Subclinical hypothyroidism in children with idiopathic childhood nephrotic syndrome at a tertiary institution in South-West Nigeria.

Background: Hypothyroidism in children with nephrotic syndrome (NS) is often attributed to prolonged loss of thyroxine binding globulin and thyroid hormones alongside protein in the urine. It has been historically associated with steroid-resistant NS alone. However, recent evidence supports the fact that subclinical hypothyroidism (SCH) does occur even in children with steroid responsive NS. Complications such as weight gain, hypercholesterolemia, delayed growth, delayed puberty, and depression could result from hypothyroidism and be erroneously attributed to NS, or the effect of steroid used in treatment. Incidentally salt intake, the major form of dietary iodine is often restricted in children with NS, possibly exacerbating any underlying hypothyroid state. Aim: The study aimed to determine the burden of SCH among our cohort of NS patients. Patients and Methods: A comparative cross-sectional study was designed to assess SCH [defined by high TSH (>6.0 mU/L and normal free T4 (0.8-2.0 ng/dl)] in hundred children with NS aged between one and fifteen years compared with hundred age and gender matched comparison group without NS. Blood and urine samples were collected to analyze thyroid function, serum albumin, serum protein and urinary protein. Results: The prevalence of SCH was significantly higher in subjects with NS than their age, sex matched comparison group (12% vs. 2%, P = 0.006). The highest proportion (24.1%) of the children with NS who had SCH was found in the age range of 11-15 years and majority were females (19.4% vs. 7.8%, respectively, P = 0.086). The proportion of children with SCH were higher in those with steroid-resistant NS than those responsive to steroids (26.3% vs. 8.6% P = 0.033). The average values of serum albumin and protein were also significantly lower in children with SCH than those without (2.91 mg/dl ± 0.8 vs. 3.78 mg/dl ± 0.9 and 3.99 mg/dl ± 1.3 vs. 5.02 mg/dl ± 1.3, respectively, P < 0.005). Also, the average value of urinary protein was significantly higher in those with SCH than those without [94.29 mg/dl (42.3-101.0) vs. 69.19 mg/dL (31.2-108.2), respectively, P = 0.023]. Participants with steroid-resistant NS have almost three-folds odd of developing SCH compared to steroid sensitive subjects (AOR 2.901; 95% CI 1.831-4.012; P = 0.038). Conclusion: Screening of children for SCH with NS especially steroid-resistant NS and frequent relapsing steroid sensitive NS for hypothyroidism before complications arise is pertinent to their holistic management. This becomes even more imperative in our environment as iodine deficiency hypothyroidism is still prevalent in some parts of the country.

Clinical Summary and Reasoning Format: Cognition Levels and Proposal of a Grading System.

The Clinical Summary and Reasoning Format (CSRF) was designed by the Faculties of Paediatrics of the National Postgraduate Medical College of Nigeria and the West African College of Physicians. The form is recommended for routine use in clinical practice as well as for training and examination purposes. The form has sections for documenting information derived from interacting with an index patient and sections for documenting sequential deductions on the way to various levels of diagnosis. The levels of cognition required to complete different sections of the Clinical Summary and Reasoning Format (CSRF) vary in complexity. The CSRF is potentially useful for assessing the quality of a clinician's clinical reasoning process. Such assessment will be enhanced by having a grading system for completed CSRF forms. In turn, grading contents of the form should reflect complexity of the levels of cognition required for the various sections. The present paper evaluated the sections of the CSRF with reference to the modified Bloom's Taxonomy of cognition and also proposed a grading scheme for assessing CSRF forms completed by trainees.

Le format de résumé clinique et de raisonnement (CSRF) était conçu par les Facultés de Pédiatrie du National Collège médical de troisième cycle du Nigeria et de l'Afrique de l'Ouest Collège des médecins. Le formulaire est recommandé pour la routine utilisation dans la pratique clinique ainsi que pour la formationet l'examen Fins. Le formulaire comporte des sections pour documenter les informations dérivé de l'interaction avec un patient index et des sections pour documenter les déductionsséquentiel les sur le chemin de diverses niveaux de diagnostic. Les niveaux de cognition requis pour compléter différentes sections du résumé clinique et du raisonnement Le format (CSRF) varie en complexité. Le CSRF est potentiellement utile pour évaluer la qualité d'un processus de raisonnement clinique du clinicien. Cette évaluation sera amélioré par la mise en placed'un système de classement pour le CSRF complété Formes. À son tour, le contenu de classement du formulaire doit refléter complexité des niveaux de cognition requis pour les différents sections.Le présent document a évalué les sections du CSRF avec référence à la taxonomie modifiée de bloom de la cognition et a également proposé un système de notation pour l'évaluation des formulaires CSRF complété par des stagiaires. Mots-clés: Cognition, Raisonnement clinique, Évaluation, Notation.

Clinical Summary and Reasoning Format: A Tool for Clinical Practice and Medical Training.

Patients' records are often bulky and unwieldy, necessitating the creation of summaries. A structured summary format adds the advantage of improved organization and easier retrieval of information. However, typical clinical summary formats do not document intermediate deductions linking symptomatology to diagnosis and to that extent fall short of tracking the cognition process of the clinician. The Clinical Summary and Reasoning Format of the Faculties of Paediatrics of the National Postgraduate Medical College of Nigeria and the West African College of Physicians was designed to track the clinical thought and reasoning processes of clinicians. It consists of two major sections. The first section is for documenting data from history, physical examination and early laboratory reports while the second section is for recording hierarchical deductions on the way to reaching various levels of diagnosis. Definitions and descriptions of the various components of the format are herein presented. The usefulness of the format for clinical practice, clinical training and assessment of trainees is discussed.

Les dossiers des patients sont souvent volumineux et peu maniables, ce qui nécessite la création de résumés. Un format de résumé structuré offre l'avantage d'une meilleure organisation et d'une récupération plus facile de l'information. Cependant, les formats de résumé clinique typiques ne documentent pas les déductions intermédiaires reliant la symptomatologie au diagnostic et, dans cette mesure, ne permettent pas de suivre le processus cognitif du clinicien. Le format de résumé clinique et de raisonnement des facultés de pédiatrie du National Postgraduate Medical College of Nigeria et du West African College of Physicians a été conçu pour suivre la pensée clinique et les processus de raisonnement des cliniciens. Il se compose de deux sections principales. La première section sert à documenter les données provenant de l'histoire, de l'examen physique et des premiers rapports de laboratoire, tandis que la seconde section sert à enregistrer les déductions hiérarchiques permettant d'atteindre les différents niveaux de diagnostic. Les définitions et les descriptions des différents composants du format sont présentées ici. L'utilité du format pour la pratique clinique, la formation clinique et l'évaluation des stagiaires est discutée. Mots clés: Cognition, Résumé clinique, Raisonnement clinique, Format, Diagnostic. Mots clés: Cognition, Résumé clinique, Raisonnement clinique, Format, Diagnostic.

Clinical Summary and Reasoning Format: A Tool for Clinical Practice and Medical Training.

Patients' records are often bulky and unwieldy, necessitating the creation of summaries. A structured summary format adds the advantage of improved organization and easier retrieval of information. However, typical clinical summary formats do not document intermediate deductions linking symptomatology to diagnosis and to that extent fall short of tracking the cognition process of the clinician. The Clinical Summary and Reasoning Format of the Faculties of Paediatrics of the National Postgraduate Medical College of Nigeria and the West African College of Physicians was designed to track the clinical thought and reasoning processes of clinicians. It consists of two major sections. The first section is for documenting data from history, physical examination and early laboratory reports while the second section is for recording hierarchical deductions on the way to reaching various levels of diagnosis. Definitions and descriptions of the various components of the format are herein presented. The usefulness of the format for clinical practice, clinical training and assessment of trainees is discussed.

Les dossiers des patients sont souvent volumineux et peu maniables, ce qui nécessite la création de résumés. Un format de résumé structuré offre l'avantage d'une meilleure organisation et d'une récupération plus facile de l'information. Cependant, les formats de résumé clinique typiques ne documentent pas les déductions intermédiaires reliant la symptomatologie au diagnostic et, dans cette mesure, ne permettent pas de suivre le processus cognitif du clinicien. Le format de résumé clinique et de raisonnement des facultés de pédiatrie du National Postgraduate Medical College of Nigeria et du West African College of Physicians a été conçu pour suivre la pensée clinique et les processus de raisonnement des cliniciens. Il se compose de deux sections principales. La première section sert à documenter les données provenant de l'histoire, de l'examen physique et des premiers rapports de laboratoire, tandis que la seconde section sert à enregistrer les déductions hiérarchiques permettant d'atteindre les différents niveaux de diagnostic. Les définitions et les descriptions des différents composants du format sont présentées ici. L'utilité du format pour la pratique clinique, la formation clinique et l'évaluation des stagiaires est discutée. Mots clés: Cognition, Résumé clinique, Raisonnement clinique, Format, Diagnostic.

The Paediatric Long Case Examination in the West African College of Physicians - Past, Present and Future.

The Faculty of Paediatrics of the West African College of Physicians has been using the long case as a major clinical examination for Membership candidates since the early 1980s. Many training institutions also retain the long case examination. Over the years, the Faculty made far-reaching changes in this method of examination geared towards the improvement of its performance indices of reliability, validity and fairness. The current paper traces the modifications that have taken place so far including the use of a structured, weighted grading format. It also discusses the need for further modifications including observation of the candidate during the "clerking" period and the practicality of video recording. Use of formats like that of the West African College is recommended for institutions still using the long case. Each institution should weigh the practicability of specific suggested modifications in the light of its circumstances.

La Faculté de pédiatrie du Collège ouest-africain des médecins utilise le cas long comme examen clinique majeur pour les candidats à l'adhésion depuis le début des années 1980. De nombreux établissements de formation conservent également le long examen des cas. Au fil des ans, la Faculté a apporté des changements profonds à cette méthode d'examen visant à améliorer ses indices de performance de fiabilité, de validité et d'équité. Le document actuel retrace les modifications qui ont eu lieu jusqu'à présent, y compris l'utilisation d'un format de notation structuré et pondéré. Il discute également de la nécessité d'apporter d'autres modifications, y compris l'observation du candidat pendant la période de "clerking" et l'aspect pratique de l'enregistrement vidéo. L'utilisation de formats comme celui du West African College est recommandée pour les institutions utilisant encore le cas long. Chaque institution devrait évaluer la faisabilité des modifications spécifiques suggérées à la lumière de ses circonstances.

Uterine incision closure at caesarean section: a randomised comparative study of intraperitoneal closure and closure after temporary exteriorisation.

BACKGROUND: The safety of the technique of uterine exteriorization at caesarean section though popular among obstetricians, remains controversial. OBJECTIVE: To evaluate the influence of exteriorization of uterus during uterine repair on caesarean morbidity. METHODS: A randomized comparative study of 136 women undergoing primary caesarean delivery at Havana Specialist Hospital Lagos Nigeria. Data on operation time, estimated blood loss, postoperative morbidities were collected and analysed with comparison between the two groups using chi square, Fischer's exact test and t-test as appropriate. RESULTS: The mean operative time, estimated blood loss, transfusion rate and postoperative anemia rate were significantly less in the exteriorized group than the intraperitoneal group (p = 0.000, 0.009,0.048 0.038 and 0.028 respectively), but not in other outcome measures. CONCLUSION: With shorter operative time, less blood loss and similar morbidity profile exteriorization of uterus during caesarean section seems to be preferred except where it is not possible because of adhesions and surgeons inexperience.

Emergency peripartum hysterectomy in a Nigerian hospital: a 20-year review.

Postpartum haemorrhage is a major cause of maternal morbidity and mortality and occasionally severe enough to warrant hysterectomy to prevent maternal death. Hysterectomy often is fraught with danger and regular audit is necessary to assist in the reduction of these dangers. A 20-year audit of all emergency peripartum hysterectomies, performed at Havana Specialist hospital Lagos, Nigeria, is reported. Of the 6599 deliveries and peripartum referrals seen during the period, 22 had an emergency hysterectomy as a result of severe postpartum haemorrhage (0.33%). The aetiological factors associated with the postpartum haemorrhage included uterine atony (45.5%), placenta praevia (27.3%), pathologically adherent placenta (18.2%) and ruptured uterus (9.1%). The majority of the procedures were subtotal hysterectomy (81.8%) and the mean operative time was significantly shorter than for total hysterectomy (P<0.05). The postoperative complications included postoperative anaemia (28.6%), febrile morbidity (36.9%), wound infection (19.0%) and urinary tract infection (9.5%), together with three maternal deaths. In conclusion, emergency peripartum hysterectomy, although life-saving, is associated with severe morbidity and mortality and subtotal hysterectomy is usually the operation of choice.

Vaginal misoprostol induction of labour: a Nigerian hospital experience.

We reviewed our experience with vaginal misoprostol induction of labour in 339 consecutive women with a live fetus and intact fetal membrane using 100 mcg 12-hourly until labour was established. The labours were monitored using the WHO partograph protocol. Two hundred and sixty-five women had a successful induction while 74 had an emergency caesarean section because of cephalopelvic disproportion (63.5%), fetal distress (14.9%), prolonged labour (12.2%), antepartum haemorrhage (6.8%) and other indications (2.8%). The induction delivery interval among the women who had successful induction ranged from 3 hours 42 minutes to 26 hours 15 minutes with a mean of 9 hours 23 minutes (SD 2 hours 41 minutes). Most (73.6%) of these patients delivered within 12 hours of starting induction, the majority (95.3%) requiring only 100 mcg to go into established labour. Complications recorded in this series include fetal distress in 32 (9.4%), postpartum haemorrhage in 23 (6.8%), hyperstimulation in six (1.8%), uterine rupture in one (0.3%), birth asphyxia in eight (2.5%), admission in neonatal intensive care ward in five (1.5%), neonatal death in one (0.3%) and maternal death in one (0.3%) patient. In conclusion, misoprostol was found not only to be efficacious but relatively safe in comparison to other methods of induction in use in our hospital.