Neurocritical Care in Nigeria.

Nigeria is the most populous country in Africa with an estimated 206 million inhabitants served by less than 300 neurologists and 131 neurosurgeons. Neurological conditions account for approximately 18% of all medical emergencies. Neurocritical care challenges in Nigeria are as complex as they are in other low-to-middle-income countries (LMICs). These include high burden of neurological diseases, poor pre-hospital care, delays in transfer, lack of neurocritical care equipment, and inadequate rehabilitative capacity. Neurocritical care units in Nigeria offer mostly limited multimodal monitoring due to out-of-pocket payment, and the success of repeat radiological imaging and blood work is low. Data gathering and outcome research in neurocritical conditions can help in clinical decision-making and enhance cost-effective clinical care. The concept of allocation requires that when medical resources are scarce, they must be efficiently utilized in the most judicious way so as to achieve the greatest possible benefit. A high degree of transparency is needed with regard to the principles, values and criteria employed to facilitate such triage decisions. Proper funding will help improve availability of equipment and drugs resulting in a higher quality of care and, subsequently, improvement in mortality. There is ample evidence that neurocritical care improves overall prognosis in neurocritically-ill patients. Neurocritical care units (NCCUs) are mostly unavailable in Nigeria, often resulting in poorer prognosis for patients. What is already known: Nigeria has an unacceptably huge deficit in the overall capacity for neurocritical care. The inadequacies affect a wide range of components - facilities, quantity and quality of personnel, and the unbearably high cost, among others. What this study adds: This article attempts to condense the challenges in one piece while highlighting previously obscure ones, with the aim of providing possible solutions to the lingering challenges in neurocritical care in Nigeria and, invariably, other LMICs. How this study might affect practice, policies or research: We envisage this article will stimulate the initial steps in a multipronged and data-driven approach to bridging the gap by government and relevant healthcare administrators.

Le Nigeria est le pays le plus peuplé d'Afrique avec une population estimée à 206 millions d'habitants et à peine moins de 300 neurologues et 131 neurochirurgiens au service de cette population. Les urgences neurologiques représentent environ 18 % de toutes les urgences médicales. Les défis posés par les soins neurocritiques au Nigeria sont aussi complexes que dans d'autres pays à revenu faible ou intermédiaire (PRFI). Il s'agit notamment du lourd fardeau des maladies neurologiques, de la médiocrité des soins préhospitaliers, des retards de transfert, du manque d'équipements de soins neurocritiques et d'une capacité de réadaptation réduite. Les unités de soins neurocritiques au Nigeria disposent d'une surveillance multimodale limitée en raison du paiement direct, et le succès de la répétition de l'imagerie radiologique et des analyses sanguines est faible. La collecte de données et la recherche sur les résultats dans les conditions neurocritiques peuvent aider à la prise de décision clinique et améliorer la rentabilité des soins cliniques. Selon le concept d'allocation, lorsque les ressources médicales sont rares, elles doivent être utilisées efficacement et de la manière la plus judicieuse possible afin d'obtenir le plus grand bénéfice possible. Un degré élevé de transparence est nécessaire en ce qui concerne les principes, les valeurs et les critères utilisés pour faciliter ces décisions de triage. Un financement adéquat permettra d'améliorer la disponibilité des équipements et des médicaments, ce qui se traduira par une meilleure qualité des soins et, par la suite, par une réduction de la mortalité. Il existe de nombreuses preuves que les soins neurocritiques améliorent le pronostic général des patients en état neurocritique. Les unités de soins neurocritiques (NCCU) sont pour la plupart indisponibles au Nigeria, ce qui entraîne un pronostic plus défavorable. Ce que l'on sait déjà : Le Nigeria souffre d'un déficit inacceptable en matière de capacité globale de soins neurocritiques. Les insuffisances touchent un large éventail d'éléments - installations, quantité et qualité du personnel, et coût insupportablement élevé, entre autres. Ce que cette étude apporte : Cet article tente de condenser les défis en un seul élément tout en mettant en lumière ceux qui étaient auparavant obscurs, dans le but de fournir des solutions possibles aux défis persistants des soins neurocritiques au Nigeria et invariablement dans les pays à faible revenu intermédiaire. Comment cette étude pourrait-elle affecter la pratique, les politiques ou la recherche ? Nous pensons que cet article stimulera les premières étapes d'une approche multidimensionnelle et axée sur les données pour combler le fossé par le gouvernement et les administrateurs de soins de santé concernés. Mots-clés: Soins Neurocritiques, Nigeria, Maladies neurologiques.

Challenges to Thrombolysis in A Resource-Poor Setting- A Case Report.

A major complication of acute ischemic stroke is death and disability. The emergence of reperfusion therapy in form of thrombolysis and endovascular thrombectomy has led to the reversal of this trend in high-income countries. Low- and middle-income countries are yet to benefit maximally from these time-bound treatment options due to some limitations. We intend to highlight some of these in this report. We report an 80-year-old male patient with hypertension and firstdegree AV block admitted 3 hours after the onset of stroke with National Institutes of Health Stroke Scale (NIHSS) score of 13 and Medical Research Council (MRC) muscle power grade 3 in both the left upper and lower limb. Urgent non-contrast brain CT revealed no evidence of hemorrhage. Intravenous tissue plasminogen activator (tPA) was administered at a dose of 0.6 mg/kg 9 hours after symptom onset. He made significant improvement afterward and was discharged. The challenges encountered in his management include prehospital and intrahospital delay, and unavailability of tissue plasminogen activator. There is a need for an improved healthcare delivery system in order to reduce the morbidity associated with acute ischemic stroke.

Une complication majeure de l'accident vasculaire cérébral ischémique aigu est le décès et l'invalidité. L'émergence de la thérapie de reperfusion sous forme de thrombolyse et de thrombectomie endovasculaire a conduit à l'inversion de cette tendance dans les pays à revenu élevé. Les pays à revenu faible et moyen n'ont pas encore pleinement bénéficié de ces options de traitement limitées dans le temps en raison de certaines limitations. Nous avons l'intention de mettre en lumière certaines de ces limitations dans ce rapport. Nous rapportons le cas d'un homme de 80 ans, connu pour son hypertension et un bloc auriculo-ventriculaire de premier degré, admis 3 heures après le début de l'accident vasculaire cérébral avec un score de 13 à l'échelle d'AVC des National Institutes of Health (NIHSS) et une force musculaire du Medical Research Council (MRC) de grade 3 dans les membres supérieurs et inférieurs gauches. Une tomodensitométrie cérébrale urgente sans produit de contraste n'a révélé aucune preuve d'hémorragie. De l'activateur tissulaire du plasminogène (tPA) par voie intraveineuse a été administré à une dose de 0,6 mg/kg 9 heures après le début des symptômes. Il a ensuite connu une amélioration significative et a été autorisé à quitter l'établissement. Les défis rencontrés dans sa prise en charge comprenaient des retards préhospitaliers et intrahospitaliers, ainsi que l'indisponibilité de l'activateur tissulaire du plasminogène. Il est nécessaire d'améliorer le système de prestation de soins de santé afin de réduire la morbidité associée à l'accident vasculaire cérébral ischémique aigu. MOTS-CLÉS: Ischémique, AVC, Thrombolyse, Tissu, Plasminogène, Thrombectomie.

Nigerian resident doctors' work schedule: A national study.

Background and Aim: The deleterious effects of Resident Doctors' (RDs') long duty hours are well documented. Driven by concerns over the physician's well-being and patient safety, the RDs' duty hours in many developed countries have been capped. However, in Nigeria and many African countries, there are no official regulations on work hours of RDs. This study evaluated the work schedule of Nigerian RDs and its impact on their wellbeing and patient safety. Subjects and Methods: A national survey of 1105 Nigerian RDs from all specialties in 59 training institutions was conducted. With an electronic questionnaire designed using Google Forms, data on the work activities of RDs were obtained and analyzed using the IBM SPSS software version 24. The associations were compared using Chi-squared test with the level of significance set at < 0.05. Results: The mean weekly duty hours (h) of the RDs was 106.5 ± 50.4. Surgical residents worked significantly longer hours than non-surgical residents (122.7 ± 34.2 h vs 100.0 ± 43.9 h; P < 0.001). The modal on-call frequency was two weekday on-calls per week (474, 42.9%) and two weekend on-calls per month (495, 44.8%), with the majority of RDs working continuously for up to 24 hours during weekday on-calls (854, 77.3%) and 48-72 hours during weekend on-calls (568, 51.4%), sleeping for an average of only four hours during these on-calls. The majority of RDs had post-call clinical responsibilities (975, 88.2%) and desired official regulation of duty hours (1,031, 93.3%). Conclusion: The duty hours of Nigerian RDs are currently long and unregulated. There is an urgent need to regulate them for patient and physician safety.

Tramadol-Induced Acute Seizures: A Report of Three Cases.

There is a rise in substance abuse in Nigeria and prescription drugs, particularly opioid analgesics, which are increasingly becoming a target of abuse. Abuse of the opiod tramadol has the potential to precipitate seizures. We present 3 cases of tramadol-induced seizures presenting at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. The three patients were men, aged 22-40 years and abused other drugs including alcohol, cannabis and Rohypnol. This report illustrates the fact that tramadol abuse may be associated with acute seizures and it is reasonable to consider drug/opiod-induced seizure in every case of unexplained first episode of seizure in a young adult.

L'abus de substances psychoactives est en hausse au Nigeria et les médicaments sur ordonnance, en particulier les analgésiques opioïdes, qui deviennent de plus en plus une cible d'abus. L'abus de l'opioïde tramadol a le potentiel de précipiter des crises d'épilepsie. Nous présentons 3 cas de crises d'épilepsie induites par le tramadol se présentant à Complexe hospitalier universitaire Obafemi Awolowo, Ile-Ife. Les trois patients étaient des hommes, âgés de 22 à 40 ans et abusaient d'autres drogues dont l'alcool, le cannabis et le Rohypnol. Ce rapport illustre le fait que l'abus de tramadol peut être associé à des crises aiguës. associé à des crises d'épilepsie aiguës et il est raisonnable d'envisager une crise induite par le médicament ou par une période dans tous les cas de premier épisode de crise inexpliqué chez un jeune adulte. Mots clés: Tramadol, Toxicomanie, Crise d'épilepsie, Opioïde.

The Prevalence and Pattern of Malnutrition in Pre-Dialytic Chronic Kidney Disease Patients at a Tertiary Care Facility in Nigeria.

BACKGROUND: Malnutrition is a common problem in chronic kidney disease contributing to adverse outcomes in terms of morbidity and mortality and overall poor quality of life. In our environment and indeed most other developing countries, the prevalence of malnutrition in the general population is high. The high cost and dearth of renal replacement therapy in developing countries underscores the need for identification of factors that if adequately addressed will lead to slowing down of the progression to End Stage Renal Disease. AIMS AND OBJECTIVES: To determine the prevalence and pattern of malnutrition in pre-dialytic CKD patients at a tertiary care renal unit in a developing country. METHODOLOGY: One hundred and two consecutive patients attending the nephrology clinic of a tertiary care facility along with apparently healthy age and sex-matched subjects were studied. Demographic data, social classification and aetiology of CKD were obtained from patients. Multiple tools were used for assessment of the nutritional status of patients in stages 2-5 CKD who are not yet on dialysis. Clinical examination, anthro-pometric measurements triceps skin fold (TSF), Body Mass Index (BMI), Mid-upper Arm Circumference (MUAC), biochemical assessment (serum albumin and serum cholesterol) and Subjective Global Assessment (SGA) were used as tools for nutritional assessment for patients and compared with controls. The proportion of patients that met the International Society of Renal Nutrition and Metabolism (ISRNM) criteria for malnutrition was also determined. RESULTS: The mean age of the CKD patients was 47±11 years with a male to female ratio of 1.2:1. Prevalence of malnutrition in the CKD patients using clinical assessment was 8.8% (control=none), Body Mass Index was 31.4% (control=7.8%), Triceps skin fold thickness 46.6% (control=14.7%), serum albumin 46.1% (control=5.9%), Mid-upper arm circumference was 30.4% (control=11.18%), serum cholesterol 11.8% (control=3.9%), Subjective Global Assessment, 5.9% (control = none) and International Study of Renal Nutrition and Metabolism criteria 31.4% (control=none). The Prevalence of malnutrition increased significantly across CKD stages 2 to 5 with the use of clinical assessment (p=0.001), SGA (p value =0.001), serum albumin (p value =0.001) and BMI (p value =0.012). CONCLUSION: Malnutrition is common in pre-dialytic CKD patients in Nigeria and possibly other developing countries. There is a need to identify those who may need nutritional intervention early as this will impact positively on the final outcome of the disease as well as reduce the number of patients progressing to ESRD.

Prevalence and Pattern of Chronic Kidney Disease and its Associated Risk Factors in a Rural Community in South Western Nigeria.

BACKGROUND: Chronic kidney disease (CKD) has now become a disease of public health importance. The increased prevalence in the population of patients with end stage renal disease (ESRD) is partly related to the failure of early detection of the pre-clinical stages of the disease and its associated risk factors. This study aimed to determine the prevalence of chronic kidney disease and its associated risk factors in Aiyepe community in Ogun state, south western Nigeria as well as determining the awareness level of the population about CKD. MATERIALS AND METHODS: It was a cross-sectional community-based study involving 456 participants recruited through cluster and simple random sampling techniques.Participants were screened for urinary albumin by dipstick and/or albumin creatinine ratio. Serum creatinine, fasting blood sugar and serum lipid profile were determined while glomerular filtration rate was estimated using Cockroft and Gault formula from serum creatinine. RESULTS: The mean age ± standard deviation (SD) of the study population was 48.09(±15.7) years, and the age range was 18-80 years. Hypertension was seen in 28.9% of studied participants while only 4.2% were diabetic. The mean waist-hip ratio (WHR) of the participants was 0.94(±0.55). The mean BMI of the participants was 26.62(±6.0) kg/m2 with a range of 15.04 to 48.68 kg/m2. The prevalence of overweight and obesity was found to be 24.4% and 30% respectively. The prevalence of proteinuria was 16.3% while 3.7% of the participants had history of haematuria. The prevalence of CKD was 27.6%. Age (OR-1.080, CI-95%, 1.059-1.102), female gender (OR-0.550, CI-95%, 0.320-0.945), BMI (OR-0.832, CI-95%, 0.785-0.882) and dyslipidaemia (OR-1.007, CI-95%, 0.978-1.037) were found to be predictive of CKD in this study. CONCLUSION: The prevalence of CKD and its associated risk factors is high in Aiyepe community in Ogun state, south western Nigeria. If this is true for other rural communities generally, it will pose huge challenges on the available healthcare resources.

Prevlaence of chronic kidney disease markers in Kumbotso rural Northern Nigeria.

BACKGROUND: Data- on the epidemiology of Chronic Kidney Disease (CKD) from sub-SaharanAfrica are sparse. We investigated the prevalence of CKD and its early markers in Kumbotso, a rural community in northern Nigeria. METHODS: A total of 480 individuals were randomly selected from the general population using multistage stratified random sampling. Relevant- demographic and clinical data were obtained using a structured questionnaire. Biological samples (urine and blood) were drawn for relevant investigations. RESULTS: CKD (estimated glomerular filtration rate [eGFR <60 mls/min) was found in 117 participants (26%). Proteinuria was present in 106 persons (23.6%) and haematuria in 7 individuals (1.6%). The most common CKD stage was stage 1 (20%). CKD was associated with hypertension (P=0.002), diabetes (P=0.001), high cholesterol (P=0.030), smoking (P=0.015), increasing BMI (P=0.020), and increasing age (P=0.003). After adjusting for potential confounding with logistic regression modeling we found BMI, family history of hypertension, history of diabetes mellitus and family history of renal disease to be independent predictors of CKD. CONCLUSIONS: Early markers of CKD are common among rural inhabitants of northern Nigeria and this call for concerted efforts towards institution of preventive measures.

Preliminary report of HLA (DNA) typing of Nigerians using sequence-specific primer technique.

AIMS AND OBJECTIVES: This communication is an attempt to present the experience and a preliminary report of results over a one-year period. PATIENTS AND METHODS: From December 2011 to December 2012, a prospective determination of the HLA types of 20 individuals referred to the Tissue Typing Laboratory of the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife was done. These consisted of prospective transplant recipients, their donors, and a migrant pair for kinship determination. DNA was extracted from the client's peripheral blood sample, using the QIAmp Blood DNA Mini kit, (Qiagen). PCR was done using OlerupR low-resolution PCR-SSP typing kit. The PCR product was resolved in 2% agarose gel, and the bands visualised under UV light. The HLA types were determined using provided tables and/or Helmberg software. Data were presented using descriptive statistics whileHLA antigen frequency (AF) was expressed in percentage and gene frequency (GF) was determined using square root method (1-(1-AF)1/2). RESULTS: A total of 20 individuals (13males and 7females) consisting of seven renal transplant recipients and seven prospective donors; a stem cell recipient and three donors and a migrant pair for kinship determination were typed. Age ranged from 4-65 years. 44 HLA alleles were detected, while HLA-A, B, C, DRB1 and DQB1 were 7, 10, 11, 8, 8 alleles respectively. The alleles were heterogeneous in distribution while 6 antigens (HLA-A*02, B*30, C*15, DRB1*03, DRB1*08 and DQB1*06) were having frequencies e"25%. CONCLUSION: This report confirms that DNA-based HLA typing is feasible locally, andit was observed that renal transplantation procedure is the most frequent indication. The HLA antigens observed to have very high frequencies (e"25% frequency) in this population were HLA-A*02, B*30, C*15, DRB1*03, DRB1*08 and DQB1*06. There is a strong need to develop a broad-based HLA data bank for Nigeria to further strengthening her transplantation programmes.

A community study of the prevalence, risk factors and pattern of chronic kidney disease in Osun State, South West Nigeria.

BACKGROUND: Chronic kidney disease (CKD) is a global public health concern. Nigeria, like other African countries has paucity of hard data derived from community based studies. AIMS: We set out to determine the awareness, level of knowledge, prevalence of chronic kidney disease and its associated risk factors in Nigerian community. METHODS: We used a pre-tested structured questionnaire to draw information on sociodemography, knowledge and risk factors of CKD from 468 residents aged ≥ 18 years. Clinical examination, blood glucose, serum creatinine, urinalysis and urinary albumin: creatinine ratio (ACR) was carried out. Glomerular filtration rate (eGFR) was estimated using Modification for Diet in Renal Disease equation. CKD was defined as eGFR < 60 ml/min and/or macroalbuminuria (ACR ≥ 300 mg/g or dipstick proteinuria). RESULTS: A total of 454 residents, mainly farmers, with a mean age of 45.8 ± 19.0 years and M: F ratio of 0.8:1 completed the study. Only 33.7% had heard of kidney disease; the level of knowledge of CKD was adjudged good, fair and poor in 25.5%, 42.2% and 30.6% respectively. There was higher prevalence of CKD in those with poor knowledge (p=0.023). Smoking habit, habitual analgesic intake, alcohol and herbal concoction use was 7%, 20%, 19% and 75% respectively. The prevalence of hypertension was 30%, diabetes mellitus (3.7%), obesity by waist circumference (14.6%) and haematuria (3.1%). Estimated GFR < 60 ml/min was present in 12.3% while macroalbuminuria was present in 8.9%. The overall prevalence of CKD was 18.8%, with CKD stages 1, 2, 3 and 4 accounting for 2.4%, 4.1%, 11.8% and 0.5% respectively. Age (p=0.00; OR 1.09), female gender (p=0.006; OR 4.87), systolic blood pressure P<0.001; OR 1.04) and diabetes (p=0033; OR 15.76) were predictive of CKD. CONCLUSION: The prevalence of CKD and its risk factors are high in this rural community of South Western Nigeria. Majority had moderately impaired kidney function. This underscores the need for primary and secondary preventive programmes.

Calciphylaxis causing digital, gangrene in end stage renal disease: a case report and review.

Calcific uraemic arteriolopathy (CUA), a potentially life-threatening vasculopathy of the skin and subcutaneous tissues is rarely associated with advanced chronic kidney disease (CKD) particularly in patients on haemodialysis. It is more frequently reported in whites than in blacks and commonly accompanies hyperphosphataemia, elevated calcium-phosphate product and marked secondary hyperparathyroidism. We report a rare case of CUA that complicated end stage renal disease secondary to obstructive uropathy in a 68 year old Nigerian. The risk factors for CUA, diagnosis, management and our peculiar limitations were reviewed and discussed.

Effects of combined aerobics and abdominal strengthening exercises on abdominal adiposity in sedentary adults.

BACKGROUND: Excess abdominal adiposity has been associated with increased morbidity and mortality. Though aerobic exercises significantly reduce general adiposity, it has no effect on abdominal adiposity. However the effects of a combination of aerobic and abdominal strengthening exercises on abdominal adiposity are not known. OBJECTIVE: This study was designed to evaluate the effects of a 12-week aerobic and abdominal strengthening exercise programme on abdominal adiposity in sedentary adults. METHODS: A total of 105 consenting sedentary adults participated in this study. They were randomly recruited from the Ibadan metropolis. Participants went through exercise training which included aerobic and abdominal strengthening exercises. Exercise was carried out thrice weekly for 12 consecutive weeks. Abdominal adiposity indices of Waist Circumference (WC), Waist-to-Hip Ratio (WHR), Sum of Abdominal Skinfold (SAS) were measured at baseline, 4th, 8th and 12th weeks. Data were analyzed using descriptive statistics of mean and standard deviation and repeated measures ANOVA at p = 0.05. RESULTS: 74 participants with mean age (34.8 +/- 9.1 yrs) completed the study. At the end of the 12 -week exercise, there was significant reduction in WC (94.8 +/- 10.2 to 89.2 +/- 9.8 cm), WHR (0.89 0.06 to 0.86 +/- 0.05) and SAS (88.9 +/- 10.9 to 77.3+/- 13.5 mm) among the female participants. Within the male participants, there was significant reduction in WC (88.5 +/- 7.4 to 83.8 +/- 4.7 cm), and in SAS (60.1 +/- 8.4 to 54.5 +/- 8.5 mm), but no statistically significant difference was observed in the WHR (0.88 +/- 0.04 to 0.87 +/- 0.06). CONCLUSION: Twelve-week aerobic and abdominal strengthening exercise programme, without caloric restriction, reduced abdominal adiposity in apparently-healthy sedentary adults, hence it is recommended for its beneficial effects on abdominal adiposity.

Iron status and benefit of the use of parenteral iron therapy in pre-dialysis Chronic Kidney disease patients.

AIMS AND OBJECTIVES: Anaemia is a major cardiovascular risk factor in chronic kidney disease (CKD). Treatment and correction of anaemia leads to improvement of cardiovascular status and quality of life of patients with CKD. This interventional open labeled randomised controlled study comparing the effect of intravenous and oral iron therapy in improving red cell indices and iron status in anaemic pre-dialysis Chronic Kidney Disease was carried out to determine iron status in anaemic pre-dialysis CKD patients to assess the benefit of parenteral iron supplementation as against empirical oral iron in CKD patients with iron deficiency. PATIENTS AND METHODS: Sixty consecutive pre-dialysis chronic kidney disease patients attending the renal clinic over a six month period were screened. Forty- one subjects (68.3%) were found to be anaemic and were subsequently studied. RESULTS: The ages of the patients ranged between 19 and 71 years with a mean age of 39 years. The mean serum creatinine and mean creatinine clearance were 201.80 (70.25)?mol/L and 37.90 (± 12.17)ml/minute respectively. The haematocrit concentration was found to correlate inversely with the level of serum creatinine and 56.1% of the anaemic patients had iron deficiency. The mean PCV rise in the intravenous iron group was 2.42 (± 1.98)% and this was statistically significant (p=0.002) while the mean PCV difference was 0.909 (± 0.94)% in the oral iron group. Intravenously administered iron alone permitted anaemia correction in about one-third of these patients without any life threatening adverse drug event. CONCLUSION: Anaemia is very common in the pre-dialysis CKD population and the prevalence of iron deficiency is high. Intravenous iron supplementation is an effective and safe treatment for the anaemia in the pre-dialysis CKD patients. Response to oral iron was poor.

An appraisal of kidney dysfunction and its risk factors in patients with sickle cell disease.

Sickle cell disease (SCD), a genetically inherited disease of blacks, often presents with disabling acute complications which can occasionally be fatal. Its renal manifestations are increasingly being recognized as affected patients now survive to middle and rarely old age. We set out to determine the magnitude of kidney dysfunction in our SCD patient population and evaluate its predictive factors. We reviewed the available case records of SCD patients managed in our hospital. Information on socio-demographic, clinical and laboratory data were retrieved and collated. A total of 374 (99.46%) were reviewed with complete data; the median age was 23 years (range 7-62), while median age at diagnosis of SCD was 4 years (range 0.25-31). 235 patients (68.2%) had no kidney disease while the remaining 139 (37.2%) had proteinuria, hematuria or reduced glomerular filtration rate (GFR) <60 ml/min. The age of patients was a significant predictor of kidney disease (p = 0.002) and correlated with the level of serum creatinine (r = 0.188, p < 0.001), GFR (r = 0.245, p < 0.0001) and the degree of proteinuria (r = 0.174, p = 0.006). Patients with kidney disease had a significantly higher number of crises/hospitalizations (p < 0.001). Seven patients died in all and 4 (57%) of them had end-stage renal disease. We concluded that kidney disease is a common complication of SCD and significantly contributes to mortality. The age of the patients, duration of SCD and frequency of crises/hospitalizations are strong predictors of development of kidney disease.

The pattern, clinical characteristics and outcome of ESRD in Ile-Ife, Nigeria: is there a change in trend?

BACKGROUND: The prevalence of chronic renal failure and End Stage Renal Disease (ESRD) has remained high worldwide and the epidemiology has changed significantly in the last decade in industrialised countries. While there have been significant improvements in these patient's outcomes in developed countries, their state and survival is still appalling in developing countries. OBJECTIVE: To determine the clinical pattern, presentation and management outcomes in our ESRD population over a 19-year period (1989-2007). METHODS: Seven hundred and sixty patients' records were reviewed. Data on major causes, clinical presentation, management and survival were retrieved and collated. Data was analysed using SPSS package version 16. RESULTS: Their ages ranged between 15-90 years (mean ± SD; 39.9±1.67years) with male preponderance (70.3%). Major presenting complaints were body swelling and uraemic symptoms in most studied patients. The predisposing conditions included chronic glomerulonephritis, hypertension, obstructive uropathy and diabetes mellitus. Renal replacement therapy offered included HD in 556(73.2%), Continous Ambulatory Peritoneal Dialysis (CAPD) in only 9(1.2%) patients and renal transplantation in only 7(0.9%). Only 38(6.8%) survived on HD for longer than three months while 7(77.8%) CAPD patients and all transplanted patients survived for between six months and four years (p<0.00001). Median duration of survival after diagnosis for all the patients was 2 weeks (range 0-50 months). CONCLUSION: End stage renal disease is still prevalent with chronic glomerulonephritis and hypertension being the common causes. Prognosis is still grave hence subsidized renal replacement therapy and preventive nephrology should be targeted in such underserved populations.

Effects of intrathecally administered fentanyl on duration of analgesia in patients undergoing spinal anaesthesia for elective caesarean section.

BACKGROUND: Intrathecal opioids have gained popularity in obstetrics; they augment the analgesia produced by local anaesthetic agents. The aim of this study is to determine the duration of analgesia following addition of fentanyl to bupivacaine during elective Caesarean section. METHOD: This is a prospective randomized study comparing the effect of addition of 25 microg of fentanyl to 2.5 mls of 0.5% hyperbaric bupivacaine intrathecally on sixty healthy women of American Society ofAnaesthesiologist (ASA) physical status I scheduled for elective Caesarean section at the UCH, Ibadan. Patients were randomized to group B, n=30 and group FB, n=30. Maternal heart rate, blood pressure, respiratory rate, sensory level, motor block, pain score (NRS) and side effects were observed every 2 minutes for first 15 minutes, then at 5 minutes interval for the remainder of the operation. Thereafter at 30 minutes interval until the first complaint of pain. RESULTS: Complete analgesia (time from injection of intrathecal drug to first report of pain) lasted longer in group FB (240 +/- 29 minutes) than group B (99 +/- 12 minutes) with a p-value of 0.002. The duration of effective analgesia (time from injection of intrathecal drug to first request for analgesic) in group FB (276 +/- 26 minutes) while group B was (121 +/- 10 minutes) with a p-value of 0.001. Both were statistically significant. CONCLUSION: We conclude that the addition of 25 microg of fentanyl to bupivacaine intrathecally for elective Caesarean section increases the duration of complete and effective analgesia thereby reducing the need for early postoperative use of analgesics.

Prevalence and pattern of renal bone disease in end stage renal disease patients in Ile-Ife, Nigeria.

BACKGROUND: Information on renal bone disease (RBD) is sparse in Nigeria. The prevalence of RBD in a dialysis population worldwide ranges between 33% and 67% and it increases with progression of renal insufficiency. OBJECTIVE: To determine the prevalence and magnitude of RBD in patients with end stage renal disease (ESRD). METHODS: Thirty consecutive ESRD patients were recruited. They had thorough clinical evaluation and investigations which included serum calcium, phosphate, alkaline phosphatase, albumin and skeletal survey. The serum iPTH, osteocalcin, and 1,25 (OH2) D3 were assessed in 20 patients. RESULTS: The patients were aged 18-72 years with a mean of 38.93+/-15.7 years. There was a male:female ratio of 4:1. Uraemic symptoms were the major presenting complaints. None of the patients complained of bone pain or fracture. The mean values for serum creatinine, urea, creatinine clearance, calcium, phosphate, albumin, alkaline phosphatase, iPTH, osteocalcin and 1,25 (OH)2 Vit D3 were 1478.96 +/- 771.12 micromol/L, 22.33 +/- 7.42 mmol/L, 3.38 +/-2.22 mls/min, 1.8 +/- 0.5 mmol/L, 1.61 +/- 0.65 mmol/L, 30.2 +/- 6.1 g/L, 124.33 +/- 63.37 IU/L, 22.66 +/- 24.72, 45.14 +/- 43.8, 37.7 +/- 22.3 respectively. There were hypocalcaemia and hyper-phosphataemia in 80% and 60% of the patients respectively. Alkaline phosphatase was elevated in 44% of the patients while 11.8% had hyperparathyroidism. Level of 1,25 (OH)2 Vit D3 was low in 83.3% of the patients. There was a significant negative correlation between serum calcium and iPTH levels (r = -0.915, p=0.029). There was also significant negative correlation between alkaline phosphatase and 1,25 (OH)2 Vit D3 and serum albumin. Radiological evidence of RBD occurred in only 16.7% of the patients. CONCLUSION: Renal bone disease is common in our patients with ESRD associated most commonly with low bone turnover while occurrence of hyperparathyroid bone disease appears low.

Caudal block anesthesia for transrectal prostate biopsy.

OBJECTIVE: Transrectal prostate biopsy is a potentially painful procedure. Our service has significant experience with caudal anesthesia for perianal procedures. This study is aimed to determine the effectiveness of caudal anesthesia for transrectal prostate biopsy. PATIENTS AND METHODS: Seventy consecutive patients undergoing transrectal prostate biopsy were entered into the study. The patients were requested to complete a questionnaire structured to assess the pain felt during the procedure using the visual analog score (VAS). The effectiveness of the caudal anesthesia was determined by the anesthesia of the perineum and the laxity of the anal sphincter. Complications from the procedures were recorded. RESULTS: All the patients completed and returned the questionnaire. The average age of the respondents is 65.8 years. Among the 34 patients with caudal block, effective anesthesia was achieved in 28 patients and ineffective in six patients. However, the mean VAS for the pain from transrectal prostate biopsy was 1.49 +/- 1.93 SD (range 0-6.0) for the patients with effective caudal anesthesia and 8.02 +/- 1.79 SD (range 5.0-10.0) for patients with no caudal anesthesia. There was a reduced requirement for analgesics after prostate biopsy for patients with effective caudal anesthesia. Three patients (8.8%) had minor complications (transient dizziness) following the injection of the anesthetic into the caudal epidural space. CONCLUSION: Satisfactory analgesia for transrectal prostate biopsy can be achieved with the use of CA and it results in better cooperation of the patient during the procedure.

Effect of Spinal Anaesthesia on Hearing Threshold

Background: Hearing loss following spinal anaesthesia is a known yet uncommonly reported complication. This study was aimed at determining the incidence and type of hearing loss (HL) following spinal anaesthesia (SA) and the relationship with the size of spinal needle. Methods: A prospective study of patients scheduled for spinal anaesthesia for surgery at the Operating room and Otorhinolaryngology department in a tertiary centre was undertaken. The audiometry was done and the pre- and post - anaesthesia results were compared.Results: Ninety - four ears of 47 patients; 16 males and 31 females; age range between 21 and 63 years (mean + SD= 41+5) were included. The duration of anaesthesia was between 90 and 150 minutes (mean + SD= 116+9). HL was seen in 9 ears of 7 patients (15) and tinnitus in 14 ears. The preoperative and postoperative BC PTA were 10 - 45dB (mean + SD= 26+ 5) and 25 - 65dB (mean + SD=38+5) respectively; (P= 0.02) while the preoperative and postoperative AC PTA in the early frequency range (0-100Hz) were between 5 - 45dB (mean + SD= 20+ 5) and 25 - 50dB (mean + SD=25+7) respectively; (P= 0.08). There was significant difference in the mean BC PTA between those who had procedure less than 1 hour; 37.2dB and those greater than 1 hour 38.4dB; (P=0.004). According to the Quincke needle sizes; the mean BC PTA among those who had 26G and 27G were 37.4dB and 38.1dB respectively (P=0.2). Conclusion: HL complicating SA is significant and associated with duration of procedure thus should be included in informed consent for medico-legal and ethical reasons and measures must be taken to avoid the leak of cerebrospinal fluid

Which factors actually influence the development and progression of overt nephropathy in Nigerian diabetics?

OBJECTIVE: To determine the risk factors predisposing Nigerian diabetics to overt nephropathy with a view to developing strategies for its prevention. DESIGN: case control study. SETTING: Tertiary care hospital, a major nephrology referral centre in Nigeria. SUBJECTS: 30 diabetic nephropathy (DN) patients and 32 age and sex-matched diabetic patients without nephropathy. MATERIALS AND METHODS: 30 diabetic nephropathy (DN) patients with chronic renal failure who have been diabetic for a minimum of five years and satisfied the inclusion criteria for the study were compared with 32 age and sex-matched diabetic patients without nephropathy. Their socio-demographic parameters, clinical and laboratory profiles were determined and compared. RESULTS were analysed using the statistical package for social sciences version 10. Chi-square test, logistic regression analysis and Spearman's rank correlation coefficient were used, p-value < 0.05 was considered as significant. MAIN OUTCOME MEASURES: The study sought to compare socio-demographic, clinical and biochemical data between diabetic patients with overt nephropathy and those without. RESULTS: Duration of diabetes, blood pressures and blood sugar levels were significantly higher in DN patients than the controls (p < 0.05). A family history of renal disease, socio-economic status, cigarette smoking, body mass index and total serum cholesterol did not distinguish between DN patients from controls (p > 0.05). Systolic blood pressure positively correlated with serum creatinine (r = 0.057, p < 0.001) and duration of DM (r = 0.284, p = 0.02). There was a constellation of clinical features viz: retinopathy, peripheral neuropathy and left ventricular hypertrophy, which were significantly associated with DN (p < 0.05). CONCLUSIONS: Prolonged duration of diabetes, hypertension, retinopathy, and peripheral neuropathy, left ventricular hypertrophy and poor glycaemic control were the major risk factors for overt nephropathy among Nigerian diabetics. Apreventive strategy should include adequate blood pressure and glycaemic control.