Eosinophilic oesophagitis in a Nigerian adolescent: a case report.

Eosinophilic oesophagitis (EoE) is a chronic immune and antigen-mediated disease characterized by symptoms related to oesophageal dysfunction, and histologically, is marked by eosinophilic infiltrate in the oesophageal mucosa. It is prevalent in developed countries and considered rare in developing countries. There is an interplay of allergic and genetic factors in the aetiology of EoE. This is a report of EoE in a 15-year-old female adolescent in Nigeria who presented to the University of Calabar Teaching Hospital with recurrent vomiting, abdominal pain, weight loss, and dysphagia. She had received treatment for Gastro-oesophageal disease three years earlier and was lost to follow-up. Weight on admission was 39 kg and height 170 cm with a BMI below the 3rd centile. Peripheral blood showed an eosinophil count of four percent. The abdominal computed tomography (CT) scan and upper gastrointestinal (GI) series were normal. Faecal antigen for H. pylori and ova for stool parasites were negative. Histologic findings of proximal and distal oesophageal mucosal biopsies showed greater than 20 eosinophils per high power field. The histology of the stomach and duodenum were normal. She was initially treated with a protein pump inhibitor, with no improvement. Swallowed fluticasone propionate and eliminating peanuts, wheat, egg, and milk from her diet were introduced. Symptoms improved with the patient no longer vomiting and had an increase in weight gain. She was discharged to follow up. This case shows that EoE occurs in developing countries, but diagnosis may be missed. There is a need for a high index of suspicion among gastroenterologists in patients with symptoms suggestive of GERD not responding to therapy.

Prevention of surgical site infection and sepsis in pregnant obese women.

Obesity is a major determinant of health outcomes and is on the increase in women worldwide. It predisposes to surgical site infection (SSI). Risk factors for the SSI include extremes of age, smoking, comorbidities such as hypertension and diabetes, inappropriate vertical abdominal and or uterine wall incisions, increased operating time, subcutaneous layer of 3 cm or more, and unnecessary use of subcutaneous drain. Most bacteria that cause SSIs are human commensals. Common organisms responsible for SSI include Staphylococcus aureus and coliforms such as Proteus mirabilis, and Escherichia coli. A surgeon's gloves post caesarean section in the obese has a preponderance of Firmicutes and Bacteroidetes, which increases SSI risk. The interaction of skin commensals and vaginal microbiome at the surgical incision site increases the risk of SSI in the obese compared to non-obese. Minimizing the risk of SSI involves modification of risk factors, timely treatment of SSI to prevent sepsis and compliance with the recommended care bundles.

Implementation of Uterine Artery Doppler Scanning: Improving the Care of Women and Babies High Risk for Fetal Growth Restriction.

Introduction: While stillbirth rates have declined in many countries, these declines are less marked in the UK. Fetal growth restriction (FGR) affects about 3% to 7% of all pregnancies and is by far the single strongest risk factor for stillbirth. FGR implies a pathological restriction of the genetic growth potential and is not synonymous with small-for-gestational age (SGA). The Royal College of Obstetricians and Gynaecologists (RCOG) defines SGA as an estimated fetal weight (EFW) or abdominal circumference (AC) less than the 10th centile. The likelihood of FGR is higher in severe SGA defined as an EFW or AC less than the 3rd centile. The second version of Saving Babies' Lives Care Bundle (SBLCBv2) recommends the second trimester uterine artery Doppler (UtAD) pulsatility index (PI) screening for pregnancies at high risk of FGR. This study was aimed at determining the prevalence of FGR and assess pregnancy outcomes following the implementation of UtAD at the United Lincolnshire Hospitals NHS Trust (ULHT). Methods: One-year retrospective cohort study (1st September 2020-31st August 2021) was conducted across both ULHT hospitals in the UK (Lincoln County Hospital in Lincoln and Pilgrim Hospital in Boston). Results: During the study period, 5197 women were booked at ULHT. Of 5197, 349 were identified as high risk for FGR. When numbers were compared for the two hospitals, FGR rate was higher in Lincoln 8.10% vs. 4.51% in Boston. In addition, an increased proportion of abnormal UtAD scans was observed in Lincoln (35.7%) vs. in Boston (22%) (P = 0.014). Of the 349 UtAD scans, 237 were normal (67.9%), 41 showed unilateral notching (11.7%), 43 bilateral notching (12.3%), and 28 raised PI (8%). Babies in the bilateral notching group exhibited the lowest birth weight (P = 0.005), born at an earlier gestation (P = 0.029), and with low Apgar scores at 1 (P = 0.007) and 5 minutes (P < 0.001). Discussion. UtAD is a useful second trimester screening tool for women identified as high risk for FGR and helps stratify the intensity of surveillance. However, the findings call into question a focus solely on the UtAD PI for improving FGR detection without taking into account bilateral notching.

"The Spiked Helmet sign": A harbinger of impending barotrauma.

The 'spiked helmet sign' (SHS) is an electrocardiographic finding associated with critical illness and a high risk of death; It is likened to ST-elevation, leading to harmful coronary imaging despite lack of apparent myocardial infarction. We describe the case of SHS secondary to high ventilation pressures in the setting of Acute Respiratory Distress Syndrome (ARDS) in a critically ill patient who subsequently developed barotrauma.

Antibody response to pneumococcal conjugate vaccine 10 among Nigerian children under 5 years.

Introduction: Invasive pneumococcal diseases have been a major contributor to childhood mortality, particularly in the developing world and pneumococcal vaccines were introduced to reduce the burden. The Pneumococcal Conjugate Vaccine 10 (PCV 10) was incorporated into the Nigerian National Programme on Immunization (NPI) in 2014 to reduce the incidence of childhood pneumococcal infections. This study was done to determine the immunogenicity of the vaccine in our clime. Methodology: This cross-sectional study was carried out between September 2019 and January 2020 at the Children Outpatient Clinic of the Federal Medical Center, Owerri, Nigeria. Two hundred and forty five children between the ages of 20 weeks and 59 months, who had received three doses of Pneumococcal Conjugate Vaccine 10 (PCV 10) at 6, 10 and 14 weeks according to the NPI schedule, were recruited into the study. The anti-pneumococcal PCV 10 IgG concentration was determined using Human Anti-Pneumococcal CPS 10 IgG vaccine ELISA Kit ®. Simple proportions, means and median (as appropriate) were used to analyse the data. Kruskal Wallis test and Spearman's correlation were done to test association. Significance was set as p< 0.05. Results: The mean anti-pneumococcal IgG concentration was 11.01±1.23 IU/ml and all the study participants formed protective levels of anti-pneumococcal IgG. There was a slight positive correlation between antibody response and age (r=0.13, p=0.04), and the antibody response was slightly more in males than females. Conclusion: All the children under the age of five years who had received PCV 10 at 6, 10 and 14 weeks of age, who participated in this study formed protective levels of antibodies to the vaccine. Antibody levels increased slightly with age. The PCV 10 currently used in the Nigerian programme is sufficiently antigenic and a downward trend in pneumococcal diseases should soon be noticeable.

Multi-national survey on the methods, efficacy, and safety on the post-approval clinical use of pulsed field ablation (MANIFEST-PF).

AIMS: Pulsed field ablation (PFA) is a novel atrial fibrillation (AF) ablation modality that has demonstrated preferential tissue ablation, including no oesophageal damage, in first-in-human clinical trials. In the MANIFEST-PF survey, we investigated the 'real world' performance of the only approved PFA catheter, including acute effectiveness and safety-in particular, rare oesophageal effects and other unforeseen PFA-related complications. METHODS AND RESULTS: This retrospective survey included all 24 clinical centres using the pentaspline PFA catheter after regulatory approval. Institution-level data were obtained on patient characteristics, procedure parameters, acute efficacy, and adverse events. With an average of 73 patients treated per centre (range 7-291), full cohort included 1758 patients: mean age 61.6 years (range 19-92), female 34%, first-time ablation 94%, paroxysmal/persistent AF 58/35%. Most procedures employed deep sedation without intubation (82.1%), and 15.1% were discharged same day. Pulmonary vein isolation (PVI) was successful in 99.9% (range 98.9-100%). Procedure time was 65 min (38-215). There were no oesophageal complications or phrenic nerve injuries persisting past hospital discharge. Major complications (1.6%) were pericardial tamponade (0.97%) and stroke (0.4%); one stroke resulted in death (0.06%). Minor complications (3.9%) were primarily vascular (3.3%), but also included transient phrenic nerve paresis (0.46%), and TIA (0.11%). Rare complications included coronary artery spasm, haemoptysis, and dry cough persistent for 6 weeks (0.06% each). CONCLUSION: In a large cohort of unselected patients, PFA was efficacious for PVI, and expressed a safety profile consistent with preferential tissue ablation. However, the frequency of 'generic' catheter complications (tamponade, stroke) underscores the need for improvement.

Predictors of In-Patient Mortality of Severe Acute Malnutrition of Hospitalised Children in a Tertiary Facility in Southern Nigeria.

Introduction Severe acute malnutrition (SAM) remains a public health concern in developing countries. Children with SAM are nine times more likely to die compared with those that are well-nourished. Most studies on SAM in Nigeria focus on disease burden without evaluating risk factors that may be useful as interventions in reducing mortality. This study evaluated predictors of mortality and outcome among hospitalised children with SAM in Southern Nigeria. Methods Children with SAM admitted into the paediatric medical ward of the University of Calabar Teaching Hospital between September 2017 and November 2019 were studied prospectively. A multivariable logistic regression was used to identify factors that independently predicted mortality with a p-value <0.05 considered significant. Results One hundred children were studied. The mean age was 14.28 ± 14.04 months, of which 89% were less than two years of age. Oedematous and non-oedematous SAM were found in 18.5% and 81.5%, respectively. Co-morbidities included tuberculosis (TB) (13.0%), HIV (12.0%), and HIV/TB co-infection (3.0%). Clinical presentation included fever (21.7%), anaemia (19.9%), diarrhoea (19.1%), skin changes (8.7%), and shock (1.8%). The mean duration of hospital stay was 11.48 ± 6.87 days. Nine of the children were discharged against medical advice and were excluded from further analysis. About 92.3% were discharged for follow-up and 7.7% died. After multivariable regression, the predictors of mortality were shock (p=0.037, adjusted odds ratio (aOR): 17.51, 95% confidence interval (95% CI): 1.19-258.77) and skin changes (p=0.035, aOR: 9.81, 95% CI: 1.18-81.46). Conclusion The presence of shock and skin changes are independently associated with mortality in hospitalised children with SAM. Prompt referral of children with SAM and more so with complications of shock and skin changes is hereby advocated to reduce mortality.

Testicular Volume in Children with Sickle Cell Anaemia in Uyo, a South-South Nigerian City.

INTRODUCTION: Sickle cell anaemia (SCA) often presents in early childhood with repeated vaso-occlusive crisis that leads to ischaemia, infarction and fibrosis which may result in a reduction in expected testicular volume (TV) at puberty. METHOD: This was a cross-sectional study of 95 children with SCA aged 1-18 years compared with 95 age-matched controls. Participants responded to an interviewer-administered questionnaire, with their anthropometric measurements taken, pubertal maturity assessed by Tanner staging and testicular ultrasonography done. Changes in TV across the ages were compared graphically and regression analyses were used to determine the factors independently associated with TV. A p-value of <0.05 was considered statistically significant. RESULTS: In the prepubertal period, the haemoglobin SS (HbSS) participants had larger median ultrasound TV (MUSTV) compared to the haemoglobin AA (HbAA) controls (p = 0.001). This trend reversed in the pubertal period. On regression analysis, the frequency of testicular pain (p = 0.04), weight (p = 0.02) and pubic hair rating (p = 0.03) of the HbSS participants were significant predictors of increased TVs in the HbSS participants, irrespective of pubertal status. CONCLUSION: The prepubertal MUSTV of the HbSS participants were higher than those of the HbAA controls, while the HbAA controls had higher MUSTV at puberty and beyond. The frequency of testicular pain episodes, pubic hair rating and weight were independent predictors of TV changes in the HbSS participants. Prevention of repeated vaso-occlusive crisis in the prepubertal period may help prevent the reduction in TV and possible hypogonadism. Lay summarySickle cell anaemia (SCA) causes repeated episodes of painful crisis and in boys, these may affect the way their testes grow. The study set out to document testicular sizes on a one-time basis in boys aged 1-18 years with SCA compared with controls of similar ages. The participants responded to structured questions assisted by the researchers and their body measurements were appropriately taken. Their level of sexual maturation was assessed according to the method by Tanner and the sizes of their testes were measured using an ultrasound machine. The research information was analysed and a statistical value less than 0.05 was taken to mean that there was a difference between the measured variables. The mid-testicular sizes of the SCA participants were noted to be higher than that of their controls during the prepubertal period while the non-SCA boys had higher sizes from puberty onwards. The frequency of testicular pain, weight and pubic hair stage of the SCA boys were important contributors to their increased testes sizes, irrespective of pubertal status. Efforts aimed at preventing painful crisis should start during early childhood to forestall future sexual challenges in adulthood.

Intraparenchymal Brain Abscess in an Adult Male With Underlying Ebstein Anomaly and Cor Triatriatum Dexter.

A 21-year-old man presented with new-onset seizures and brain abscess. Echocardiography and cardiac magnetic resonance imaging revealed underlying Ebstein anomaly, secundum atrial septal defect, and cor triatriatum dexter. The elevated right heart pressures shunting through the septal defect and transient bacteremia were the likely mechanisms for his presentation. (Level of Difficulty: Intermediate.).

Spontaneous pneumothorax: An emerging complication of COVID-19 pneumonia.

Spontaneous Pneumothorax in the setting of coronavirus disease 19 (COVID-19) has been rarely described and is a potentially lethal complication. We report our institutional experience. Patients with confirmed COVID-19 who were admitted at 5 hospitals within the Inova health system between February 21 and May 2020 were included in the study. We identified 1619 patients, 22 patients (1.4%) developed spontaneous pneumothorax during their hospitalization without evidence of traumatic injury.

Ventricular septal rupture and cardiogenic shock complicating STEMI during COVID-19 pandemic: An old foe re-emerges.

The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant.

Medical Therapy for Fibroids: What Next for Ulipristal Acetate?

Ulipristal acetate (UPA) was introduced as a novel progesterone receptor modulator as effective therapy for symptomatic fibroids. Randomised clinical trials established its effectiveness in the management of heavy menstrual bleeding due to uterine leiomyomas. The trials did not find any significant evidence of clinical harm to the participants. Recently, however, there have been reports of liver injury necessitating liver transplant in women who have had UPA treatment. This has led to the suspension of UPA as one of the medical therapies in the treatment for uterine fibroids while the European Medicines Agency (EMA) conducts a review of liver injury risk with its use. The European Medicine Agency safety committee has advised that women should stop taking 5 mg UPA and that no new patients should commence treatment with the medicine until the ongoing review is completed. In this article, we review the rise of UPA as one of the emerging medical therapies for symptomatic uterine fibroids and the subsequent reports of adverse events leading to the suspension of its use.

Care of the Sick Newborn in a Cottage Hospital Level in a Developing Country.

INTRODUCTION: Neonatal morbidity and mortality are high in Nigeria. The establishment of more centers that could offer adequate management of high-risk pregnancies and neonates is essential. OBJECTIVES: This study seeks to describe sick newborn care at the cottage hospital level in Southern Nigeria with the aim of drawing lessons that may be useful to similar environments. SUBJECTS AND METHODS: A description of facility upgrading and staff training in perinatal care at a public-private partnership cottage hospital with a robust community health insurance scheme in Nigeria is made. A retrospective descriptive study of the morbidity and outcomes of admitted neonates in the facility between March 2016 and February 2017 was made. RESULTS: Out of 3630 babies born in the facility (302 per month), 189 were admitted, yielding an admission rate of 52.1/1000 live births. The main morbidities were neonatal hypoglycemia (32.4%), preterm low-birth weight (24.9%), neonatal sepsis (22.8%), and neonatal jaundice (12.7%). Sixteen of the 109 neonates died giving a mortality rate of 8.5%. The main causes of deaths were birth asphyxia (7 or 43.8%), meconium aspiration (6 or 37.5%), and congenital malformation (3 or 18.8%). CONCLUSION AND RECOMMENDATIONS: The neonatal admission and mortality rates are quite low in this cottage hospital and similar to the situation even in developed environments. This salutary scenario is probably due to good antenatal and perinatal care, and a robust community health insurance scheme which enhances services uptake and public-private partnership which engenders infrastructure expansion and maintenance. This model is recommended for the hospitals in our region.

The clinical spectrum of myocardial injury associated with COVID-19 infection.

Although respiratory symptoms are the dominant features of COVID-19 infection, myocardial injury has been described in these patients. Reported cardiac manifestations of COVID-19 infection include myocarditis, arrhythmia and acute coronary syndrome including ST elevation myocardial infarction (STEMI). STEMI is a medical emergency and timely intervention is of utmost importance to prevent mortality and long-term morbidities. In this report, we present a wide spectrum of clinical presentations, management, and outcomes for five patients with COVID-19 infection and ST elevation on ECG.

Acute hemiplegia: aetiology and outcome in Nigerian children.

INTRODUCTION: acute hemiplegia of childhood is a postnatally acquired nonspecific clinical response of the brain to various aetiological insults in a child who was neurologically normal at birth. This study aims at evaluating the aetiology and outcome of acute hemiplegia in children admitted into the University of Calabar Teaching Hospital (UCTH), Nigeria. METHODS: a 5-year retrospective review of all children admitted to the Neurology Unit of the Department of Paediatrics of UCTH with a diagnosis of acute hemiplegia. The demographic characteristics of the children and the clinical features were noted. Investigations including neuroimaging of the brain and haemoglobin genotype were documented. The outcomes of the patients were recorded as either dead, recovered with deficit or loss to follow up. Data obtained was analysed using the SPSS version 24. Simple tables were used to display the results in number and percentages. RESULTS: twenty-five children with diagnosis of hemiplegia were admitted. Associated clinical features were prolonged seizures (68%), speech defect (32%), cranial nerve deficit (36%) and loss of consciousness (12%). Viral encephalitis was the common aetiology in 11(44%) of the patients, followed by meningitis and sickle cell anaemia in 6(24%) patients each. Four(16%) of the patients recovered completely within the follow up period of three month, 19(76%) had varying degrees of weakness; 2(8%) died. Twelve (48%) were lost to follow-up. CONCLUSION: central nervous system infections and sickle cell disease as dominant aetiological factors of acute hemiplegia in Nigerian children. This calls for effective infection control and genetic counselling.

Combined Venoarterial ECMO and Impella-CP Circulatory Support for Cardiogenic Shock Due to Papillary Muscle Rupture.

Papillary muscle rupture (PMR) is a catastrophic complication of acute myocardial infarction (AMI). We report on 3 consecutive patients with AMI cardiogenic shock due to PMR, treated with combined venoarterial extracorporeal membrane oxygenation and Impella-CP axial flow circulatory support as a bridge to definitive surgery. (Level of Difficulty: Intermediate.).

Management of Epilepsies at the Community Cottage Hospital Level in a Developing Environment.

BACKGROUND: The epilepsy problem in much of Africa is characterized by stigmatization and neglect. This article describes the efforts at a cottage hospital level to ameliorate the epilepsy problem in a resource-limited environment. METHODS: A seizure clinic was started in a cottage hospital after targeted health talks. The International League against Epilepsy (ILEA)/World Health Organization (WHO)/International Bureau for Epilepsy (IBE) manual was adopted for the training of staff and to guide management. Patients were followed up in the clinic and with the use of simple information communication technology. RESULTS: Forty-five patients with ages ranging from 3 months to 42 years (who had lived with epilepsy for periods ranging from 3 weeks to 32 years) were registered over 12 months period. The most common seizure type was generalized tonic clonic (21 or 46.67%) followed by generalized clonic (8 or 17.78%). Ten (22.22%) had comorbidities mainly cerebral palsy (4 or 8.89%) and attention-deficit hyperactivity disorder (3 or 6.67%). Most (98.15%) were placed on carbamazepine. Twenty-three (51.11%) had complete control of seizures, 21 (46.67%) had reduced frequencies of attacks, and all 8 children who had dropped out of school resumed schooling. CONCLUSION: The epilepsy challenge in the developing world can be demystified and effectively managed at the cottage hospital level. Targeted health education, affordable management regimes, and committed follow-up are keys. A training manual based on the ILEA/WHO/IBE document should be developed for Africa.