Frequency of relapse among Nigerian children with steroid-sensitive nephrotic syndrome.

BACKGROUND: The clinical course of steroid-sensitive nephrotic syndrome (SSNS) among Nigerian children has rarely been reported; this makes prognostication difficult. OBJECTIVES: The objective was to determine the frequency of relapses including frequent relapses (FR) and steroid-dependence (SD) in a cohort of Nigerian children with SSNS. A secondary objective was to identify clinical and demographic factors associated with relapse in these children. METHODS: Medical records of children with SSNS in a Tertiary Hospital in Nigeria were reviewed. Children with onset of nephrotic syndrome (NS) at age <1-year, follow-up period <12 months and secondary causes of NS were excluded. The relapse status of each child was determined in the 1st and 2nd year after diagnosis and the proportions with no relapse, FR and SD were calculated. RESULTS: Fifty children (68% males; median [range] age at onset of NS 4.8 [1.1-14.9] years) were followed-up for 31.1 (12.1-79.8) months. In the 1st and 2nd year of follow-up, 23 (46%) and 24 (70.6%) children experienced relapse, respectively. In the 1st-year, 0% and 10% had FR and SD while in the 2nd year 2.9% and 11.8% had FR and SD, respectively. Age at onset of NS, gender, time to first remission, serum creatinine or presence of hypertension or microscopic hematuria was not associated with 1st or 2nd year relapse. CONCLUSION: About half and two-thirds of children with NS in our center experience relapse in the 1st and 2nd year of follow-up, respectively; much fewer proportions experienced FR and SD in these periods. None of the commonly reported demographic and clinical factors was associated with NS relapse.

Immunological and Virological Outcomes of Patients Switched from LPV/r to ATV/r-Containing Second- Line Regimens.

BACKGROUND: Atazanavir/ritonavir (ATV/r) recently became the preferred protease inhibitor (PI) for use in Nigeria since it is dosed once daily, which may improve treatment adherence and has fewer side effects than lopinavir/ritonavir (LPV/r)--the most widely available PI in resource-limited settings. We, therefore, aimed to evaluate the immunologic and virologic effects of switching patients to an ATV/r-containing regimen. METHODS: In a large antiretroviral treatment programme at the Lagos University Teaching Hospital in Nigeria, 400 patients were switched to ATV/r-based second-line ART. We conducted a retrospective evaluation of immunologic and virologic outcomes following 24 months on the ATV/r regimens. RESULTS: Of the 400 patients switched to an ATV/r containing regimen, 255 were virologically suppressed on LPV/r prior to switch, 107 were switched due to failure on a first-line regimen, 28 were on saquinavir/ritonavir (SQV/r)-based regimen, while 10 were unintentionally switched while non-suppressed on a LPV/r-based regimen. Demonstrable and sustained immunological responses were documented as the median (IQR) CD4+ cell count increased steadily from 466 (323) cells/mm3 at the time of switch to 490 (346) cells/mm3 at 6 months, and 504 (360) cells/mm3 at 24 months. Of 99 patients evaluated 12 months after ATV/r switch, 2 (2%) had detectable viral load (VL). None of the 26 (0%) in this group evaluated at 24 months had detectable viral load. In a comparison group of 576 patients who were maintained on LPV/r-based second line regimens, 359 (62.3%) had undetectable viral loads. Of 318 patients with VL data 24 months later, 25 (7.9%) had detectable VL. There was no significant difference between the proportion of patients maintained on LPV/r (7.9%) and those switched to ATV/r (0%) in the development of virologic failure after 24 months of follow-up. CONCLUSION: Among patients that were switched to ATV/r-containing regimens, we found improvements in immunological responses and no increase in risk of virologic failure.

Clinical presentation of congenital malaria at the Lagos University Teaching Hospital.

BACKGROUND: Congenital malaria has been increasingly documented in endemic regions. It is important to recognize those clinical features that are due to congenital malaria, which if undetected, might worsen the morbidity of the newborn. The aim of this study was to document the clinical presentation of neonates with congenital malaria born at the Lagos University Teaching Hospital and followed up for 28 days. METHODS: A total of 100 consecutive mothers and their newborns were recruited between August and October 2002 (during the rainy season) from the labour ward and followed up from birth to 28 days of age. Blood films from the placentae and babies were stained with Giemsa stain within 24 hours of collection. All parasitaemic babies that became symptomatic were screened for sepsis using acute phase responses and cultures. All data were entered into a prepared proforma. Symptoms were attributed to malaria when sepsis screening was negative. RESULTS: Congenital malaria was documented in 13.6% of babies at delivery. Jaundice, irritability and poor feeding were most common symptoms associated with congenital malaria. Irritability and poor feeding had positive predictive values (PPV) of 100% on Day 14. CONCLUSION: Babies who present with poor feeding and irritability on Day 14 of life should be screened for malaria in addition to the routine investigations for neonatal sepsis.

Clinical neuropsychiatric correlates and EEG findings among children with developmental disorders in Lagos, Nigeria.

OBJECTIVE: Developmental disorders with or without associated neuropsychiatric complications continue to be one of the major health problems in Africa. The grossly inadequate management/ rehabilitative facilities further worsen this. A prospective study aimed at finding the types of developmental disorders and associated neuropsychiatric complications among children aged

Plasma magnesium and calcium levels in children with epilepsy in lagos.

BACKGROUND: Magnesium and calcium have been found to have increasing roles in the patho-physiology of epilepsy. Hypomagnesaemia and hypocalcaemia cause hyper-exitability of neurons and have been associated strongly with seizures in adults and children. OBJECTIVES: To determine if hypomagnesaemia or hypocalcaemia is present in Nigerian children with epilepsy and to determine the relationship between serum magnesium and calcium levels and frequency and control of epilepsy. DESIGN: A prospective case control study at the Lagos University Teaching Hospital. PATIENTS AND METHODS: 45 children with epilepsy and 45 controls were recruited from the paediatric neurology unit of the Lagos University Teaching Hospital. Serum magnesium and calcium were measured by spectrophotometric methods. RESULTS: Serum magnesium and calcium was significantly lower in the patients compared to the controls; Magnesium - 0.98 (0.0005) Vs 1.2 (0.04) mmol/L, p< 0.0001 and Calcium - 2.29 (0.04) Vs 2.3 (0.02) mmol/L, p<0.05 respectively. No significant differences were noted in the plasma phosphorus and albumin concentrations. CONCLUSION: Magnesium and calcium levels are lower in the epileptic children compared to the controls during the seizure-free periods. More studies are needed to evaluate these electrolytes during seizures and the effect of the different anticonvulsant drugs on these electrolytes.

Regional versus general anaesthesia for caesarean section.

BACKGROUND: Regional and general anaesthesia (GA) are commonly used for caesarean section (CS) and both have advantages and disadvantages. It is important to clarify what type of anaesthesia is more efficacious. OBJECTIVES: To compare the effects of regional anaesthesia (RA) with those of GA on the outcomes of CS. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 1), MEDLINE (1966 to December 2005), and EMBASE (1980 to December 2005). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials evaluating the use of RA and GA in women who had CS for any indication. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trials for inclusion, data extraction and trial quality. MAIN RESULTS: Sixteen studies (1586 women) were included in this review. Women who had either epidural anaesthesia or spinal anaesthesia were found to have a significantly lower difference between pre and postoperative haematocrit (weighted mean difference (WMD) 1.70, 95% confidence interval (CI) 0.47 to 2.93, one trial, 231 women) and (WMD 3.10, 95% CI 1.73 to 4.47, one trial, 209 women). Compared to GA, women having either an epidural anaesthesia or spinal had a lower estimated maternal blood loss (WMD -126.98 millilitres, 95% CI -225.06 to -28.90, two trials, 256 women) and (WMD -84.79 millilitres, 95% CI -126.96 to -42.63, two trials, 279 women). More women preferred to have GA for subsequent procedures when compared with epidural (odds ratio (OR) 0.56, 95% CI 0.32 to 0.96, one trial, 223 women) or spinal (OR 0.44, 95% CI 0.24 to 0.81, 221 women). The incidence of nausea was also less for this group of women compared with epidural (OR 3.17, 95% CI 1.64 to 6.14, three trials, 286 women) or spinal (OR 23.22, 95% CI 8.69 to 62.03, 209 women). No significant difference was seen in terms of neonatal Apgar scores of six or less and of four or less at one and five minutes and need for neonatal resuscitation with oxygen. AUTHORS' CONCLUSIONS: There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.

Congenital malaria among inborn babies at a tertiary centre in Lagos, Nigeria.

Congenital malaria is increasingly reported among babies born to mothers continually residing in endemic areas. Given the high morbidity and mortality associated with malaria it is pertinent to determine its current status among newborns in Lagos, Nigeria. The aim was to determine the incidence of congenital malaria in newborn babies delivered at the Lagos University Teaching Hospital and also to determine the frequency of parasitaemia in their mothers and placentae. A cross-sectional study of mothers attending the antenatal clinic of the Lagos University Teaching Hospital was done. The Sociodemographic and clinical characteristics of mothers were documented. Samples of maternal, placental, cord and neonatal blood were taken and stained with Giemsa and examined for malaria parasites. Neonatal samples were examined at birth, on days 3, 7, 14 and 28. One hundred mothers and their placentae, as well as 104 babies and their cord blood were studied. The incidence of congenital malaria was 16/104 (15.3%) and parasite counts ranged from 47 to 1019/mul. Plasmodium falciparum was the predominant species. There was a strong association between placental, maternal, cord and neonatal parasitaemia. All the babies with congenital malaria had infected mothers, placentae and cords (p < 0.0001). In conclusion congenital malaria is not uncommon in Lagos nowadays, and there are relatively high rates of maternal, placental and cord blood parasitaemia. It is, therefore, recommended that babies born to mothers with malaria should be screened for congenital malaria.

Communication disorders in Nigerian children.

BACKGROUND/AIM: Communication disorders have been acknowledged as a major public health issue because they compromise early childhood development, restrict vocational attainment and undermine the economic well being of the society. The aim of this study is to determine the pattern of communication disorders among children in a developing country and the requisite intervention services. MATERIALS AND METHODS: This prospective study was conducted in Lagos University Teaching Hospital, Lagos between January 2002 and June 2003 among children aged 6 months to 15 years that presented in the audiology clinic of the hospital with communication disorders. All the patients had neurological, otolaryngological, audiological and speech evaluations. RESULTS: A total of 184 patients were seen during the period out of whom 136 (74%) were between the ages of 6-47 months. Hearing impairment was documented in 120 (65.2%) children, speech disorders in 56 (30.4%), rhinolalia 2.2% and stuttering 2.2%. Of those with hearing impairment, 70% had delayed speech and language. Among children with speech disorders 78.6% had specific language impairment (SLI). Aetiological factors recorded for the communication disorders were seizures 10.9%, measles 8.7% meningitis 8.7%, birth asphyxia 6.5%, otitis media with effusion (OME) 4.3%, kernicterus 4.3%, congenital deformity 4.3%, ototoxicity 2.2%, cerebral palsy 2.2%, and undetermined causes 47.9%. CONCLUSION: Hearing impairment is the commonest communication disorder. Early detection and appropriate follow up is recommended for all children in their first year of life. The role of parents and caregivers in seeking early help should be strengthened while capacity building for the training of more audiologists and speech therapists should be pursued rapidly.

Pattern of cerebral malaria in children at the Lagos University Teaching Hospital.

UNLABELLED: Cerebral malaria is one of the most lethal forms of malaria. Given that malaria is a constantly evolving disease, it is therefore necessary to document patterns of presentation even in the same centre over a period of time. OBJECTIVE: To document the prevalence and pattern of cerebral malaria in children. DESIGN: Cross-sectional descriptive study of children with cerebral malaria attending the emergency room of the Lagos University Teaching Hospital. Age, sex, month at which diagnosis was made, associated clinical features, condition at discharge and mortality were assessed. RESULTS: Cerebral malaria was documented in 107/3309 (3.2%) children. There was an equal male:female ratio. Cerebral malaria occurred most frequently between July and September and in children between 2 and 2.9 years. A total of 79/107 (73.8) recovered fully at discharge, 9/107 (8.4%) recovered with some neurological sequelae while 19/107 (17.8%) died. Coma score on admission was significantly lower among those who died compared with those who survived (p = 0.001). Clinical signs observed in these children were seizures-88/107 (82.2%), pallor-75/107 (70.1%), jaundice-55/107 (51.4%) and hepato-splenomegaly-18 (16.8%). However, decerebrate posturing was the only clinical sign associated with a fatal outcome OR, 11.47 (p = 0.009). CONCLUSION: This study shows that cerebral malaria still remains a problem of the under fives with unacceptably high mortality. The clinical significance of decerebrate posture as an indicator of mortality would require further evaluation.

Clinical evaluation of extract of Cajanus cajan (Ciklavit) in sickle cell anaemia.

The major pathology in sickle cell anaemia (SCA) is sickling of red cells due to the precipitation of reduced haemoglobin. We report our experience with extract of Cajanus cajan as a possible antisickling agent by determining changes, if any, in clinical and laboratory features of the disease in patients given the extract in a single-blind placebo-controlled study. One hundred patients with steady-state SCA were randomized into treatment and placebo arms. The extract/placebo were administered twice daily to the subjects. Weight, hepatosplenomegaly, blood levels of biliurubin, urea, creatinine, and packed cell volume (PCV) were monitored over a 6-month period. Recall episodes of pain 6 months before enrolment were compared with episodes of pains recorded during the treatment period. Twenty-six cases (55.3 per cent) had hepatomegaly on enrolment. This significantly reduced to 33.3 per cent at 6 months (p = 0.03); but increased in the placebo arm (p > 0.05). The total number of recall painful episodes in cases was 207 (mean 4.4 +/- 10.3 (SD), range 0-60) and fell to 191 (mean 4.2 +/- 4.4 (SD), range 0-16); p = 0.03. Episodes of pain increased from 109 in controls (mean 2.6 +/- 5.0 (SD), range 0-26) to 164 (mean 3.9 +/- 4.3 (SD), range 0-22); p = 0.01. Mean PCV in the cases showed no appreciable changes (p = 0.1) but there was a significant increase in the controls (p = 0.02). In conclusion, the extract may cause a reduction of painful crises and may ameliorate the adverse effects of sickle cell anaemia on the liver. The mechanism of action remains to be determined.

Basic trauma life support: knowledge of medical students.

BACKGROUND: The first hour of management (golden hour) of any trauma patient might be the determining factor if he/she will survive. The first contact most patients have in an emergency room is with a young medical graduate. The knowledge of basic trauma life support (BTLS) by all doctors therefore becomes important. AIMS AND OBJECTIVES: This study set out to assess how much knowledge medical students had about BTLS in their final year compared with their knowledge at the beginning of clinical postings. METHOD: A cross-sectional study of fourth and sixth (final) year medical students to evaluate their knowledge of BTLS using a test of 30 questions under examination conditions. One hundred and twenty-three fourth year students were given a test after a lecture on the care of injured patients. The same test was administered on 41 sixth year students without prior lecture on day of test, having had a similar lecture 2 years before. Data analysis was performed using the SPSS 11.0 for Windows statistical software and EPI INFO version 6.04. RESULT: Mean scores were 25.8 +/- SD1.91 for the 4th year students and 21.0 +/- SD2.93 for the 6th year students. There was a statistically significant difference between scores of the 4th year and the 6th year (P < 0.000001). CONCLUSION: Knowledge was imparted in the 4th year but was forgotten by the 6th year. It is essential that courses in BTLS be given periodically to all medical graduates and all personnel involved in care of the traumatised patient.

Diazepam for treating tetanus.

BACKGROUND: Clinical management of the muscle spasms and rigidity of tetanus poses a difficult therapeutic problem to physicians everywhere, especially in resource poor countries. There are wide variations in therapeutic regimens commonly used in clinical practice due to uncertainties about effectiveness of conventional drugs. Diazepam compared to other drugs (eg phenobarbitone and chlorpromazine) may have advantages because of combined anticonvulsant, muscle relaxant, sedative and anxiolytic effects. OBJECTIVES: To compare diazepam to other drugs in treating the muscle spasms and rigidity of tetanus in children and adults. SEARCH STRATEGY: We searched the Cochrane Neonatal Group trials register (October 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to October 2003), EMBASE (1980 to October 2003), LILACS (2003), CINAHL (October 2003), Science Citation Index, African Index Medicus, conference abstracts and reference lists of articles. We contacted researchers, experts and organizations working in the field and used personal communication. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials. DATA COLLECTION AND ANALYSIS: We independently identified eligible trials, assessed trial methodological quality and extracted data. MAIN RESULTS: Two studies met the inclusion criteria. Method of generation of allocation sequence, concealment of allocation and blinding were unclear in both studies. A total of 134 children were allocated to three treatment groups comprising diazepam alone, phenobarbitone and chlorpromazine, or phenobarbitone and chlorpromazine and diazepam.Meta-analysis of in-hospital deaths indicates that children treated with diazepam alone had a better chance of survival than those treated with combination of phenobarbitone and chlorpromazine (Relative Risk for death 0.36; 95% confidence interval 0.15 to 0.86; Risk Difference -0.22; 95% CI -0.38 to -0.06). Giving diazepam alone, or supplementing conventional anticonvulsants (phenobarbitone and chlorpromazine) with diazepam, was reported in one study to be associated with a statistically significantly milder clinical course and shorter duration of hospitalization. REVIEWER'S CONCLUSIONS: Although there is evidence that diazepam alone compared with combination of phenobarbitone and chlorpromazine is more effective in treating tetanus, the small size, methodological limitations and lack of data on drug safety from available trials preclude definite conclusions to support change in current clinical practice. The application of the present evidence should be moderated by local needs and circumstances, pending the availability of more evidence. We recommend a large multicenter, randomized controlled trial which compares diazepam alone with combinations of other drugs (excluding diazepam).

Management of children with cerebral malaria in Lagos - a medical audit.

UNLABELLED: Cerebral malaria, one of the severe forms of malaria, carries a very high fatality rate even when managed in the best of centres. This underpins the need for a medical audit to review patient management steps or procedures to improve the standard of patient care of children with cerebral malaria in the Lagos University Teaching Hospital. METHODS: A retrospective audit of records of children with cerebral malaria who presented in the emergency room of the Lagos University Teaching Hospital in the last five years. Relevant clinical and patient management information of survivors were extracted from the records and analysed. RESULTS: The records show that critical information useful in the management of these children was lacking in 50 - 60% of the records reviewed. The appropriate anti-malarial drug (intravenous quinine) in adequate doses was used in 54(94.7% ) of cases. A total of 12 patients (21.1% ) still had either mannitol or dexamethasone given to them. Blood transfusion was ordered in 60% of the children despite severe anaemia being present in only 30% of them. CONCLUSION: This study highlights the sub-optimal level of knowledge and practice among doctors and the need for retraining of medical staff in maintaining proper records. The authors recommend the use of patient management guidelines.

Clinical and management factors related to outcome in neonatal tetanus.

Although tetanus is a well-recognised, well-described, preventable and eradicable infection, it continues to ravage the lives of children in developing countries, especially among neonates. A cross-sectional review of cases of neonatal tetanus seen in LUTH was carried out retrospectively. Thirty-nine (39) cases were studied, comprising 26 (63.4%) males and 15 (36.6%) females, giving a male: female ratio of 1.6:1. Case fatality rate was 10.3%, thirty-five (89.7%) cases survived, of which nine (23.8%) survived with complications. Clinical factors that influence outcome were: a short interval between onset and presentation (p = 0.03), low tetanus score below 6.0 (p = 0.002), hyperpyrexia (p = 0.0001), heart failure (p = 0.035), cyanosis (p = 0.008) and crepitations (p = 0.003). Although several management factors were associated with mortality, these failed to meet statistical significance (p > 0.05). In this study, clinical factors, including presentation interval, were the principal determinants of outcome. The need for intensification and sustenance of preventive measures, early recognition and presentation, prompt treatment as well as improved care are emphasised. We recommend periodic audit of patient clinical data towards improving quality of care.

Evaluation of a maize-cowpea-palm oil diet for the dietary management of Nigerian children with acute, watery diarrhea.

A randomized clinical trial was carried out to compare a locally available maize-cowpea-palm oil diet (group MCP) with a commercially produced lactose-free, soy protein isolate formula (group SF) for the dietary management of 69 Nigerian boys, 6-24 months of age, hospitalized for acute, watery diarrhea. Although the treatment groups were generally similar initially, the children in group SF had slightly lower mean weight-for-age z scores (p = 0.08), lower serum bicarbonate levels (p = 0.04) and greater stool outputs during the period of rehydration before the diets were initiated (p = 0.01). Rates of treatment failure in group MCP (5.7%) and group SF (8.8%) were similar (p = 0.67). There were no significant differences in the adjusted mean stool outputs by study group on days 1-5, but the children in group SF had slightly lower fecal weights on day 6 (p = 0.05). Children in group MCP had a substantially reduced duration of liquid stool excretion (estimated median duration 42 h versus 140 h; p < 0.001). On the other hand, children in group SF consumed considerably more of their diet, had greater net absorption of macronutrients and greater rates of weight gain than those in group MCP. We conclude that children can safely consume the MCP diet during acute, watery diarrhea without increasing their risk of treatment failure or augmenting stool output. However, the diet may not be adequate as a sole source of nutrients beyond the period of acute illness.

Problems related to the management of sickle cell disease in Nigeria.

Sickle cell disease, a disease prevalent among the negroes all over the world, is discussed first from the historical point of view. Its geographical occurrence which is highest in the African subcontinent and lowest in the United States depends on the prevalence of malaria in the environment and intermarriage of races. The sociocultural background of Nigeria is discussed along with its existing health and education problems. These are related to the profound clinical manifestation of sickle cell disease. Some pitfalls in the diagnosis and manifestation of sickle cell disease are mentioned. The problems to the use of certain drugs are highlighted. In solving some of the problems of sickle cell disease attention should be focused on continuous health education, establishing sickle cell clinics, and research aimed at improving the environment of patients in the underprivileged situation of the world where sickle cell disease poses problems.

Ocular findings in children with homozygous sickle cell anemia in Nigeria.

The ophthalmological findings in 91 Nigerian children with homozygous sickle cell anemia is reported. While the most constant sign was abnormality of the conjunctival vasculature, seen in 74(81%) of the patients, retinal lesions were found in a total of 53(58%) patients. Only tortuosity of major vessels was seen in some patients but several others had more than one type of retinal lesion.