Acute Pulmonary Embolism in an Intensive Care Unit Setting in Sierra Leone.

INTRODUCTION: In Sierra Leone, the lack of information on pulmonary embolism (PE) limits the access to evidence-based standard of diagnostic work-up and management of the disease. The objective of this study was to describe the clinical characteristics and management of acute pulmonary embolism in our setting and to determine whether the pre-test probability scoring algorithms were used prior to Computed Tomography Pulmonary Angiogram (CTPA) request. METHODS: This retrospective observational study was conducted on CTPA-confirmed PE patients admitted to the Intensive Care Unit, Choithrams Memorial Hospital, in Freetown, Sierra Leone between July 2014 to June 2019. Clinical data, and pertinent investigations related to PE were determined. CTPA findings were correlated with the patient's hemodynamic status. The calculated pretest clinical probability scores (PCPS) for each patient were compared to the CTPA results. RESULTS: CTPA-confirmed PE in the study cohort was 79, with a rate of 16 new PE per year. The frequency of PE was 1.9% of the total hospital admission per year. The mean age was 64.1 ± 17.9 years, median age was 63.3years (range: 23-89 years), with 55.7% of the cohort being females. Dyspnea (78.5%) and tachycardia (69.6%) were the commonest signs and symptoms documented, with immobilization (34.2%) being the prevalent risk factor, while hypertension (48.1%) was the most common co-morbidity. The PCPS algorithm was underutilized, as "Wells Score" was documented in only 9.5% while "modified Geneva score" was never used by hospital physicians. PE with hemodynamic stability was significantly more common than PE with unstable hemodynamic status [55 (69.6%) vs 24 (30.4%), p=0.015]. All patients were managed only with anticoagulants. The overall in-hospital mortality was 17.7%. CONCLUSION: Since PCPS was hardly calculated by doctors in the diagnosis of PE, the study showed that the diagnostic algorithm for suspected PE was infrequently used in clinical practice. The use of empirical judgement by doctors in requesting for CTPA may have accounted for low rate in the diagnosis of PE per year. The establishment of P.E registry in Sierra Leone is imperative.

INTRODUCTION: En Sierra Leone, le manque d'informations sur l'embolie pulmonaire (EP) limite l'accès à des normes de diagnostic et de prise en charge de la maladie fondées sur des preuves. L'objectif de cette étude était de décrire les caractéristiques cliniques et la prise en charge de l'embolie pulmonaire aiguë dans notre établissement et de déterminer si les algorithmes de notation de la probabilité pré-test étaient utilisés avant la demande d'angiographie pulmonaire par tomodensitométrie (CTPA). MÉTHODES: Cette étude observationnelle rétrospective a été menée sur des patients atteints d'EP confirmée par CTPA admis à l'unité de soins intensifs, Choithrams Memorial Hospital, à Freetown, Sierra Leone, entre juillet 2014 et juin 2019. Les données cliniques, et les investigations pertinentes liées à l'EP ont été déterminées. Les résultats du CTPA ont été corrélés avec l'état hémodynamique du patient. Les scores de probabilité clinique prétest (PCPS) calculés pour chaque patient ont été comparés aux résultats du CTPA. RÉSULTATS: Le nombre d'EP confirmées par CTPA dans la cohorte étudiée était de 79, avec un taux de 16 nouvelles EP par an. La fréquence de l'EP était de 1,9 % du nombre total d'hospitalisations par an. L'âge moyen était de 64,1 ± 17,9 ans, l'âge médian de 63,3 ans (fourchette : 23-89 ans), 55,7 % de la cohorte étant des femmes. La dyspnée (78,5 %) et la tachycardie (69,6 %) étaient les signes et symptômes les plus fréquemment documentés, l'immobilisation (34,2%) étant le facteur de risque prévalent, tandis que l'hypertension (48,1 %) était la comorbidité la plus courante. L'algorithme PCPS était sous-utilisé, le " score de Wells " n'étant documenté que dans 9,5 % des cas, tandis que le " score de Genève modifié " n'était jamais utilisé par les médecins hospitaliers. L'EP avec stabilité hémodynamique était significativement plus fréquente que l'EP avec état hémodynamique instable [55 (69,6 %) vs 24 (30,4 %), p=0,015]. Tous les patients ont été traités uniquement par anticoagulants. La mortalité globale à l'hôpital était de 17,7 %. CONCLUSION: Étant donné que le PCPS était rarement calculé par les médecins pour le diagnostic de l'EP, l'étude a montré que l'algorithme diagnostique pour l'EP suspectée était rarement utilisé dans la pratique clinique. L'utilisation d'un jugement empirique par les médecins pour demander un CTPA peut expliquer le faible taux de diagnostic de l'EP par an. L'établissement d'un registre de l'E.P. en Sierra Leone est impératif. Mots-clés: Embolie pulmonaire, caractéristiques cliniques, gestion, Sierra Leone.

Persistent left superior vena cava in a 29-year-old lady with Ebstein's anomaly and complete heart block. A case report and literature review.

Introduction: Persistent Left Superior Vena Cava (PLSVC) is a rare congenital vascular anomaly that may occur alone or in combination with complex congenital heart anomalies and dangerous arrhythmias. We report the first case in the literature of combined PLSVC, Ebstein's Anomaly (Type A) and complete atrioventricular block in an adult female, being successfully managed with permanent pacemaker implantation in Sierra Leone. Case summary: We present an interesting case of a 29-year-old female, referred to the cardiology clinic on account of breathlessness, dizziness, and recurrent syncope. Physical examination revealed a pulse rate of 39 bpm, jugular venous pulse with occasional cannon waves, and grade 3/6 pansystolic murmur in the tricuspid valve area. An electrocardiogram confirmed complete atrioventricular block with junctional escape rhythm, while Transthoracic Echocardiogram (TTE) confirmed Ebstein's Anomaly (Type A) and moderate tricuspid regurgitation. PLSVC was discovered as an incidental intraprocedural finding. Deploying a pacemaker lead through this venous anomaly from the left side was futile. Nevertheless, we used a right sided approach that resulted in a successful permanent pacemaker implantation with optimal and stable parameters. Conclusion: This rare case report highlights the practical challenges often encountered in the practice of cardiology during pacemaker and other cardiac device implantation. Cardiologists and critical care physicians should be acquainted with the venous anomaly of PLSVC, its variants, and procedure-associated risks, for better clinical decision making.

Prevalence, Awareness and Risk Factors of Hypertension among Health Workers at the Connaught Teaching Hospital, Sierra Leone.

BACKGROUND: Hypertension among the health workforce is a major public health problem due to its high prevalence and dire consequences. This study aimed to determine the prevalence of hypertension, awareness, and related cardiovascular risk factors among health workers in a Teaching Hospital in Sierra Leone. METHODS: This was a cross-sectional descriptive study conducted among 250 health workers. A modified World Health Organization Non-Communicable Disease (WHO NCD) questionnaire was used to collect information on the socio-demographic characteristics, anthropometric, and lifestyle variables. RESULTS: The prevalences of hypertension and pre-hypertension were 37.2% and 22.4% respectively. The level of hypertension awareness was 36.6 %. The univariate logistic regression showed a significant crude odds ratio for gender, age, marital status, smokers, alcohol, extra sugar to tea/coffee, years of employment, weight, Waist Circumference, Hip Circumference, and Waist-Hip-Ratio (WHR) in the prediction of hypertension. The multivariate logistic regression revealed that male sex (AOR = 1.89; C.I 95%: [0.01- >20], p = 0.002), duration of employment (AOR = 0.36; C.I 95%: [0.17- 0.94], p = 0.01), and Waist Circumference (WC) (AOR = 1.46; C.I 95%: [0.58 - 3.68], p = 0.017), were positive predictors of hypertension. Males were about 2 times more likely to have hypertension, (AOR = 1.89; C.I 95%: [0.01- >20]). Participants with abnormal Waist Circumference (WC) were 1.5 times more likely to have hypertension (AOR = 1.46; C.I 95%: [0.58 - 3.68]). CONCLUSION: The prevalence of hypertension in this study population was slightly higher than the 34.8% reported for the general population even though this study population is relatively younger. The level of awareness was low. This calls for the implementation of an effective workplace health education program to improve lifestyle and reduce the risk of cardiovascular diseases.

Geospatial analysis of household spread of Ebola virus in a quarantined village - Sierra Leone, 2014.

We performed a spatial-temporal analysis to assess household risk factors for Ebola virus disease (Ebola) in a remote, severely-affected village. We defined a household as a family's shared living space and a case-household as a household with at least one resident who became a suspect, probable, or confirmed Ebola case from 1 August 2014 to 10 October 2014. We used Geographic Information System (GIS) software to calculate inter-household distances, performed space-time cluster analyses, and developed Generalized Estimating Equations (GEE). Village X consisted of 64 households; 42% of households became case-households over the observation period. Two significant space-time clusters occurred among households in the village; temporal effects outweighed spatial effects. GEE demonstrated that the odds of becoming a case-household increased by 4·0% for each additional person per household (P < 0·02) and 2·6% per day (P < 0·07). An increasing number of persons per household, and to a lesser extent, the passage of time after onset of the outbreak were risk factors for household Ebola acquisition, emphasizing the importance of prompt public health interventions that prioritize the most populated households. Using GIS with GEE can reveal complex spatial-temporal risk factors, which can inform prioritization of response activities in future outbreaks.

Sexually transmitted diseases among randomly selected attenders at an antenatal clinic in The Gambia.

One hundred randomly selected women attending a free government antenatal clinic in the town of Bakau, The Gambia, were examined. Vaginal swabs were taken for microscopical examination for Trichomonas vaginalis and for culture on Sabouraud's medium. Cervical swabs were taken for culture of Neisseria gonorrhoeae and Chlamydia trachomatis and, in 50 cases, Herpesvirus hominis; in addition, urethral swabs were taken for culture of N gonorrhoeae. Serum samples were tested for antibodies to Treponema pallidum by the Venereal Diseases Research Laboratory (VDRL) test and T pallidum haemagglutination assay (TPHA), and to C trachomatis and H hominis by microimmunofluorescence. The prevalence of infection with Candida albicans was found to be 35%, T vaginalis 32%, C trachomatis 6.9%, N gonorrhoeae 6.7%, T pallidum 1%, and H hominis 0%. IgG antibodies at a titre of at least 1/16 to C trachomatis serotypes D-K were found in 29.4%, and to serotypes A-C in a further 10.6%. IgG antibodies at a titre of at least 1/16 to H hominis type I were found in 94%, and to type II in 53%, although a proportion of the latter probably represent cross reacting antibodies to type I.

PIP: 100 randomly selected attenders of a free government antenatal clinic in Bakau, Gambia, were examined between November 1981 and February 1982, to discover the prevalence of a variety of sexually transmitted diseases (STDS). The age, tribal origin, and obstetric history of each patient were recorded. Patients were asked specifically about the presence of lower abdominal pains, vaginal discharge, and pain on passing urine. A vaginal speculum was passed and specimens were taken for Trichomonas vaginalis, Candida albicans, Neisseria gonorrhea, Chlamydia trachomatis, and Herpesvirus hominis. An abnormal vaginal discharge was noted on examination in 67 patients; only 24 of these patients had complained of discharge. The prevalence of infection was 35% with Candida abicans, 32% with Trichomonas vaginalis, 6.9% with Chlamydia trachomatis, 6.7% with Neisseria gonorrhea, and 0% with Herpesvirus hominis. IgG antibodies to H hominis type I were present. At a titre of at least 1.16 in 94% of women tested and to type II in 52.9% tested.

Leishmaniasis in The Gambia. 3. Is its incidence increasing?

During 1982 a further case of visceral leishmaniasis and six cases of cutaneous leishmaniasis were seen at the Medical Research Council Laboratories in The Gambia, suggesting that the incidence of this infection in The Gambia is increasing.

Leishmaniasis in The Gambia. I. A case of cutaneous leishmaniasis and a case of visceral leishmaniasis.

Leishmaniasis is thought to be rare in The Gambia but in June 1980 two patients with this infection were seen at Fajara, one with cutaneous leishmaniasis and one with visceral leishmaniasis. A possible diagnosis of visceral leishmaniasis was considered only late in the course of the illness of the second patient who died a few days after specific chemotherapy was started. Visceral leishmaniasis must be considered as a possible cause of fever and splenomegaly in The Gambia and in adjacent parts of West Africa.

A comparison of bottle tops, teaspoons and WHO glucose-electrolyte packets for home made oral rehydration solutions in The Gambia.

Three methods of preparation of oral rehydration solution were taught to Gambian mothers and the sodium concentration and osmolality of the solutions prepared were estimated. Most of the solutions made up using WHO glucose-electrolyte mix had a satisfactory sodium content (70 to 120 mmol/l) and osmolality (200 to 350 mosmoles/kg). Of the sugar and salt mixtures using a teaspoon as a measure, 17% were hypertonic (greater than 120 mmol sodium/l) and 24% were hyperosmolar (greater than 350 mosmol/kg). Nearly all the sugar and salt solutions prepared using a soft drink bottle top as a measure had sodium contents of 30-88 mmol/l and none was hyperosmolar. We suggest that wider trials of this simple, widely available measure are indicated.

Effect of a lipid load on blood and urinary carnitine in man.

Blood and urine carnitine contents have been determined in patients before and after a lipid load and in patients on haemodialysis. Oral and intravenous lipid administration significantly depressed blood carnitine content and after 500 ml intravenous Intralipid urinary carnitine excretion fell by 43%. Blood carnitine was reduced by 50% by haemodialysis and returned to the pre-dialysis value within 20 h in 5 out of 8 patients. It is concluded that the blood carnitine level is normally controlled over a narrow range. The fall in blood carnitine concentration and urine excretion which follows a lipid load indicate a limiting role for carnitine in lipid utilization in man, and suggest that carnitine supplements could be of value during parenteral nutrition with fats.