COVID-19: Challenges and coping strategies in radiology departments in Nigeria.

Context: COVID-19 came suddenly, bringing to the fore the challenges inherent in the health system. In a developing country, such as Nigeria, which already had myriad problems with funds and equipment in the health sector. Aims: This study aims to examine the challenges encountered by the staff in Radiology facilities and how they combated the challenges. Settings and Design: A descriptive cross-sectional study of radiology facilities in Nigeria. Subjects and Methods: Radiologists from nine government and four private facilities who attended to COVID-19 patients were asked to fill questionnaires on challenges faced and their coping strategies. Responses were sent through E-mail. Statistical Analysis Used: Data from the responses were analyzed using Microsoft excel for Mac 2011 and presented as figures and tables. Results: Majority of the government 7 (77.8%) and private facilities 4 (100%) had no equipment dedicated only to COVID-19 patients. Seven (77.8%) government facilities complained of inadequate staff, poor availability of personal protective equipment (PPEs) 8 (88.9%), and lack of technology for remote viewing 7 (77.8%). Fear of cross-infection was a challenge in one of the facilities 1 (11.1%). Coping strategies adopted include ensuring less traffic in the department by discouraging walk-in patients and canceling non-emergent cases, booking suspected/confirmed cases for lighter times, using old film for face shields and cloth for facemasks, staff education on COVID-19 and preventive measures, and sending reports to physicians through E-mail. Conclusions: There were a lot of challenges during the COVID-19 crisis, with government hospitals experiencing more challenges than private facilities. The challenges included among others inadequate staff strength and lack of technology for remote viewing. Some were overcome using education and by production of facemasks/shields production using recycled materials.

RésuméLe contexte: COVID-19 came suddenly, bringing to the fore the challenges inherent in the health system. Dans un pays en développement, comme Le Nigeria, qui avait déjà une myriade de problèmes de fonds et d'équipements dans le secteur de la santé. Objectifs : Cette étude vise à examiner les défis rencontrés par le personnel des établissements de radiologie et comment ils ont relevé les défis. Paramètres et conception: une section descriptive étude des installations de radiologie au Nigeria. Sujets et méthodes: Radiologues de neuf établissements publics et de quatre établissements privés qui ont participé aux patients COVID-19 ont été invités à remplir des questionnaires sur les défis rencontrés et leurs stratégies d'adaptation. Les réponses ont été envoyées par courrier électronique. Analyse statistique utilisée: Les données des réponses ont été analysées à l'aide de Microsoft Excel pour Mac 2011 et présentées sous forme de figures et de tableaux. Résultats: La majorité des établissements publics 7 (77,8 %) et privés 4 (100 %) ne disposaient d'aucun équipement dédié uniquement aux patients COVID-19. Sept (77,8 %) établissements publics se sont plaints d'un personnel inadéquat, d'une faible disponibilité des équipements de protection individuelle (EPI) 8 (88,9 %), et le manque de technologie pour la visualisation à distance 7 (77,8 %). La peur d'une infection croisée était un défi dans l'un des établissements 1 (11,1 %). Faire faceles stratégies adoptées comprennent la réduction de la circulation dans le service en décourageant les patients sans rendez-vous et en annulant les cas non urgents, en réservant les cas suspects/confirmés pour des périodes plus légères, en utilisant un vieux film pour les écrans faciaux et un tissu pour les masques faciaux, la formation du personnel sur COVID-19 et mesures préventives et l'envoi de rapports aux médecins par courrier électronique. Conclusions: Il y a eu beaucoup de défis pendant la COVID-19 crise, les hôpitaux publics étant confrontés à plus de défis que les établissements privés. Les défis comprenaient entre autres l'insuffisance la force du personnel et le manque de technologie pour la visualisation à distance. Certains ont été surmontés grâce à l'éducation et à la production de masques faciaux/boucliers utilisant des matériaux recyclés. Mots-clés: défis, les stratégies d'adaptation, COVID-19, Nigeria.

Incidence of postpartum urinary retention in a tertiary hospital in Ibadan, Nigeria.

OBJECTIVE: To determine the incidence of postpartum urinary retention (PUR) after vaginal delivery and associated risk factors. METHODS: A total of 250 women were recruited following vaginal delivery at the UCH, Ibadan. Sociodemographic and obstetrical data were collected using a pro forma. Transabdominal ultrasound scan of the urinary bladder was performed 6 hours after delivery to estimate the post-void residual bladder volume (PVRBV) of participants. PVRBV was compared with obstetrical characteristics and labor events. Data collected were analyzed using SPSS 17.0. The level of statistical significance was set at P value less than 0.05. RESULTS: The incidence of PUR was 17.6%. Women with PUR, had longer duration of first stage (591 versus 501 minutes; P = 0.001), and second stage (50 versus 32 minute; P < 0.001) of labor compared with those without PUR. There was evidence that augmentation of labor (P < 0.01), catheterization during labor (P < 0.01), perineal injury (P < 0.01), and episiotomy (P < 0.01) were associated with developing PUR. Also, women with PUR were more likely to experience storage and obstructive urinary symptoms than those without PUR. Resolution of PUR occurred within 24 hours. CONCLUSION: This study showed that postpartum urinary retention is relatively common following vaginal delivery. Awareness of risk factors will increase index of suspicion especially in women with storage and obstructive symptoms.

Household air pollution, ultrasound measurement, fetal biometric parameters and intrauterine growth restriction.

BACKGROUND: Low birthweight, intrauterine growth restriction (IUGR) and perinatal mortality have been associated with air pollution. However, intervention studies that use ultrasound measurements to assess the effects of household air pollution (HAP) on fetal biometric parameters (FBP) are rare. We investigated the effect of a cookstove intervention on FBP and IUGR in a randomized controlled trial (RCT) cohort of HAP-exposed pregnant Nigerian women. METHODS: We recruited 324 women early in the second trimester of pregnancy. Between 16 and 18 weeks, we randomized them to either continue cooking with firewood/kerosene (control group) or receive a CleanCook stove and ethanol fuel (intervention group). We measured fetal biparietal diameter (BPD), head circumference (HC), femur length (FL), abdominal circumference (AC) and ultrasound-estimated fetal weight (U-EFW) in the second and third trimesters. The women were clinically followed up at six regular time points during their pregnancies. Once during the women's second trimester and once during the third, we made 72-h continuous measurements of their personal exposures to particulate matter having aerodynamic diameter < 2.5 µm (PM2.5). We adopted a modified intent-to-treat approach for the analysis. Differences between the intervention and control groups on impact of HAP on fetal growth trajectories were analyzed using mixed effects regression models. RESULTS: There were no significant differences in fetal growth trajectories between the intervention and control groups. CONCLUSIONS: Larger studies in a setting of low ambient air pollution are required to further investigate the effect of transitioning to a cleaner fuel such as ethanol on intrauterine growth. TRIAL REGISTRATION: ClinicalTrials.gov NCT02394574 ; September 2012.

Pediatric radiology as a subspecialty in Nigeria: to be or not to be?

We describe the advent of pediatric radiology in Nigeria and the challenges associated with establishing the subspecialty. Nigeria has very few radiologists with a special interest in pediatric radiology caring for more than 82 million children. One major challenge is the lack of interest in the subspecialty owing to the lack of remuneration when compared with others like interventional radiology. The majority of the radiologists also do not have specialized training in pediatric radiology. With very few children's hospitals, where to work after graduation is also a deterrent for pediatric radiologists. Put simply, Nigeria needs help. We also suggest ways to overcome these challenges.

Where COVID-19 testing is challenging: a case series highlighting the role of thoracic imaging in resolving management dilemma posed by unusual presentation.

The COVID-19 pandemic remains an evolving disease posing a challenge of incomplete understanding escalated by random atypical clinical presentations. Numerous challenges still exist with accessibility and availability of standard COVID-19 viral testing using real-time Polymerase Chain Reaction (RT-PCR), in low- and middle-income countries, especially in several hospital settings. The clinical information of three select patients at a major health facility in Southwestern Nigeria with unusual COVID-19 clinical presentation and clinical management dilemma related to challenges with COVID-19 viral laboratory testing, were retrospectively reviewed. The medical history in all three cases closely mimicked that of other medical conditions because of assumptions created by red herrings like an acute exacerbation of an underlying non-communicable disease (diaphragmatic eventration) in case 1, re-activation of a previously treated lung condition (tuberculosis) in case 2 and a sequalae of a previously diagnosed but poorly-managed chronic non-communicable disease (decompensated hypertensive heart disease). Also, viral testing was challenging in all cases due to reasons ranging from late turn-around time to inconsistent results. However, thoracic imaging was employed in all cases to heighten suspicion of COVID-19 infection, resolve management dilemma and limit intra-hospital spread. Thoracic imaging can play a major role within hospital settings in low-and middle-income countries in resolving diagnostic challenges of atypical COVID-19 clinical presentations, raising suspicion for early institution of intra-hospital disease containment measures, limiting exposure among hospital staff and guiding clinical case management of COVID-19; especially where challenges with confirmatory viral testing remain persistent.

The use of uterine artery doppler indices for prediction of pre-eclampsia in Port-Harcourt, Nigeria.

CONTEXT: Pre-eclampsia (PrE), a clinical syndrome characterised by elevated blood pressure arising after 20 weeks of gestation, is a leading cause of maternal death worldwide. We evaluated the role of uterine artery Doppler (UtAD) in screening for PrE among unselected, pregnant women. METHODOLOGY: This was a prospective cohort study of 170 healthy gravid women between 18 and 26 weeks of gestation recruited consecutively from the Antenatal Clinic of Braithwaite Memorial Specialist Hospital, Port-Harcourt, Nigeria, between July 2016 and June 2017. All had UtAD scans with an abnormal result defined as pulsatility index (PI), resistance index or systolic/diastolic (S/D) ratio >95th centile for gestational age or proto-diastolic notching. Outcome was obtained from antenatal records. Data were analysed using Statistical Package for Social Sciences, version 20 at statistical significance level of P < 0.05. RESULTS: The prevalence of PrE was 7.6%. There was significant association between an abnormal PI (χ2 = 16.29, P = 0.00), S/D ratio (χ2 = 8.55, P = 0.00) and the combined result (χ2 = 11.5, P = 0.007) with subsequent PrE. The highest sensitivity (53.8%) was obtained for the combined result with specificity, negative predictive value (NPV) and positive predictive value of 86.6%, 95.8% and 25%, respectively, area under the curve (AUC) of 0.71 (95% confidence interval [CI]: 0.534-0.871). A normal result had a very high NPV for all indices. The accuracy for the prediction of severe PrE was greater for all indices being highest for the combined result AUC of 0.830 (95% CI: 0.624-1.000; P = 0.01). CONCLUSION: Abnormal UtAD indices were associated with PrE and may be used in PrE screening.

Role of computed tomography scan in assessment of skull fracture patterns among motorcycle road traffic accident patients in South Western Nigeria

Background: Commercial motorcycling is a common means of transportation in Nigeria, and motorcycle road traffic accidents (MCRTAs) are commonly associated with multiple skull fractures. Cranial computed tomography (CT) scan is the standard imaging modality of patients with head injury. Aim: The aim of this study is to describe the pattern of skull fractures on cranial CT scan in patients with head injury following MCRTA. Patients and Methods: This was a descriptive cross-sectional study conducted at the University College Hospital, Ibadan, between June and October 2016. Noncontrast cranial CT scan was performed on 190 patients who presented with head injury following MCRTAs. Results: Over half (n = 59.8%) of the patients were within the ages of 20­39 years with a mean age of 33 ± 14.37 years. A total of 183 patients did not use crash helmet at the time of accident, out of which 168 (n = 88.4%) sustained skull fractures. Six different skull fracture patterns were identified on cranial CT scan of these patients. The most common fracture pattern seen was the combined calvarial, facial, and base of skull fractures representing 22.1% while the least fracture pattern was the base of skull fracture (n = 4.7%). Most of the patients with calvarial fractures were without helmet at the time of injury (n = 98.3%) compared to 1.7% of patients who wore helmet at the time of injury. This was statistically significant (P = 0.040). Conclusion: This study further underscores the usefulness of cranial CT scan in identifying and evaluating patients with skull fractures following MCRTA in our environment, thus guiding proper medical and surgical management of such patients in a low-resource setting

Comparison between testicular volumes as measured with prader orchidometer and ultrasonography in Healthy Nigerian Newborns.

BACKGROUND: We compared the testicular volume (TV) measured with Prader orchidometer (PO) to the volume measured with ultrasonography in male neonates and their relationships with some selected neonatal characteristics. SUBJECTS AND METHODS: A cross-sectional study of all term male neonates who had clinical examination of their external genitalia performed and TV was measured using PO and ultrasonography. Information about the gestational age, birth weight, and birth length was also recorded to determine their relationships with TV measured. RESULTS: The mean TV measured with PO was 1.06 (standard deviation [SD] ± 0.24) ml for both sides. With ultrasonography, the mean left TV was 0.273 (SD ± 0.081) ml and the mean right TV was 0.272 (SD ± 0.079) ml. There were significant correlations between TV using both methods with the birth weight and length. CONCLUSION: TV measured with the two methods was comparable and correlates well with their birth weight and birth length.

Magnetic resonance imaging pattern of congenital brain anomalies in the neurosurgery department of a teaching hospital in Nigeria: An initial experience

Context: Congenital brain anomalies are of diverse types however few are seen in clinical practice. They are associated with high morbidity and mortality; prompt diagnosis and management aid in mitigating some of their adverse effects. Magnetic resonance imaging (MRI) is ideal for imaging these conditions, especially in pediatric cases due to its lack of ionizing radiation and excellent soft-tissue delineation. Not much literature exists for Nigeria due to challenges with statistics and record keeping. Aim: The aim of this study is to document the common congenital brain anomalies encountered using MRI in our environment. Settings and Design: A 5-year retrospective study of all pediatric brain MRI conducted and reviewed in Lagos University Teaching Hospital. 73 pediatric brain MRI scans were reviewed. Materials and Methods: Morphologic evaluation of all pediatric brain MRI conducted in the last 5 years (March 2012­February 2016) was reviewed, retrospectively, by three independent radiologists. Clinical presentations were also documented. Statistical Analysis Used: Descriptive statistics was done using SPSS: PASW Statistics for Windows, Version 18.0 Results: Seventy-three pediatric brain MRI scans were conducted in the last 5 years with congenital brain anomalies seen in 19 (26.0%) of the cases. Their ages ranged from 3 months to 17 years with a mean age of 6.7 ± 6.1 years. There were 9 (47.4%) males and 10 (52.6%) females. The common anomalies are congenital hydrocephalus 7 (35%), of which aqueductal stenosis was 6 (32%), arteriovenous malformations 3 (16%), cerebral atrophy 3 (16%), and arachnoid cysts 2 (11%). Predominant clinical features were delayed developmental milestones, macrocephaly, seizures, headaches, and vomiting. Conclusion: The common congenital brain anomalies in our environment are congenital hydrocephalus, aqueductal stenosis, arteriovenous malformations, cerebral atrophy and arachnoid cysts. MRI is useful in evaluating these anomalies; early diagnosis and prompt intervention can be offered to mitigate adverse effects

Unusual presentations of child abuse: A report of two cases and the role of imaging.

Insufficient attention has been paid to child abuse in Nigeria, where corporal punishment is still acceptable both at home and in the wider public including schools. This is notlimited to the parents; these punitive measures can also be undertaken by the extended family, caregivers, and neighbors. Mild to extreme force is allowed particularly when the crime involves tarnishing the family image. We hereby report two cases of extreme discipline that can be termed as a form of child abuse to draw the attention of clinicians and radiologists to other possible findings aside from those already reported in literature.

Electroencephalography as a tool for evidence-based diagnosis and improved outcomes in children with epilepsy in a resource-poor setting.

INTRODUCTION: Electroencephalography (EEG) remains the most important investigative modality in the diagnostic evaluation of individuals with epilepsy. Children living with epilepsy in the developing world are faced with challenges of lack of access to appropriate diagnostic evaluation and a high risk of misdiagnosis and inappropriate therapy. We appraised EEG studies in a cohort of Nigerian children with epilepsy seen in a tertiary center in order to evaluate access to and the impact of EEG in the diagnostic evaluation of the cases. METHODS: Inter-ictal EEG was requested in all cases of pediatric epilepsy seen at the pediatric neurology clinic of the University College Hospital, Ibadan, Nigeria over a period of 18 months. Clinical diagnosis without EEG evaluation was compared with the final diagnosis post- EEG evaluation. RESULTS: A total of 329 EEGs were recorded in 329 children, aged 3 months to 16 years, median 61.0 months. Clinical evaluation pre-EEG classified 69.3% of the epilepsies as generalized. The a posteriori EEG evaluations showed a considerably higher proportion of localization-related epilepsies (33.6%). The final evaluation post EEG showed a 21% reduction in the proportion of cases labeled as generalized epilepsy and a 55% increase in cases of localization-related epilepsy(p<0.001). CONCLUSION: Here we show that there is a high risk of misdiagnosis and therefore the use of inappropriate therapies in children with epilepsy in the absence of EEG evaluation. The implications of our findings in the resource-poor country scenario are key for reducing the burden of care and cost of epilepsy treatment on both the caregivers and the already overloaded tertiary care services.

Renal Doppler Indices in Children with Nephrotic Syndrome: Findings from a Tertiary Hospital in Nigeria.

The resistive and pulsatility indices are known tools for assessing renal function in kidney diseases, especially in proteinuric conditions like Paediatric Nephrotic syndrome (NS) which is a glomerular disease. However, there is a limited knowledge in the use of Doppler Resistive and pulsatility indices in the management of this disease condition. This was a case control study involving 53 cases and 57 controls. The Doppler parameters, resistive index (RI) and pulsatility index (PI) of the renal interlobar arteries were determined for the upper, middle, and lower poles bilaterally for both controls and cases. The mean RI on the right and left were 0.59 ± 0.06 and 0.58 ± 0.06 respectively for the NS cases whereas for the controls it was 0.61 ± 0.05 and 0.60 ± 0.04 on the right and left respectively. The mean PI on the right and left measured 0.96 ± 0.16 and 0.94 ± 0.15 respectively for the NS cases while that for the control cases measured 0.98 ± 0.13.and 0.95 ± 0.12 on the right and left respectively. Although, the interlobar arteries mean RIs were generally less than that for the controls, but only the left middle pole showed statistically significant mean difference (p= 0.004). There was also statistically significant mean difference (p= 0.048) between the cases and controls in the left middle pole PI. However, no correlation was found when the renal RI and PI are compared with the serum albumin and creatinine. Although there was no statistical significance between the mean RI and PI of the NS cases and controls, except in the left middle pole RI, it is recommended that Doppler ultrasound should still be part of management of Nephrotic syndrome patients especially those who have developed end stage renal disease in order to monitor their renal function.

Cranial magnetic resonance imaging findings in kwashiorkor.

Protein energy malnutrition (PEM) is an important public health problem in the developing countries, although it is becoming uncommon in South West Nigeria. Cerebral changes have been associated with severe PEM. This study evaluated the neurological changes using Magnetic Resonance Imaging (MRI) in Ibadan south west Nigeria. The 5 children evaluated had a median age of 16 months and all the children had brain changes compatible with cerebral atrophy. In addition two of the children had periventricular white matter changes, while one these two had mega cisterna magna in addition. Though this study did not re-evaluate the brains of these children after nutritional rehabilitation, it is possible that changes are reversible as demonstrated in earlier studies.