Disseminated Tuberculosis in a Nigerian Adolescent with Linear IgA Bullous Dermatosis: A Case Report and Review of Literature.

Linear IgA bullous dermatosis (LABD) is an auto-immune disease affecting young children and adults, characterized by the linear deposition of IgA at the basement membrane zone with resultant complement activation and a cascade of immune reactions. There is a loss of adhesion at the dermo-epidermal junction and subsequent blister formation. It is a rare disease that has a good prognosis with adequate therapy. However, the underlying depressed immunity associated with the disease may expose them to such infections as tuberculosis. We report the case of an 11-years-old Nigerian female adolescent with LABD, diagnosed at the age of four years but defaulted on follow-up, who developed disseminated tuberculosis (pulmonary, lymph nodes, abdominal and pericardial effusion) seven years after the appearance of the initial blistering skin lesions. She commenced anti-tuberculosis drugs, steroids, and a tube pericardiostomy for the pericardial effusion. Dapsone was initiated for the LABD during the continuation phase of anti-tuberculosis therapy, with subsequent disappearance of the skin rash within two weeks.

La dermatose bulleuse linéaire à IgA (DBL) est une maladie auto-immune affectant les jeunes enfants et les adultes, caractérisée par le dépôt linéaire d'IgA dans la zone de la membrane basale, avec l'activation du complément qui en résulte et une cascade de réactions immunitaires. Il y a une perte d'adhérence à la jonction dermo-épidermique et une formation ultérieure de vésicules. C'est une maladie rare qui a un bon pronostic avec un traitement adéquat. Cependant, l'immunité déprimée sous-jacente associée à la maladie peut les exposer à des infections telles que la tuberculose. Nous rapportons le cas d'une adolescente nigériane de 11 ans atteinte de la LABD, diagnostiquée à l'âge de quatre ans mais en défaut de suivi, qui a développé une tuberculose disséminée (pulmonaire, ganglions lymphatiques, épanchement abdominal et péricardique) sept ans après l'apparition des lésions cutanées vésiculeuses initiales. Elle a commencé à recevoir des médicaments antituberculeux, des stéroïdes et une péricardiostomie par sonde pour l'épanchement péricardique. La dapsone a été initiée pour la DLB pendant la phase de continuation du traitement antituberculeux, avec une disparition de l'éruption cutanée en deux semaines. Mots clés: IgA linéaire, dermatose bulleuse, tuberculose disséminée, adolescent.

Interventions for improving attraction and retention of health workers in rural and underserved areas: a systematic review of systematic reviews.

BACKGROUND: Global health workforce shortages exist with disparities in the skill mix and distribution of health workers. Rural and underserved populations are often disadvantaged in terms of access to health care. METHODS: This systematic review summarized all systematic reviews that assessed interventions for improving attraction and retention of health workers in rural and underserved areas. We systematically searched selected electronic databases up to 31 March 2020. The authors independently screened the reviews, extracted data and assessed the certainty of evidence using GRADE. Review quality was assessed using the ROBIS tool. RESULTS: There was a paucity of evidence for the effectiveness of the various interventions. Regulatory measures were able to attract health workers to rural and underserved areas, particularly when obligations were attached to incentives. However, health workers were likely to relocate from these areas once their obligations were completed. Recruiting rural students and rural placements improved attraction and retention although most studies were without control groups, which made conclusions on effectiveness difficult. CONCLUSIONS: Cost-effective utilization of limited resources and the adoption and implementation of evidence-based health workforce policies and interventions that are tailored to meet national health system contexts and needs are essential.

Recurrent pericardial effusion associated with hypothyroidism in Down Syndrome: a case report.

BACKGROUND: The complex of Down Syndrome-hypothyroidism-pericardial effusion is largely unreported in sub-Sahara. OBJECTIVE: To present and highlight an unusual manifestation of hypothyroidism. METHODS: A 16-year-old girl with confirmed Down Syndrome presented with complaints of generalised body swelling of eight months' duration. Her work-up consisted of full clinical and laboratory evaluation including ECG and echocardiography. RESULTS: The patient was diagnosed of Down's Syndrome at birth but was lost to follow-up after at eight years of age. Body swelling was associated with clinical features of heart failure. Echocardiography showed massive pericardial effusion. Serum l-thyroxine was less than 0.5mg/dl and TSH >40iu/l. The heart failure and menstrual irregularities responded to l-thyroxine therapy. CONCLUSION: This appears to be the first report of the complex of Down syndrome, hypothyroidism and pericardial effusion in a Nigerian child. Thyroid function test is therefore recommended as a part of baseline investigation for Nigerian children with Down syndrome as is the practice.

Assessing the Patient Safety Culture in Dentistry.

OBJECTIVES: Medical errors are among the leading causes of death within the United States. Studies have shown that patients can be harmed while receiving care, sometimes resulting in permanent injury or, in extreme cases, death. To reduce the risk of patient safety incidents, it is imperative that a robust culture of safety be established. The primary objective of this study was to evaluate the patient safety culture among providers at 4 US dental institutions, comparing the results with their medical counterparts in 2016. METHODS: This cross-sectional study uses the Medical Office Survey on Patient Safety Culture that was modified for dentistry and administered at 4 US dental institutions during the 2016 calendar year. All dental team members were invited to complete electronic or paper-based versions of the questionnaire. RESULTS: Among 1,615 invited participants, 656 providers responded (rate, 40.6%). Medical institutions outperformed the dental institutions on 9 of the 10 safety culture dimensions, 6 of the 6 overall quality items, and 8 of the 9 patient safety and quality issues. The surveyed dental institutions reported the strongest average percentage positive scores in organizational learning (85%) and teamwork (79%). CONCLUSION: These findings suggest that the patient safety culture progressed over time. However, there is still heterogeneity within safety culture among academic dental, private (nonacademic), and medical clinics. KNOWLEDGE TRANSFER STATEMENT: Patient safety is the first dimension of quality improvement. Administering the Medical Office Survey on Patient Safety Culture within dental clinics represents a key measure to understand where improvements can be made with respect to patient care safety.

Finding Dental Harm to Patients through Electronic Health Record-Based Triggers.

BACKGROUND: Patients may be inadvertently harmed while undergoing dental treatments. To improve care, we must first determine the types and frequency of harms that patients experience, but identifying cases of harm is not always straightforward for dental practices. Mining data from electronic health records is a promising means of efficiently detecting possible adverse events (AEs). METHODS: We developed 7 electronic triggers (electronic health record based) to flag patient charts that contain distinct events common to AEs. These electronic charts were then manually reviewed to identify AEs. RESULTS: Of the 1,885 charts reviewed, 16.2% contained an AE. The positive predictive value of the triggers ranged from a high of 0.23 for the 2 best-performing triggers (failed implants and postsurgical complications) to 0.09 for the lowest-performing triggers. The most common types of AEs found were pain (27.5%), hard tissue (14.8%), soft tissue (14.8%), and nerve injuries (13.3%). Most AEs were classified as temporary harm (89.2%). Permanent harm was present in 9.6% of the AEs, and 1.2% required transfer to an emergency room. CONCLUSION: By developing these triggers and a process to identify harm, we can now start measuring AEs, which is the first step to mitigating harm in the future. KNOWLEDGE TRANSFER STATEMENT: A retrospective review of patients' health records is a useful approach for systematically identifying and measuring harm. Rather than random chart reviews, electronic health record-based dental trigger tools are an effective approach for practices to identify patient harm. Measurement is one of the first steps in improving the safety and quality of care delivered.

Utilization and Validity of the Dental Diagnostic System over Time in Academic and Private Practice.

INTRODUCTION: To fill the void created by insufficient dental terminologies, a multi-institutional workgroup was formed among members of the Consortium for Oral Health Research and Informatics to develop the Dental Diagnostic System (DDS) in 2009. The adoption of dental diagnosis terminologies by providers must be accompanied by rigorous usability and validity assessments to ensure their effectiveness in practice. OBJECTIVES: The primary objective of this study was to describe the utilization and correct use of the DDS over a 4-y period. METHODS: Electronic health record data were amassed from 2013 to 2016 where diagnostic terms and Current Dental Terminology procedure code pairs were adjudicated by calibrated dentists. With the resultant data, we report on the 4-y utilization and validity of the DDS at 5 dental institutions. Utilization refers to the proportion of instances that diagnoses are documented in a structured format, and validity is defined as the frequency of valid pairs divided by the number of all treatment codes entered. RESULTS: Nearly 10 million procedures ( n = 9,946,975) were documented at the 5 participating institutions between 2013 and 2016. There was a 1.5-fold increase in the number of unique diagnoses documented during the 4-y period. The utilization and validity proportions of the DDS had statistically significant increases from 2013 to 2016 ( P < 0.0001). Academic dental sites were more likely to document diagnoses associated with orthodontic and restorative procedures, while the private dental site was equally likely to document diagnoses associated with all procedures. Overall, the private dental site had significantly higher utilization and validity proportions than the academic dental sites. CONCLUSION: The results demonstrate an improvement in utilization and validity of the DDS terminology over time. These findings also yield insight into the factors that influence the usability, adoption, and validity of dental terminologies, raising the need for more focused training of dental students. KNOWLEDGE TRANSFER STATEMENT: Ensuring that providers use standardized methods for documentation of diagnoses represents a challenge within dentistry. The results of this study can be used by clinicians when evaluating the utility of diagnostic terminologies embedded within the electronic health record.

Blood loss at fibroids surgery: myomectomy versus total abdominal hysterectomy.

Two hundred and fifty patients with uterine fibroids were reviewed to compare operative outcomes and blood loss.

Frequency of MNSs blood groups in south eastern Nigeria.

A total of 614 inhabitants of Calabar, south eastern Nigeria were tested with anti-M, anti-N and anti-S sera to determine the frequency of MNSs blood groups in that population. The results showed that neither ABO blood group nor sex has influence on the occurrence of MNSs blood groups in the population. It was also observed that whereas S antigen was more frequently associated with M antigen, s associated more frequently with N antigen. One half of the Su antigen occurred with MN phenotype. Significantly, the Su antigen occurred in 94% of the male subjects.

Haemoglobin C gene in south eastern Nigeria.

Haemoglobin C (Hb C) is very rare in eastern Nigeria (east of River Niger). Isolated cases have been reported. The incidence is however as high as 6% in western Nigeria. This study was undertaken to locate the isolated cases with a view to determining their origin. Hb electrophoresis was performed on 4,263 subjects in Akwa Ibom State in south eastern region of Nigeria. The subjects were selected from all the local government areas of the state and were aged 15 years and above. They comprised secondary school children, civil servants, farmers and fishermen. The results revealed complete absence of Hb C from the upland population whereas this was present in the fishing settlement population (6 or 0.4% Hb AC and one or 0.07% Hb SC subjects). The possible entry points of Hb C gene into south eastern Nigeria is discussed.

Comparison of the thermal properties of clay samples as potential walling material for naturally cooled building design.

The thermal properties of different clay samples obtained from locations in Akwa Ibom State, Nigeria were investigated and compared, and in order to establish their suitability as building material from energy conservation point of view. The results showed that stoneware clay has the highest solar radiation absorptivity of 22.32 m(-1) while kaolin clay has the lowest radiation absoptivity of 14.46 m(-1). A model for the prediction of temperature variation with thickness of the samples was developed. Results showed that kaolin would make the best choice for the design of a naturally cooled building.

Socioeconomic constraints to effective management of Burkitt's lymphoma in south-eastern Nigeria.

This paper presents health outcomes and associated socioeconomic factors of 41 children admitted to a tertiary care institution in south-east Nigeria with Burkitt's lymphoma (BL) between 1987 and 2004. BL responds well to chemotherapy and does not pose a significant threat to health in industrialized nations. However, in resource-poor settings where it is endemic, socioeconomic factors significantly affect access to care for affected children, making this readily treatable condition a cause of considerable distress and early death in affected children. Half of the children reported in this paper presented with late stage disease. Although laboratory facilities were available, they were not accessible to all the children. Nearly a quarter of parents of these children could not afford the cost of confirmatory tests, and about a fifth (n = 8; 19.5%) of the children received no chemotherapy because of their parents' inability to pay. Only 21 of 41 children (51.2%) remained on treatment long enough (at least 12 weeks) to enable them to be confirmed either as short-term cure (n = 9; 64.3%), or as early relapse (n = 2; 4.9%). Owing to financial constraint, 13 of the parents (31.7%) withdrew their children against medical advice (n = 7; 17.1%) or left the hospital (n = 6; 14.6%). To address the challenge posed by these factors, we call for the establishment of a regional BL programme in Africa to help establish a critical mass of resources (human and material) to facilitate the development of an effective and accessible control programme in the region.

Determinants of pain perception in labour among parturients at the University College Hospital, Ibadan.

This cross-sectional study of one thousand parturients aims to evaluate the factors, which are associated with pain perception in labour and to identify women who will benefit most from analgesia in labour. The instrument applied was a structured questionnaire incorporating the Box numerical scale (BNS) for pain assessment. Patients who delivered by elective or emergency caesarean section and women who did not give informed consent were excluded from the study. Spearman's and Pearson's correlational analyses were applied. Pain scores showed significant correlation with age (r=- 0.087, p<0.01), parity (r=- 0.226, p<0.01), gestational age at delivery (r=- 0.074, p<0.05), onset of labour (rho=0.195, p<0.01), mode of delivery (rho=0.160, p<0.01), booking status (rho=- 0.070, p<0.05) and educational status (rho=0.182, p<0.01). Certain groups of patients would benefit from obstetric analgesia. These patients include, nulliparous patients, young patients, patients who have had labour induced, those with preterm deliveries and those with an assisted vaginal delivery especially if they are well educated.

Attitudes of patients to obstetric analgesia at the University College Hospital, Ibadan, Nigeria.

Pain relief, for different reasons, is controversial worldwide. We designed this study to assess the level of awareness of antenatal patients to analgesia in labour and to evaluate the effect of age, parity and educational status on the awareness and acceptability of pain relief in labour. A structured questionnaire was administered to 1,000 antenatal patients between 1 June 2000 and 31 May 2001. Spearman's correlation coefficient was applied to estimate the correlation between the ranked dependent variable (awareness and acceptability) and age, parity and educational status (independent variables). Awareness of pain relief methods was seen in only 27.1%. The most common method known was the use of systemic opioids (80%); only 10% were aware of epidural analgesia and about 14% knew of inhalational analgesia. Acceptance of methods was, however, 57.6%. The most common reason for non-acceptance was that 'The pain of labour is natural' in 76.5%, 12% feared complications to the baby and 25% gave other reasons. Age, parity and educational status did not affect awareness. Educational status had positive correlation (rho = 0.13, P < 0.05) with acceptance while age had a negative correlation (rho = -0.124, P<0.05). Awareness of obstetric analgesia is still relatively low in this environment; however, a high proportion of patients would accept analgesia in labour if offered.

A neutral glycoprotease of Pasteurella haemolytica A1 specifically cleaves O-sialoglycoproteins.

A neutral metalloprotease with marked specificity for an O-sialoglycoprotein has been isolated from culture supernatants of Pasteurella haemolytica A1. The 35-kDa enzyme cleaves human erythrocyte glycophorin A, which is O glycosylated, but does not cleave N-glycosylated proteins or nonglycosylated proteins. Glycophorin A was cleaved when it was present in situ in erythrocyte ghost plasma membranes or when it was free in solution. The glycoprotease did not hydrolyze glycophorin A from which sialate residues had been removed by neuraminidase treatment. An immobilized preparation of the enzyme cleaved glycophorin A at several positions, with a major site of cleavage at Arg-31-Asp-32. The glycoprotease is inhibited by EDTA, citrate, and ascorbate, but inhibition appears to be due to the masking of metal ion activators rather than to their removal. The enzyme is not inhibited by phosphoramidon, an inhibitor of other bacterial neutral metalloproteases.

Pattern of chloroquine-induced pruritus in antenatal patients at the University College Hospital, Ibadan.

The importance of Malaria, especially in pregnancy, cannot be over-emphasised. A major determinant of compliance with treatment in this environment is the pruritus chloroquine induces when ingested. This cross-sectional study of 200 antenatal patients was aimed at obtaining the pattern of the pruritus in antenatal patients. The prevalence of chloroquine-induced pruritus was 64.5%; 76.3% of the patients experienced the itching within 24 hours of ingestion of the drug and 60% of the patients still use the drug in spite of the itching for various reasons. Among the indices of severity, the frequency of itching with chloroquine use was the only factor that correlated with continuation of use (P < 0.01).