Impact and burden of sickle cell disease in critically ill obstetric patients in a high dependency unit in Sierra Leone-a registry based evaluation.

INTRODUCTION: Sickle cell disease (SCD) in pregnancy is associated with worse maternal and neonatal outcomes. There is limited available data describing the burden and outcomes of critically ill obstetric patients affected by SCD in low-income settings. OBJECTIVES: We aimed to define SCD burden and impact on mortality in critically-ill obstetric patients admitted to an urban referral hospital in Sierra Leone. We hypothesized that SCD burden is high and independently associated with increased mortality. METHODS: We performed a registry-based cross-sectional study from March 2020 to December 2021 in the high-dependency unit (HDU) of Princess Christian Maternity Hospital PCMH, Freetown. Primary endpoints were the proportion of patients identified in the SCD group and HDU mortality. Secondary endpoints included frequency of maternal direct obstetric complications (MDOCs) and the maternal early obstetric warning score (MEOWS). RESULTS: Out of a total of 497 patients, 25 (5.5%) qualified to be included in the SCD group. MEOWS on admission was not different between patients with and without SCD and SCD patients had also less frequently reported MDOCs. Yet, crude HDU mortality in the SCD group was 36%, compared to 9.5% in the non SCD group (P < 0.01), with an independent association between SCD group exposure and mortality when accounting for severity on admission (hazard ratio 3.40; 95%CI 1.57-7.39; P = 0.002). Patients with SCD had a tendency to longer HDU length of stay. CONCLUSIONS: One out of twenty patients accessing a HDU in Sierra Leone fulfilled criteria for SCD. Despite comparable severity on admission, mortality in SCD patients was four times higher than patients without SCD. Optimization of intermediate and intensive care for this group of patients should be prioritized in low-resource settings with high maternal mortality.

Diagnostic Accuracy of Noun- and Verb-Naming Tasks in Detecting Cognitive Impairment in Parkinson's Disease.

BACKGROUND: In Parkinson's disease (PD), verb-naming tasks (VNTs) have been proposed as superior to noun-naming ones in detecting language deficits, although such a hypothesis is not supported at a statistical level. OBJECTIVES: The main aim of this study was to provide diagnostic accuracy evidence for a VNT and noun-naming task (NNT) in detecting cognitive impairment (CI) in PD patients. METHOD: Thirty-three consecutive PD patients were subdivided into participants with (PD-CI; N = 12) or without CI (cognitively unimpaired, PD-CU; N = 21), based on a raw score ≤25 or >25 on the Mini-Mental State Examination, respectively. The NNT and VNT by Neuropsychologia [2006 Jan;44(1):73-89] were administered. Diagnostic accuracy of the NNT and VNT was assessed through receiver-operating characteristics analyses by comparing PD-CU to PD-CI patients. At the optimal cut-off, sensitivity, specificity, positive and negative predictive values (PPV, NPV), and likelihood ratios (LR+, LR-) were separately tested for the NNT and VNT against PD-CU versus PD-CI classification. RESULTS: Diagnostic accuracy was higher for the NNT (AUC = 0.85; p = 0.001) versus the VNT (AUC = 0.68; p = 0.092). Consistently, the NNT yielded higher sensitivity, specificity, and post-test features than the VNT (NNT: sensitivity = 0.75, specificity = 0.81, PPV = 0.69, NPV = 0.85, LR+ = 3.94, LR- = 0.31; VNT: sensitivity = 0.67, specificity = 0.67, PPV = 0.53, NPV = 0.78, LR+ = 2, LR- = 0.5). CONCLUSIONS: In accordance with the Movement Disorders Society guidelines, NNTs are diagnostically sound psychometric instruments to discriminate PD patients with versus without CI. However, these findings need replication by (1) employing a gold standard different from the Mini-Mental State Examination, which does not capture the full range of CI in this population and (2) subdividing PD patients into those with mild CI and dementia.

Cost-Utility of Intermediate Obstetric Critical Care in a Resource-Limited Setting: A Value-Based Analysis.

Background: Sierra Leone faces among the highest maternal mortality rates worldwide. Despite this burden, the role of life-saving critical care interventions in low-resource settings remains scarcely explored. A value-based approach may be used to question whether it is sustainable and useful to start and run an obstetric intermediate critical care facility in a resource-poor referral hospital. We also aimed to investigate whether patient outcomes in terms of quality of life justified the allocated resources. Objective: To explore the value-based dimension performing a cost-utility analysis with regard to the implementation and one-year operation of the HDU. The primary endopoint was the quality-adjusted life-years (QALYs) of patients admitted to the HDU, against direct and indirect costs. Secondary endpoints included key procedures or treatments performed during the HDU stay. Methods: The study was conducted from October 2, 2017 to October 1, 2018 in the obstetric high dependency unit (HDU) of Princess Christian Maternity Hospital (PCMH) in Freetown, Sierra Leone. Findings: 523 patients (median age 25 years, IQR 21-30) were admitted to HDU. The total 1 year investment and operation costs for the HDU amounted to €120,082 - resulting in €230 of extra cost per admitted patient. The overall cost per QALY gained was of €10; this value is much lower than the WHO threshold defining high cost effectiveness of an intervention, i.e. three times the current Sierra Leone annual per capita GDP of €1416. Conclusion: With an additional cost per QALY of only €10.0, the implementation and one-year running of the case studied obstetric HDU can be considered a highly cost-effective frugal innovation in limited resource contexts. The evidences provided by this study allow a precise and novel insight to policy makers and clinicians useful to prioritize interventions in critical care and thus address maternal mortality in a high burden scenario.

Single primer pair for PCR identification of Candida parapsilosis group I isolates.

A DNA fragment, isolated from a genomic DNA mini-library of Candida parapsilosis group I reference strain ATCC 22019, was sequenced and characterised. The fragment was first probed by Southern blotting against a pool of DNA from several yeasts. The hybridisation tests revealed that the probe was specific for strain ATCC 22019 and 49 (90.74%) of 54 C. parapsilosis clinical and soil isolates that were attributed to C. parapsilosis group I by the electrophoretic images of their restriction fragment length polymorphisms (RFLPs) and electrophoretic karyotype (EK). The remaining five negative isolates, according to the same criteria, were attributed to group II (one isolate) and III (four isolates). Two primers were selected from the probe DNA sequence and a PCR-based test was developed for specifically detecting C. parapsilosis group I isolates, which represent the majority of the common clinical isolates. The PCR assay confirmed the Southern hybridisation results. This PCR assay could be a simple and reproducible tool for the rapid, sensitive and species-specific identification of C. parapsilosis major group I isolates.

Catheter-related candidemia caused by Candida lipolytica in a patient receiving allogeneic bone marrow transplantation.

Candida lipolytica was recovered from the blood and the central venous catheter in a patient receiving allogeneic bone marrow transplantation. Two C. lipolytica strains from different geographical areas and the ATCC 9773 strain of C. lipolytica were used as controls. C. lipolytica was identified by standard methods. MICs indicated antifungal susceptibilities to amphotericin B, fluconazole, and itraconazole for all strains. In vitro testing and scanning electron microscopy showed that C. lipolytica was capable of producing large amounts of viscid slime material in glucose-containing solution, likely responsible for the ability of the yeast to adhere to catheter surfaces. Restriction fragment length polymorphisms revealed an identical profile for all clinical isolates, unrelated to those observed for the control strains. This finding suggested the absence of microevolutionary changes in the population of the infecting strain, despite the length of the sepsis and the potential selective pressure of amphotericin B, which had been administered to the patient for about 20 days. The genomic differences that emerged between the isolates and the control strains were indicative of a certain degree of genetic diversity between C. lipolytica isolates from different geographical areas.