Predictors of Loss to Follow-up Among HIV-infected Patients in a Rural South-Eastern Nigeria Hospital: A 5-year Retrospective Cohort Study.

BACKGROUND: Patient attrition has been a challenge in managing HIV programs in resource-limited settings. AIM: This study reviews the predictors of loss to follow-up (LTFU) in our hospital and suggests the best practices for dealing with the issue. SUBJECTS AND METHODS: A 5-year retrospective cohort study of 1256 HIV-infected patients. Baseline CD4 counts, age, gender, year of enrolment, and antiretroviral therapy combination regimen were considered in this study. Kaplan-Meier models were used to estimate the univariate time-to-LTFU and Cox proportional hazards models to identify the multivariate predictors of LTFU. RESULTS: Twenty-four percent (23.9% [301/1256]) of patients were lost to follow-up. Baseline CD4 count, year of enrolment, and drug combination were significant predictors of LTFU. Patients enrolled earlier (2008/2009) were twice as likely to be LTFU compared with those enrolled later (2010-2013). Gender and age did not significantly predict LTFU nor confound other predictors. CONCLUSION: The program showed higher LTFU rates than most studies in Nigeria and Africa, maybe due to difficulties with the access to the hospital and possible treatment fatigue. This study recommends the provision of transportation subsidies and proactive patient follow-up with "peer-tracking" to reduce LTFU among HIV infected patients, especially in resource-limited settings.

Mesenteric lipoma causing recurrent intestinal obstruction.

Although lipoma is a common tumor found in almost all parts of the body, that occurring in the mesentery of the gut is a rarity. A 29-year-old man presented in our center with a 10-year history of recurrent central colicky abdominal pain, vomiting, constipation, and central abdominal mass. Exploratory laparotomy revealed a huge smooth yellow mass in the mesentery of the mid ileum. Resection of the affected segment of the ileum and end to end ileal anastomosis were carried out. Histology report confirmed lipoma. He had uneventful post-operative recovery. Mesenteric lipoma should be considered as a possible differential diagnosis in a patient with recurrent features of intestinal obstruction and a mobile abdominal mass. A high index of suspicion and improvement on the pre-operative diagnosis and treatment are needed in secondary health facilities in Africa.

Sacrohysteropexy with synthetic mesh in Aba, South-Eastern Nigeria: a report of three cases and review of the literature.

The surgical treatment of uterovaginal prolapse in women who wish to preserve their uteri for fertility presents a challenge to a gynecologist. This is particularly more challenging in Nigeria and the rest of Africa where there is not only a strong cultural aversion to hysterectomy but women also prefer large family size and male babies. This underscores the need for fertility friendly, uterus-preserving procedures. Three young women under the age of 40 presented with uterovaginal prolapse. They were of low parity and wanted to preserve their uteri for future reproductive function. They had open abdominal suspension of their uteri to the sacrum using a synthetic polypropylene mesh. A pus-string suture was also used to obliterate their pouch of Douglas to prevent future enterocele. Pelvic anatomy was restored and normal vaginal axis was achieved. They had uneventful post-operative period. In resource-limited settings, open abdominal (rather than laparoscopic) sacrohysteropexy with synthetic mesh is an effective and safe alternative to Manchester operation and other vaginal procedures in women who desire to preserve the uterus for future reproductive function.

Symphysiotomy- a dying art: the experience at Federal Medical Centre Umuahia Nigeria.

AIMS AND OBJECTIVES: To review the indications, outcome and complications of symphysiotomy done in Federal Medical Centre Umuahia during the study period. PATIENTS AND METHODS: This study is a 5-year review of all women who had symphysiotomy at Federal Medical Centre Umuahia. The total number of the procedure performed, and all the deliveries conducted at the hospital in the study period were obtained from the labour ward register. The case notes of the patients were then retrieved and their biodata and other relevant information were obtained and summarized in frequency tables and percentages. RESULTS: Ten (10) symphysiotomies were performed among 3702 deliveries conducted during the period under review giving a rate of 0.27%. Seventy per cent of the patients were aged 30 years and below, mean age was 26 (± SD4.9) years. Most of the patients were multiparous women, only one was grandmultiparous. All were for mild to moderate cephalopelvic disproportion (CPD). In one particular case, the patient also presented with retained second twin. They were all unbooked patients. Main complication was pelvic and leg pain but there were two cases of vesicovaginal fistula which may be a complication of obstructed labour since leakage of urine did not start immediately after the procedure. The birth weight of the babies ranged from 3kg to 4.2kg. There was no maternal mortality but two fresh stillbirths were recorded giving a perinatal mortality rate of 200 per 1000 total births. CONCLUSION: Symphysiotomy if done by a trained person, in well selected patients is still safe and can be life saving in environments where caesarean delivery is not well accepted and late presentation is common.

Placenta accreta and the developing world--a review.

BACKGROUND: The rising Caesarean section rate in the developing world implies that the incidence of placenta accreta might be on the increase and this might worsen the maternal mortality burden. OBJECTIVE: To draw the attention of Obstetricians and other relevant professionals to this emerging but challenging trend. DATA SOURCES: Original research findings and reviews published in the English literature. Additional information was obtained from texts and electronic books such as CD ROMS. DATA EXTRACTION: Online searches of electronic database (Medline, Pubmed and Embase), requests for reprints from corresponding authors and institutional/private subscriptions. DATA SYNTHESIS: Information obtained was categorised accordingly. CONCLUSION: Optimal treatment of women with placenta accreta requires recognition of the clinical risk factors, accurate pre-operative diagnosis and meticulous planning to ensure safety at the time of delivery. In view of the rising incidence of this condition, and the absence of a highly reliable antenatal diagnostic method especially in developing countries, a high index of suspicion and advanced preparation is required to reduce its associated maternal morbidity and mortality.

Placenta accreta in Aba, south eastern, Nigeria.

BACKGROUND: Placenta accreta is a rare and challenging complication of pregnancy associated with increased maternal morbidity and mortality, loss of reproductive organs and high demands on health resources. The objective of this study was to identify the incidence, demographic characteristics, and mode of treatment of patients with placenta accreta. METHODS: A prospective descriptive study of 11 cases of placenta accreta seen at Nigerian Christian Hospital Aba, Nigeria between January 2002 and December 2005. RESULTS: The incidence of placenta accreta was 1 in 282 deliveries (0.35%). Median maternal age was 30 years, with a median parity of 3. The associated risk factors observed were: previous caesarean section(82%); placenta praevia (73%) and previous uterine curettage (54.5%). No antenatal diagnosis was achieved as all cases were either diagnosed at surgery or manual removal of placenta. The total estimated intra-operative blood loss for all the 11 cases was 24,500 mls, with a median of 2000 mls. The total number of units of blood transfused was 46 with a median of 4. Emergency hysterectomy was carried out in 72.7% of the patients. There was one maternal death (9%) and three perinatal deaths (27%). CONCLUSION: Placenta accreta is a major cause of obstetric haemorrhage and loss of reproductive organ with a huge demand on our meager health resources. It should be considered a possibility in women with previous caesarean section and placenta praevia.

Management of cervical incompetence in Aba, south-eastern Nigeria.

BACKGROUND: There have been relatively few reports on the outcome of cervical cerclage performed in non-tertiary centres. The aim of this study was to determine the pregnancy complications and outcome in patients following cervical cerclage. METHODS: Seventy-one patients who had 103 pregnancies and underwent cervical cerclage at Women's Hospital, Aba over a ten-year period were reviewed. The diagnosis of cervical incompetence was made from the history in 90.6% of cases and also in some cases by hysterosalpingography and ultrasonography. RESULTS: The Shirodkar (65%) and McDonald (35%) techniques were employed and 10.7% of cases were done as emergency procedures. The more common post-insertion complications were urinary tract infection (50.4%), preterm rupture of membranes (20.4%) and vulvovaginitis (14.6%). Common labour associated complications were antepartum haemorrhage, perineal/cervical tears and malpresentations. The preterm birth rate was 32%. Term births accounted for 68% of the deliveries. The overall fetal salvage rate was 92.2%. Antepartum haemorrhge was a significant indication for caesarean section delivery. The perinatal mortality was 63.2 per 1000 and there was no maternal death. CONCLUSION: The high fetal salvage rate of 92.2% justifies the procedure of cervical cerclage.

Case Report - Heterotopic Pregnancy with Spontaneous Vaginal Delivery at 36 Weeks and Laparotomy at Term - A Case Report

Heterotopic pregnancy; although rare; is occurring more frequently because of an increase in genital infection and the escalating use of new reproductive technologies in infertility patients. The case of a 30-year-old para 2+1 prophetess is presented. She had a spontaneous vaginal delivery at term. Persistent abdominal pain and distension led to suspicion of heterotopic pregnancy. This was confirmed by ultrasonography. Laparotomy revealed a macerated fetus in the peritoneal cavity. The purpose of this report is to sensitise practitioners about the reality and existence of the condition

Effect of histamine H2-receptor antagonists on acute inflammatory of the rat paw oedema.

The effect of three histamine H2-antagonists, cimetidine, ranitidine, and loxtidine, on acute rat paw oedema induced by histamine, carrageenan or complete Freund's adjuvant, have been examined. Administered intraperitoneally, all three antagonists inhibited histamine-induced paw oedema dose-dependently in the range 0.5-15 mumol kg-1. The highest dose of cimetidine produced an inhibition of 92% as against 38% with the same dose of mepyramine. Analysis of the concentration-effect curves produced IC50 values of 1.66, 5.12 and 12.30 mumol kg-1 for cimetidine, loxtidine, and ranitidine, respectively, on histamine-induced oedema. In carrageenan-induced inflammation 12.3 mumol kg-1 of each of the three drugs produced significant inhibition, whereas in adjuvant-induced inflammation, (acute phase), cimetidine was very active, loxtidine less so and ranitidine inactive. Thus the relative effectiveness of the antagonists (cimetidine greater than loxtidine greater than ranitidine) appears to differ from their known potency relationship (loxtidine greater than ranitidine greater than cimetidine) on H2-mediated effects. We conclude that H2-receptors are involved in the induction of rat paw oedema, especially those induced by histamine and carrageenan, but that their relative effectiveness appears atypical.