Ours was a descriptive observational cross-sectional study carried out in a tertiary care hospital in eastern India over a period of one year to study the profile of neurological involvement in paediatric dengue patients. Of 71 laboratory-confirmed cases, 20 (28.17%) had neurological involvement. Common forms observed were acute encephalopathy (40%), encephalitis (30%), pure motor weakness (15%), transverse myelitis (5%), acute disseminated encephalomyelitis (5%) and Guillain–Barré syndrome (5%). The dengue IgM antibody could be detected in the cerebrospinal fluid of only two patients with encephalitis. Neurological involvement was present in all four patients who died during the study period (two-tailed P value = 0.005).
Bone marrow aspirate examination is a gold standard to assess bone marrow iron stores. The correlation between serum ferritin and bone marrow iron has not been established in detail, as the cutoff value for iron stores have not been uniformly established. Ours was a cross-sectional study. Perl’s Prussian blue stain was used to stain bone marrow, assessed by Gale’s grading. Receiver operating characteristic curve analysis and Spearman’s correlation coefficient calculated. Gale’s grading revealed iron store deficiency in 26 and sufficiency in 13. Spearman’s correlation coefficient of 0.90 showed a significant relation between serum ferritin and bone marrow iron stores. A serum ferritin of 228 pmol/L had high sensitivity and specificity for iron deficiency; our study suggests that this level be taken as the cutoff value to predict iron store deficiency in bone marrow.
We sought to determine the incidence and clinical spectrum of the paradoxical reaction (PR) to treatment in 1000 children with tuberculosis (TB). Its incidence was 3.3%, presenting as mediastinal adenopathy (n = 12), central nervous system (CNS) tuberculoma (n = 8), increasing size of lymph nodes (n = 8) and serositis (n = 5). Symptoms included breathlessness (n = 7, 21.2%), neck swellings (n = 5, 15.2%), hemiplegia (n = 3, 9.1%), raised intracranial tension (n = 2, 6.1%) and fever or diabetes insipidus (n = 1, 3% each). The mean age of onset of PR was 3.5 months after the start of anti-TB medication. PR was seen predominantly in boys. Mediastinal lymphadenopathy was more common in children aged <2 years. Tuberculomas were more common in children aged 2–5 years. Nodal enlargement and serositis were seen equally in all age groups.
The diagnosis of smear-negative pulmonary tuberculosis (PTB) is particularly challenging, and automated liquid culture and molecular line probe assays (LPA) may prove particularly useful. The objective of our study was to evaluate the diagnostic potential of automated liquid culture (ALC) technology and commercial LPA in sputum smear-negative PTB suspects. Spot sputum samples were collected from 145 chest-symptomatic smear-negative patients and subjected to ALC, direct drug susceptibility test (DST) testing and LPA, as per manufacturers’ instructions. A diagnostic yield of 26.2% was observed among sputum smear-negative TB suspects with 47.4% of the culture isolates being either INH- and/or rifampicin-resistant. Complete agreement was observed between the results of ALC assay and LPA except for two isolates which demonstrated sensitivity to INH and rifampicin at direct DST but were rifampicin-resistant in LPA. Two novel mutations were also detected among the multidrug isolates by LPA. In view of the diagnostic challenges associated with the diagnosis of TB in sputum smear-negative patients, our study demonstrates the applicability of ALC and LPA in establishing diagnostic evidence of TB.
Adolescence is a highly vulnerable period for malnutrition. This study was based on a Global School Health Survey methodology in the 13–15-year age group; employing WHO AnthroPlus to evaluate the nutritional status, find the prevalence of both extremes of malnutrition, compare with the growth curves and to find its sociodemographic correlates. A total of 1456 students were sampled and the mean BMI for age Z score was found to be –0.11. The prevalence of overweight and obese were 11.95% and 2.27%, respectively, whereas 2.75% suffered from thinness, defined as BMI for age <2 standard deviations. The prevalence of being overweight and obese was associated with a higher standard of living, a higher education of father or mother, working mothers and father’s occupation being service/business. The evident double burden of malnutrition presages a large public health burden in future, requiring interventional attention.
Leptospirosis is a zoonosis and a major public health problem. Blood sampling was done in the province of Kurdistan from 250 members of different groups, including hunters and their families, butchers and slaughterhouse workers, healthcare workers (HCWs) and those referred to medical diagnostic laboratories for routine testing. Sera were tested using an ELISA method to detect specific Leptsopira IgG antibodies. We found 20.80% (95% confidence interval, 16.23–26.25%) to be positive. The highest and lowest seroprevalence were in hunters (26%) and HCWs (18%). There was significant positive correlation between age and seropositivity (P = 0.01). Hunting and eating the meat of the hare and exposure to dead or dying wild animals were found to be the main risk factors (P < 0.05).
Our study sought to determine the characteristics of antenatal patients with tuberculosis (TB) and their pregnancy outcomes. Case records of 50 antenatal women with extra-pulmonary and pulmonary TB at a tertiary centre in India were compared to 150 antenatal women not suffering from TB, for adverse medical, obstetric and neonatal outcomes. The prevalence of TB was 1.16 per 1000 deliveries. Of these, 62% had extra-pulmonary TB. There were two maternal deaths. TB in pregnancy was associated with a five times higher risk of prematurity and three times higher risk of intrauterine growth restriction than the norm. Maternal prognosis depends on the complications of tuberculosis and treatment compliance.
Urgent investment in human resources for surgical and anaesthesia care is needed globally. Responsible training and education is required to ensure healthcare providers are confident and skilled in the delivery of this care in both the rural and the urban setting. The Tropical Health and Education Trust (THET), a UK-based specialist global health organisation, is working with health training institutions, health professionals, Ministries of Health and Health Partnerships or ‘links’ between healthcare institutions in the UK and low- or middle-income country (LMIC) counterparts. These institutions may be hospitals, professional associations or universities whose primary focus is delivery of health services or the training and education of health workers. Since 2011, THET has been delivering the Health Partnership Scheme (HPS), a UK government-funded programme that provides grants and guidance to health partnerships and promotes the voluntary engagement of UK health professionals overseas. To date, the £30 million Scheme has supported peer-to-peer collaborations involving more than 200 UK and overseas hospitals, universities and professional associations across 25 countries in Africa, Asia and the Middle East.
In this paper, we focus on four partnerships that are undertaking training initiatives focused on building capacity for surgery and anaesthesia. In order to do so, we discuss their role as a responsible and effective approach to harnessing the expertise available in the UK in order to increase surgical and anaesthesia capacity in LMICs. Specifically, how well they: (1) respond to locally identified needs; (2) are appropriate to the local context and are of high quality; and (3) have an overarching goal of making a sustainable contribution to the development of the health workforce through education and training.
The HPS has now supported 24 training initiatives focused on building capacity for surgery and anaesthesia in 16 countries across sub-Saharan Africa, Asia and the Middle East. THET argues that these initiatives are both responsible and effective. The four partnerships featured in this paper have demonstrated not only their effectiveness in increasing health worker skills and knowledge, but have done so across a variety of surgical and anaesthesia disciplines and within different contexts. This wide reach and applicability of partnership initiatives adds even greater value to their use as responsible training interventions. One challenge that has faced these partnerships has been the capture of improvements to patient outcomes as a result of improved practice. To counteract the problems of data collection, partnerships are collecting anecdotal evidence of improvements at the patient outcome level.
The interventions supported by THET have been able to demonstrate success in improving health worker skills and knowledge, and albeit to a lesser extent, in improving patient outcomes. The implementing partners are achieving these successes by training responsibly: responding to locally identified need, implementing projects that are appropriate to the local context and are of high quality, and establishing mechanisms that ensure self-sufficiency of the health worker training and education that is delivered. Greater investment in responsible training initiatives such as these are required to address the significant lack of access to appropriate and safe surgical and anaesthesia interventions when needed and the growing burden of disease.
Plague is a re-emerging zoonotic disease caused by the bacterium Yersinia pestis. The disease has caused periodic global devastation since the first outbreak in the 6th century. Two months after a suspected plague outbreak in Nyimba district, samples were collected from 94 livestock (goats and pigs), 25 rodents, 6 shrews and 33 fleas. Enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) techniques were used to investigate the presence of Y. pestis, which showed that 16.0% (4/25) of rodents, 16.7% (1/6) of shrews (Crocidura spp) and 6.0% (5/83) of goats were positive for IgG antibodies against Fraction 1 antigen of Y. pestis. Plasminogen activator (Pla) gene (DNA) of Y. pestis was detected in five pools containing 36.4% (12/33) fleas collected from pigs (n = 4), goats (n = 5) and rodents (n = 3). The detection of Pla gene in fleas and IgG antibodies against Fraction1 antigen in rodents, shrews and goats suggest that Y. pestis had been present in the study area in the recent past.
Tungiasis is highly prevalent in resource-poor communities in sub-Saharan Africa, but studies among schoolchildren are scanty. We assessed prevalence, parasite load and clinical aspects of tungiasis in schoolchildren in south-western Nigeria. A total of 545 schoolchildren was examined. Of these, 133 (24.4%; 95% CI, 20.9–28.2%) were infested with Tunga penetrans. Boys showed a higher prevalence than girls (31% versus 18%, P < 0.0001); in those infested, the median number of lesions was two, with no gender difference (2 boys, interquartile range, 1–4; 2 girls; interquartile range, 1–4; P = 0.34). The maximum number of 44 lesions was found in a 14-year-old boy. Desquamation was present in 90.2%, followed by erythema (54.9%) and oedema (43.6%); 54.9% showed any chronic pathology and more one-third nail deformations. Our study indicates that tungiasis is an important health problem in rural Nigerian schoolchildren. Sustainable interventions are required to control the disease in this and similar communities.
Prognostic markers of acute liver failure (ALF) are based on clinical, laboratory or radiological parameters. Most of the biochemical markers are based on hepatic degeneration. We studied the impact of serial serum alpha-fetoprotein (AFP) levels, a marker of liver regeneration, on the outcome of the patients with ALF. AFP levels were estimated on days 1 and 3 of hospitalisation of 32 patients with ALF and the ratio (AFP day3/day1) was calculated. All subjects were categorised as group A (expired) or group B (survived). The AFP ratio was 0.84 + 0.15 in group A (n = 20) versus 1.55 + 0.70 in group B (n = 10); P < 0.001. However, the absolute initial AFP values were not associated with the outcome, favourable or unfavourable. We conclude that AFP levels change dynamically during ALF and have the potential to be used as a predictor of outcome in isolation or in combination with well-established prognostic markers.
Effective medical care for non-communicable diseases (NCD) remains lamentably poor in Ethiopia and many low-income countries. Consequently, where modern medicine does not reach or is rejected, traditional treatments prevail. These are fragmented and esoteric by nature, and their understanding of illness is so fundamentally different that confusion proliferates when attempts are made to introduce modern medical care. Ethiopia is host to a variety of longstanding medical belief systems that coexist and function together, where modern medicine is often viewed as just another choice. This multiplicity of approaches to illness is accompanied by the Ethiopian custom of weaving layers of meaning, often contradictory, into speech and conversation – sometimes referred to as ‘wax and gold’, the ‘wax’ being the literal and the ‘gold’ the deeper, even hidden, meaning or significance. We argue that engagement with traditional belief systems and understanding these subtleties of meaning could assist in more effective NCD care.
Myasthenia Gravis (MG) is an autoimmune disease which is characterised by disruption of signal transmission at neuromuscular junction. We aimed to search about a newly reported association between MG and West Nile Virus (WNV) infection.
We searched WNV IgG by ELISA in serum samples of 50 available MG patients and 38 controls.
None of the samples gave positive results for past WNV infection.
No evidence of past WNV infection was found in our study population of MG patients. This may have been because MG has been showed to be related with neuroinvasive WNV, which none of our study subjects seem to have had based on their stories. New multicentre studies focusing on immunological mechanisms and held with larger groups or especially neuroinvasive disease patients can cast light onto the answer of this question.
The spectrum of liver disease among HIV-infected patients is changing. In the era of antiretroviral therapy, opportunistic infections are diminishing and deranged liver function appears to be due usually to drug-induced liver injury, alcohol, non-alcoholic steatohepatitis (NASH) or chronic hepatitis B. To test this hypothesis, 98 HIV-positive patients with deranged liver function were compared with matched HIV-positive patients with normal liver function and likewise matched HIV-negative patients with normal liver function tests.
Ours was a retrospective chart review of all elective open inguinal hernia repairs performed in a single unit at King Edward VIII Hospital, South Africa over an 18-month period. Comparison was made regarding duration of operation, length of hospital stay and complications such as pain, haematoma formation and recurrence between the Lichtenstein and Desarda techniques. The latter was noted to have a shorter operative time and avoided cost and possible complications of mesh usage, which are significant in resource-deprived settings. A larger comparative study with longer follow-up is needed to evaluate the wider suitability of the Desarda repair.
Antibiotics to treat healthcare-associated infections (HCAIs) contribute to a substantial proportion of drug expenditure in intensive care units (ICUs). Our study aimed to determine the common HCAIs in our hospital ICU, to assess the antibiotics prescribed and the mean antibiotic cost per HCAI. All adult patients, admitted to the ICU over a 1-year period, were included in the study. HCAIs were determined according to CDC definition. The incidence of HCAIs in the ICU was 16%. Ventilator associated pneumonia (50%) was the most common HCAI, followed by urinary tract infection (35.6%). The total cost of antibiotic treatment for HCAIs in ICU over a 1-year period was approximately Rs. 2 million (US$32,000); the mean antibiotic cost per HCAI was calculated as Rs. 17,000 (US$255). HCAIs in the ICU thus put a significant economic burden on the patient and the healthcare network and should be prevented by implementing recommended infection control guidelines.
This institutional-based cross-sectional study examines the burden of self-medication during pregnancy in a middle-income country setting and the impact on fetal wellbeing. Using a blend of open-ended and indication-oriented questionnaires, 346 pregnant women at term were interviewed about their pregnancy complaints and drug intake. Inferential statistical data analysis was employed with level of significance (α) set at 0.05. Excluding routine supplements and vaccinations, 251 (72.5%) women used medicines, of whom 79 (31.5%) had self-medicated. Consuming drugs without prescription was associated with increased US Food & Drug Administration (FDA) risk category (2 = 8.375; P = 0.015). There is therefore a need to scale up efforts towards educating women about the dangers of self-medication, while also introducing effective restrictive policies on over-the-counter drug sales.
Tuberculosis (TB) and malignancy are among the most important current global health problems. Many authors suggest that their coexistence is a chance association owing to their high prevalence. There is, however, enough evidence that one condition may predispose the other. In our retrospective report of two cases, TB in draining lymph nodes was discovered incidentally on histopathology, following surgical resection for malignancy. The possibility of coexistent lesions, especially in regions endemic for TB, mandate a detailed histopathological examination to prevent the chances of diagnostic failure and thus therapeutic error.
A cohort of 50 newly diagnosed patients with pulmonary tuberculosis was prospectively studied and compared with controls to assess and quantify their quality of life using the World Health Organization’s (WHO) Quality of Life (QOL)–BREF score before and after a Directly Observed Therapy Short (DOTS) course. It was concluded that health-related quality of life is impaired by tuberculosis and shows significant improvement with the DOTS treatment.
Studies related to vitamin D deficiency and lower respiratory tract infections (LRTI) in children have inconsistent findings. The objective of this systematic review was to assess the prevalence of vitamin D deficiency in children with LRTI, and to evaluate the correlation between vitamin D levels and the incidence and severity of LRTI. A total of 12 studies enrolling 2279 participants were included in our analysis. Children with LRTI were found to have significantly lower mean vitamin D levels as compared to controls There was likewise a correlation between vitamin D levels and incidence and severity of LRTI. Large randomised controlled trials are needed to evaluate effect of vitamin D supplementation for LRTI.
Severe respiratory distress is a serious complication common to the three major causes of neonatal mortality and morbidity (prematurity, intra-partum-related hypoxia and infections). In low- and middle-income countries (LMICs), 20% of babies presenting with severe respiratory distress die.
Continuous positive airway pressure (CPAP), is an effective intervention for respiratory distress in newborns and widely used in high-income countries. Following the development of simple, safe and relatively inexpensive CPAP devices, there is potential for large-scale implementation in the developing world.
In this article, we describe existing CPAP systems and present a review of the current literature examining the effectiveness of CPAP compared to standard care (oxygen) in newborns with respiratory distress. We also discuss the evidence gap which needs to be addressed prior to its integration into health systems in LMICs.
In order to study the neurological manifestations in adult patients suffering from scrub typhus, 323 patients aged over 18 years, admitted with a positive diagnosis, were screened for neurological dysfunction; 37 patients with symptoms and/or signs suggestive of neurological dysfunction were included in the study. Of these, 31 (84%) patients had altered sensorium, four (11%) had cerebellitis, one (2%) patient had acute transverse myelitis and one (2%) had bilateral papilloedema without focal neurological deficit. Of the 31 patients with altered sensorium, 15 (40%) had meningoencephalitis, three (8%) had seizures, two (5%) had cerebral haemorrhages, one (2%) had a presentation likened to neuroleptic malignant syndrome (NMS) and one (2%) had a 6th nerve palsy with inflammation of the right cavernous sinus. Cerebrospinal fluid (CSF) analysis was abnormal in 23 patients (raised lymphocytes in 68%, raised protein in 80%). All patients improved with anti-rickettsial therapy.
Non-cirrhotic portal fibrosis (NCPF) is one of the important causes of upper gastrointestinal haemorrhage in patients in tropical countries. The aim of this study was to describe the clinical and laboratory profile of 68 patients with NCPF.
NCPF is defined as liver disease with: (1) evidence of portal hypertension; (2) a liver biopsy showing no cirrhosis or a Tc-labelled sulphur colloid scan showing a pattern suggestive of NCPF; and (3) a patent splenoportal axis. The clinical, laboratory and demographic features of 68 patients with such criteria were studied and analysed.
NCPF was common in women (73.5%) in the fourth decade of life. The median duration of illness was 24 months (range, 1 month–28 years). Patients presented to hospital with the sensation of a mass in the abdomen (50%) or with haematemesis (26.5%). They had splenomegaly (95.6%) and thrombocytopenia (88.2%). The majority of patients had normal liver function tests. Abdominal ultrasonography showed increased periportal and peri gallbladder echoes (72%), spontaneous collaterals (41.2%) and ascites (19.1%). Liver biopsy revealed portal venous sclerosis (76.3%) and periportal fibrosis (55.3%). Tc-labelled sulphur colloid scan was suggestive of NCPF in the remaining 30 cases.
NCPF is common in South India. Transient ascites occurs due to decompensation of liver function after variceal bleeding and in long standing cases of NCPF. Our study used Tc-sulphur scan for diagnosing NCPF in patients where liver biopsy was contraindicated in view of severe thrombocytopenia; however, the diagnostic utility of Tc-sulphur nuclear scan to diagnose NCPF in patients with severe hypersplenism needs to be further evaluated in future studies.
Many developing countries, including Ghana, are water stressed. As such, farmers, particularly those in urban areas, have adopted the use of wastewater for irrigation. This study evaluated the bacteriological water quality of the wastewater used for irrigation in the vegetable farms at Korle-Bu Teaching Hospital (KBTH), Accra Metropolis, Ghana. In all, 40 wastewater samples were collected and analysed bacteriologically using the total aerobic plate count method. The isolated bacteria were identified biochemically using Bergey’s manual for determinative bacteriology. Mean total bacterial colony count values in the range of 2.75–4.44 x 105 CFU/100 mL were isolated which far exceeds values of 1 x 103/100 mL recommended by the World Health Organization (WHO) for unrestricted irrigation of crops likely to be eaten raw. Enterobacter cloacae (51.4%), Klebsiella sp. (24.1%), Pseudomonas aeruginosa (11.3%), Salmonella typhi (10.6%), Escherichia coli (2.2%) and Proteus sp. (0.4%) were the predominant bacteria isolated. Growers should use treated wastewater for farming while processors and consumers should minimize contamination risks of produce from the vegetable farms/garden to the plate.
The prevalence of amoebiasis is often overestimated owing to its epidemiological overlap with the non-pathogenic Entamoeba dispar. To provide evidence for this conjecture, a cross-sectional study was conducted from November 2013 to January 2015. A range of 180–200 µg of semi-solid and formed stools and 200 µL of diarrhoeic stool samples were used for DNA extraction from microscopically E. histolytica/dispar positive samples using the QIAamp® DNA Stool Mini Kit according to manufacturers’ instructions. Nested PCR targeting 18S ribosomal RNA gene was used. In 422 microscopically positive E. histolytica/dispar stools, molecular prevalence revealed that E. histolytica infestation was present in only 1.7% (95% confidence interval [CI], 0.47–2.93) and E. dispar was found in 42.2% (95% CI, 37.49–46.91), while 56.2% (95% CI, 51.47–60.93) had neither E. histolytica nor E. dispar (P < 0.001). We conclude that infestation with E. histolytica is rarer in our study areas than was previously believed. Hence, accurate differentiation of E. histolytica and E. dispar is crucial.
To analyse the prevalence of hypothyroidism in rheumatoid arthritis (RA) patients and to elucidate its correlation with disease activity.
A total of 52 RA patients were enrolled in this study. All patients were assessed fully clinically and underwent routine laboratory investigation including thyroid function testing.
Hypothyroidism (defined as having a TSH level >4.20 μIU/mL) was observed in 20/52 (38.4%). Erythrocyte sedimentation rates (ESR) were found significantly elevated in patients with hypothyroidism compared to those without (36.3 ± 24.2 vs. 24.6 ± 9.0 mm/h). Disease activity parameters such as DAS-28-ESR, tender joint count; VAS scores were also significantly higher in the former. A significant correlation with serum TSH levels was observed with ESR and DAS-28-ESR.
Thyroid function test should be included in clinical evaluation of RA patients.
A comparison of induction of labour (IOL) using three doses of 25 µg vaginal misoprostol inserted at intervals of 4 h or more with a stepwise oral regime starting with 50 µg followed by two doses of 100 µg was studied in a double-blind placebo-controlled trial in a tertiary centre in South India. Primary outcome was vaginal delivery in 24 h. Significantly more women in the first group required oxytocin augmentation and a third dose of the drug than women in the second group. Uterine tachysystole and other maternal and neonatal complications were similar. Thus it is concluded that women induced with oral, as compared to vaginal misoprostol are more likely to labour without oxytocin.
There is a paucity of data on the spectrum of benign gastric outlet obstruction in India. Our aim was to evaluate its spectrum and to identify the subgroup which would be most amenable to endoscopic therapy. We studied 64 patients whose aetiology revealed in approximately equal proportions: corrosive injury; gastroduodenal tuberculosis (TB); and peptic ulcer disease. The median number of endoscopic dilations required was two for TB, four for peptic ulcer disease and five for corrosive injury. Gastroduodenal TB and corrosive injury appear now to be more, or at least as, common as peptic ulcer disease as causes of benign gastric outlet obstruction in India. Gastroduodenal TB responds best to endoscopic therapy.
The present study is done to study different aspects of Helicobacter pylori (H. pylori) such as its prevalence, association with upper gastrointestinal pathology, diagnosis and treatment outcome. Gastric antral biopsy and serology for H. pylori was done for all dyspeptic patients. Histopathology, gram stain and biopsy urease test was done from the gastric biopsy specimen. The prevalence of H. pylori infection was 58.8%. The sensitivity, specificity, positive and negative predictive value for histopathology was 96.9%, 100%, 100% and 95.8%, respectively; for biopsy urease test 80.4%, 100%, 100% and 78.2%, respectively; for gram stain 85.6%, 97.1%, 97.6% and 82.5%, respectively, and for serology 94.8%, 77.9%, 86% and 91.4%, respectively. Mostly peptic ulcer and duodenitis cases followed by chronic active gastritis were associated with H. pylori infection. Repeat biopsy revealed eradication of H. pylori in 90.7% cases. In dyspeptic patients, endoscopic biopsy not only detects H. pylori infection, but also reveals different gastric pathologies.
Hyperuricaemia in type 2 diabetes mellitus (T2DM) has been less well investigated in sub-Saharan Africans. Our study of 438 patients found that alcohol intake, body mass index ≥25 kg/m2, hydrochlorothiazide use, statin use, diabetic retinopathy and glomerular filtration rate <60 mL/min/1.73m2 were independently positively associated with hyperuricaemia; whereas smoking reduced this risk. Hyperuricaemia is strongly associated with some modifiable factors, diabetic complications and certain drugs. Our results suggest that further studies should evaluate the potential cost–benefit of screening for hyperuricaemia in type 2 diabetes.
Inducing labour with a Foley balloon catheter rather than using oxytocin or prostaglandins is considered to be less risky if the uterus is scarred.1 It is not known if more fluid in the balloon is more effective without being more dangerous. Volumes of 80 mL and 30 mL were compared in 154 eligible women. Mode of delivery, duration of labour and delivery within 24 h were similar in both groups. However, the second group required oxytocin more frequently. Though more scar dehiscences occurred in the first group, the difference was not significant.
There are limited data on the aetiology of acute undifferentiated febrile illnesses (AUFIs) in Iran. Moreover, Coxiella burnetii has not previously been detected in clinical samples in this country. Previous studies have highlighted the importance of considering C. burnetii as a cause of AUFI. In this retrospective study, in 92 cases of AUFI where Q fever was suspected, C. burnetii DNA was detected in seven samples (7.36%). This is the first molecular confirmation of C. burnetii from clinical samples from Iran.
To determine the clinical and biochemical characteristics of Yemeni adults and children with visceral leishmaniasis (VL) and the differences between them.
A prospective cross-sectional study on patients with bone marrow aspirate confirmed VL evaluated at Al-Jomhori Teaching Hospital in Sana’a, Yemen.
Twenty-eight (59.6%) patients were adults with a mean age (± SD) of 24.3 years ± 9.2 and 19 (40.4%) patients were children with a mean age (± SD) of 7.1 years ± 4.7. Fever, pallor, splenomegaly and hepatomegaly were the most common clinical findings. Hypoalbuminaemia, hyperglobulinaemia, elevated LDH, hypocalcaemia and elevated CRP were common biochemical abnormalities. There was no significant difference in splenomegaly size or biochemical parameters with regard to grade of parasitic load. Both children and adults showed similar significant improvement after treatment.
Biochemical abnormalities were not related to degree of parasitic load and there were no clinical, biochemical or treatment differences between adults and children.
Overdiagnosis and overtreatment of malaria is a major problem in children in malaria-endemic countries. This retrospective study identified children who were admitted with fever and were treated with or without anti-malarial medications and discharged at the Paediatric Unit of the Effia-Nkwanta Regional Hospital. The medical records of all children were searched, retrieved and assessed. A total of 1160 records from children (age range, 0–12 years) were reviewed and evaluated. Of the total number, 21.3% had laboratory confirmed malaria, 38.4% were malaria negative, while 40.3% had no malaria tests performed. In addition, the results showed that 4.5% of the laboratory confirmed malaria positive cases were not given anti-malarial medication while 84.1% of the malaria negative cases were given these incorrectly. Furthermore, 78.2% of the children with no malaria tests were prescribed anti-malarial medication. The presumptive diagnosis of malaria should be abandoned and the installation of a functional laboratory services promoted.
There is a paucity of data on the prevalence of suicidality in HIV/AIDS, and associated psychological factors in sub-Saharan Africa, shown to be high in Uganda. Yet, the region accounts for over 70% of the world HIV burden. Our study used a cross-sectional survey of 226 HIV-positive (HIV+) adults and adolescents (aged 15–17 years) in Mbarara, Uganda. The relationship between suicidality and depressed mood, anxiety symptoms, state anger, self-esteem, trait anger and hopelessness was examined; anger was the predominant factor in suicidality, suggesting that anger management could potentially lower the prevalence of suicidality.
The aim of this study was to describe and define an outbreak of human anthrax in two villages in the northern savannah region of Togo.
In December 2009, localised groups of deaths occurred among villagers and their livestock, confirmed to be due to anthrax at the district hospital of Dapaong in Northern Togo. The National Disease Control department undertook an investigation to describe the epidemiological, clinical and bacteriological characteristics of this outbreak.
Thirty-four individuals presented with clinical manifestations of anthrax. All patients were known to have consumed meat from cattle who had died of unknown causes or had been killed as a result of unknown illness. All patients presented with muco-cutaneous lesions; some had gastro-intestinal, neurological or meningeal symptoms, or septicaemia. One patient was co-infected with Plasmodium falciparum. Six deaths (17.6%) were reported at the beginning of the epidemic; 28 patients were successfully treated with a 10-day course of intravenous Penicillin or oral Amoxicillin. The two factors that contributed to the ultimate resolution of the anthrax outbreak were the increase of community awareness toward health promotion and vaccination of all farm animals.
Although six deaths occurred among families’ members who were infected, new human anthrax cases were prevented by rapid treatment of victims as well as aggressive public health interventions. However the risk of re-emergence of infection and exposure still exists as there are no existing epidemiological mapping and no identification of infected zones; and furthermore, no functional anthrax surveillance system exists in the affected region.
One of the most common malignancies in HIV-endemic, resource-poor countries is Kaposi sarcoma (KS). It is an AIDS-defining disease and as Malawi’s incidence and prevalence of HIV is high, KS is now the most common cancer in adult male Malawians and the second most common in women and children. Most attention has focused on HIV-seropositive adults as their number far outweighs those of children. This audit concerns the presentation and outcome of HIV-seronegative children with KS who presented in a 12-year period (2002–2014) to The Queen Elizabeth Central Hospital. Twenty (10.5%) of the 191 children with KS presenting to the paediatric oncology ward during 2002–2014 were HIV-seronegative. They were usually younger than seropositive children and 62% had severe anaemia. The main presenting complaints in the HIV-seronegative group were woody oedema, commonly of a limb, and lymphadenopathy. Woody oedema was common in children with or without HIV infection. Seronegative children with KS were less likely to have oral KS than HIV infected children. Of 11 children who completed courses of chemotherapy, seven (63%) had complete cure sustained over a 1-year follow-up period. KS is potentially curable in this group of children. Chemotherapy regimens are equally effective in HIV-seropositive and HIV-seronegative children. The presentation of HIV-seronegative children with KS differs from adults and HIV-seropositive children. Further research is necessary to determine possible triggers for developing KS in HIV-seronegative children.
To evaluate clinically the efficacy and safety in northern India of cefepime monotherapy versus piperacillin-tazobactam in patients of paediatric age group with febrile neutropenia.
Children aged ≤18 years admitted febrile with chemotherapy-induced neutropenia were randomised into two groups comprising 20 cases in each group viz. CEF (receiving cefepime only) and PIP-TAZO (receiving piperacillin-tazobactam). Based on clinical and laboratory tests, patients were classified into: microbiologically documented infections (MDI); clinically documented infections (CDI); and unexplained fever (UF). They were assessed for clinical signs and symptoms as well as laboratory parameters at the time of enrolment and subsequently on days 3 and 7.
Incidence of MDI, CDI and UF were 22.5%, 47.5% and 30%, respectively. The mean duration of neutropenia (in days) was 5.45 ± 2.1 in the PIP-TAZO group and 5.5 ± 1.5 in the CEF group (P = 0.305). The success rate defined as clearing infection effectively and improvement of neutropenia was comparable (P = 0.705). There was a mortality rate of 20% in the PIP-TAZO group as compared to 10% in the CEF group.
We conclude that cefepime monotherapy and piperacillin-tazobactam are equally efficacious and safe in treating patients with febrile neutropenia. Empirical monotherapy with cefepime would prevent an unnecessary extra economic burden as well as avoiding the serious adverse or toxic effects of multi-drug regimes, especially in low- and middle-income countries.
With few end-stage renal disease patients having access to dialysis, we sought to determine the average duration of survival of these patients, after creation of an arteriovenous fistula. Out of 36 patients, 26 had died a little over 6 months later.
In Malawi the orthopaedic clinical officer (OCO) training programme trains non-physician clinicians in musculoskeletal care. We studied the cost-effectiveness of this program.
Hospital logbooks were reviewed for data pertaining to activity in seven district hospitals over a 6-month period. The total costs were divided by the total effectiveness, calculated as disability adjusted life years (DALYs) averted.
The total cost-effectiveness of providing orthopaedic care through the OCO training programme was US$92.06 per DALY averted. The mean per hospital was US$138.75 (95% CI: US$69.58–207.91) per DALY averted which is very cost-effective when compared with other health interventions. Of the 837 patients treated 63% were aged <15 years and 36% were in the ‘economically active’ demographic of ages 15–74 years.
Training of clinical officers in orthopaedic surgery is very cost-effective and allows transfer of skills into rural areas. The demographics suggest that failure to provide such care would have a negative economic impact.
To study the retinal changes in subjects suffering from dengue fever and check if these changes can be taken as sufficient indicator of severity and progression of the disease.
A detailed history was recorded of 118 patients on whom ocular examination, including direct ophthalmoscopy, indirect ophthalmoscopy and coloured fundus photography, was performed.
Forty-seven percent of patients were found to have posterior segment abnormalities. Retinal vein dilatation or tortuosity was the most common finding followed by changes in the optic disc (8.4% of patients) and background haemorrhage (6.7% of patients). With increasing severity of thrombocytopenia, the proportion of patients with retinal abnormalities increased. In patients with grade I thrombocytopenia, no fundal abnormality was found. In those with grade II thrombocytopenia, fundal abnormality was found in 13.63% patients, whereas in the grade III category it was 27.90%.
Severity of thrombocytopenia had a significant association with retinal abnormalities. Occurrence of fundus changes increases with an increase in severity of thrombocytopenia. Fundus changes were found in all patients with grade IV thrombocytopenia.
We retrospectively documented indications for Caesarean sections in a rural district level hospital in the highlands of Papua New Guinea. Over a 53-month study period, 745 Caesarean sections were performed. Prolonged labour, previous history of Caesarean section, cephalopelvic disproportion, malpresentation and fetal distress accounted for over 88% of Caesarean sections performed. In older mothers (aged >30 years), antepartum haemorrhage (Fisher exact test, P = 0.05) and multiple indications (P = 0.001) were leading reasons for Caesarean sections while cephalopelvic disproportion (P = 0.005) was the leading indication in younger mothers. Further prospective studies incorporating perinatal and maternal mortality rates are required to optimise the value of Caesarean sections at district level hospitals in Papua New Guinea.
To report the clinical profile and management of orbital tuberculosis (TB) in children.
Eight cases were studied retrospectively.
Ages in the range of 3–16 years. Three cases presented with discharging sinus in upper lid, three with a cystic mass and two with lid necrosis. Underlying bony changes were found in five patients. Drainage and curettage was done for five patients, needle drainage of fluid was done in one patient and in two patients local debridement was done. Polymerase chain reaction for tuberculosis was positive in four cases and acid fast bacilli (AFB) were isolated on culture in three cases. On histopathology, six cases had granulomatous inflammation with caseating necrosis in one, though AFB could not be found. A favourable response to anti-tubercular treatment was achieved in all cases.
High index of suspicion is required for diagnosis of orbital TB. Microbiological and pathological diagnosis may not be achieved in all cases.
A structured questionnaire was administered to 50 medical patients, 50 surgical patients and 50 staff members at Vila Central Hospital, Vanuatu. A similar study was conducted 10 years earlier. In the intervening decade, Vanuatu has seen unprecedented population growth, increasing expatriate numbers, and the introduction of mobile phone and Internet networks. Given these social transformations, this study aimed to identify changes in custom medicine use over this period. Fifty-nine percent of interviewees had used custom medicine at least once, compared to 86% reported in the 2003 study. Thirty-two percent had used custom medicine in the last 12 months, a significant decline from 60% in the previous study. Collectively, rates of custom medicine use have declined but especially in the physical therapies such as bone setting. We believe this declining custom medicine use reflects an overall weakening traditional culture within Vanuatu and believe that within a generation, custom medicine knowledge will likely be lost.
Sub-Saharan Africa countries like Malawi have a paucity of ear, nose and throat (ENT) data, services and training opportunities.
To reflect on new Malawian ENT experience and to propose guidelines to poorly resourced countries.
Analysis of data predating and following establishment of ENT services in Malawi.
In 2008 the first and only Malawian ENT specialist established ENT services with external funding. Fifteen clinical officers have been trained and a nurse placed at each outreach hospital. In 2012, 15,284 consultations were recorded: 543 (3.6%) from outreach clinics. Forty-nine percent needed medical treatment, while 45% needed medical advice. Surgery was performed on 2.7% of patients; 21% for foreign bodies in the nose and throat and 18% for foreign bodies and biopsies of ears.
To establish accessible and sustainable specialist ENT services in a poor country requires building on an established local health delivery system, careful planning and investment in personnel, infrastructure, training and data collection.
Scrub typhus is an important cause of acute febrile illness. This observational study describes the clinical features and complications of the patients diagnosed to have scrub typhus in Christian Medical College & Hospital, Ludhiana, Punjab, India. The diagnosis of scrub typhus was made by using Bioline SD Tsutsugamushi test kit which detects IgM, IgG or IgA antibodies to Orientia tsutsugamushi. Sixty-two patients of scrub typhus were seen during the study period of 1 year. The mean age of the study group was 39.9 years. All the patients presented with fever, and of these 31 (50%) had non-specific symptoms. All others had some complication, namely ARDS/ALI in 18 (29%), neurological involvement in 12 (19.4%), acute kidney injury (AKI) in 16 (25.8%), hypotension in eight (12.9%), thrombocytopenia in 23 (37.1%), hepatitis in 34 (54.8%) and MODS in 19 (30.7%). Eschar was present only in nine patients. Three patients expired due to multi-organ failure, hypotension and metabolic acidosis.