Vascular Access in Hemodialysis: Peculiarities in a Low-Income Setting, Pattern, Prevalence and Relationship with Intradialysis Events and Dialysis Dose.

OBJECTIVES: Dialysis vascular access has remained a major determinant of intra and inter-dialytic events and the dialysis dose, and this impacts the quality of life, morbidity and mortality of dialysis patients. Assessing the different access types would help minimize peri-dialytic events and improve outcome. METHODS: This was a retrospective, age and sex-matched, comparative study that assessed dialysis sessions with tunneled dialysis catheters (TDCs) with arteriovenous fistula (AVF). RESULTS: Two hundred and four participants with 1062 sessions were involved. The male participants had 66.7% of all sessions, 60.6% of sessions with TDCs and 87.3% of sessions with AVF, P=0.001. The elderly constituted 23.5% of all participants but 37.7% of sessions with AVF, P=0.04. The percentage of the health-insured was more in sessions with AVF compared to the study population, P<0.001. Diabetics were more likely to use the TDCs, P=0.06. Participants using AVF were more likely to receive full dialysis and erythropoietin treatment, P<0.001. Intradialytic hypotension and dialysis termination were commoner with AVF than TDCs, P=0.03 and P=0.04 respectively. The dialysis dose was higher with AVF than TDCs, P=0.02. Predictors of AVF as dialysis access were male gender, advancing age, health insurance and full treatment compliance. CONCLUSION: There is predominance of venous catheters in our dialysis population. The AVF gave better BP control, fluid and solute clearance, and dialysis dose, and was commoner with males, the health insured and older participants. Intradialytic hypotension was commoner with AVF as IDHT was commoner with TDCs.

OBJECTIFS: L'accès vasculaire à la dialyse reste un déterminant majeur des événements intra et inter-dialytiques et de la dose de dialyse, ce qui a un impact sur la qualité de vie, la morbidité et lamortalité des dialysés. L'évaluation des différents types d'accès permettrait de minimiser les événements péridialytiques et d'améliorer les résultats. MÉTHODES: Il s'agit d'une étude comparative rétrospective, appariée selon l'âge et le sexe, qui a évalué les séances de dialyse avec des cathéters de dialyse tunnellisés (CDT) et des fistules artérioveineuses (FAV). RÉSULTATS: Deux cent quatre participants ont participé à 1 062 séances. Les hommes représentaient 66,7 % de toutes les séances, 60,6 % des séances avec CDT et 87,3 % des séances avec FAV, P=0,001. Les personnes âgées représentaient 23,5 % de l'ensemble des participants, mais 37,7 % des séances avec FVA, P=0,04. Le pourcentage d'assurés sociaux était plus élevé dans les sessions avec AVF que dans la population étudiée, P<0.001. Les diabétiques étaient plus susceptibles d'utiliser les CDT, P=0,06. Les participants utilisant la FVA étaient plus susceptibles de recevoir une dialyse complète et un traitement à l'érythropoïétine, P<0,001. L'hypotension intradialytique et l'arrêt de la dialyse étaient plus fréquents avec l'AVF qu'avec les CDT, P=0,03 et P=0,04. La dose de dialyse était plus élevée en cas de FVA qu'en cas de CDT, P=0,02. Les facteurs prédictifs de l'utilisation de la FVA comme accès à la dialyse étaient le sexe masculin, l'âge avancé, l'assurance maladie et l'observance totale du traitement. CONCLUSION: Il y a une prédominance des cathéters veineux dans notre population de dialysés. Le FVA permet un meilleur contrôle de la PA, de la clairance des fluides et des solutés et de la dose de dialyse, et il est plus fréquent chez les hommes, les assurés sociaux et les participants plus âgés. L'hypotension intradialytique était plus fréquente avec le FVA que l'IDHT était plus fréquente avec les CDT. Mots-clés: Cathéters veineux centraux, fistule artério-veineuse, veine jugulaire interne tunnellisée.

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.

Acute renal failure (ARF) in developing countries: which factors actually influence survival.

Acute renal failure, a relatively common clinical condition, is still associated with a high mortality rate in both developed and developing countries despite the differences in the epidemiology, clinical characteristics and therapeutic modalities offered to affected patients. The various modalities of renal replacement therapy are still largely inaccessible, unaffordable and unavailable in most parts of sub-Saharan Africa, hence the need to judiciously utilise available resources. Consequently we studied patients with acute renal failure to critically appraise the factors that influence survival and determine the usefulness or otherwise of available renal replacement therapies (Acute HD and Acute PD). A total of 46 (34 (73.9%) males and 12 (26.1%) females) patients satisfied the inclusion criteria. Their ages ranged between 15 and 76 years (mean +/- SD; 38.2 +/-16.3 years). The commonest causes were gastro-enteritis (cholera) and septicaemia in 36.9% and 30.5% respectively. Twenty six (56.5%) of all the patients survived while the remaining 20 (43.5%) died. Twenty four (52.2%) patients had different complications of which pulmonary oedema was singularly found to significantly influence survival. Other factors that were found to significantly influence survival included availability of renal replacement therapy, the aetiology of ARF; gender; age of the patients and the duration of oliguria. We further compared the patients managed with haemodialysis with those managed with peritoneal dialysis and found no difference(s) in the age; duration of oliguria or hospitalisation; survival figures; effect of pulmonary oedema and the aetiology of ARF. However, the number of sessions for HD and the duration of PD significantly influenced survival. We conclude that ARF is still associated with a high mortality rate and prompt institution of available renal replacement therapy and aggressive management of complications would assist in reducing the trend.

The epidemiology of needlestick and sharp instrument accidents in a Nigerian hospital.

OBJECTIVES: To characterize the epidemiology of percutaneous injuries of healthcare workers (HCWs) in Ile-Ife, Nigeria. DESIGN: A cross-sectional survey of a random sample of HCWs regarding details of needlestick and sharp instrument injuries within the previous year. SETTING: University hospital and clinics in Ile-Ife, Nigeria. PARTICIPANTS: Hospital personnel with potential occupational exposure to patients' blood. RESULTS: Needlestick accidents during the previous year were reported by 27% of 474 HCWs, including 100% of dentists, 81% of surgeons, 32% of nonsurgical physicians, and 31% of nursing staff. The rate of needlestick injuries was 0.6 per person-year overall: 2.3 for dentists, 2.3 for surgeons, 0.4 for nonsurgical physicians, and 0.6 for nursing staff. Circumstances associated with needlestick injuries included unexpected patient movement in 29%, handling or disposal of used needles in 23%, needle recapping in 18%, accidental stick by a colleague in 18%, and needle disassembly in 10%. Sharp instrument injuries were reported by 15% of HCWs and most commonly involved broken glass patient specimen containers (39%). Almost all HCWs were aware of the potential risk of HIV transmission through percutaneous injuries, and 91% considered themselves very concerned about their occupational risk of HIV acquisition. CONCLUSIONS: The high frequency of percutaneous exposure to blood among HCWs in this Nigerian hospital potentially could be reduced by simple interventions at modest cost.

PIP: During the spring of 1991 in Nigeria, 474 health care workers (HCWs) of the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) in Ile-Ife responded to a questionnaire on needlestick and sharp instrument injuries they had experienced in the last year and on their knowledge of HIV transmission. Current HIV seroprevalence at OAUTHC was less than 2%. 97% knew that an HIV-contaminated needlestick or skin penetration with HIV-infected blood could transmit HIV. 91% were very worried about occupational exposure to HIV. Gloves were always available to only 43%. 34% had experienced at least one accidental percutaneous injury due to a needle stick or sharp instrument during the last 12 months. The rate of percutaneous injuries was 0.8 per person-year. 27% (126) reported at least one needlestick injury. The rate of needlestick injury was 0.6 per person-year. 39 HCWs experienced at least 3 needlestick injuries. Dentists, surgeons, and mortuary attendants experienced the most needlestick injuries (100%, 81%, and 60%, respectively). The most common needlestick injuries occurred during suturing (24%), intramuscular injection (23%), and handling or disposal of used needles (23%). Unexpected patient movement (29%), needle recapping (18%), and accidental stick by colleague accounted for needlestick injuries. 15% (69) of HCWs reported at least one sharp instrument injury. 12 HCWs had at least 3 sharp instrument injuries. HCWs most affected by sharp instrument injuries were dental therapists/assistants (42%), dentists (40%), mortuary attendants (40%), surgeons (35%), and laboratory staff (25%). Broken glass containers containing patient specimens (39%), scalpels (32%), and dental instruments (20%) contributed to most injuries by sharp objects. Some possible cost-effective interventions to prevent occupational exposure to HIV among HCWs include educational seminars, preparation of patients before procedures to reduce unexpected patient movement, and infection control committees.

Efficacy of lamisil in the treatment of onychomycosis of the finger nail

Fungal infection of the nail is commonly encountered dermatological problem in Nigeria. It is observed to be more frequently encountered in female patients who for cosmetic reasons seek dermatological services readily than males. A strong association between tinea pedis and onychomycosis has also been established. The most commonly encountered dermatophyte in the infection of the nail is trichophyton rububrum; which is known to be very difficult to treat and to re-occur very often

Bifonazole in the treatment of fungal skin infections in the tropics: a clinical and mycological study.

A study was carried out in 40 patients with various superficial fungal diseases, confirmed by culture or microscopic examination, to assess the therapeutic efficacy and local tolerability of 1% bifonazole cream. Patients with more than one clinical diagnosis at the time of entry were treated according to the number of conditions present. The cream was applied once daily to the affected areas and treatment duration varied according to persistence or resolution of the clinical signs and symptoms in the individual patient. The results were evaluated by clinical and mycological examination 3 and 14 days after the end of treatment. A cure rate of 100% was achieved in cases of pityriasis versicolor, tinea corporis and candidiasis, and 90% in patients with tinea pedis. Clinical signs and symptoms disappeared completely in all but a few patients. No side-reactions were observed in any patient, and patch tests carried out in selected patients with known allergy and those with normal skin showed no evidence of any allergic or photosensitivity reaction to bifonazole.

[Lichenoid sarcoidosis on skin tattoos produced by traditional herbal treatments]. / Sarcoidosis liquenoide sobre tatuaje de la piel producida por los tratamientos herbarios tradicionales.

An unusual case of generalised sarcoidosis of the skin on tattoo marks done two years for "medicinal" purposes on a 56 year old woman is presented. The lesions were lichenoid and scaly in appearance with closely grouped papules. The old tattoo marks on the skin were not involved and areas of skin between the new tattoo marks were also spared. In addition, the sarcoidosis lesion were pruritic and burning. The circumstantial evidence indicated the medical agent applied on the tattoo wounds as the provocative factor for the development of sarcoidosis of the skin.

Sexual behavior among university students in Nigera.

Sexual behavior patterns among Nigerian university students and factors influencing them were studied. While permarital cohabitation is common, a large percentage (48%) had their first coital experience between the ages of 22 and 27. Religion does not appear to have a strong inhibiting influence on premarital sex, although it does affect the frequency of changing partners. Contraceptives, although known to almost all the respondents, are not widely used. The use of contraceptives had little influence on premarital cohabitation. Oral-genital, male-male, and female-female sexual practices are very uncommon.

PIP: An attempt is made to assess the sexual behavior of a group of students with similar environmental and socioeconomic characteristics, and to determine their knowledge of contraceptives. A survey was conducted on a university campus, with questionnaires distributed to students on a random basis. Variables considered were age, religion, marital status, sex, and the number of sessions spent at the university. Final analysis was based on responses of 729 students out of 850 questionnaires sent, with results summarized under: 1) age group, sex and marital status; 2) premarital coitus by sex and marital status; 3) 1st coital experience; 4) forms of sexual practices; 5) frequency of changing sexual partners; 6) knowledge and use of contraceptives; 7) sexual problems; and 8) visits to prostitutes. 66.1% of the students had premarital sexual intercourse. Age and sex were important factors in the sexual behavior patterns, with the older group more restrictive than the younger group, and females more restrictive than males. Concerning contraception, 1/3 of the unmarried students had used some sort of contraceptive, and the usage of contraception appears to have little influence on the incidence of premarital sex, especially among females. In Nigeria, it is concluded that any sexual act other than direct coitus is considered abnormal, and it was documented that oral-genital sex and homosexuality appear to be uncommon.

Contact allergic dermatitis "current topic in tropical dermatology".

Out of a total of 2,666 new dermatology patients, 128 (4.8%) were clinically diagnosed as allergic contact dermatitis. Of these, 107 (4%) reacted positively to different antigens in the patch-test. The commonest contact sensitizers among females were nickel and dyes. Among male patients, the commonest sensitizers were mecaptobenzol-thiazole, chrome and nickel. The incidence of occupational contact dermatitis among bricklayers, construction workers and builders were found to be low and the sensitization rate against chromate was 0.6%. There was no sensitization against cobalt and nickel in the group, however, the length of occupational contact with cement among these group was short. Allergic contact dermatitis is not as uncommon among the Nigeria populace as is generally believed. It seems to be on the increase especially with increase rate of industrialization.

Ectopic lesion of schistosomiasis of the penis simulating an early carcinoma.

A case of ectopic lesion of Schistosoma haematobium of the penis with extensive tissue destruction, simulating an early carcinoma of the penis and almost resulting in an autoamputation of the crown of the penis, is presented. The penis was surgically repaired and the patient treated with ambilhar. In schistosoma endemic area, it is important to think of ectopic schistosoma lesion by such a presentation. Existing theories to explain the presence of schistosoma eggs in locations outside the portal-caval system were reviewed and another one was advanced: its being sexually transmitted.

Epidemiologic study of dermatophyte infections in Nigeria (clinical survey and laboratory investigations).

The commonest dermatophyte infection among the referred dermatology cases in Nigeria is tinea pedis, whereas among the surveyed population of school children, the commonest fungal infection was tinea capitis. It was found that the most ubiquitous causative organism for tinea pedis was E. fluccosum, that for tinea capitis was M. audouinii, while that for tinea corporis was T. soudanese. The source of infection of tinea capitis among the school children was found to be most likely the local barber who serviced the schools in all the villages, and this might explain the high incidence rate of T. soudanese in tinea capitis. Tinea pedis infection is believed to be highly favoured by the wearing of shoes among the senior students. Animals were not a major source of transmission of dermatophytes in Nigeria. No new species of dermatophytes has been identified among the cultured organisms.

Allergic manifestation in Nigerian asthmatics.

Intracutaneous and inhalative provocation tests performed on 185 asthmatic Nigerian patients and 50 control patients using indigenous antigen extracts as well as imported ones showed that moulds, house dust and D. farinae are the most common allergens responsible for the patients' asthmatic symptoms. Food allergy, though present, does not play a significant role among the patients. Pollinosis is not a common symptom among the patients although the Nigerian pollens are believed to possess antigenic properties. Environmental factors were thought to be responsible for the scarcity of pollen allergy in Nigeria. The importance of making use of indigenous antigen for allergy tests in stressed as this would reveal the true allergic state of the people.

Keratosis circumscripta. A distinct dermatological entity or a variant of psoriasis?

45 cases of a dermatosis believed to be the same as those originally described by Schrank in 1963 among Nigerian children of Yoruba ethnic origin and named keratosis circumscripta by him are reviewed. All evidences point towards the fact that the dermatosis observed by us as well as those originally described by Schrank are a variant of psoriasis possibly modified by environmental factors. It has therefore been suggested that this dermatosis should not be regarded as a new dermatological entity, and that the original names should be modified. To reflect the original work done by Schrank as as well as the true clinical picture of this dermatosis, the nomenclature psoriasis circumscripta with palmo plantar keratosis is suggested.

[Epidemiology of occupational disease among bricklayers in Nigeria. Effects of age and duration of contact]. / Epidemiologie der Berufskrankheit von Maurern in Nigeria. Einflüsse des Alters und der Kontaktdauer.

Clinical and epidemiological investigations on 240 bricklayers in Nigeria show an incidence of 2,3% of cement-eczema, 2,0% of wear and tear dermatosis, and 2,8% of sensitivity against chrome. None of the examined showed a concomitant reaction to cobalt chloride. The workers with longest professional contact with cement showed the highest incidence of cement-eczema, and sensitivity against chrome. Workers of the lower age group had a higher alkali neutralization power of the skin than the older workers. The same tendency was noticed in the control tests. Generally, the African skin showed a higher alkali neutralization power than the white skin. The discussion tried to expand on the possible factors which could have influenced the observed rate of sensitization in Nigeria.