Chest Diseases and Tuberculosis

Dilemma of community-acquired pneumonia Lamia H Shaaban The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):1-4 The lungs are particularly susceptible to infection, owing to continuous direct interaction with the external atmosphere in the process of gas exchange, and many anatomical facts, such as the presence of the pharynx, which constitutes a common pathway for both of the lung and stomach. With the process of development of many new generations of antibiotics, pneumonia still continues to be an important unsolved problem worldwide. Community-acquired pneumonia is still considered a problem and is associated with significant morbidity and mortality with cost load, especially with the emergent pathogens that presented with aggressive pictures of community-acquired pneumonia.

Prognostic values of neutrophilic count and neutrophil–lymphocyte ratio among chronic obstructive pulmonary disease patients admitted with acute exacerbation Ibrahim Dwedar, Mohamed Ali, Hossam M Abdel-Hamid The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):5-8 Introduction Chronic obstructive pulmonary disease (COPD) is characterized by chronic inflammatory pathway with neutrophils and lymphocytes representing the main cells of inflammation. Patients and methods A prospective study was designed to assess the neutrophilic count as well as neutrophil–lymphocyte ratio (NLR) as predictors of mortality among patients admitted in the hospital with acute exacerbation COPD. Fifty COPD patients were admitted to Ain Shams Hospital complaining of acute exacerbation. They were followed up during their course inside the hospital with routine blood tests assessment. Results From the 50 patients admitted, eight patients died along their in-hospital course. No differences regarding their ages and sex. Total leucocytic count (TLC), neutrophilic count, lymphocytes, and NLR were found to be significantly higher in the nonsurvival versus the survival groups. Mean C-reactive protein values showed no significant difference between both the subgroups. The nonsurvival group tend to stay more days in the respiratory care unit in comparison to the survival group. Conclusion The neutrophilic count and the NLR were strongly valuable inflammatory markers with reported higher sensitivity and specificity in predicting the mortality among COPD patients admitted for acute exacerbation.

Does vitamin D deficiency worsen the hospital outcome in patients with acute exacerbation of chronic obstructive pulmonary disease? Mohamed F Abdel Ghany, Hoda A Makhlouf, Aliae A.R.M Hussein, Amal A Mahmoud The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):9-13 Background There are limited data about the hospital outcome in hospitalized patients diagnosed as chronic obstructive pulmonary disease (COPD) with concomitant deficiency of vitamin D. Objectives To assess the level of serum 25-hydroxyvitamin D in patients with severe exacerbation of COPD and to find if there is any correlations between vitamin D and clinical, functional parameters, as well as survival, days of hospital stay, and need for ICU admission. Patients and methods In this case–control study, 60 patients with acute exacerbation COPD requiring hospital admission were recruited and 24 healthy controls. Chest radiography, spirometry, arterial blood gases, 6 min walking distance, modified Medical Research Council dyspnea scale, and St George Respiratory Questionnaire were assessed. Serum 25-hydroxyvitamin D level was measured by enzyme-linked immunosorbent assay. Results About 90% COPD patients had vitamin D deficiency. Serum vitamin D levels were statistically significantly lower in COPD with and without comorbidities when compared with normal controls (P<0.001) but COPD with or without comorbidities did not differ statistically (P>0.05). No significant correlation was found between serum 25-hydroxyvitamin D and survival; days of hospital stay or need for mechanical ventilation. As well, no significant correlation between vitamin D and forced expiratory volume in the 1 s %, 6 min walking distance, modified Medical Research Council, or St George Respiratory Questionnaire scores was found. Conclusion Vitamin D deficiency is found in most COPD patients. However, in patients suffering from severe exacerbation, the presence of low vitamin D levels did not have any effect on survival, days of hospital stay, or need for mechanical ventilation.

Assessment of prevalence of active pulmonary tuberculosis among patients with ocular tuberculosis Heba A Eshmawey, Eiman M Abd El Latif, Hadir A.S Okasha The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):14-23 Background Tuberculosis (TB) is considered a multisystemic disease showing many extrapulmonary presentations. TB uveitis is one of the common forms of extrapulmonary TB. The lung is still the first organ to be attacked by TB, and pulmonary TB is the only infectious form of the disease. Aim The aim of the study was to detect the prevalence of active pulmonary TB among patients with TB uveitis. Patients and methods The present study included 37 patients with diagnosis of ocular TB on the basis of previous history, ocular examination, and exclusion of other suspected causes of uveitis. In addition, positive tuberculin skin test, or positive interferon-gamma release assays were carried out. All included patients were subjected to sputum examination for acid-fast bacilli and plain radiography of chest P-A view, and certain cases had a bronchoalveolar lavage. Patients with active pulmonary TB were detected. Both groups (patients with active pulmonary TB and patients with free chest) were compared with regard to all the previously mentioned studied parameters. Results The mean age of the studied patients was 34.8±12.5 years. All the studied patients showed positive tuberculin test with a mean of 18.5±3.4 mm. With regard to the Quantiferon Gold test, 34 patients (91.9%) had positive results. Concerning radiography, only 10 (27%) patients had normal radiograph, the rest of the patients showed various radiological lesions. Thirty (81.1%) patients were diagnosed to have active pulmonary TB. Sputum examination for acid-fast bacilli revealed that 22 (59.5%) patients had positive results; an additional eight patients (who had negative results on sputum examination) showed positive results when they underwent a bronchoalveolar lavage. There was no statistically significant difference with regard to all the previously mentioned parameters between patients with active pulmonary TB and patients with a free chest. Conclusion The present study revealed that a considerable percentage of the patients with TB uveitis had active pulmonary TB.

Treatment outcomes of patients on non-Revised National Tuberculosis Control Programme (private) anti-tuberculosis regimen from a tertiary-care centre in Kerala, India Akhilesh Kunoor, Rakesh Purushothama Bhat Suseela, Mithula Raj, Rajesh Chemmarissery Thankappan, Ponneduthamkuzhi Thomas James The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):24-27 Introduction Although standardised tuberculosis (TB) treatment in India is delivered by the public sector through the Revised National TB Control Programme (RNTCP), majority of patients in the country are treated with private anti-TB drugs. The objective of the study was to assess the treatment outcome of patients initiated on non-RNTCP regimen from a private tertiary-care centre from January to June 2016. Patients and methods A nonconcurrent cohort study was done which followed up the patients who have been initiated on private anti-TB regimen from a private tertiary-care centre in Kerala, India, during the first and second quarter of 2016. Details of further visits were sought from the hospital health management information system. A phone call interview was done with all patients, 9–12 months after treatment initiation. Results There were 81 patients who were initiated on private anti-TB regimen. Of them, 26 were of pulmonary TB and 55 were of extrapulmonary tuberculosis (EPTB). Among pulmonary TB, 17 (65.38%) cases and in EPTB, 41 (74.54%) cases had successful treatment outcome. The overall success of the non-RNTCP regimen was 71.6%. In pulmonary TB, six (23.1%) cases and in EPTB 11 (20%) cases came under lost to follow-up category. Conclusion The results calls for urgent actions to have a system in place for tracking patients initiated on private anti-TB drugs so as to ensure the standards of TB care. The national programme may further strengthen monitoring of treatment adherence in private sector with established ICT-based treatment support models.

Raised dsDNA autoantibodies in tuberculosis patients Faheem Shahzad, Atia Ali, Abid Mushtaq, Khursheed Javaid, Afzaal Nazir, Amna Pervez, Mohammad Kashif, Noman Bashir, Afia Abbas, Romeeza Tahir, Shah Jahan, Nadeem Afzal The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):28-31 Background Tuberculosis (TB) is caused by Mycobacterium tuberculosis. M. tuberculosis can become dormant, resist the hostile environment of the phagosome, and trigger a delayed-type hypersensitivity reaction leading to chronic infection and granuloma formation. In granulomas, destruction of tissues results in the release of intracellular self-antigens that may provoke the development of autoantibodies. Therefore, the present cross-sectional study was conducted to detect anti-dsDNA antibodies in local TB patients. Patients and methods In all, 160 patients were recruited for this comparative study. Anti-dsDNA antibodies were detected by enzyme-linked immunosorbent assay. Independent Student’s t test was used to compare mean anti-dsDNA values between TB patients and healthy individuals. A p value less than or equal to 0.05 was considered as statistically significant. Results Anti-dsDNA antibodies were high in TB patients as compared with healthy controls and the difference between the two groups was statistically significant (P<0.0001). No significant association of dsDNA autoantibody between TB patients and healthy controls was obtained. Similarly, no significant association of dsDNA autoantibodies was obtained in drug resistance TB patients and TB patients without drug resistance. Conclusion Increased level of dsDNA autoantibody was detected in TB patients and its level was clinically significant in TB patients, but no association of this autoantibody was established with TB.

Hurdle in the eradication of tuberculosis: delay in diagnosis Jayasri H Gali, Harsha V Varma, Aruna K Badam The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):32-38 Objective Identifying the factors responsible for the delay in the diagnosis of tuberculosis (TB). Patients and methods In this retrospective study, data on pulmonary and extrapulmonary forms of TB, registered for the treatment at the directly observed treatment, short course, centre were analysed. Results Of 163 patients, 34 (20.86%) were diagnosed at the first visit. The delay in seeking medical care ranged from 0 to 25 days from the diagnosis. A total of 110 (67%) patients started on the same day or the day after diagnosis, less than 1 month in 33 (20.25%) and 1–3 months in 83 (51%). Delay from patient and health services (both combined) ranged from half a month to 48 months; the mean±SD diagnostic delay was 4.09±4.19 days (range: 0–24 days), whereas the mean±SD treatment delay (n=162) was 2.19±3.89 days. of the 124 patients who received medical help, 90% of them did so within six months of onset of Symptoms. There was a statistically significant difference in patients’ delay in receiving the treatment/medical care by sex. Mean±SD delay for pulmonary and extrapulmonary TB was 48±24 and 240±386 days, respectively. Conclusion Delay in diagnosis is a preventable factor. Patient delay is longer compared with healthcare delays. Active surveillance, even in the urban areas by healthworkers, may help in reducing this delay.

Role of echocardiographic tissue Doppler imaging in the assessment of myocardial diastolic dysfunction in children with diffuse lung diseases Waleed Mohamed Elguindy, Maryam Ali Abdelkader The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):39-43 Background Pulmonary arterial hypertension (PAH) is a common complication of prolonged diffuse lung diseases in children. It is considered a crucial factor of morbidity, mortality, and severity of the disease in these children. Conventional echocardiography is an indirect tool to assess pulmonary hypertension (PH) with a limited sensitivity compared with right heart catheterization and requires well-trained physicians. So, the aim of the current study was to determine the role of echocardiographic tissue Doppler imaging in the assessment of the effect of pulmonary hypertension on right ventricular functions in children with prolonged, diffuse lung diseases and if it can have a predictive role of the secondary right ventricular (RV) dysfunction in these children. Patients and methods This is a case–control study in which 40 children with diffuse lung diseases were recruited from the chest clinic, Ain Shams University Hospitals. The patients were classified into PH and non-PH groups according to the echocardiographic measurement of mean PAP greater than 25 mmHg. Results Patients with PAH had significantly higher RV stroke volume as well as indexed RV systolic and diastolic areas. Furthermore, these patients had significantly higher RV myocardial performance index and E/E′ ratio suggesting diastolic dysfunction as well as decreased compliance. Conclusion Although conventional echocardiography could detect changes in RV dimensions and stroke volume, tissue Doppler imaging could further highlight changes in RV diastolic functions as well as compliance secondary to PAH.

Functional evaluation of patients with progressive systemic sclerosis-associated diffuse parenchymal lung disease Ahmed A.A Hussieny, Yosri M.K Akl, Reem I Elkorashy, Amira I Mostafa, Doaa H Attia, Mohamed Faheem, Fatma E.-Z Ahmed The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):44-49 Background Interstitial lung diseases are common features in scleroderma that seem to add to the morbidity and mortality of the disease. Other complications that may occur with scleroderma are pulmonary hypertension. Aim to evaluate the functional status of patients with progressive systemic sclerosis-associated diffuse parenchymal lung disease. Methodology A total of 44 adult patients with a confirmed diagnosis of scleroderma were included. The disease severity was assumed by using the grading of the inter-incisor distance and finger-to-palm distance. Assessment of the chest high-resolution computed tomography (HRCT) was performed, and then functional assessment in the form of arterial blood gas, spirometry, 6-min walk distance, and echocardiography was performed. Results There were no significant differences between the scleroderma with diffuse parenchymal lung disease and those with normal HRCT regarding the measured and calculated parameters, except for the pulmonary artery systolic pressure, which was significantly higher in the normal HRCT group than those with interstitial lung disease.

Idiopathic pulmonary fibrosis and subclinical hypothyroidism: an underestimated comorbidity Heba H AboElNaga, Alyaa A ElSherbeny, Emad A AbdelHady The Egyptian Journal of Chest Diseases and Tuberculosis 2019 68(1):50-56 Background Idiopathic pulmonary fibrosis (IPF) is the most damaging and mysterious form of lung fibrogenesis, with worldwide growing prevalence and mortality. Subclinical hypothyroidism (SCH) is evidenced that its prevalence is still higher in patients with IPF. Objectives To study the incidence of SCH in patients with IPF in comparison with the controls with a focus on the different clinical characteristics and spirometry measurements. Patients and methods The research involved 50 patients who were diagnosed as IPF and 30 healthy participants, enrolled from the outpatient clinic departments of pulmonary medicine of October 6 University Hospital. The patients performed spirometry tests, high-resolution computed tomography chest, and thyroid function test. Results There were significant differences in spirometry data and thyroid-stimulating hormone level between the IPF and the control group, indicating more prevalence of SCH in IPF patients. IPF patients diagnosed with SCH have a significant decline in some spirometry measurements than those with IPF only. Conclusion The prevalence and clinical outcomes of SCH in patients with IPF certainly require advanced research, since the thyroid function tests were not done regularly for most patients with IPF. This study intensely proposes that in future encouraging management should be further studied to enhance the prognosis of IPF patients.

Surgery

Surgical strategies to reduce recurrence in Crohn's disease Charlotte Austin, Randolph M Steinhagen World Journal of Colorectal Surgery 2019 8(1):1-3 Almost from the time of initial description of Crohn's disease 85 years ago, it has been known that surgical resection is not curative. The disease invariably recurs. Over this period of time, numerous strategies have been proposed in an attempt to reduce the recurrence rate, or delay the development of recurrent disease. The purpose of this review is to examine a number of strategies and to evaluate their effectiveness. It also aims to look at what might lie ahead in the future. This review consists of an English language literature search to identify previous studies that have proposed various surgical strategies to reduce the recurrence rate following surgery for Crohn's disease. A number of surgical strategies have been proposed including widening the resection margins, changing the type of anastomosis, use of laparoscopy, and most recently, resecting wide mesenteric margins. To date, none of these strategies has proven to be effective in reducing recurrence rates. Although a surgical strategy to reduce recurrence in Crohn's disease has not been identified, there are currently investigators looking at other possibilities that may be shown to be effective in the future.

Evaluating the efficacy of biofeedback for chronic constipation using the constipation severity instrument and constipation-related quality of life measure Yuan-Tzu Lan, Lillian G Jahan, Madhulika G Varma World Journal of Colorectal Surgery 2019 8(1):4-9 Background: Many studies have described using biofeedback to treat chronic constipation, but few reports have addressed its impact on quality of life (QOL). Objective: The aim was to evaluate the effect of biofeedback with a validated Constipation Severity Instrument (CSI) and Constipation-Related QOL (CRQOL) measure. Design: Prospectively collected data with retrospective analysis. Setting: Tertiary care academic center. Patients and Methods: Patients referred to the Center for Pelvic Physiology with chronic constipation and objective signs of pelvic floor dyssynergia, who received a complete course of biofeedback therapy and returned all of their questionnaires, were enrolled in the study. Questionnaires were given upon initial evaluation, immediately after the complete course of biofeedback, and 6 months later. Main Outcome Measures: Improvement of dyssynergia symptom and QOL by CSI and CRQOL. Sample Size: A total of 25 patients (20 females and 5 males) were included. Results: Overall, 75% of patients reported satisfactory symptom and QOL improvement. CSI total scores decreased after treatment (35.0 vs. 31.0, P = 0.06) and at 6-month follow-up (35.0 vs. 30.0, P = 0.05). Only the obstructive defecation (OD) subscale of CSI improved significantly after treatment (median 21.0 vs. 16.5, P < 0.01) and sustained to 6 months after therapy (median 21.0 vs. 18.5, P = 0.03). Statistically significant improvement was seen in the distress subscale of the CRQOL immediately after biofeedback (24.0 vs. 18.0, P = 0.02). Conclusions: This study demonstrated that the active effects of biofeedback in constipated patients were specific to OD symptoms and the distress subscale for QOL. CSI and CRQOL are both useful tools to evaluate the specific response of constipated patients after biofeedback therapy. Limitations: The study limitation was the small sample size due to difficulty in obtaining complete information in the enrolled patients.

Outcomes in cecal volvulus: Does age affect outcomes in patients who undergo surgery? Ashley M Tameron, Amy E Murphy, Lala R Hussain, David Lee, Hamza Guend World Journal of Colorectal Surgery 2019 8(1):10-13 Background: Colonic volvulus is a rare cause of bowel obstruction with an incidence of 2%–10%. Cecal volvulus accounts for 10%–40% of cases, with a mean age of 53 years. There is a paucity of literature reporting how older patients with cecal volvulus fair relative to their younger counterparts. Objective: The goal of our study is to evaluate the outcomes after surgical resection in patients ≥50 years old with cecal volvulus. Design: The design of the study was to collect the National Surgical Quality Improvement Program (NSQIP) data and analyze primary outcomes. Settings: These data were collected from NSQIP database focusing on patients with cecal volvulus. Materials and Methods: We utilized the NSQIP database. We identified volvulus by ICD-9 code 560.2. We selected patients with cecal volvulus who underwent surgical resection by specifying the CPT codes for open and laparoscopic right hemicolectomy. Main Outcome Measures: The primary outcomes were mortality and major and minor postoperative complications. Student's t-test was used to compare continuous variables. Chi-square and Fisher's exact tests were used to compare categorical variables. Sample Size: Analyzing the NSQIP database from 2010 to 2015, 1220 patients were identified. Results: 21.8% of patients were <50 years old and 78.2% were ≥50 years old. Patients aged ≥50 years had higher rates of comorbid conditions. There was no significant difference in mortality between the two groups or major and minor complications. Patients aged ≥50 years had a longer length of total hospital stay, i.e., days from operation to discharge. Conclusion: Cecal volvulus is an uncommon reason for bowel obstruction with unclear outcomes in elderly patients in the literature. Our study demonstrates no differences in outcomes after surgical intervention for cecal volvulus. Limitations: Limitations of this study include large database collection and selection bias. As we specifically included right hemicolectomy, this excludes patients who underwent nonresection intervention.

Right versus left Colon cancer: Is there a difference in outcomes? Aris Plastiras, Evangelia Iosif, Georgia Georgiou, Amyn Haji, Asif Haq, Savvas Papagrigoriadis, Joseph W Nunoo-Mensah World Journal of Colorectal Surgery 2019 8(1):14-21 Background: Colorectal cancer is a major healthcare problem due to its high prevalence and mortality rates. Objective: The objective of the study is to delineate the relationship between the location of the colon cancer and the outcomes. Design: This is a retrospective, single-center study including patients diagnosed with right and left colon cancer from January 2010 to December 2015. Setting: Patients with no rectal or synchronous metastatic disease were included in the study. Diagnosis was confirmed following a computed tomography and colonoscopy. Patients and Methods: Four hundred and seventy-five patients with colon cancer were included; 226 right-sided tumors (RCC) and 249 with left-sided colon cancer (LCC) underwent surgery. Main Outcome Measures: We compared right- and left-sided tumors in terms of epidemiological, histological, clinical, and perioperative characteristics, and we also attempted to determine whether there is a difference in the overall and per stage survival. Sample Size: Four hundred and seventy-five patients with colon cancer. Results: Patients with colon cancer were analyzed, 226 (47.5%) with RCC and 249 (52.4%) with LCC underwent surgery. Patients with RCC were more likely to be women, older, and with more comorbidities. Furthermore, RCC were more likely to be poorly differentiated (29.65%, P < 0.001) and more locally advanced at the time of diagnosis (P < 0.001). Controlling the differentiation for each stage, there was no statistical significant difference between left and right survival and recurrence (P > 0.05). When stratified according to tumor stage, Stage II LCC had better overall survival (odds ratio [OR], 1.694, 95% confidence interval [CI], 1.015, 2.827) and Stage III LCC had a better overall survival (OR, 1.403, 95% CI, 1.007, 2.143), disease-free survival (OR, 1.293, 95% CI, 1.011, 1.714), and less cancer-related deaths (OR, 0.282, 95% CI, 0.080, 1.000). Conclusions: Comparing similar stages, patients with LCC appear to have better oncological outcomes irrespective of tumor differentiation. Limitations: Single-center, retrospective study without excluding patients with hereditary cancers. Oncological biomarkers were not available in all patients, and further analysis was not performed.

The hanging pouch Daniel J Wong, Michael Q Tran, Vitaliy Y Poylin World Journal of Colorectal Surgery 2019 8(1):22-23 Ileoanal pouch reconstruction can be complicated intraoperatively by the inability for the pouch to reach the anus in a tension-free manner. Here, a case is presented where standard “mesentery lengthening” procedures did not allow the pouch to reach the anus and thus the pouch was left hanging in situ resulting in pouch lengthening over several months and a successful anastomosis at a later date.

Leiomyoma of the sigmoid mesocolon associated to hemorrhagic infarct and high count of mast cells Carlo Lozano-Burgos, Claudio Etcheverry-Pizarro, Wilfredo Alejandro González-Arriagada, Paola Ochova-Gallardo World Journal of Colorectal Surgery 2019 8(1):24-26 Leiomyoma is a soft-tissue benign tumor and its occurrence in the mesocolon is extremely rare. We present a particular case of a leiomyoma of the sigmoid mesocolon of a 58-year-old man, associated to a hemorrhagic infarction treated surgically and without recurrences after 1 year of follow-up. The macroscopic, histopathologic, and immunohistochemical features are presented and discussed. The high mast cell count associated with a low rate of cell proliferation is a sign of the benign biological behavior in this entity and may be helpful hallmarks for the differential diagnosis with other gastroenterological neoplasia.

Rare complication of a common disease: Coccygeal osteomyelitis following Pilonidal sinus Mugdha Kowli, Pranav Mandovra, Gautam Zaveri, Roy Patankar World Journal of Colorectal Surgery 2019 8(1):27-29 Pilonidal sinuses commonly arise in the sacrococcygeal region. The common complications are local cellulitis, abscess formation which is related to the infectious process, and recurrence after surgery. They rarely evolve with osteomyelitis, meningitis, or malignant transformation. Coccygeal osteomyelitis as a direct complication of sacrococcygeal pilonidal sinus disease (PSD) is extremely rare with limited data. We report a case of complicated sacrococcygeal PSD with coccygeal osteomyelitis. It was managed with: wide local excision of the pilonidal sinus, coccygectomy, perineal musculature reconstruction, and defect closure by Limberg rhomboid flap.

Right hemicolectomy in a patient with heterotaxy syndrome Maxime Dewulf, Roel Beckers, Pieter Pletinckx World Journal of Colorectal Surgery 2019 8(1):30-33 In this communication, we present a first description of right hemicolectomy in a patient with heterotaxy syndrome (HS). A 78-year-old male was admitted to the outpatient clinic with complaints of dysphagia. Diagnostic workup revealed the presence of an esophageal web. On subsequent colonoscopy, a tumoral lesion was found in the ascending colon. Computed tomography scan illustrated abdominal situs ambiguous with right-sided polysplenia, right-sided stomach, and intestinal nonrotation. Furthermore, a preduodenal portal vein, azygos continuation of the inferior vena cava, and hemiazygos continuation of the left renal vein were observed. After careful assessment of the anatomy, a right hemicolectomy with radical lymphadenectomy was performed. HS consists of a rare and complex situs anomaly, with an abnormal arrangement of the thoracic and/or abdominal organs along the left–right axis. To our knowledge, right hemicolectomy has not been described in patients with HS.

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