Mycobacteriology

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

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

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

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

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

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

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

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

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

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

Postgraduate Medical Journal

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

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

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

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

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

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

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

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

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

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

Atherosclerosis

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

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

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

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

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

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

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

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

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

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

Public Health

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

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

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

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

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

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

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

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

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

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

Medicine

Editorial RN Srivastava Apollo Medicine 2019 16(1):1-1

Posttraumatic brain edema: Pathophysiology, management, and current concept Subhas K Konar, Dhaval Shukla, Amit Agrawal Apollo Medicine 2019 16(1):2-7 Post traumatic cerebral edema is a multiplex process. Mainly two types of cerebral edema occurred after traumatic brain injury-vasogenic edema and cytotoxic edema. Cytotoxic cerebral edema is due to accumulation of water in the intercellular space. Mitochondria mainly cause cytotoxic edema due to the involvement of oxidative metabolism. Various molecules are involved in the formation of cytotoxic edema- like aquaporin, Sulfonylurea-receptor 1 – transient receptor potential member 4 (Sur1-Trpm4), Glutamate, Na+-K+-2Cl− cotransporter, Arginine vasopressin, Histamine, and Erythropoietin .Vasogenic edema develops due to disruption of blood-brain barrier or altered permeability of blood-brain barrier so correlate with the level of impact and or activation of molecular pathways related with neuroinflammation. Molecules involved in neuroinflammation are tumor necrosis factor (TNF), interleukins (IL) 6 and I beta, Substance P and Bradykinin. Management is mainly dived into two part- medical and surgical. Medical management includes management of increased intracranial pressure and later blocking of the pathways involved in the formation and progression of cerebral edema. In refractory cases, surgical decompression plays a role in controlling the intracranial pressure due to cerebral edema.

The importance of microscopic diagnosis of respiratory infections Isabella Princess, Rohit Vadala Apollo Medicine 2019 16(1):8-10 The need for mastering microscopic diagnosis arises in all laboratory specialties, especially when working in resource-poor community laboratories which lack newer diagnostic instruments. Certain clues from microscopic appearance should be carefully analyzed to clinch diagnosis and to not miss out these findings. In addition, if turnaround time is reduced, there is better patient outcome and satisfaction from the clinical colleagues.

Primary fungal laryngitis: An overlooked clinical entity Santosh Kumar Swain, Mahesh Chandra Sahu, Priyanka Debdta, Manas Ranjan Baisakh Apollo Medicine 2019 16(1):11-15 Primary fungal laryngitis is a fungal infection of the larynx without affecting the other body parts such as lungs, pharynx, and oral cavity. It is an extremely rare clinical entity, especially in immunocompetent patients. Aspergillus fumigatus and Candida albicans are common fungi associated with primary fungal laryngitis. Hoarseness of the voice is common clinical presentations. The diagnosis of the primary fungal laryngitis is often overlooked and delayed among patients as it is usually evident among immunocompromised patients. It is often confused with certain laryngeal diseases such as granulomatous diseases, leukoplakia, and malignancy. Misdiagnosis or delayed diagnosis or inadequate treatment may lead to impaired functioning of the larynx and sometimes suffered from permanent disability. It is always important to identify the lesion earliest for avoiding morbid or life-threatening consequences. The purpose of this review article is to discuss the etiopathology, clinical presentations, diagnosis, and treatment of primary fungal laryngitis.

Isolation and identification of fungus associated with skin and nail scalps of patients in a tertiary care teaching hospital Kaniska Uthansingh, Manoj Kumar Sahu, Nagen Kumar Debata, Debasmita Behera, Kirtika Panda, Mahesh Chandra Sahu Apollo Medicine 2019 16(1):16-21 Background and Objectives: Ringworm of the scalp is starting at now a disease of overall criticalness and a general prosperity teaching care hospitals. It is otherwise known as dermatophytes, which attack and create on dead animal keratin. This assessment was intended to recognize the regular dermatophyte causing parasitic infection with both minute just as social strategies. Materials and Methods: This is a Prospective study which was carried out for the period 1 year and included the patients with tinea cruris and tinea corporis, tinea unguium, tinea pedis, and tinea barbae which are seen in the patients between 6 to 70 years of age. Dermatophytes were confirmed with microscopic examination of skin and nail tests taken from the influenced lesion of the body. Both cotton blue and potassium hydroxide grouping of 10%– 30% were utilized to see under magnifying micrioscope. All information were broken down with SPPS 20 programming. Results: Out of 78 patients, the recurrence of ringworm infection among those patients attending in the department of Skin and VD, IMS and SUM Hospital was Trichophyton rubrum (73%), Trichophyton mentagrophytes (53%), Epidermophyton floccosum (26.82%), and Trichophyton verrucosum (7.31%). T. rubrum was the most widely recognized etiological fungus in tinea corporis, and this positioned first in the other type of ringworm infection. Recurrence of dermatophytes infection partner with various clinical examples; for example, nail pieces and skin swabs from the infected area. Conclusions: The greater part of the tinea corporis patients were infected with T. rubrum then comes the disease of Trichophyton violaceum, Trichophyton tonsurans, and T. mentagrophytes. The most astounding recurrence of disease was among the patients matured 20– 30 years. It is additionally essentially noticed that this infection takes a somewhat serious turn in patients of cutting edge in older age (60– 80 years).

Assessment of level of depression and anxiety in pre- and postoperative stages: A prospective cross-sectional study in SCB Medical College, Cuttack Srikanta Panda, Narendranath Samantaray, Monisha Patanaik, Debasish Sahoo, Anshuman Sarangi, Somanatha Jena Apollo Medicine 2019 16(1):22-25 Objectives: Mood disorders are considered to be prevalent in hospitalized patients. Our study aimed to investigate the prevalence of depression and anxiety symptoms in pre- and postoperative stage in surgical patients. Methods: We included 60 surgical patients in this cross-sectional study which includes 43 male and 17 female patients and average age of 38.8 years. Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were used to screen for symptoms of depression and anxiety at 12 h after admission for electively scheduled surgeries and 12–24 h after the surgery for patients undergoing emergency surgery. Results: In presurgery stage, anxiety was found to be prevalent in 43.3% of patients while depression is 38%. In postsurgery stage, anxiety and depression were found in 18.3% and 35% of patients, respectively. Conclusions: Both anxiety and depression are highly prevalent in pre- and postoperative stage of surgery. Such symptoms should be attended with more seriousness, otherwise would lead to higher morbidity and mortality.

Surgical outcome of 60 operated patients with acute extradural hematomas based on the preoperative glasgow coma scale Ajaydeep Singh, Arvinpreet Kour, GS Bindra, Ajay K Gehlot, Rahul Midha, Kartik Nandra Apollo Medicine 2019 16(1):26-32 Aim and Objective: This study aims to evaluate the outcome of the patients operated for acute extradural hematoma (EDH). Patients and Methods: Sixty consecutive cases of acute EDH were treated at medical college hospital to assess the outcome of the patients based on their Glasgow Coma Scale (GCS), radiological assessment, and pupil size. The patients were monitored of their GCS, pupillary size, and vitals. The Glasgow outcome scale was used to evaluate patient outcome at the discharge from the hospital and after 3 months. Observation and Results: Sixty patients constituting 56 males and 4 females were the part of the study. The mean age of the patients was 23.21 years (range: 2–47 years). On an average, the patients were operated around 9.91 h after the trauma (ranging 2–24 h). Out of sixty patients, 25, 17, and 18 patients had GCS of mild, moderate, and severe groups. Prompt surgery with better care obtained us with mortality 1.6%, morbidity 21.7%, and complete recovery in 83% patients. Conclusion: We may conclude in our study that presurgical clinical findings such as sensorium of patient and pupillary status were an important indicator for surgical outcome. In most of the cases, the outcome was favorable with progressive recovery.

Aggressive surgical resection following neoadjuvant imatinib therapy for advanced duodenal tumor with hepatic metastasis Varun Madaan, Rigved Gupta, GK Adithya, Satya Prakash Jindal, Deepak Govil Apollo Medicine 2019 16(1):33-35 Duodenal gastrointestinal stromal tumors (GISTs) are rare tumors which constitute <5&#37; of all cases of GIST. The treatment of locally advanced/inoperable and metastatic GIST is primarily tyrosine kinase inhibitor therapy (TKI), i.e., imatinib mesylate. In some patients, initial TKI therapy may result in significant downstaging of the primary tumor and metastatic disease. The role of aggressive surgical resection in such patients remains controversial. We present a case of advanced duodenal GIST treated successfully by Whipple&#39;s procedure with liver wedge resection following neoadjuvant TKI therapy. This case shows that aggressive surgical resection for metastatic duodenal GIST following neoadjuvant imatinib seems to be a feasible treatment option.

Primary paravertebral low-grade fibromyxoid sarcoma Binod Kumar Singhania, Jummo Jini, Gobinda Pramanick Apollo Medicine 2019 16(1):36-38 Low-grade fibromyxoid sarcoma is a distinctive variant of fibrosarcoma. Despite its benign histological appearance, it is a tumor with malignant potential. Usually, it is occur in the proximal lower extremities and trunk. However, it is very rare in paravertebral region. The diagnosis is based on the histology and specific immunohistochemistry results. The treatment of choice is total excision followed by radiotherapy to prevent the possibility of recurrence. We excised the tumor to near total and a wide fixation has been done. Frozen section biopsy was misleading and reported a schwannoma.

Multiple spinal neurofibromas Kodeeswaran Marappan, Prabhu Marudamuthu, Sherina Paul Raj Apollo Medicine 2019 16(1):39-41 A 55-year-old male, with a 2-month history of urinary incontinence, a suspected case of pyelonephritis was initially treated by a nephrologist, but with no relief in spite of medication. On further evaluation, he was found to have a history of back pain, progressive bilateral weakness of lower extremities, and difficulty walking. He was thus referred to us for further management. Magnetic resonance imaging (MRI) of the spine was done, which revealed the presence of multiple bilateral dumbbell-shaped lesions at multiple spinal levels, associated with widening of the neural foramina of the cervical, dorsal, and lumbar regions. Surgical excision of all lesions was done in a single sitting. The patient had postoperative weakness and urinary incontinence, which slowly recovered and weakness gradually improved by physiotherapy. On follow-up, the patient was able to walk without any weakness. Surgical excision is the treatment of choice for spinal neurofibromatosis. Diagnosis of the condition may be difficult due to the lack of symptoms in majority of the cases or presentation with rare symptoms. However, it is recommended that a routine MRI of the spine be performed in patients with a history of urinary incontinence associated with weakness of limbs.

Surgery

The duration of intra-abdominal hypertension and increased serum lactate level are important prognostic markers in critically ill surgical patient's outcome: A prospective, observational study Hnuman Prasad Gupta, Pema Ram Khichar, Rekha Porwal, Amit Singh, Anil Kumar Sharma, Mukesh Beniwal, Satyaveer Singh Nigerian Journal of Surgery 2019 25(1):1-8 Aim: The present study analyzed the clinical significance of duration of intra-abdominal hypertension (IAH) associated with increased serum lactate in critically ill patients with severe sepsis. Materials and Methods: Our study was an observational, prospective study carried out in the Surgical Intensive Care Unit (ICU) at J.L.N Medical College, Ajmer, Rajasthan, India. In our study, we included a total of 100 patients and intra-abdominal pressure (IAP) was measured through intravesical route at the time of admission and after 6, 12, 24, 48, and 72 h via a urinary catheter filled with 25 ml of saline. Duration of ICU and hospital stay, need for ventilator support, initiation of enteral feeding, serum lactate level at time of admission and after 48 h, and 30-day mortality were noted as outcomes. Results: In our study, an overall incidence of IAH was 60%. Patients with cardiovascular surgery and renal and pulmonary dysfunction were 93.3%, 55%, and 60%, respectively, at the time of admission and 65%, 10%, and 10%, respectively, after 72 h of admission in the surgical ICU. Nonsurvivors had statistically significant higher IAP and serum lactate levels than survivors. Patients with longer duration of IAH had longer ICU and hospital stay, longer duration of vasopressors and ventilator support, and delayed enteral feeding. Conclusion: There is a strong relationship “risk accumulation” between duration of IAH associated with increased serum lactate and organ dysfunction. The duration of IAH was an independent predictor of 30-day mortality. Early recognition and prompt intervention for IAH and severe sepsis are essential to improve the patient outcomes.

Bone level measurements around platform switched and platform matched implants: A comparative study Vivek Rana, Varsharani Madhukar Dhakne, Shrikant Jadhawar, Ishan Kadam, Koyena Mishra, Parisha Patil Nigerian Journal of Surgery 2019 25(1):9-13 Background: The overall success of dental implants depends on the crestal bone support around the implants. During the initial years, the bone loss around the implants determines the success rate of treatment. Platform switching (PLS) preserves the crestal bone loss, and this approach must be applied clinically. Aim: The purpose of this study was to determine the changes in vertical and horizontal marginal bone levels in platform-switched and platform-matched dental implants. Materials and Methods: One fifty patients received one fifty dental implants in the present study over a 1-year period. Measurement was performed between the implant shoulder and the most apical and horizontal marginal defect by periapical radiographs to examine the changes of peri-implant alveolar bone before and 12 months after prosthodontic restoration delivery. Results: These marginal bone measurements showed a bone gain of 1.56 ± 2.4 mm in the vertical gap and 1.49 ± 2.24 mm in the horizontal gap of the platform matching, while in the PLS, a bone gain of 2.67 ± 2.0 mm in the vertical gap (P < 0.05) and 2.89 ± 1.67 mm in the horizontal gap was found. Only a statistically significant difference was found comparing bone gains in the vertical gap between the two groups (P < 0.05). Conclusion: PLS helps preserve crestal bone around the implants, and this concept should be followed when clinical situations in implant placement permit.

Comparison of vacuum-assisted closure therapy and conventional dressing on wound healing in patients with diabetic foot ulcer: A randomized controlled trial Sangma M D James, Sathasivam Sureshkumar, Thirthar P Elamurugan, Naik Debasis, Chellappa Vijayakumar, Chinnakali Palanivel Nigerian Journal of Surgery 2019 25(1):14-20 Background: Vacuum-assisted closure (VAC) therapy has been shown to be beneficial in a variety of wounds. However, evidence of its benefit in diabetic foot ulcers (DFUs), especially with respect to Indian population, is sparse. Methodology: This randomized controlled trial included DFUs of Wagner's Grades 1 and 2. Patients were further stratified with respect to DFU size <10 cm and ≥10 cm. Patients with vascular disease, osteomyelitis, and bilateral DFUs were excluded from the study. The enrolled patients were randomized to receive VAC therapy or conventional dressing. The time to wound healing, granulation tissue formation, and complications such as pain, infection, and bleeding were compared between the two groups. Results: A total of sixty patients were randomized, of which 27 in each group were analyzed. The mean time to healing in days was significantly less in VAC group (22.52 vs. 3.85; P < 0.0001). Mean time to achieve 75%–100% granulation tissue cover was significantly less in VAC group (23.33 vs. 32.15; P < 0.0001). Rate of granulation tissue formation was also found to be significantly better in VAC group (2.91 cm2/day vs. 2.16 cm2/day; P = 0.0306). There was no difference between the two groups with respect to wound infection and bleeding which are commonly attributed to VAC therapy. VAC therapy group had significantly lesser pain at week 3 (Visual Analog Scale score 3 vs. 4; P = 0.004). Conclusion: VAC therapy significantly decreases the time to complete wound healing, hastens granulation tissue formation, and reduces the ulcer area compared to conventional dressing. The study did not find any significant increase in the bleeding and infection in the VAC therapy group.

Histopathological changes in gallbladder mucosa associated with cholelithiasis: A prospective study Amandeep Singh, Guramritpal Singh, Kanwardeep Kaur, Gagandeep Goyal, Girish Saini, Deepika Sharma Nigerian Journal of Surgery 2019 25(1):21-25 Background and Aims: Cholelithiasis is known to produce diverse histopathological changes in the gallbladder mucosa. In the present study, we aimed to find the correlation between various gallstone characteristics (i.e., number, size, and morphological type) with the type of mucosal response in gallbladder mucosa (i.e., inflammation, hyperplasia, metaplasia, and carcinoma). Methods: The present study was conducted prospectively on 100 patients undergoing cholecystectomy for symptomatic cholecystitis. Gallstones were assessed for various parameters, i.e., number, size, and morphological type. Gallbladder mucosa was subjected to histopathological examination. Sections were taken from body, fundus, and neck of gallbladder. Results: Of 100 cases, maximum type was of mixed stones (54%) and was multiple in number (46%). However, gallstone type and number are nonsignificant variables to produce precancerous lesions (i.e., hyperplasia and metaplasia). Statistically significant results were obtained while comparing the mucosal response with gallstone size (P = 0.012). Conclusion: As the gallstone size increases, the response in gallbladder mucosa changes from cholecystitis, hyperplasia, and metaplasia to carcinoma. Gallstone type and number are nonsignificant variables to produce precancerous lesions.

Endoscopic management of ureteric stones: Our initial experience Taiwo Opeyemi Alabi, Emmanuel Ajibola Jeje, Moses Adebisi Ogunjimi, Rufus Wale Ojewola Nigerian Journal of Surgery 2019 25(1):26-29 Aims: The aim of this study is to present our initial experience with intracorporeal pneumatic ureterolithotripsy highlighting the pattern of patients' clinical presentation, techniques, and limitation of the procedure. Materials and Methods: This is a retrospective study of cases of ureteric stones managed over a period of 18 months in a private hospital. Data obtained include patients' sociodemography, clinical presentation, stone burden, procedural technique, complication, and need for a secondary procedure. Data were analyzed using the Statistical Package for the Social Sciences version 21. Results: The total number of patients managed was 20 with an age range of 28–75 years and a mean of 48.2 ± 12.4 years. Majority of them, i.e., 11 (55%) were middle aged. Female gender was more predominant, 11 (55%). Flank pain was the most common mode of presentation. Right-sided stone occurred in 9 (45%), left sided in 7 (35%), and bilateral in 4 (20%). Stone location was in the upper ureter in 4 (16.7%), mid-ureter in 7 (29.2%), and lower ureter in 13 (54.2%). The stone size ranged from 6 to 18 mm with a mean of 9.7 ± 2.5 mm. Four patients (20%) required initial bilateral ureteric stenting before definitive procedure to allow for recovery from sepsis and/or nephropathy. All patients had double-J stenting and were discharged 2 days after the procedure. The procedure was successful in 19 (95%) with 100% stone clearance rate and complete resolution of symptom without any complication. One patient (5%) had a very hard upper ureteric stone which retropulsed into the renal pelvis requiring open nephrolithotomy. Conclusion: Endoscopic treatment of ureteric stone with intracorporeal pneumatic lithotripsy is a safe and effective treatment modality. It is, however, limited in the management of hard upper ureteric stone, especially those that are close to the pelviureteric junction due to the risk of retropulsion of the stone into the kidney.

Determination of visual portfolio for surgeons overseas assessment of surgical needs Nigeria study: Consensus generation through an e-Delphi process Felix Makinde Alakaloko, Etienne St-Louis, Adesoji O Ademuyiwa, Dan Poenaru, Christopher Bode Nigerian Journal of Surgery 2019 25(1):30-35 Background: Surgery as a public health priority has received little attention until recently. There is a significant unmeasured and unmet burden of surgical illness in low- and middle-income countries (LMICs). Our aim was to generate a consensus among expert pediatric surgeons practicing in LMICs regarding the spectrum of pediatric surgical conditions that we should look out for in a community-based survey for Surgeons OverSeas Assessment of Surgical Needs Nigeria study. Materials and Methods: The Delphi methodology was utilized to identify sets of variables from among a panel of experts. Each variable was scored on a 5-point Likert scale. The experts were provided with an anonymous summary of the results after the first round. A consensus was achieved after two rounds, defined by an improvement in the standard deviation (SD) of scores for a particular variable over that of the previous round. We invited 76 pediatric surgeons through e-mail across Africa but predominantly from Nigeria. Results: Twenty-one pediatric surgeons gave consent to participate through return of mail. Thirteen (62%) answered the first round statements and 8 (38%) the second round. In general, the strength of agreement to all statements of the questionnaire improved between the first and second rounds. Overall consensus, as expressed by the decrease in the mean SD from 0.84 in the first round to 0.68 in the second round, also improved over time. The strength of consensus improved for 23 (74%) of the statements. The strength of consensus decreased for the remaining 8 (26%) of statements. Out of the 31 consensus-generating statements, 16 (51%) scored high agreement, 13 (42%) scored low agreement, and 2 (15%) scored perfect disagreement. Conclusion: We have successfully identified the pediatric surgical conditions to be included in any community survey of pediatric surgical need in an LMIC setting.

Fast-track protocol versus conventional protocol on patient outcome: A randomized clinical trial Sandhya P Iyer, Zeeshan Kareem Nigerian Journal of Surgery 2019 25(1):36-41 Background: The aim of this study is to compare fast-track methodology with traditional methods of surgical care in achieving better patient outcome, and ensuring a timely discharge from the hospital, and also note the factors that are responsible for a delayed discharge from the hospital. Materials and Methods: One hundred patients undergoing elective surgeries were randomly allocated into fast-track and traditional protocol of perioperative care. Patients who underwent fast-track protocol (FTP) were started on early oral feeding and were encouraged for early discharge, while the others were made to follow the traditional method of recovery. The gastrointestinal functions, postoperative complications and hospital stay time were recorded. The results were tabulated and analyzed. Results: Early feeding was well tolerated by all the patients in the “fast track” group, while the patients in the control group had increased number of “nil by mouth” days, and this result was statistically significant. Ambulation was started earlier in the case group as compared to the controls, and the mean period of starting of ambulation was statistically significant, in the cases as compared to the controls. The patients in the case group had an earlier discharge from the hospital, as compared to the control group. The most common reason for a delay in discharge from the hospital, in either group, was seen to be inadequate pain relief postoperatively. Conclusion: The FTP can significantly shorten the postoperative hospital stay after elective surgery, as compared to the traditional protocol.

Ocular fireworks injuries in Eastern Nigeria: A 3-year review Akunne Ijeoma Apakama, Cosmas C Anajekwu Nigerian Journal of Surgery 2019 25(1):42-44 Aim: The aim of this study is to determine the incidence and types of ocular injuries caused by fireworks in patients seen at Guinness Eye Centre Onitsha and their effects on vision. Methods: This was a 3-year retrospective study evaluating case files of patients with ocular fireworks injuries seen at Guinness Eye Centre Onitsha during the Christmas and New Year festivities (2010–2012). Information was extracted into a pro forma and analyzed using Excel, AutoSum, and calculators. Results: Subconjunctival hemorrhage, corneal lacerations, and hyphema were the most common injuries seen. Patients had multiple ocular pathologies, and the left eye was affected in 62.5% of cases. Bystanders accounted for 75% of those with ocular fireworks injuries. All were males. Half of the affected eyes went blind. Conclusion: Fireworks injuries constituted only 5.1%, 0%, and 10% of ocular injuries in 2010, 2011, and 2012, respectively, with devastating consequence of blindness in 50% of affected eyes.

Risk-adjusted analysis of patients undergoing emergency laparotomy using POSSUM and P-POSSUM score: A prospective study Mohan Lal Echara, Amit Singh, Gunjan Sharma Nigerian Journal of Surgery 2019 25(1):45-51 Background: Comparison of operative morbidity rates after emergency laparotomy between units may be misleading because it does not take into account the physiological variables of patients' conditions. Surgical risk scores have been created, and the most commonly used is the Physiological and Operative Severity Score for the enumeration of Mortality (POSSUM) or one of its modifications, the Portsmouth-POSSUM (P-POSSUM), usually requires intraoperative information. Objective: The objective of this study is to evaluate the POSSUM and P-POSSUM scores in predicting postoperative morbidity and mortality in patients undergoing emergency laparotomy. Methodology: This is a prospective, cross-sectional, and hospital-based study that was conducted at J.L.N. Medical College and Hospital, Ajmer, Rajasthan, India, from April 2017 to December 2017. Adult patients who presented at the causality and underwent emergency laparotomy were included in the study. Observed and predicted mortality and morbidity were calculated using POSSUM and P-POSSUM equations, and statistical significance was calculated using Chi-square test. Results: A total of 100 patients were included in this study, with a mean age of 42.83 ± 18.21 years. The observed (O) mortality was 12 (12.0%), while POSSUM predicted 40 (40%) and P-POSSUM 27 (27%). The O/E ratio for POSSUM was 0.29 and for P-POSSUM was 0.44, and this means that they both overestimate mortality. When the results were tested by Chi-square test, the P value was found to be 0.55 and 0.85 for POSSUM and P-POSSUM, respectively, which showed no significant correlation for observed and expected mortality. The observed morbidity was 69 (69%), while POSSUM expected morbidity was 79 (79%), O/E ratio is 0.87, and this again overestimates the morbidity. POSSUM is overpredicting the rate of morbidity, and test of correlation showed no significance with P = 0.75. Conclusion: POSSUM and P-POSSUM were found to overestimate mortality and morbidity in our patient's population.

Micronuclei in exfoliated cells: A biomarker of genotoxicity in tobacco users Meenakshi Upadhyay, Parul Verma, Robin Sabharwal, Santosh Kumar Subudhi, Suruchi Jatol-Tekade, Vihang Naphade, Basanta Kumar Choudhury, Pravudeva Devidutta Sahoo Nigerian Journal of Surgery 2019 25(1):52-59 Aims: The aim of this study was to analyze the tobacco-related genotoxic effects in individual with habit of smoking and chewing tobacco. Materials and Methods: The present study sample consisted of 120 individuals attending the outpatient department of D. J. College of Dental Sciences and Research, Modinagar, Uttar Pradesh (UP). The sample was divided into four groups as follows: Group I (individuals with habit of smoking tobacco), Group II (individuals with habit of chewing tobacco), Group III (individuals with habit of smoking and chewing tobacco), and Group IV control group (nontobacco-exposed individuals). Patients were asked to rinse their mouth gently with water. The exfoliated cells were obtained by scraping the buccal mucosa of individuals with a wooden spatula. The scraped cells were placed on the precleaned slides. The smears were then stained with RAPID-PAP™ and analyzed under the microscope. Data were analyzed using SPSS statistical software. Results: In the present study, an arbitrary unit was obtained using frequency/day multiplied by the duration of years (risk multiplication factor [RMF], a positive and significant correlation were observed between the RMF and the mean percentage of micronucleated cell count in smokers, chewers, and in individuals with both smoking and chewing habit, respectively. A weak positive and nonsignificant correlation were observed between age and mean percentage of micronucleated cells in smokers and smokers + chewers, respectively, while it was weak negative and nonsignificant in chewers. In control group, correlation between age and percentage of micronucleated cells was weak positive and nonsignificant at 5% level of significance. Conclusion: The micronuclei in exfoliated mucosal cells from buccal mucosa can be used as a biomarker of genotoxicity in predicting the effects of carcinogens.