Adherence to Immunosuppressive Medications in Kidney Transplant Patients at Three Centers in Khartoum State, Sudan: A Cross-sectional Hospital Study

Background: Graft survival post-kidney transplantation is of paramount importance to patients and nephrologists. Nonadherence to immunosuppressive therapy can be associated with deterioration of renal function and graft rejection. This study aimed to evaluate the adherence to immunosuppressive medications in kidney transplant patients at three centers in Khartoum, Sudan. Methods: In this descriptive cross-sectional hospital-based survey, 277 post-kidneytransplant patients were recruited. Data were collected using a questionnaire and analyzed using the SPSS v.23. Our scoring method was calculated based on Morisky Medication Adherence Scale (MMAS-8) related to immunosuppressive medications and was expressed as questions in the questionnaire; every correct answer was given one mark, then the marks were gathered and their summation was expressed. Results: Overall, 33% ,45%, and 22% of the studied participants reported high, medium, and low adherence, respectively. The major factor for nonadherence was forgetfulness affecting 36.1% of those who did not adhere. The cost of the immunosuppressive medications did not negatively affect any of the participants' adherence (100%). However, a significant association was seen between adherence and occupational status, duration of transplantation, shortage of immunosuppressants, recognizing the name of immunosuppressant, side effect, and forgetfulness (P-values = 0.002, 0.01, 0.006 , 0.000, 0.022, and 0.000, respectively). Logistic regression analysis showed a significant association with occupational status, side effects, and forgetfulness.

Evaluation of limberg rhomboid flap technique for sacrococygeal pilonidal sinus surgery

This study aims to determine advantages, disadvantages, and long-term results of rhomboid excision and Limberg flap procedure for sacrococygeal pilonidal sinus repair using either general or spinal anesthesia. A prospective randomized study involved 40 patients with sacrococygeal pilonidal sinus disease scheduled for elective pilonidal sinus excision using the Limberg rhomboid flap technique. The patients were asked about their complaints and choice of treatment. Physical examination was performed, and hospital records were reviewed. The 40 patients were randomized into two equal groups: group G, general anesthesia, with endotracheal intubation and group S, spinal anesthesia, who got 2.5 ml of 0.5% heavy marcaine with 25 micro g fentanyl subarachnoid injection, Total operating room time, time from entry into theatre till readiness for surgery, duration of surgery, time from end of surgery till shift to recovery room, recovery room time, onset of pain, analgesic use in recovery room, in the ward and at home, patients satisfaction, hospital stay and time taken to return to normal activity were compared. Perioperatfve side effects, wound healing and surgical complications were recorded. P <0.05 is considered statistically significant. All patients were satisfied with the final surgical results except 3 cases in group G who got seroma with negative bacterial culture and 2 cases in group S; 1 partial wound dehiscence and 1 purulent discharge. $o recurrent cases were recorded over the period of two years follow up. Time of hospital stay and time taken to return to normal activity were comparable in both groups; P > 0.05, Total operating room time and time from end of surgery till shift to recovery room were less in group S; P<0.05. However, time spent in recovery room was less in group G; P <0.05. Group S patients complained of pain after a longer period of time and required less analgesics in the first 24 postoperative hours; P<0.05. Patients were more satisfied with anesthesia in group S; P < 0.05. Anesthetic problems in group G included 2 laryngeal spasm, 3 nausea/vomiting, 1 respiratory depression, and 4 sore throat cases. On the other hand, group S problems included 1 pruritis and 1 urine retention cases. Rhomboid excision and Limberg flap procedure for managing sacrococcygeal pilonidal sinus has a low complication rate, short hospital stay, short time to return to normal activity and good long-term results. The procedure is proved to be safe whether done under general or spinal anesthesia. However, spinal anesthesia using 2.5 ml 0.5% heavy marcaine and 25 micro g fentanyl ensures less operating room time, better patient anesthesia satisfaction and prolonged postoperative analgesia. General and spinal anesthesia were proved to be safe in prone position if required precautions are followed

Fast-track laparoscopic cholecystectomy ensures surgical and anesthetic safety

This study looks at the anesthetic and surgical safety of fast-track day case laparoscopic cholecystectomy [LC] when bispectral index [BIS] guided desflurane, sevoflurane or propofol are combined with remifentanil. Times of recovery, return of early and late cognitive functions as well as complications for the first 7 postoperative days are compared. The study involved 75 patients who underwent elective laparoscopic cholecystectomy scheduled on day-case basis. The patients were divided into three groups [25 cases each]: desflurane/remifentanil [group D], sevoflurane/remifentanil [group S] and propofol/remifentanil [group P]. All patients received midazolam, dexamethazone and ondansetrone premedication. Anesthesia was induced with remifentanil, propofol and cis-atracurium. Infusions of cisatracurium and remifentanil were continued in all patients. Bispectral index [BIS] was kept between 40-50 to guide desflurane, sevoflurane or propofol. IV paracetamol [Perfalgan] register and pethidine and local bupivacaine were used for analgesia. The selection criteria were an American Society of Anesthesiologists [ASA] grade I, low risk of common bile duct stones, adult company at home, and residence within 10km of the hospital with easy transfer. Cases with history of allergy to the used anesthetic agents or psychiatric history, also cases with history of jaundice or history of biliary pancreatitis were excluded. The LC procedure was performed using a standard four-canula technique. Early and late recovery times, the incidence of postoperative nausea and vomiting, pain, shivering and additional use of antiemetic and anti-shivering were documented. Follow up of patients were done to record hospital admission, readmission, visit to accident and emergency department and surgical problems. The patients were between 35 and 50 years of age and the male to female ratio was 12:63. The mean length of the operation was 45 +/- 16 min. Early and late recovery times were faster in [group D] than [group P] and [group S]. Postoperative nausea, vomiting, shivering and pain did not differ significantly between the three groups. There was no hospital mortality and only one patient needed open cholecystectomy. 63 [84%] of the 75 patients went home on the same operative day, while 12 [16%] were admitted overnight. Causes of admission included social reasons [4 cases], surgeon preference [3 cases], pain and nausea [4 cases] with no significant differences between the three groups. One case was converted to open cholecystectomy in [group S] and was also admitted. For selected patients, fast track day-case LC using remifentanil with BIS guided desflurane, sevoflurane or propofol ensures safe operative and postoperative course. Recovery was earlier in desflurane in comparison to the other two groups

Evaluation of a new technique for Macintosh oral intubation

Laryngoscopic view grades, according to modified Cromack and Lehane [C and L], I and possibly IIA denote easy while IIB, III and IV difficult intubation. Over the last three years, using Macintosh blade [MCB] for oral intubation in adults, the author found that by manipulating the proximal end of the tube with your fingers, the distal end moves facilitating intubation. The aim of this study is to evaluate a new technique invented by the author, which is called the manual tube control [MTC] technique, during MCB oral intubation in adults. The technique depends mainly on control of the proximal end of the endotracheal tube [ETT] between the thumb, the index and the middle fingers of the intubator's right hand and manipulating according to the laryngoscopic view. Material and In a prospective single blind randomized clinical study, oral tracheal intubation using MCB size 4 was evaluated in 100 adult patients scheduled for elective surgery under general anesthesia, according to the tube holding technique. Inclusion criteria are American Society of Anesthesiologists [ASA] I adult patients who showed Mallampati III and IV during preoperative airway assessment and then initial laryngoscopic view [C and L] III and IV [without external laryngeal pressure] after general anesthesia. The study excluded cases that showed limited mouth opening [less than 2 fingers], problems related to mouth, teeth, pharynx, cervical spine, gastric reflux, sleep apnea and cases of pregnancy or bad anesthetic history. 7 cm height foam pillows were put under the patient's head, neck and shoulders and the initial laryngoscopic view was improved with external laryngeal pressure. The patients were divided into two groups according to the method of ETT holding during intubation: group U: 50 patients where the ETT was held in the usual way, and group M: 50 patients where the MTC technique was used. Patients who could not be intubated after two trials in the same group would be shifted to the other group. If the patients still could not be intubated after two trials in the other group, LMA FastrachT [intubating laryngeal mask airway] would be used. Both groups were comparable as regards demographic data, operative procedures and airway variables P>0.05. In group U, it was easy to intubate all cases of view I [C and L] in the first trial and only 4 cases [57%] of group IIA in the second trial while all other cases were shifted to group M where they were successfully intubated. All group M cases were successfully intubated in the same group. The total number of successful intubations using the group M technique was more than that using the group U technique with a highly significant difference P<0.001. LMA FastrachT was not needed in any case and no complications were recorded. The MTC technique is an efficient way for adult oral tracheal intubation using MCB size 4 even in cases of difficult laryngoscopic views