FAST implementation in Bangladesh: high frequency of unsuspected tuberculosis justifies challenges of scale-up.

SETTING: National Institute of Diseases of the Chest and Hospital, Dhaka; Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka; and Chittagong Chest Disease Hospital, Chittagong, Bangladesh. OBJECTIVE: To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a tuberculosis (TB) transmission control strategy. DESIGN: FAST was implemented sequentially at three hospitals. RESULTS: Using Xpert® MTB/RIF, 733/6028 (12.2%, 95%CI 11.4-13.0) patients were diagnosed with unsuspected TB. Patients with a history of TB who were admitted with other lung diseases had more than twice the odds of being diagnosed with unsuspected TB as those with no history of TB (OR 2.6, 95%CI 2.2-3.0, P < 0.001). Unsuspected multidrug-resistant TB (MDR-TB) was diagnosed in 89/1415 patients (6.3%, 95%CI 5.1-7.7). Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1-7.6, P < 0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding. CONCLUSION: FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a previous history of TB have an increased risk of being diagnosed with unsuspected TB. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.

Appraisal of timing for oral glucose tolerance testing in relation to risk factors for gestational diabetes mellitus in pregnant women in a Nigerian Teaching Hospital.

OBJECTIVE: We investigated the pattern of common risk factors present in women undergoing oral glucose tolerance test (OGTT) in our center and to determine their relationship with time of presentation for the test. MATERIALS AND METHODS: The records of women referred to the metabolic clinic for OGTT over a 1-year period were reviewed. Data available for retrieval included age, gravidity and gestational age, weight, and risk factors for gestational diabetes mellitus (GDM). RESULTS: Two hundred and fifty-three (253) pregnant women form the subject of this study. Thirty-five (13.8%) of the study population had GDM by WHO criteria. Approximately, 10% of the women were tested before 24 weeks and 87.6% of the women had at least one of the common risk factors as indication for testing. The most frequent indications were a history of previous macrosomic baby 77 (30.4%) and maternal obesity 61 (24.1%). Among the indications for OGTT, only a history of previous intrauterine fetal death was significantly associated with testing before 24 weeks of gestation. CONCLUSION: Early screening for GDM is not common in our environment. The presence of risk factors for GDM did not prompt early screening. Public enlightenment on the risk factors for GDM and the need for early screening should be vigorously pursued particularly for women at risk for GDM.

Analysis of cases of rape as seen at the Jos University Teaching Hospital, Jos, North Central Nigeria.

OBJECTIVE: Women are at a higher risk of being sexually harassed. There is a need to document the clinical findings of this crime and its outcome in order to improve the quality of care the victims receive. MATERIALS AND METHODS: Case notes of patients who presented with alleged rape at Jos University Teaching Hospital between January 2001 and December 2003 were retrieved and analyzed. RESULTS: During the study period, 2,135 patients were seen in the Gynaecological Emergency Unit. A total of 120 were for alleged rape, representing 5.6% of the total cases seen. However, only 105 case notes were available for analysis. Of these, 63.8% of the alleged rapes were in children, with the infantile age group accounting for 26.7%. 36.2% of the victims had experienced some form of sexual exposure prior to the rape. A previous relationship with the rapist was established in 77.4% of the cases. Most cases delayed in presenting to hospital. Thirty six percent of the cases did not have a human immunodeficiency virus screening test done. Candida albicans (13.3%) accounted for most of the infectious agents. Emergency contraception was administered to the victims when indicated. CONCLUSION: Women under 16 years of age were at an increased risk of being raped, possibly because they are defenseless and vulnerable. Three quarters (3/4) of the assailants had some form of relationship with the victims, which may account for the delays in reporting. Children and young adolescents were more at risk than adults to be raped.

Analysis of Cases of Rape as Seen at the Jos University Teaching Hospital; Jos; North Central Nigeria

Objective: Women are at a higher risk of being sexually harassed. There is a need to document the clinical findings of this crime and its outcome in order to improve the quality of care the victims receive. Materials and Methods: Case notes of patients who presented with alleged rape at Jos University Teaching Hospital between January 2001 and December 2003 were retrieved and analyzed. Results : During the study period; 2;135 patients were seen in the Gynaecological Emergency Unit. A total of 120 were for alleged rape; representing 5.6of the total cases seen. However; only 105 case notes were available for analysis. Of these; 63.8of the alleged rapes were in children; with the infantile age group accounting for 26.7. 36.2of the victims had experienced some form of sexual exposure prior to the rape. A previous relationship with the rapist was established in 77.4of the cases. Most cases delayed in presenting to hospital. Thirty six percent of the cases did not have a human immunodeficiency virus screening test done. Candida albicans (13.3) accounted for most of the infectious agents. Emergency contraception was dministered to the victims when indicated. Conclusion: Women under 16 years of age were at an increased risk of being raped; possibly because they are defenseless and vulnerable. Three quarters (3/4) of the assailants had some form of relationship with the victims; which may account for the delays in reporting. Children and young adolescents were more at risk than adults to be raped

Ectopic pregnancy in Jos Northern Nigeria: prevalence and impact on subsequent fertility.

BACKGROUND: Ectopic pregnancy remains a major gynaecological problem in contemporary gynaecological practice. Not only do women die from this disease, but also of greater clinical importance is the indirect morbidity of poor fertility prognosis and adverse outcome in subsequent pregnancies. We were interested in documenting the prevalence of ectopic pregnancy and its impact on subsequent fertility. METHODOLOGY: This retrospective descriptive study was done at the Jos University Teaching Hospital. The case notes of all patients who had tubal ectopic pregnancy managed in JUTH between January 1997 and December 2000 were retrieved. Subsequent fertility and reproductive outcome were assessed among women who reported back for follow up fora minimum period of twelve months post surgery. The data was analyzed using frequencies. RESULTS: During the study period, January 1997 and December 2000 a total of 168 ectopic pregnancies were managed and 9,638 deliveries occurred during the same period. This gives a prevalence rate of 1.74%. Of the 168 cases of ectopics, 130 case records containing relevant information were retrieved (77.4%) and this constituted the sample population for the study. Majority (53.8%) of the women were between 20 and 29 years. Majority of the women were either nulliparous or primiparous (23.8% and 20.0% respectively). Tubal rupture occurred in 86.9% of the women at the time of laparotomy. Total salpingectomy was the surgical modality in 77.7% of the cases. The right fallopian tube was affected in 66.2% and the left 33.8% of the cases. The contralateral fallopian tube was grossly normal in 73.1% of cases. Of the 64 women who were followed up for a minimum of 12 months, 40.6% achieved viable intra uterine pregnancies, 6.3% had a repeat ectopic pregnancy in the contra lateral tube and 53.1% were unable to achieve pregnancy. CONCLUSION: Ectopic pregnancy is prevalent in our environment affecting mainly young women of low parity who desire future pregnancies. The subsequent impact on future fertility of these women could be improved if efforts are focused on early diagnosis to prevent tubal rupture. Early diagnosis prior to rupture offers opportunity for medical management and conservative surgical procedures that are proven to improve future fertility prognosis.

Review of maternal deaths from unsafe abortion in Jos, Nigeria.

BACKGROUND: Unsafe Abortion assumes one of the lead causes of maternal deaths so long as contraceptive services remain low or unavailable and abortion laws remain restrictive. This study seeks to highlight abortion mortality, the practice of contraception amongst these women and complications arising from unsafe abortion. METHOD: This is a retrospective review of abortion related deaths in Jos University Teaching Hospital over a five year period (1st December 1989 to 30th November 2004). Patients files were retrieved from the hospital records and were reviewed in relation to socio demographic profile, clinical features and cause of death. RESULTS: Fourteen cases of abortion related deaths out of a total number of 188 induced abortion cases. The case fatality rate was 7.4% with abortion mortality of 74.4/100,000 deliveries. It constituted 12.8% of maternal deaths during the period. Seventy eight point six percent (78.6%) were below 24 years, while 85.7% of the patients were nulliparous. Ninety two point nine percent (92.9%) and 57.1% were single and dependent respectively. Fifty seven point one percent had never practiced contraception and 35.7% had previous pregnancy terminated. In 64.3%, the index pregnancy was terminated at 9 weeks and above because the pregnancies were unwanted in all (100%) cases. In 78.6% of cases the pregnancies were terminated by quacks. Forty two point nine percent (42.9%) presented after a week of termination. The causes of death were septicemia (71.4%), and hypovolaemic shock (28.6%). The average duration of hospital stay before demise was 5.6 days. CONCLUSION: Unsafe abortion is a public health problem in Jos and policy makers should promote contraception and review existing abortion laws.

Implanon sub-dermal implants: a 10-month review of acceptability in Jos, North-Central Nigeria.

OBJECTIVE: To determine the acceptance of Implanon so far, the group of women accepting it, insertion complications and immediate post insertion problems, if any, and report our initial experience with the method. METHODOLOGY: This was a retrospective review study of all cases of Implanon acceptors between 1st May and 28th February 2007. Demographic and social factors were collated. Insertion and post-insertion complications were evaluated. RESULTS: A total of 2,608 clients accepted contraceptive methods out of which 350 clients had Implanon capsules inserted within the study period (13.4%). One hundred and ninety-one (54.6%) of the acceptors desired more children, and therefore using it to space pregnancies, 154 (44.0%) would not want more children, but opted for the temporary long term method, and 5 (1.4%) were uncertain whether to have more children in the future or not. The mean age and parity of acceptors were 32.4 years and 3.6 respectively. The mean number of living children to the women was 3.4. All the women were married. About three-quarters (75.8%) of the women had secondary and tertiary education. Seventy-two (20.6%) of the women were taking a modern contraceptive method for the first time. The rest 278 (79.4%) had used one or more methods of contraception, and were only switching over to Implanon sub-dermal implants. The patients weighed between 40 and 122 kg with an average of 62.4 kg. Post-insertion complications like infection, expulsion, bruising and induration were not reported. Four women discontinued the method for varying reasons. CONCLUSION: Women are accepting the new method. Over three-quarters of the clients are switching from other methods to Implanon. The method appears to have good continuation rate and therefore a promising long term sub-dermal contraceptive method amongst our women.

Intensive care unit admissions in the Jos University Teaching Hospital.

OBJECTIVE: To determine the pattern of admissions to the intensive care unit (ICU) of the Jos University Teaching Hospital (JUTH), a tertiary level referral hospital. METHOD: This is a retrospective study of the record of patients admitted between January 1994 and December 2002 to the ICU of the Jos University Teaching Hospital. The information obtained from the admission/discharge record as well as the patients' case notes included demographic data, working diagnosis, type of treatment, length of stay (LOS) in the ICU and outcome. RESULT: A total of 738 patients were admitted over this period and comprised 403 males (54.6%) and 335 females (45.6%) giving a male: female ratio of 1.2:1. The age ranged from one day to 98 years with a mean of 28.3 +/- 19.8 years. Postoperative surgical patients accounted for 48.2% of all admissions, while 15.2% were medical cases. Other indications for admissions included polytrauma (9.5%), Obstetrics and Gynaecological complications (16.1%) and burns (11%). The length of stay (LOS) in the unit ranged from 1 to 56 days, with a mean of 4.5 +/- 5.1 days. A total of 241 patients died while on admission giving an overall mortality of 42.8%. Postoperative surgical admissions accounted for 38.6% of deaths followed by burn and polytraumatised patients with 23.2% and 11.6% respectively. The lowest mortality of 8.7% was in the obstetrics and gynaecology patients. CONCLUSION: The pattern of admission into the unit and the outcome of treatment has not significantly changed after 1-2 decade of an initial report. There is need to increase the number and quality of equipment to cope with the increasing need for ICU care, as well as draw up a policy on the type of cases to be managed in order to improve the out come of care.

Scanty AFB smears: what's in a name?

SETTING: A tuberculosis control project in Bangladesh. OBJECTIVE: To document the frequency and diagnostic value of smears with scanty acid-fast bacilli (AFB) (IUATLD/WHO scale, < 10/100 high power fields), and to assess the appropriateness of the current positivity threshold. DESIGN: Analysis of databases of laboratory registers, patient records and the diagnostic yield of sputum collection strategies. RESULTS: Scanty smears constituted about 10% of suspect and almost 50% of follow-up smears. In suspect series, 10% of scanty 1-9/100 were not confirmed by another positive or scanty AFB sputum, compared to 7.5% of results at the current cut-off value of 10/100. Considering such results as positive by adopting a lower cut-off as low as the 1/100 used in the ATS scale added 1.5% false positives at the most. In return, the gain in confirmed positive cases was up to 10%, and that in positive results exceeded the incremental yield of the third diagnostic sputum. Significance of scanty follow-up smears at the end of the intensive phase was suggested by their association with treatment failure and unfavourable outcome overall. CONCLUSIONS: Scanty results (IUATLD/WHO scale) are not rare and should not be ignored. Adoption of a considerably lower positivity threshold would be appropriate in control programmes where basic conditions for reliable AFB microscopy, including regular quality assessment, are present.

Drug resistance monitoring: combined rates may be the best indicator of programme performance.

SETTING: Greater Mymensingh District, Bangladesh. OBJECTIVES: To determine changes in prevalence of drug resistance of Mycobacterium tuberculosis under DOTS. DESIGN: Drug susceptibility testing of systematic samples of M. tuberculosis isolated from all sputum smear-positive cases newly registered in sentinel centres during 1995 and 2001. Continuous monitoring of retreatment registrations and resistance of strains from relapse and failure cases. RESULTS: Of 942 strains from the new cases in 2001, 10.8% showed resistance to any drug, 6.2% to isoniazid, 0.4% to rifampicin (all of them multidrug-resistant, MDR), 7.1% to streptomycin, and 1.0% to ethambutol. Corresponding rates for 99 strains from previously treated cases were 32%, 20%, 3%, 20% and 2%, respectively. Although most rates of resistance had decreased since 1995, increased streptomycin resistance was the only significant change when new and previously treated cases were considered separately. However, combined resistance for any drug, isoniazid, rifampicin and MDR had decreased significantly. CONCLUSION: As suggested by monitoring of resistance in failure and relapse cases and by routine programme reports, drug resistance had decreased. Combined resistance demonstrated changes between periodic surveys better than its subgroups, and may be a more reliable and comprehensive indicator. However, continuous monitoring of the pool of resistant retreatment cases is a more efficient strategy.

Assessing the prevalence and determinants of unwanted pregnancy and induced abortion in Nigeria.

This study was conducted to determine the prevalence and sociodemographic determinants of unwanted pregnancy and induced abortion in the Jos and Ife local government areas of Nigeria. A total of 1,516 randomly selected women aged 15-45 responded to a pretested structured questionnaire designed to elicit information concerning previous unwanted pregnancies and induced abortions in a value-free manner. Nearly 20 percent of the women reported having had an unwanted pregnancy. Of these, 58 percent reported that they had successfully terminated the pregnancies; 32 percent continued the pregnancies; and nearly 9 percent stated that they had attempted termination but failed. Overall, the prevalence of self-reports of induced abortion was 11 percent. The results reveal that information can be obtained on abortion in areas with restrictive abortion policies if an indirect interviewing approach is used.

PIP: This study examined the prevalence and determinants of induced abortion in the Jos and Ife local government areas of Nigeria, a country that restricts abortion. Data were obtained from a survey conducted during 1995-96 among a systematic random sample of 1516 unmarried and married women 15-45 years old. Ife was largely Yoruba, while Jos was ethnically diverse. Over 25% in Ife were Muslims; over 50% in Jos were Christians. Ife respondents had greater knowledge of reproduction and family planning than those in Jos. More women had ever or currently used contraception in Ife. 20% of all women (19% in Ife and 21% in Jos) had an unwanted pregnancy (UP). Among women with UPs, 57.6% terminated it successfully. Around 30% took no action. 8.5% had unsuccessful terminations. About 19% of women with UPs became pregnant while using family planning. Well-educated women, women who were currently using a method, and women who correctly knew the most fertile period were each three times more likely to report a UP. Women who had knowledge of a modern method were twice as likely to report a UP. Women who had knowledge of family planning and women who were currently using a method were more likely to report an induced abortion. In Jos, women with a university education were more likely to report an induced abortion.

[A simple method of cervical myelography by lumbar injection of Omnipaque]. / A nyaki myelographiák egyszerü módszere lumbalis úton beadott Omnipaque-kal.

The authors report on the experiences with cervical myelography performed in 94 cases in the past years at their Institute. On the basis of the results a simple and reliable procedure easy to perform with the lumbar administration of Omnipaque contrast material in lying position is described and recommended. Examinations performed by cervical puncture are justified only according to the authors' opinion if their method fails to be successful.

Indomethacin is effective against neurogenic hyperthermia following cranial trauma or brain surgery.

The effectiveness of indomethacin treatment (1 mg/kg) as an antipyretic was tested in patients after cranial trauma or brain surgery involving the centromedial forebrain. Indomethacin was effective in reducing temperature in 10 of 11 cases which showed a dipyrone-resistant hyperthermia developing in the first 24 hours after brain damage, while no significant antipyretic effect was seen in hyperthermic cases developing more than 72 hours after cranial trauma or brain surgery. Biochemical tests estimating the effect of indomethacin, and pyrazolone derivatives on the arachidonic acid metabolism showed significant effects of indomethacin only in influencing cyclooxygenase activity and no effect of any drugs on lipoxygenase actions. In view of these observations, the use of indomethacin is recommended as a treatment for neurogenic hyperthermia.