Screening tool to improve patient referral to acute surgical care from accident and emergency.

INTRODUCTION: This study aimed, first, to audit the appropriateness of surgical referrals to an acute surgical unit for urgent assessment and, second, to devise a screening tool for use in the emergency department to categorise patients into those who need an urgent surgical review and those who can be seen in an ambulatory setting within the next few days. METHODS: The first phase of the study was an audit of surgical referrals between 1 and 18 February 2020 to check the appropriateness of the surgical referral. In the second phase, a tool was designed to screen patients who did not require urgent surgical review and could be seen in the ambulatory clinic. A prospective questionnaire study was conducted from 1 February to 24 March 2020 with patients who were admitted to an acute surgical ward. Based on responses to the screening tool, patients were given the outcome of whether they can be discharged and seen in an ambulatory clinic. The accuracy of the screening tool outcome was assessed and compared with actual patient discharge outcomes by the surgical team evaluating patients' electronic medical records. RESULTS: In the first audit of referrals to the acute surgical ward, 206 patients were referred to the acute surgical unit and seen by the senior surgeon. Of these, 142 (68.9%) were discharged on the same day with or without follow-up in the ambulatory surgical clinic. In the prospective questionnaire phase of the study, 98 patients completed the questionnaire. The most common presentation was abdominal pain (n=60) followed by urological symptoms (n=11), symptoms of hernia complication (n=10), abscess (n=7), testicular pain (n=2) and trauma (n=2). Of the patients discharged on the same day, 50% were given ambulatory care appointments and 50% were discharged with no further follow-up. The sensitivity and specificity of the screening tool were 100% and 60.7%, respectively; the overall accuracy was 88.4%. CONCLUSION: A large proportion of patients who are referred to the acute surgical unit can be deferred and seen in the ambulatory clinic. The screening tool used for acute surgical referral had reasonable sensitivity and high specificity to screen patients who can be seen in ambulatory clinics. At the same time, it identified patients who were unwell and required urgent surgical admission.

Efficacy of Hexetidine, Thymol and Hydrogen Peroxide-Containing Oral Antiseptics in Reducing Sars-Cov-2 Virus in the Oral Cavity: A Pilot Study.

BACKGROUND: Studies have demonstrated the role of sputum as a site of severe acute respiratory syndrome-coronavirus-2 (SARSCoV-2) transmission. However, there is limited literature on the virucidal efficacy of oral antiseptics against SARS-CoV-2 virus. This study investigated the virucidal efficacy of three oral-antiseptics compared to a placebo-control in the sputum of SARS-CoV-2 infected individuals. METHODOLOGY: A pilot study of adults with SARS-CoV-2 positive results, as determined by reverse transcription-polymerase chain reaction (RT-PCR) of <7 days. The oral antiseptics investigated were: Hexetidine (0.1% w/v); Thymol (0.063% w/v) and H2O2(1.5%) compared to de-mineralized sterile water (Placebo-control). The primary outcome measure was the proportion of negative RT-PCR results at 15-mins, 30-mins, 1-hour, 2-hours and 4-hours After Oral antiseptics Interventions (AOI) compared to the placebo-control. Statistical analysis was done using STATA 15.0 software with p-values of <0.05 considered statistically significant. RESULTS: Data from a total of 66 participants that were RT-PCR SARS-CoV-2 positive at baseline (0-min) was analysed. At 15-mins AOI, the highest proportion of negativation from sputum samples was observed in the Hexedine group, with 69.2% of the baseline PCR positive cases converting to negative compared to 46.7% in the placebo-control group. In addition, H2O2 demonstrated efficacy at 2-hours AOI compared to placebo-control (62.5% vs 37.5% respectively) and other oral-antiseptics. Across all time-points, the oral-antiseptic groups compared to the placebo-control group, there was no statistically significant difference in the proportion of sputum samples which converted to a negative status (p>0.05). CONCLUSION: The findings in this study suggest there was no significant difference in the proportion of participants who converted to a negative sputum status across the treatment groups at various time points. Future studies could compare the cycle threshold (ct) viral titre values of sputum samples to determine quantitative differences.

CONTEXTE: Des études ont démontré le rôle des expectorations comme un site de transmission du syndrome respiratoire aigu sévère-coronavirus- 2 (SRAS-CoV-2). Cependant, il existe peu de documentation sur l'efficacité virucide des antiseptiques oraux contre le virus du SRASCoV-2. Cette étude a examiné l'efficacité virucide de trois antiseptiques oraux par rapport à un contrôle placebo dans les expectorations de personnes infectées par le SRAS-CoV-2. MÉTHODOLOGIE: Une étude pilote menée auprès d'adultes dont les résultats sont positifs pour le SRAS-CoV-2, tels que déterminés par la réaction en chaîne de la polymérase par transcription inverse (RT-PCR) pendant 7 jours. Les antiseptiques oraux étudiés étaient : Hexetidine (0,1% p/v) ; Thymol (0,063% p/v) et H2O2 (1,5%) par rapport à l'eau stérile déminéralisée (Placebo-contrôle). Le principal critère d'évaluation était la proportion de résultats RT-PCR négatifs 15 minutes, 30 minutes, 1 heure, 2 heures et 4 heures après les interventions antiseptiques orales (AOI) par rapport au contrôle placebo. L'analyse statistique a été réalisée à l'aide du logiciel STATA 15.0, les valeurs p de <0,05 étant considérées comme statistiquement significatives. RÉSULTATS: Les données d'un total de 66 participants qui étaient positifs à la RT-PCR SARS-CoV-2 au départ (0 minute) ont été analysées. Au bout de 15 minutes, la plus forte proportion de négativation des échantillons d'expectoration a été observée dans le groupe Hexedine, 69,2 % des cas positifs au départ par PCR devenant négatifs, contre 46,7 % dans le groupe témoin placebo. En outre, l'H2O2 a démontré son efficacité à 2 heures après l'apparition de la maladie par rapport au groupe placebo (62,5 % contre 37,5 % respectivement) et aux autres antiseptiques oraux. Pour tous les points temporels, les groupes d'antiseptiques oraux comparés au groupe placebo n'ont pas présenté de différence statistiquement significative dans la proportion d'échantillons d'expectoration qui sont devenus négatifs (p>0,05). CONCLUSION: Les résultats de cette étude suggèrent qu'il n'y a pas de différence significative dans la proportion de participants qui sont passés à un statut négatif d'expectoration dans les groupes de traitement à différents moments. Les études futures pourraient comparer les valeurs du titre viral au seuil de cycle (ct) des échantillons d'expectoration afin de déterminer les différences quantitatives. MOTS CLÉS: SRAS-CoV-2, antiseptiques oraux, hexétidine, peroxyde d'hydrogène.

A multi-centre, randomized, double-blind, placebo-controlled clinical trial of the efficacy and safety of chloroquine phosphate, hydroxychloroquine sulphate and lopinavir/ritonavir for the treatment of COVID-19 in Lagos State: study protocol for a randomized controlled trial.

BACKGROUND: The coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was first identified in Wuhan, Hubei, China, in December 2019. It was recognized as a pandemic by the World Health Organization on 11 March 2020. Outbreak forecasting and mathematical modelling suggest that these numbers will continue to rise. Early identification of effective remedies that can shorten the duration and severity of illness is critical for Lagos State, which is the epi-centre of the disease in Nigeria. METHODS: This is a multi-centre, randomized, double-blind placebo-controlled superiority trial. The study investigates the efficacy of chloroquine phosphate, hydroxychloroquine sulphate and lopinavir/ritonavir added on to standard of care compared to standard of care only in patients with COVID-19 disease. The primary outcome is the clinical status of patients measured using a 7-point ordinal scale at day 15. Research participants and clinicians will be blinded to the allocated intervention. Outcome measures will be directly assessed by clinicians. Statistical analysis will be done by a team blinded to the identity and allocation of research participants. Data analysis will follow intention-to-treat methods, using R software. DISCUSSION: The current study is of strategic importance for Lagos State in potentially curbing the health, social and economic burden of COVID-19 disease. Should the current study demonstrate that either of the three intervention drugs is more efficacious than standard therapy alone, the State Ministry of Health will develop an evidence-based guideline for the management of COVID-19 in Lagos State. The findings will also be shared nationally and with other states which may lead to a standardized national guideline for the treatment of COVID-19 in Nigeria. TRIAL REGISTRATION: Pan African Clinical Trials Register PACTR202004801273802 . Registered prospectively on April 2, 2020.

The pattern of comorbidity and its prevalence among drug-resistant tuberculosis patients at treatment initiation in Lagos, Nigeria.

BACKGROUND: Multimorbidity is increasingly being recognized as a serious public health concern in the control of both drug-susceptible and drug-resistant tuberculosis (DR-TB). This study assessed the pattern of comorbidities and their prevalence in DR-TB patients at treatment initiation in Lagos, Nigeria. METHODS: A cross-sectional study was conducted. The baseline laboratory records (human immunodeficiency virus [HIV] status, fasting blood sugar, audiometry, thyroid function tests, serum electrolyte, haemoglobin level and pregnancy test) of DR-TB patients initiated on treatment in Lagos, Nigeria between 1 August 2014 and 31 March 2017 were reviewed. RESULTS: A total of 565 DR-TB patients' laboratory records were reviewed, of which 397 (70.3%) had comorbidities. The proportion with one, two, three and four comorbidities was 60.2%, 29.7%, 8.1% and 2.0%, respectively. Anaemia was the most common (48.1%) comorbid condition, while anaemia and hypokalaemia (7.3%), anaemia and hypothyroidism (6.5%) and anaemia and HIV (5%) were most common among patients with more than one comorbid condition. DR-TB patients with comorbidity were significantly older (34.8±12.3 y) than those without comorbidity (32.0±12.8 y) (p=0.038). Of the 176 females in the reproductive age group, 8 (4.5%) were pregnant at baseline. CONCLUSIONS: The prevalence of comorbidity among DR-TB patients was high. There is a need for the national TB program to expand its DR-TB council of experts and also integrate reproductive health services into DR-TB management in Nigeria.

HIV-TB co-infection in children: associated factors and access to HIV services in Lagos, Nigeria.

BACKGROUND: Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading causes of death from infectious disease worldwide. The World Health Organization estimates that the prevalence of HIV among children with TB in moderate to high prevalence countries ranges between 10% and 60%. This study aimed to determine the access to HIV services of HIV-TB co-infected children. METHODS: A retrospective review of data of children diagnosed with TB in Lagos State, Nigeria from 1 January 2012 to 31 December 2013. RESULTS: A total of 1199 children aged between 0 and 14 years were diagnosed with TB. Of 1095 (91.3%) who underwent testing for HIV, 320 (29.2%) were HIV seropositive. The male-to-female ratio of HIV-TB positive outcomes was 1:0.9. Of the 320 HIV-TB co-infected children, 57 (17.8%) were aged <1 year, 86 (26.9%) 1-4 years and 186 (58.1%) 5-14 years; 186/320 (58.1%) began cotrimoxazole preventive therapy (CPT), and 151 (47.2%) were put on antiretroviral treatment (ART). ART uptake was not significantly higher in facilities where HIV-TB services were co-located (P > 0.05). CONCLUSION: The uptake of CPT and ART was low. There is a need to intensify efforts to improve access to HIV services in Lagos State, Nigeria.

Contexte : Le virus de l'immunodéficience humaine (VIH) et la tuberculose (TB) sont les causes majeures de décès dû à une maladie infectieuse dans le monde. L'Organisation Mondiale de la Santé estime que la prévalence du VIH parmi les enfants atteints de TB dans des pays à prévalence modérée à élevée va de 10% à 60%. Cette étude a eu pour but de déterminer l'accès aux services VIH pour les enfants coinfectés par TB-VIH.Méthodes : Une revue rétrospective des données d'enfants ayant eu un diagnostic de TB dans l'état de Lagos au Nigeria entre le 1e janvier 2012 et le 31 décembre 2013.Résultats : Un total de 1199 enfants âgés de 0 à 14 ans ont eu un diagnostic de TB. Parmi eux, 1095 (91,3%) ont eu un test VIH, dont 320 (29,2%) ont été positifs. Le ratio garçon/fille de coinfection TB-VIH a été de 1:0,9. Sur les 320 enfants coinfectés TB-VIH, 57 (17,8%), 86 (26,9%) et 186 (58,1%) respectivement avaient <1 an, 1­4 ans et 5­14 ans. Sur les 320 enfants coinfectés TB-VIH, 186 (58,1%) ont débuté le cotrimoxazole (CPT) tandis que 151 (47,2%) étaient sous traitement antirétroviral (ART). La mise sous ART n'a pas été significativement plus élevée dans les structures où les services TB-VIH se trouvaient au même endroit (P > 0,05).Conclusion : La mise sous CPT et ART a été faible. Il est nécessaire d'intensifier les efforts d'amélioration de l'accès aux services VIH à Lagos, Nigeria.

Marco de referencia: La infección por el virus de la inmunodeficiencia humana (VIH) y la tuberculosis (TB) son las principales causas de muerte por enfermedad infecciosa en todo el mundo. La Organización Mundial de la Salud considera que la prevalencia de infección por el VIH en los niños con TB de los países con prevalencia moderada o alta oscila entre 10% y 60%. El presente estudio tuvo por objeto determinar el acceso de los niños coinfectados por el VIH y la TB a los servicios relacionados con el VIH.Método: Se llevó a cabo un examen retrospectivo de los datos sobre los niños con diagnóstico de TB en el estado de Lagos en Nigeria del 1° de enero del 2012 al 31 de diciembre del 2013.Resultados: Se estableció el diagnóstico de TB en 1199 niños de 0 a 14 años de edad, de los cuales 1095 contaban con una prueba diagnóstica del VIH (91,3%) y 320 habían obtenido un resultado positivo (29,2%). La proporción entre el sexo masculino y femenino fue 1:0,9 en los niños coinfectados. De los 320 casos de coinfección, 57 eran menores de un año de edad (17,8%), 86 tenían entre 1 y 4 años (26,9%) y 186 entre 5 y 14 años de edad (58,1%). De los 320 niños coinfectados, se inició tratamiento preventivo con cotrimoxazol (CPT) en 186 (58,1%) y 15 niños comenzaron el tratamiento antirretrovírico (ART) (47,2%). La aceptación del ART no fue significativamente más alta en los establecimientos donde los servicios contra la TB y el VIH compartían la ubicación (P > 0,05).Conclusión: La aceptación del CPT y el ART fue baja. Es preciso intensificar las iniciativas tendentes a mejorar el acceso a los servicios relacionados con el VIH de Lagos, en Nigeria.

Public-private mix for TB and TB-HIV care in Lagos, Nigeria.

SETTING: Private and public tuberculosis (TB) treatment centres in Lagos State, Nigeria. OBJECTIVE: To assess the contribution of private health care providers to TB and TB-HIV (human immunodeficiency virus) case finding in Lagos State. DESIGN: A retrospective review of programme data submitted to the Lagos State TB and Leprosy Control Programme in 2011 by public, private for-profit (PFP) and private not-for-profit (PNFP) health care providers. RESULTS: A total of 8425 TB cases were notified by 31 private (11 PFP and 20 PNFP) and 99 public health facilities in Lagos State. Overall, the private facilities were responsible for 10.3% (866/8425) of the total TB cases notified. The proportion of TB patients tested for HIV was respectively 86.2%, 53.1% and 96.5% among public, PFP and PNFP facilities. Overall, 22.4% of the TB patients were HIV-positive. The HIV positivity rate among public, PFP and PNFP facilities was respectively 23.8%, 7.8% and 9.9%. Uptake of cotrimoxazole preventive therapy was respectively 69.6%, 25% and 38.2% among public, PFP and PNFP facilities, while that of antiretroviral therapy was respectively 23.8%, 8.3% and 9.1% in public, PFP and PNFP facilities. CONCLUSION: There is a need to scale up collaboration with the private sector, and particularly PNFP health providers.

The influence of rumen volatile fatty acids on protein metabolism in growing lambs.

The effect of acetic or propionic acid rumen fermentation patterns on whole-body protein turnover, tissue protein synthetic rates and body composition was investigated in growing lambs. Protein turnover was assessed using a continuous intravenous infusion of [2,3-3H]tyrosine and tissue protein fractional synthetic rates (FSR) from the specific activities of plasma free, intracellular free and tissue bound tyrosine. Only the FSR of muscle tissue approached significance. The high FSR in the propionic group was attributed to the high plasma insulin concentration. Values for whole-body protein synthesis, corrected for tyrosine oxidation, were similar to those obtained by summating protein synthesis in individual tissues, confirming that tyrosine oxidation should be measured accurately if reliable whole-body protein synthesis values are required. Tyrosine oxidation and flux were high in the acetic acid group, suggesting that amino acids are used for gluconeogenesis. The high protein turnover rate probably ensures an adequate supply of gluconeogenic amino acids and that the penalty of mobilizing body proteins for gluconeogenic amino acids is minimal. In the propionic acid group, high plasma glucose and insulin concentrations were associated with a low protein turnover rate, high ratio of deposited: synthesized protein and a high body fat content. It is concluded that changing the proportion of ruminal volatile fatty acids influences protein turnover, protein synthesis and the efficiency of protein retention. Such factors probably contribute, indirectly, to the observed differences in body composition.

Solitary caecal diverticulitis. Recognition and management.

Nine cases of solitary caecal diverticulitis treated in Kuwait are presented and the literature is reviewed. The preoperative diagnosis was acute appendicitis in all cases, but diverticulitis was detected during surgical exploration and histologically confirmed. The surgical management in seven cases was simple excision of the diverticulum with closure of resultant defect or invagination of the mucosal bulge with suture of the colonic wall. Right hemicolectomy was performed in two cases because of gangrenous patches in the caecal wall and suspicion of carcinoma. Recognition of solitary caecal diverticulitis requires considerable experience, especially in order to avoid more radical procedures such as right hemicolectomy. Solitary caecal diverticulum does not seem to occur in the indigenous people of Kuwait. All nine patients were of other nationalities, including five from countries of the Far East.