(1):35-41 Background: Monitoring the outcome of tuberculosis (TB) treatment and investigating factors associated with unsuccessful outcome are essential, as unsuccessful treatment fuels resistance to antibiotics. This study aimed to investigate the treatment outcome and associated factors with an unsuccessful outcome at Jimma University Medical Center (JUMC), Southwest Ethiopia. Methods: A 5-year retrospective analytical study, including all types of TB cases who sought care at JUMC between September 1, 2012, and August 31, 2017, was conducted. Treatment outcomes and TB types were categorized according to the National TB Control guideline. Bivariate analysis was used to analyze the association between treatment outcome and potential variables. Results: Overall data from 1249 patients' records were included in the study. The proportion of male patients was higher (815, 65.3%) than that of females. The mean age (± standard deviation, range) of the cases was 26 (±11. 6, 1–71) years. Of the total, 292 (23.3%) were smear-positive pulmonary TB (PTB), 489 (39.2%) smear-negative PTB, and 468 (37.5%) extra-PTB (EPTB) cases. Available treatment outcomes indicate that 253 (20.2%) were cured, 850 (68.0%) completed therapy, 58 (4.8%) died, 83 (6.6%) defaulted, and 5 (0.4%) failed the therapy. About 76 (5.6%) cases were transferred out and 44 (3.2%) cases were lost to follow-up. In total, 146 (11.7%) patients had an unsuccessful outcome. Unsuccessful treatment outcome was associated with smear-negative PTB (odds ratio [OR] =2.0, 95% confidence intervals [CI] =1.1, 3.7), EPTB (OR = 2.1, 95% CI = 1.2, 3.4), and unknown human immunodeficiency virus (HIV) status (OR = 7.9, 95% CI = 2.5, 25.0). Conclusion: The treatment success rate of overall TB patients is lower than end TB Strategy target of ≥90% success rate. Smear-negative PTB, EPTB cases, and those with unknown HIV status tend to have unsuccessful outcome.

Common alternative diagnoses among a pediatric hospital-based cohort evaluated for tuberculosis in Karachi, Pakistan: The need for facilitated referral in tuberculosis clinics Sadia Shakoor, Fatima Mir, Rumina Hasan International Journal of Mycobacteriology 2019 8(1):42-47 Background: Children evaluated for tuberculosis (TB) are often diagnosed with miscellaneous conditions that mimic TB. Knowledge of differentials informs policy on service provision through liaison with referral centers offering definitive diagnosis and treatment for common alternative disorders. Methods: We reviewed medical records of children who were offered diagnostic testing for TB (culture or Xpert MTB/RIF) at a tertiary care hospital in Karachi, Pakistan to identify common alternative diagnoses among children who are evaluated for TB. Results: From January 2014 to December 2015, of 126 culture or Xpert MTB/RIF negative children presenting with chronic symptoms, 31 were diagnosed and treated for TB based on clinical criteria (5 of 48 children with pulmonary and 26 of 78 with extrapulmonary presentations; 10.4% and 33.3%, respectively). Among remaining 95 patients, common alternative diagnoses to pulmonary TB (n = 43) were bacterial pneumonia or empyema (60.5%, n = 25) and underlying bronchiectasis (20.9%, n = 9). Among 52 extrapulmonary presentations, the most common alternative diagnoses were lymphoproliferative disorders (n = 11, 21.1%), bacterial infections (n = 11, 21.1%), and autoimmune disorders (n = 9, 17.3%). Of note, five children were diagnosed with underlying primary immunodeficiencies (9.6%). Children with alternative disorders were treated for TB in 25 of 95 cases (26.3%). Although 77.8% (n = 98) children were followed up at the facility, 15.9% (n = 20) were lost to follow-up. Conclusions: Pediatric TB mimics many disorders that primary level centers are not equipped to diagnose or manage, leading to suboptimal outcomes. Knowledge of common alternative diagnoses is essential to inform facilitated referral for common mimicking disorders in children.

Survey of local fauna from endemic areas of Northern Queensland, Australia for the presence of Mycobacterium ulcerans Avishek Singh, John Hannan William McBride, Brenda Govan, Mark Pearson International Journal of Mycobacteriology 2019 8(1):48-52 Background: Buruli ulcer (BU), regionally known as the Daintree ulcer or Bairnsdale ulcer is caused by the environmental pathogen Mycobacterium ulcerans (MU). This disease is characterized by extensive and painless necrosis of skin and soft tissue with the formation of large ulcers and has been reported in >33 countries worldwide. This organism is geographically restricted and in Australia, the disease has been reported primarily in coastal Victoria and the Mossman–Daintree areas of northern Queensland. Australia is the only country where nonhuman cases of BU have been confirmed. The common ringtail possums and mountain brushtail possums have been suggested as potential animal reservoirs of MU in coastal Victoria, Australia. The exact mode of transmission of this disease remains unknown. Methods: In this study, we surveyed local fauna from endemic areas of northern Queensland, Australia, for the presence of MU in scat samples. We collected 140 bandicoot, four white-tailed rats, and two possum scat samples from 56 overnight trapping sessions. Samples were examined for the presence of MU DNA by the polymerase chain reaction. Results: Two out of five samples did not contain a sufficient amount of DNA to detect IS2606 and the ketoreductase B (KR) domain of the mycolactone polyketide synthase gene, which is represented by higher cycle threshold (Ct) values for IS2404 shown in table below. Despite of having desired Ct values for IS2404, one IS2404 positive sample possibly contained DNA of closely related M. ulcerans subspecies with lower copy number of IS2606 that do not commonly cause disease in human. All three targets: IS2404, IS2606 and KR were detected from the remaining two scat samples. Conclusion: We confirm the presence of M. ulcerans DNA in the scat samples collected from a Buruli ulcer endemic region of Northern Queensland, Australia.

Blood cytokine responses to early secreted protein antigen-6/culture filtrate protein-10 tuberculosis antigens 2 months after antituberculosis treatment among patients with drug-susceptible pulmonary tuberculosis Happiness Cornel Mvungi, Peter Masunga Mbelele, Joram Josephat Buza, Stellah George Mpagama, Elingarami Sauli International Journal of Mycobacteriology 2019 8(1):53-59 Background: Human tuberculosis is a chronic inflammatory disease caused by mycobacterium tuberculosis. Pulmonary tuberculosis is the result of the failure of host immune system to control mycobacterium tuberculosis. The aim of the study was to asses the changes of the cytokines in active pulmonary tuberculosis patients before and after the use of anti-TB therapy. Methods: Multiple cytokine responses in active tuberculosis (TB) patients were investigated in this study following anti-TB drug therapy after 2 months. Ninety-six participants with pulmonary TB were engaged in the study between May 2018 and October 2018. Samples of blood were taken early before treatment at 0 and 2 months after using anti-TB therapy. The levels of interferon-gamma (IFN)-γ, interleukin-4 (IL-4), IL-6, IL-10, and tumor necrosis factor (TNF)-α in whole blood plasma collected from the QuantiFERON-TB Gold Plus were measured. Results: Compared with baseline levels, TNF-α, IL6 and IL10 were significantly lower following treatment whereas the IFN-γ and IL-4 increased significantly after treatment. The responses of five cytokines varied significantly after treatment (P < 0.0001) where IFN-γ was highest compared to other cytokines with 123.6%, AUC=0.757 and P < 0001, TNF-α AUC: 0.529 and P = 0.743, IL-4 AUC:0.557 and P = 0.514, IL-6 AUC:0.629 and P = 0.047, IL-10 AUC:0.549 and P = 0.581. Conclusion: It is concluded that changes of cytokines that observed during the treatment of TB patients play a very important role in monitoring pulmonary TB and can be suitable biomarkers to assess the effectiveness of anti-TB therapy in patients with TB.

Tuberculosis transmission in the population of patients from the Krakow Region (Poland) based on the epidemiological and molecular methods Katarzyna Kruczak, Ewa Augustynowicz-Kopeć, Monika Kozińska, Grażyna Passak-Stańda, Ewa Niżankowska-Mogilnicka, Krzysztof Sładek International Journal of Mycobacteriology 2019 8(1):60-69 Background: The transmission of tuberculosis may affect the incidence rate of the disease in Poland. Genetic methods are of assistance in tracing the infection transmission, identifying its sources, determining the risk groups, and focusing on the preventive actions. Objectives: The objectives of this study lie in an assessment of tuberculosis transmission by genetic methods with the assistance of the standard epidemiologic interview. Methods: The genome DNA of 275 Mycobacterium tuberculosis (Mtb) strains from tuberculosis patients, inhabitants of the city of Krakow, was subjected to a genetic analysis via the spoligotyping method and the IS6110-Mtb1–Mtb2 polymerase chain reaction (PCR) method. If the DNA profiles were identical in both of the PCRs, they were considered identical and classified within one molecular family. Results: Among 275 strains, 104 genetic patterns (spoligotypes) were identified. Two hundred and three strains were divided into 66 molecular families (clusters) and analyzed with the IS6110- Mtb1–Mtb2 PCR method. Eighteen clusters were separated. In the Mtb1–Mtb2 clusters, 21 patients were in the risk groups (the homeless, prisoners, and nursing home residents). We did not confirm any direct or temporary contacts between the patients constituting the Mtb1–Mtb2 clusters (apart from the risk groups). However, the patients in these clusters often lived in the same parts of Krakow. Conclusions: The standard epidemiologic interview in tuberculosis patients should be combined with genetic methods. Active transmission of tuberculosis occurs largely among the individuals maintaining probably periodic contacts. The patients who are in the risk groups may play an important role in the transmission of tuberculosis.

Postgraduate Medical Journal

Towards zero mortality in sickle cell pregnancy: A prospective study comparing haemoglobin SS and AA women in Lagos, Nigeria Ochuwa Adiketu Babah, Monsurat Bolanle Aderolu, Ayodeji A Oluwole, Bosede B Afolabi Nigerian Postgraduate Medical Journal 2019 26(1):1-7 Introduction: Sickle cell disease in pregnancy carries increased risk of maternal and perinatal morbidity and mortality. Past studies on pregnancy complications in sickle cell disease women were limited by relatively small sample sizes, and use of retrospective and hospital discharge data. Study Design: This prospective case-control study compared booked pregnant Haemoglobin (Hb) SS women with AA controls from two tertiary centres in Lagos, in order to precisely identify their complication and mortality rates and identify associated factors. Eligible pregnant HbSS and HbAA women were recruited from antenatal clinics at booking and follow-up visits. Information was collected on a proforma and data was analyzed using IBM SPSS version 20. Results: We found higher complication rate in HbSS group, commonest complications being vaso-occlusive crisis (RR 1.47, 95% CI 1.22 – 1.78), pregnancy induced hypertension (RR 1.31, 95% CI 1.08 – 1.57), urinary tract infection (RR 1.32, 95% CI 1.12 – 1.57), and intrauterine growth restriction (RR 1.2, 95% CI 1.05 – 1.34). HbSS group had higher systolic and mean arterial blood pressure values in early puerperium compared to HbAA group (p = 0.014 and 0.024 respectively). No maternal death recorded in both group. Incidence of low birth weight <2.5Kg was 38% in HbSS and 4% in HbAA subjects, p = 0.001. However, overall maternal and perinatal outcomes were comparable in both groups (p = 1.000). Conclusion: Although sickle cell disease poses higher obstetric risk in pregnancy, maternal and perinatal outcome can be as good as in the non-sickle cell pregnant women if adequate and prompt individualized care is given to this group of women.

Heart rate variability study in adult Nigerian subjects with sickle cell disease during vaso-occlusive crisis Adewole Adesoji Adebiyi, Olaniyi Mabayomije Oyebowale, Ayodele John Olaniyi, Ayodele Olawale Falase Nigerian Postgraduate Medical Journal 2019 26(1):8-12 Context: Autonomic nervous system (ANS) dysfunction assessed by abnormalities in heart rate variability (HRV) is thought to play a role in the pathophysiology of sickle cell disease (SCD). There is suggestion that changes in ANS may occur in SCD subjects during episodes of vaso-occlusive crises (VOC). Aims: The aim of this study was to evaluate the ANS by determining the HRV in patients with SCD during VOC. Settings and Design: This was a cross-sectional observational study. Materials and Methods: HRV studies were carried out in 76 participants with SCD during episodes of VOC. Eighty-two SCD participants in steady state served as controls. Statistical Analysis Used: Comparison of two independent groups with Student's t-test and Mann–Whitney's test, and multiple linear regressions were also carried out. Results: Participants with SCD and VOC had significant reductions in the time-domain HRV parameters of standard deviation of RR intervals (45.8 [59.36] ms vs. 66.3 [129.2] ms, P = 0.0073) and root mean square of successive differences of RR intervals (48.3 [87.66] ms vs. 74.2 [174.5] ms, P = 0.0015). The frequency-domain HRV indices of low frequency (145.8 [81.62] ms2 vs. 157.5 [68.9] ms2, P = 0.1442) and high frequency (145.0 [118.40] ms2 vs. 146.3 [90.3] ms2, P = 0.3683) were similar between the two groups. Age and the heart rate were the major independent relations of the HRV parameters. Conclusions: Time-domain HRV parameters were impaired during crises in participants with SCD. This finding suggests further impairment of ANS activity in SCD patients during crises. Further studies are needed to clarify the prognostic implication of these findings.

Haematological values in steady-state sickle cell anaemia patients and matched heamoglobin AA Controls in a Rural Area of Eastern Gabon Landry Erik Mombo, Gaël Mabioko-Mbembo, Cyrille Bisseye, Kevin Mbacky, Fatoumata Thiam, Apollinaire Edou Nigerian Postgraduate Medical Journal 2019 26(1):13-17 Background: In Gabon, universal neonatal screening of sickle cell disease is not carried out in rural areas, often leading to late detection of the disease. However, complete blood counts are available in rural areas. Materials and Methods: We evaluated the haematological parameters of 45 homozygous steady-state sickle cell anaemia (SCA) patients and compared them with 45 sex- and age-matched Haemoglobin AA controls in Koula-Moutou, a rural area in Eastern Gabon. Results: Homozygous SCA patients had low erythrocyte values (red blood cells: 2.50 × 1012/L, haemoglobin: 7.20 g/dL and haematocrit: 20.70%) and high leucocyte values (white blood cells: 14.40 × 109/L, lymphocytes: 5.24 × 109/L and monocytes: 1.60 × 109/L). Most of the SCA patients had severe anaemia (67%), normochromia (76%), lymphocytosis (73%) and monocytosis (84%). A haemoglobin level of < 8.5 g/dL together with a leucocyte level above 9.5 × 109 cells/L was used as screening test to detect homozygous SCA patients, with sensitivity of 84.4% and specificity of 97.8%. Conclusion: The values for erythrocyte and leucocyte cell lines of SCA patients in steady state are clearly different from those of the matched HbA/A controls. This makes it possible to set up a tool to detect SCA based on the haemogram in a rural area that does not possess haemoglobin electrophoresis. This tool could be used by healthcare workers in the absence of universal newborn screening for SCA.

Medication adherence and 24-h blood pressure in apparently uncontrolled hypertensive Nigerian patients Abiodun Moshood Adeoye, Akindele Olupelumi Adebiyi, Oladimeji Muritala Adebayo, Mayowa Ojo Owolabi Nigerian Postgraduate Medical Journal 2019 26(1):18-24 Background: Uncontrolled hypertension is a major risk for major cardiovascular events. While medication adherence determines blood pressure (BP) control, studies on treatment adherence among apparently uncontrolled hypertensives are sorely lacking in sub-Saharan Africa. We report the pattern and correlate of medication adherence among the uncontrolled hypertensive population. Materials and Methods: We investigated 148 age- and sex-matched hypertensive adults on anti-hypertensive medication for a minimum of 1 year. Apparent uncontrolled BP was defined as clinic BP ≥140/90 mmHg, whereas 24-h ambulatory BP monitoring was used to determine the true uncontrolled hypertension and other BP phenotypes. Using the 8-item Morisky medication adherence scale participants were classified into high, moderate and low adherence while Modified Morisky Scale was used to assess knowledge and motivation. Results: The mean age and BP were 61 ± 13.3 years and 158/91 mmHg, respectively. High adherence was found in 4.1% of the participants while 68.9% and 27% had moderate and low adherence, respectively. A third had true uncontrolled hypertension. A high proportion of the study participants also had a high motivation (68.9%) and knowledge (89.2%). Medication adherence was associated with motivation (P = 0.0001), knowledge (P = 0.002) and obesity (P = 0.036). Knowledge was an independent determinant of medication adherence with no significant effect on BP control. Conclusion: High medication adherence was low and a third had true uncontrolled hypertension. Knowledge was an independent predictor of medication adherence with no significant effect on blood control. High medication adherence rather than moderate adherence, and knowledge are indeed needed for adequate BP control.

Comparison of visual estimation of intra-operative blood loss with haemoglobin estimation in patients undergoing caesarean section Sampson Uzo Anya, Fidelis Anayo Onyekwulu, Elias Chukwujioke Onuora Nigerian Postgraduate Medical Journal 2019 26(1):25-30 Background: Obstetrical haemorrhage is a potentially preventable cause of maternal morbidity and mortality; and measurements of surgical blood loss (BL) are often inaccurate. Accurate BL estimation is paramount as it may substantially alter the timing of interventions to control haemorrhage. The study compares the assessment of intra-operative BL by visual estimation with BL calculated from haemoglobin estimation using the HemoCue®201+. Materials and Methods: A total of 60 pregnant patients at term undergoing elective caesarean section under spinal anaesthesia were enrolled into the study. In the theatre, the patients' haemoglobin level was determined before and after the surgery using the HemoCue®201+; and a modified Gross formula was used to calculate the BL. BL was also visually estimated and documented by counting the blood-soaked abdominal mops and gauze pieces and multiplying them by the estimated volume of blood each would hold; fixed size mops and gauzes were used. Statistical analysis was performed to compare both methods using SPSS Version 17. To compare BL assessment, Pearson's correlation and the Bland and Altman's method of assessing agreement between two methods of clinical measurement were used. Results: The mean visually estimated BL (EBL) and HemoCue calculated BL (CBL) were 470 ± 221 ml and 563 ± 204 ml, respectively (P = 0.125). The bias (mean difference between both methods) was negligible (45.25 ml), and the limit of agreement between both methods was −222.20–275.43 ml. The discrepancy between the two methods increased when BL was ≥500 ml. Conclusion: This study showed that visually EBL was closely related to HemoCue CBL when the quantity of BL was <500 ml.

Post-operative management in uncomplicated caesarean delivery: A randomised trial of short-stay versus traditional protocol at the Lagos University Teaching Hospital, Nigeria Nuvie Oyeyemi, Lawal Oyeneyin, Ayodeji Oluwole, Abisoye Oyeyemi, Bosede Afolabi Nigerian Postgraduate Medical Journal 2019 26(1):31-37 Context: Caesarean section (CS) is the most common major obstetric operation. There has, therefore, been an increasing interest in issues pertaining to the management and length of hospital stay following the procedure. Aim: This study aimed to evaluate morbidity outcomes as well as incurred costs between traditional and short-stay protocols, following uncomplicated CS deliveries. Settings and Design: This was a randomised controlled trial conducted among booked antenatal patients who had elective CS at the Lagos University Teaching Hospital. Materials and Methods: Using a parallel study design, patients were randomised into short-stay and traditional protocols. Patients in the short-stay group were ambulated and graded oral intake initiated from 6 h post-operation. Their urethral catheters were discontinued at 12 h, and subsequent discharge was at 3rd day post-op. Those in the traditional group were ambulated from 12 h, graded oral intake initiated and urethral catheters removed at 24 h, then the patients were discharged on the 5th day post-operation. Pain scores of all the patients at 72 h, fever in the first 10 days (excluding the first 24 h), clinical signs of wound sepsis, urinary tract infection and puerperal sepsis in the first 14 days post-op were recorded. Statistical Analysis: Descriptive statistics were used to summarise the quantitative variables. The association between categorical variables was tested using Chi-square test, and differences in group means were assessed using t-test. The confidence level was 95%, and the level of significance was set at P < 0.05. Results: There were no significant differences in febrile and infective morbidities between the two groups. However, women in the short-stay group had significantly lower pain scores (t = 4.75, P < 0.001) and hospital expenses (t = 5.53, P < 0.0001) than women in the traditional group. Conclusions: The short-stay protocol following uncomplicated CS delivery was safe and more cost-effective than the traditional protocol.

Mentoring in a resource-constrained context: A single-institutional cross-sectional study of the prevalence, benefits, barriers and predictors among post-graduate medical college fellows and members in South-Eastern Nigeria Gabriel Uche Pascal Iloh, Miracle Erinma Chukwuonye, Obianma Nneka Onya, Ezinne Uchamma Godswill-Uko Nigerian Postgraduate Medical Journal 2019 26(1):38-44 Background: Globally, the post-graduate medical education has undergone tremendous changes with emphasis on training, services and research to equip trainees with competence for independent professional development. However, not all the fellows and members of the West African Post-graduate Medical College and the National Post-graduate Medical College of Nigeria recognise the values of mentoring in achieving the career success. Aim: The study was aimed at describing the prevalence, benefits, barriers and predictors of mentoring in a cross-section of the Post-graduate Medical College fellows and members in a tertiary health institution in South-Eastern Nigeria. Participants and Methods: A cross-sectional study was carried out among 168 study participants who were sampled from the Post-graduate Medical College fellows and members in the Federal Medical Centre, Umuahia, Nigeria. Data collection was done using a pre-tested, self-administered questionnaire that elicited information on awareness, prevalence, barriers and benefits of mentoring. Results: The age of participants ranged from 26 to 59 (41 ± 9.4) years. All the respondents were aware of the mentorship. The prevalence of mentoring was 33.3%. The most common benefit was personal and professional growth and development (100.0%). The most common barrier was the pressure of professional duties and personal exigencies (100.0%). The most significant predictor of mentoring had departmental mentoring programme participants who had departmental mentoring programmes were two times more likely to have mentoring relationships when compared to their counterparts who had none (adjusted odds ratio = 2.32; 95% confidence interval: 1.20–3.10; P = 0.002). Conclusion: The level of awareness of mentoring was very high but did not translate to appropriate involvement in mentoring. The most common benefit was personal and professional growth and development. The most common barrier was the pressure of professional duties and personal exigencies. The most significant predictor of mentoring relationship had departmental mentoring programme.

Demographic characteristics and causes of death for persons brought in dead to emergency department of a Tertiary Health Facility in South-West Nigeria Oluseyi Adegoke, Janet Ngozi Ajuluchukwu Nigerian Postgraduate Medical Journal 2019 26(1):45-52 Introduction: Identifying the demographic characteristics and causes of death in persons 'brought-in-dead' (BID) will inform possible strategies for the prevention of their occurrence. Objective: To characterise the demography as well as document the autopsy-determined underlying and immediate causes of death in BID cases presenting to the emergency department (ED) of a tertiary health facility. Methods: This is a 5-year retrospective descriptive study of 253 autopsied-BID cases. Data were obtained from ED 'death-register' and the hospital 'autopsy-register'. The underlying and immediate causes of death were classified and analysed across the age groups of 21–40, 41–60 and >60 years. Results: The age of the cases ranged from 22 to 101 years with a median of 56.0 (38-72) years. Almost half [110(43.5%)] of the cases were in the age-group >60 years. The male-to-female ratio was 1.04:1, and their ages were comparable. Non-communicable diseases accounted for 216 (85.4%) of the underlying causes of death. Three major specialities contributing to death were medicine 117 (46.2%), oncology 45 (17.0%) and surgery/trauma 42 (16.6%). Specialties of medicine and surgery/trauma were predominantly in age groups >60 years (60.0%) (P ≤ 0.0001) and 20–40 years (31.5%) (P = 0.0001), respectively. The chief underlying causes of death in the specialities of medicine, oncology and surgery/trauma were cardiovascular diseases (61 [52.1%]), breast cancer (11 [24.4%]) and road traffic accidents (31 [73.8%]), respectively. Overall immediate causes of death included heart failure (21.3%), unspecified circulatory collapse (17.0%), central nervous system pathologies (16.6%) and haemorrhagic shock (10.7%). Heart failure (33.6% [37/110]) and haemorrhagic shock (28.8% [21/73]) were the most common immediate causes of death in the >60 years' and 20–40 years' age groups, respectively. Conclusion: Non-communicable diseases are the leading causes of death in persons 'BID'. Deaths from medical conditions, especially heart failure, occurred mainly in the elderly. Deaths from trauma and haemorrhage occurred predominantly in the young.

The pattern and outcomes of childhood renal diseases at University of Abuja Teaching Hospital, Abuja, Nigeria: A 4 year retrospective review Emmanuel Ademola Anigilaje, Temilade Christianah Adesina Nigerian Postgraduate Medical Journal 2019 26(1):53-60 Introduction: Renal disorders contribute to childhood morbidity and mortality in developing countries. Therefore, the knowledge of the burden of childhood renal diseases is required for preventive and management purposes. This article determines the pattern and the outcomes of childhood renal diseases seen at the University of Abuja Teaching Hospital (UATH), Gwagwalada, Abuja, Nigeria. Materials and Methods: This was a retrospective review of children aged 1 month to 17 years, who were seen at the paediatric nephrology clinic, emergency paediatric unit and paediatric ward of the UATH over 4 years from January 2013 to December 2016. Results: A total of 4327 children were seen during the study period, with 163 of them having renal disorders, including 95 (58.3%) males and 68 (41.7%) females (mean age of 5.9 ± 4.7 years) giving a prevalence of 3.8% (38 cases per 1000 children). There was a progressive increase in the diagnoses of renal diseases during the study period, from 3.1% in 2013 to 5.4% in 2016. The most common disorders were urinary tract infection (UTI) 50 (30.7%) and acute kidney injury (AKI) 50 (30.7%). Others included nephrotic syndrome (11.7%), congenital anomalies of the kidney and the urinary tract (9.2%), acute glomerulonephritis (7.9%), chronic kidney disease (CKD, 6.7%), nephroblastoma (3.7%) and urolithiasis (2.5%). Twenty-three children died (mortality rate of 14.1%), resulting mostly from AKI (7.8%) and CKD (9.1%). Conclusion: UTI and AKI are the leading renal disorders in this study. Concerted efforts are needed to promote preventive nephrology in the face of high cost of treating acute kidney disease and CKD in Nigeria.

Undiagnosed placenta praevia percreta: A rare case report and review of management Adeyemi Adebola Okunowo, Ephraim Okwudiri Ohazurike, Fatimah Murtazha Habeebu-Adeyemi Nigerian Postgraduate Medical Journal 2019 26(1):61-64 Placenta accreta spectrum disorders, especially placenta percreta (PP) and placenta praevia (PLP), are major risk factors for massive obstetric haemorrhage which is a common cause of maternal morbidity and mortality in our environment. This risk becomes exponential and life-threatening when the two conditions co-exist in the same patient. Even in advanced countries with readily available expertise and state of the art resuscitative and supportive facilities, these conditions are associated with grave maternal and perinatal morbidity and mortality. We present a challenging case of PP co-existing with major PLP, which was diagnosed intraoperatively and the patient had total abdominal hysterectomy and bilateral internal iliac artery ligation to control haemorrhage.

Atherosclerosis

Audit of pcsk9 inhibitor prescribing in the north east of england Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): P. Banerjee, R.D.G. Neely, S. Pattman, S. Artham, P. Carey, S. Kamaruddin, S. Mada, J. Weaver, S. Chiu

Epidemiology of cardiovascular risk factors in two population-based studies Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 35 Author(s): Elena Olmastroni, Evgeny V. Shlyakhto, Aleksandra O. Konradi, Oxana P. Rotar, Asiiat S. Alieva, Maria A. Boyarinova, Andrea Baragetti, Liliana Grigore, Fabio Pellegatta, Elena Tragni, Alberico L. Catapano, Manuela Casula Abstract We aimed to compare cardiovascular risk factors prevalence in Italy and Russia through cross-sectional database analysis. The study has been based on data from ESSE-RF and from baseline of PLIC study, two population-based epidemiological studies aimed to investigate prevalence of risk factors and evaluating contribution of traditional and new risk factors into morbidity and cardiovascular mortality. A total of 2203 patients with left and right intima-media thickness (IMT) measurements constituted the source population (1205 from PLIC study and 998 from ESSE-RF study). Sample of ESSE-RF study had slightly more diabetic and hypertensive individuals, while the percentage of subjects with high cholesterol value was lower than in the other sample (67.1% vs 79.9%). The median LDL-C value was higher among individuals not treated with statins in the PLIC sample (p < 0.001), while was comparable among subjects receiving statin therapy. On the other hand, the percentage of individuals with positive cardiovascular history was higher in ESSE-RF sample. This could also explain the higher mean IMT value (0.71 ± 0.17 vs 0.63 ± 0.13) in the whole sample, and among patients without past cardiovascular events (regardless of statin treatment), despite some differences in major risk factors. Despite Russian and Italian populations are culturally and geographically different, they are not so different based on characteristics analyzed.

Large artery stiffness according to different assessment methods in adult population of St.Petersburg Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 35 Author(s): A.S. Alieva, O.P. Rotar, A.V. Orlov, M.A. Boyarinova, E.V. Moguchaya, A.N. Rogoza, A.O. Konradi, E.V. Shlyakhto Abstract Objective The aim of the present study was to assess the prevalence of increased arterial stiffness by different diagnostic methods and its association with cardiovascular risk in Russian population-based cohort. Design and methods In terms of Russian epidemiological study ESSE-RF a random selection of 452 apparently healthy Saint-Petersburg inhabitants aged 25–65 years was performed. Fasting lipids, glucose and blood pressure measurements were performed. We used 3 diagnostic methods of arterial stiffness assessment: pulse wave velocity by applanation tonometry (SphygmoCor - PWV-S) and pulse wave velocity by volumetric sphygmography (VaSera - PWV-V), and cardio-ankle vascular index (CAVI) by VaSera. Results 341 (75,4%) had normal parameters of arterial stiffness assessed by all methods. Spearmen's coefficient of correlation and "kappa" coefficient for PWV-S and CAVI were 0,74 and 0,04, for PWV-S and PWV-V - 0,10 and 0,06, for CAVI and PWV-V - 0,28 and 0,03, respectively. There was a significant correlation between cardiovascular risk (defined by SCORE) and PWV-S (r = 0,38, p < 0,001) and a non-significant trend of increasing CAVI along with cardiovascular risk (r = 0,35, p = 0,14). Conclusions Different methods of arterial stiffness assessment showed a weak correlation with each other. Carotid-femoral pulse wave velocity detected by applanation tonometry is associated with high cardiovascular risk score and might be considered as better additional risk marker for cardiovascular risk stratification.

Effect of combination therapy with pcsk9 inhibitors and lipoprotein apheresis Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): A. Pottle, C. Browne, E. Neves, M. Barbir

An experience of dedicated fh service implementation in hull and east yorkshire hospitals nhs trust Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): P. Sutton, R. Dunn, R. Desborough, M. Malik, A. Bandyopadhyay, K. Haramblos, D. Narayanan

Setting up a regional fh service; a summary of the achievements and challenges Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): K. Mitchell, J. Webster, C. Tuson, C. Burton, P. Sutton, R. Dunn, D. Chandrajay, D. Narayanan, M. Mansfield, J. Barth, A. Bandyopadhyay, K. Haralambos, B. Power, J. Jessop

? Dual pathology for pancreatitis in pregnancy Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): O. Kirresh, U. Srirangalingam, C. Lunken

Unusual presentation of rhabdomyolysis after co-administration of statin and clarithromycin Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): O. Kirresh, C. Lunken

The impact of socio-economic status on case finding for familial hypercholesterolaemia. Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): L. Gritzmacher, K. Haralambos, P. Downie, G. Bayly

Patient experience at a dedicated multidisciplinary non-alcoholic fatty liver disease (nafld) clinic encompassing cardiovascular risk assessment and management. a new model of care? Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 34 Author(s): A. Goyale, M.G. Misas, D. Roccarina, D.R. Nair, E. Tsochatzis

Public Health

Rheumatic heart disease: A neglected public health priority Rajesh Kumar Indian Journal of Public Health 2019 63(1):1-3

Effectiveness of a community-based intervention on nutrition education of mothers of malnourished children in a rural coastal area of South India G Pavithra, S Ganesh Kumar, Gautam Roy Indian Journal of Public Health 2019 63(1):4-9 Background: There is a paucity of evidence on improvement in malnutrition status after follow-up intervention among malnourished under-five children. Objective: The objective of the study is to assess the effect of community-based follow-up health education intervention on the awareness level of mothers, calorie intake, protein intake, and weight gain of malnourished children. Methods: This intervention study was conducted from December 2012 to October 2014 in three phases at rural Puducherry, coastal South India. The intervention group (57 mothers of 64 children) and control group (60 mothers of 64 children) included moderate and severely malnourished children aged 13–60 months. Children in the control group were taken from different areas and matched for age (±6 months) and sex. Health education intervention and follow-up supervision for 15 months were given to the mothers. Results: Awareness level in all domains increased significantly in the intervention group. In the intervention group, 81% (52) of malnourished children turned out to normal, whereas in the control group, 64% (41) of them became normal. There was a statistically significant difference between the mean changes in the protein intake among boys (15.34 g to 19.91 g in the intervention group against 13.6 g to 16.24 g in the control group) and girls (15.09 g to 19.57 g in the intervention group against 13.36 g to 16.51 g in the control group) and calorie intake among girls (993.86 kcal to 1116.55 kcal in the intervention group against 992.65 kcal to 1078.75 kcal in the control group) between the two groups. Conclusion: There was comparatively marginal increase in protein intake, calories' intake, and weight gain in the intervention group.

Barriers for low acceptance of no scalpel vasectomy among slum dwellers of Lucknow City Shazia Shafi, Uday Mohan, Shivendra K Singh Indian Journal of Public Health 2019 63(1):10-14 Background: Uttar Pradesh is the most populated state of the country having population of 199.581 million and total fertility rate of 3.3 (annual health survey [AHS] 2012–2013) with high fertile trajectory. Currently, female sterilization accounts for about 18.4% and male sterilization for 0.3% of all sterilizations in Uttar Pradesh (AHS 2012–2013). A strategy to promote men's involvement in effective birth control is needed to reduce the population growth. Since no scalpel vasectomy (NSV) is an easy method but still not being utilized; hence, the purpose of this research is to ascertain various factors of nonutilization of NSV. Objectives: The objective of the study is (i) to determine the barriers among married males for adopting NSV as a method of family planning, (ii) to determine the awareness about NSV, (iii) to suggest measures to increase uptake of NSV by the people. Methods: A cross-sectional study was carried out. A two-staged multistage random sampling technique was used. Lucknow is divided into eight Nagar Nigam zones. In the first stage, two urban slums from each geographical zone were selected randomly. In the second stage, from each selected slum a sample of 24 eligible households was selected at random to achieve the desired sample size. Results: It was observed that among the study participants maximum 89.2% perceived Sociocultural barriers, while 0.6% of the participants perceived service delivery barriers. However, 14% of the participants also perceived procedure-related barriers as the most important cause for not accepting NSV. Conclusion: Measures should be taken to remove these barriers, and increase uptake of NSV.

Oral health-related quality of life among elderly patients visiting special clinics in public hospitals in Delhi, India: A cross-sectional study Puneet Chahar, Vikrant R Mohanty, YB Aswini Indian Journal of Public Health 2019 63(1):15-20 Background: Oral health is recognized as an integral component of general health, and poor oral health is reflected in general health and quality of life (QoL). India has seen a profound shift in the elderly population and is currently home to 103.9 million elders. General Oral Health Assessment Index (GOHAI) is a self-reported oral health assessment index used in elderly population and has been tested in multiple countries. Objective: The study aimed to assess the oral health-related QoL (OHRQoL) using GOHAI and various factors affecting it, among elderly patients visiting special Sunday geriatric clinics at Delhi public hospitals. Methods: A cross-sectional study was conducted among four purposively selected special geriatric public clinics in Delhi, India, and a convenience sample of 145 elderly patients was obtained. OHRQoL was measured using a prevalidated instrument (GOHAI) along with other variables (sociodemographic factors, self-perceived oral health, utilization of medical/dental services, dental problems in the past 12 months, and prosthetic status/need). Statistical analysis was done using Statistical Package for the Social Sciences software version 21, and descriptive results were obtained. Results: The sample consisted of 66 males (45.5%) and 79 females (55.5%), and around 58% (n = 84) of the participants were illiterate. Around 39% (n = 57) of the elderly had never visited a dentist and 48% (n = 69) were financially dependent (no income) on others. The mean GOHAI score for the population was 26.69 + 4.44 (median = 25, interquartile range = 23–27). GOHAI score was compared for age, oral hygiene practices, dental problems in the past 12 months, self-reported oral health, and prosthetic need, and a statistically significant difference was observed. Conclusions: The current study assessed GOHAI score and highlighted important determinants of OHRQoL in elderly population visiting the special clinics in Delhi. Thus, OHRQoL should be considered as a surrogate measure to clinical oral examination.

Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study Pothiraj Pitchai, Hiral Bipin Dedhia, Nidhi Bhandari, Deepa Krishnan, Nikshita Ria John D'Souza, Jayesh Mahesh Bellara Indian Journal of Public Health 2019 63(1):21-26 Background: Falls is one of the common problems faced by elderly population and in preventing falls in India, research has largely focused on identification and management of risk factors, but the circumstances of the fall and its associated factors are sparsely researched. Objectives: The primary objective is to find the prevalence of fall, investigate risk factors, and its circumstances for falls and level of functional independence in elderly population. The secondary objective is to find out fear of fall (FOF) and its association of demographic factors on elderly population. Methods: This was a cross-sectional study; 2049 elderly population of 60 years and above were recruited by one-stage cluster sampling technique within Mumbai, Panvel, and Thane cities, Maharashtra. Data were collected using a questionnaire, Fall Efficacy Scale-International, Barthel Index, and Kuppuswamy Scale. Obtained responses were analyzed using SPSS software; descriptive statistics and Chi-square test were applied. Results: The prevalence of falls in this study found as 24.98%. Demographic factors such as age group, education, marital status, and socio-economic status had demonstrated a significant association with older adults (P < 0.05); 44.92% of falls occurred in the morning, the majority of falls (65.43%) occurred indoors, 56.45% of the fallers reported to had slips, and 60.55% of the fallers had sustained injuries. From the total participants, 34.70% of the fallers reported FOF, 23.67% of the fallers expressed reduced functional activities, and 18.06% of the fallers demonstrated affection in activities of daily living. Conclusion: This study reveals fall as a significant health problem and provides insight into the influencing risk factors for falls among older adults.

Determinants of infant mortality in rural India: An ecological study Abhijit Mukherjee, Sharmistha Bhattacherjee, Samir Dasgupta Indian Journal of Public Health 2019 63(1):27-32 Background: Long-term reductions in infant mortality (IM) are possible only by addressing the distal determinants. Objectives: The objective of the present study was to determine the relationship between IM and its major distal determinants in rural India. Methods: The dependent variable used in the study was state wise IM rate (IMR), the values of which were obtained from the Sample Registration System, 2015. State level literacy rate in females, unemployment rates of females, GINI index, and round-the-clock neonatal services in primary health centers in the rural areas and the per capita gross state domestic product at purchasing power parity (GSDP at PPP) of the states, were used as the predictor variables for IM. Relationship between the variables was obtained by the Pearson's correlation coefficient. Bivariate and multivariable linear regressions were used to identify the magnitude and direction of the predictors on IM. Results: Correlation statistics showed none or weak positive correlation between the Gini coefficient and 24 × 7 primary health-care services and IMR. There was a strong negative correlation between female literacy rate and IMR, while the unemployment rates and per capita gross state domestic product (GSDP) were moderately negatively correlated to IMR. Bivariate analysis revealed that, for unit increase in unemployment rates in females, proportion of literate women, and 1000$ increase in the GSDP at current prices, IMR decreased by 0.07, 0.763, and 1.702, respectively. However, after adjustment, only the female literacy rates showed significant association with IMR. Conclusions: Of the major determinants included in the study, rural female literacy is the most important distal determinant of IM in rural areas of India.

Trends and future burden of tobacco-related cancers incidence in Delhi urban areas: 1988–2012 Rajeev Kumar Malhotra, Nalliah Manoharan, Omana Nair, S V S Deo, Gourva Kishore Rath Indian Journal of Public Health 2019 63(1):33-38 Introduction: Tobacco products are the major contributors for various cancers and other diseases. In India, tobacco-related cancers (TRCs) contribute nearly half of the total cancers in males and one-fifth in females. Objective: The objective of the study is to investigate 25-year trends and projection of TRCs for 2018–2022. Methods: Joinpoint analysis was performed to assess the trends of TRCs on world age-adjusted rates. Age-period-cohort model with power link function was performed to project the future incidence burden of TRCs in urban Delhi. Results: During the 25 years, a total of 67,129 TRCs (53,125 males and 14,004 females) were registered which was 25.4% of total cancer cases registered. Males contributed 39.1% and females 10.8% of total cases. In males, TRCs declined significantly from 1988 to 2003 with estimated annual percentage change (EAPC) = −0.91% and thereafter increasing trend was observed with EAPC = 3.42%, while in females, the EAPC values were 2.2% and 3.54% respectively for the same period. The total burden of TRCs will be doubled in 2018–2022 with around 46% change due to cancer risk and around 54% due to population age and size in both the genders. The average annual count in males will be 7310 in 2018–2022 as compared to 3571 in 2008–2012 while in females this count will be increased to 2066 from 955 based on recent slope. Conclusion: The incidence of TRCs is increasing due to increase in population age, size, and factors other than population. TRCs are the preventable cancers, and load of these cancers can be controlled with strictly adhering the policy and acts.

Depression among tuberculosis patients attending a DOTS centre in a rural area of Delhi: A cross-sectional study Umang P Salodia, Surabhi Sethi, Anita Khokhar Indian Journal of Public Health 2019 63(1):39-43 Background: Studies have shown that the prevalence of psychiatric disorders, particularly depression, is high among tuberculosis (TB) patients, and may adversely affect treatment compliance. A person suffering from TB can develop depression in due course of time owing to a number of factors, namely the long duration of treatment for TB, stigmatization faced by the patient due to the disease and lack of family support to name a few. Objectives: The present study aimed to determine the prevalence of depression and its correlates among TB patients enrolled at a Directly Observed Treatment Short-course (DOTS) center in a rural area of Delhi. Methods: The study was a DOTS center-based, cross-sectional study, among 106 patients of pulmonary and extrapulmonary TB, above 18 years of age. An interviewer-administered questionnaire in Hindi was used to collect basic sociodemographic data and the Patient Health Questionnaire (PHQ)-9 was used for detecting depression. Those with a score of 10 or more were considered to be suffering from depression. Data analysis was done using SPSS licensed version 20. Chi-square was used to test for association between qualitative variables, and a P < 0.05 was considered statistically significant. Results: A total of 106 patients participated in the study, of which 61 (57.5%) were males. The median age was 30 years (inter-quartile range 24–40 years). Depression was found to be present in 25 (23.6%) participants. A higher proportion of patients with depression were unemployed currently, and also belonged to middle or lower class (P < 0.05). Depression was not found to be associated with religion, gender, marital status, HIV status, presence of diabetes, DOTS category nor with the phase of treatment. Conclusion: Depression among TB patients is common, affecting almost one in four TB patients. Physicians and DOTS providers should have a high index of suspicion for depression when assessing TB patients.

Common mental disorders among HIV-uninfected women living in HIV serodiscordant setting: A clinic-based study in Pune, Maharashtra, India Shrinivas S Darak, Swapna R Pawar, Sanjay S Phadke, Vinay V Kulkarni Indian Journal of Public Health 2019 63(1):44-50 Background: India is home to 2.1 million people living with HIV with an estimated 44% people having an uninfected partner. Living in HIV serodiscordant setting can be stressful, especially for women and can lead to several common mental disorders (CMDs). However, the occurrence of CMD in this population is not studied in India. Objectives: The study aimed to assess the occurrence of CMD in HIV-uninfected women living in HIV serodiscordant setting. A sample of 152 HIV-uninfected women who are wives of HIV-infected men attending an HIV clinic were interviewed by trained interviewers. Methods: The International Classification of Diseases-10 diagnosis of any of the CMDs was done using standard structured diagnostic interview MINI 5.0.0. Current, past, and lifetime occurrence was estimated for various CMDs. Chi-square and point-biserial correlation coefficients were used to understand the relationship between various sociodemographic and HIV-related factors with current CMD. Results: The current, past, and lifetime occurrence of at least one CMD was 35.5%, 49.3%, and 62.5%, respectively. Common diagnoses were mixed anxiety-depressive disorder, major depressive disorder, and posttraumatic stress disorder. Of the women with CMD, 22% had accompanying suicidality. Conclusions: The high rate of occurrence of CMD observed among the study population calls for more attention on the policy and program level to address the mental health needs of this population. Globally, more number of HIV-infected people are now linked to the care. This provides an opportunity to incorporate mental health care into routine HIV care.

Development of integrated care tool – BRIEF for screening the unmet psychosociomedical needs of older Indians Prasun Chatterjee, George W Rebok, Sada N Dwivedi, Deepa A Kumar, Ruchika Madan, Aparajit B Dey Indian Journal of Public Health 2019 63(1):51-57 Background: With demographic shifts, there is an unprecedented increase in noncommunicable diseases, multimorbidity, and geriatric syndromes among older adults, especially in economically weaker sectors. However, there is no socioculturally appropriate tool to screen older adults for age-related health needs, multimorbidity, and geriatric syndromes at their doorstep. Objective: Our objective was to create a self-assessment tool, “integrated care tool” (ICT), and to assess its psychometric properties by applying it on older adults from multiple settings such as hospital, community, and old-age home (assisted living services). Methods: new questionnaire was developed using standardized procedure including item development, pilot testing, and psychometric validation. After obtaining the institutional ethics committee clearance, data were collected from consenting respondents attending the Outpatient Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, community settings through health camps, and long-term care center, between May 2016 and February 2017. Data were computerized and analyzed by principal component analysis as extraction method and orthogonal varimax as rotation method. Results: The final 30-item questionnaire was arranged into various domains as per rotated component matrix analysis. Overall internal consistency of the final questionnaire, as calculated by Cronbach's alpha, was 0.79, and the measure of sampling adequacy was 0.79. Conclusion: ICT-BRIEF is a simple, self-assessment/caregiver-assisted tool to screen the health needs of older adults. This tool can be validated for developing risk score and scaled up to generate a large database to create elderly centered care plans.