Tropical Doctor current issue

Addressing the attitudes of service providers: increasing access to professional midwifery care in Nepal

Clapham, S, Pokharel, D, Bird, C, Basnett, I — 2008-09-26

Increasing access to professional care during labour and delivery is the central strategy in Nepal's commitment to reducing its maternal mortality ratio. This paper outlines a number of complementary interventions used by the Nepal Safer Motherhood Project to address the negative attitudes prevalent among service providers, which is a contributing factor to the under-utilization of the health-care services. The perspectives of the community and the service providers are presented, with a discussion of the importance of effective communication, the establishment of positive relationships and a demonstration of the critical role of local ownership and involvement in bringing about a positive change.

Pattern of severe maternal morbidity in a tertiary hospital of Delhi, India: a pilot study

Chhabra, P., Guleria, K., Saini, N. K., Anjur, K. T., Vaid, N. B. — 2008-09-26

Severe maternal morbidity also known as ‘near miss’ may be a good indicator of the quality and effectiveness of obstetric care, as it may identify priorities in maternal care more rapidly than mortality alone. The objective of the study was to observe the pattern of severe maternal morbidity and its associated factors in a tertiary care hospital in Delhi. All patients admitted to the obstetrics and gynaecology department who fulfilled the definition of severe maternal morbidity conditions were included. A proforma was used to record sociodemographic, obstetric, antenatal care treatment and outcome details. A total of 63 women were included for analysis. The incidence of severe maternal morbidity was 3.3/100 deliveries. The mean age of the patients was 26.3 ± 5 years. More than half (55.5%) were uneducated: almost one-third (32%) were from outside Delhi – the median distance travelled was 10 km. The majority were antenatal admissions (68.3%). The proportion of postdelivery or abortion cases were greater among women who came from outside Delhi. Only 38.1% were registered during the antenatal period. The diagnoses were: eclampsia/pre-eclampsia (35%); haemorrhage (35%); sepsis (13%); obstructed labour (9.5%) and other medical conditions (11%). Severe anaemia was observed in 22% of cases. Only 43.5% were normal vaginal deliveries and 54.5% were delivered by caesarean section or with the use of instruments; 61.3% were live births. Hysterectomy was performed in 14.8%: the proportion of hysterectomy was higher in obstructed labour. Severe maternal morbidity cases constitute a significant burden on health resources.

Maternal morbidity during postpartum period in a village of north India: a prospective study

Patra, S., Singh, B., Reddaiah, V P — 2008-09-26

This prospective community-based study was conducted in the village of Chhainsa, Haryana, India, in order to discover the incidence and types of postpartum morbidity and the factors associated with the morbidities. The subjects were followed up to 42 days of postpartum with a minimum of three visits; the first visit was within 14 days of delivery and subsequent visits were every 14 days. A first visit was made to 211 women and 174 (82.46%) completed the study. Seventy-four percent reported at least one morbidity and there were 1.75 reported morbidities per woman per postpartum period. Common problems reported were: weakness, lower abdominal pain, perineal pain, abnormal vaginal discharge, high fever, breast problems, excessive vaginal bleeding, etc. There was greater morbidity among women of lower socioeconomic status, parity >4, birth interval >36 months, having a breech or caesarean delivery or a delivery assisted by relatives/neighbours. A significant positive association was found between age and non-maintenance of the ‘five cleans’ during delivery. Seventy-five percent of those who had reported morbidity had taken some action, but only 20% sought help from a qualified doctor and 14% from other health workers.

Childhood cancer in Sudan: 1999-2007

Abuidris, D. O, Ahmed, M. E, Elgaili, E. M, Arora, R. S — 2008-09-26

There is paucity of information on childhood cancer from Sudan with the last studies published more than 20 years ago. This study aims to provide a current picture of childhood cancer in Sudan. Data was obtained from the hospital registry for the period May 1999 to June 2007 on all paediatric patients presenting to the Institute of Nuclear Medicine and Oncology, University of Gezira, Wad Madani, Sudan. There were 322 children with cancer during this time period with a male:female ratio of 1.6:1. Lymphomas (111, 35%), leukaemia (83, 26%) and Wilms' tumour (43, 13%) were the three most common groups of tumours. Thirty percent of all lymphomas were Burkitt's lymphoma; 3.4% of all childhood cancer cases were nasopharyngeal carcinomas.

Conservative management of splenic injury in the tropics

Kuzma, J., Atua, V. — 2008-09-26

We undertook this study in order to determine whether the conservative management of splenic injuries is a safe practice in a low-volume tropical hospital. We evaluated 69 consecutive patients with splenic injury prospectively. The outcome measures were morbidity and mortality rates, overall hospital stay and blood transfusion requirements. Spleen preservation was achieved in 85% (59) of cases. Of the 16 patients who underwent splenic surgery, six had splenorraphy (38%). The overall mortality was 4.3% (3) and the deaths were not related to the conservative management. Our findings suggest that not only is the conservative management of splenic injuries safe, but also that the repair of an enlarged spleen (splenorrhaphy) is safe and feasible in tropical hospital settings. The findings in this study provide further evidence that the conservative management of splenic injury in a tropical hospital without computed tomography scan is a safe practice.

Laparoscopic cholecystectomy in a small rural hospital in Kashmir Valley, India

2008-09-26

This study evaluates the feasibility of performing laparoscopic cholecystectomy in order to reduce the expenditure in a 28-bed sub-district hospital in Kashmir, India. We report on a prospective clinical trail involving patients with gall bladder disease reported to the hospital from June 2005 till May 2007.

A structured training module using an inexpensive endotrainer for improving the performance of trainee surgeons

Mir, I. S., Mohsin, M., Malik, A., Shah, A. Q., Majid, T. — 2008-09-26

Training in minimal access surgery has always been difficult in developing countries with limited resources, non availability of formal animal labs, inaffordability of conventional endotrainers and lack of trained endosurgeons to help the amateurs. It is always difficult to start a new procedure in such places where not only the patients but the orthodox surgical fraternity are reluctant to accept new ideas and newer trends in surgery. After thorough discussions with senior surgeons, the author (who was the only trained endosurgeon to begin with) developed a training policy to train the surgeons over a period of time through various exercises before allowing them to assist him in the actual surgeries. A homemade, inexpensive endotrainer was designed for these exercises. Audio-visual seminars were held in between the training sessions. This training module can be employed by other rural hospitals to improve the skills of surgeons who are new to the art of endosurgery.

The characteristics and causes of pleural effusions in Kumasi Ghana - a prospective study

Afful, B., Murphy, S., Antunes, G., Dudzevicius, V. — 2008-09-26

Fever of unknown origin in the elderly: nine years experience in China

Zheng, M., Lin, H., Luo, S., Xu, L., Zeng, Y., Chen, Y. — 2008-09-26

This is a retrospective study of older patients admitted to the First and Second Affiliated Hospitals of Wenzhou Medical College, China, with a diagnosis of fever of unknown origin. The study took place from January 1998 to December 2006 among 102 patients who fulfilled the criteria. Infections were responsible for 50 cases (49.1%), followed by no diagnosis in 27 (26.5%), miscellaneous in nine (8.8%), neoplasms in eight (7.8%) and connective tissue disease in another eight (7.8%). Mycobacterium TB was the most frequent type of infection diagnosed.

The rise and fall of epidemic Neisseria meningitidis from a tertiary care hospital in Delhi, January 2005-June 2007

Kumar, S., Kashyap, B., Bhalla, P. — 2008-09-26

Meningococcal meningitis is endemic in India. There has been a sudden surge of cases of meningococcal meningitis in 2005 in Delhi. Present study was undertaken to find out changing trends in incidence of this disease from a tertiary care hospital in New Delhi over a period of two and half years. All samples from suspected cases of meningococcal meningitis were subjected to Gram staining, culture and latex agglutination test for detection of Neisseria meningitidis (N.meningitidis). Antimicrobial susceptibility of all isolates was performed using the disc diffusion test. 78.6%, 71.4% and 100% of the samples were positive for N.meningitidis by smear examination, culture and latex agglutination test respectively. Except for resistance to Penicillin and Erythromycin in 8.8% and 5.9%, the isolates were sensitive to the commonly used antibiotics. Using simple, rapid and reliable methods for diagnosis, defining risk factors and continuing surveillance remain important public health goals for the control of meningococcal disease.

Frequency and determinants of the metabolic syndrome in apparently healthy adult Nigerians

Wahab, K. W., Sani, M., Gbadamosi, M., Yandutse, M. — 2008-09-26

Non-communicable disease conditions such as the metabolic syndrome further strain the already insufficient health resources in Africa, where communicable diseases such as malaria and HIV/AIDS are still causing significant morbidity and mortality. We studied the frequency and determinants of the syndrome in apparently healthy Nigerian volunteers in order to provide a basis for the establishment of a prevention programme.

Pigs are the most important animal reservoir for Tunga penetrans (jigger flea) in rural Nigeria

Ugbomoiko, U. S, Ariza, L., Heukelbach, J. — 2008-09-26

We examined the domestic animals and rodents in a community in rural Nigeria. Of the 133 animals examined, 29 (21.8%) were infested, the highest prevalence of infestation and highest parasite load was found in the pigs (prevalence 54.8%, median = nine embedded parasites), followed by dogs (45.5%; median = 4), Rattus rattus (29.4%; median = 2) and Mus minutoides (15.4%; median = 1.5). Of all the tungiasis lesions identified 83% were found in pigs. Our data confirm that tungiasis is a zoonotic disease, and that pigs are its most important animal reservoir in this endemic community.

The mental health consequences of intimate partner violence against women in Agaro Town, southwest Ethiopia

Tadegge, A. D. — 2008-09-26

There are very few population-based studies on the mental health consequences of intimate partner violence (IPV) from Ethiopia. This study was conducted among 510 ‘ever partnered’ women in Agaro Town in February 2007. Mental distress and depression were measured using self-reporting questionnaires and Kessler's Scales. All types of IPV (physical, sexual and emotional abuses) were significantly associated with mental distress and depression. Women who suffered from physical, sexual and emotional abuses were more likely to have mental distress. We recommend using information education communications to educate the community and thereby preventing IPV and the mental health consequences.

Risk perception and water purification practices for water-borne parasitic infections in remote Nepal

Kovalsky, A. N, Lacey, S. E, Kaphle, U. R., Vaughn, J. M — 2008-09-26

This study assesses water-borne infection risk perception and water boiling habits in a remote Sankhuwasava region of Nepal using a brief interview-style questionnaire. All subjects were aware of the risks associated with drinking unpurified water, but a majority (65%) reported they did not boil water regularly, and almost 60% of villagers interviewed had history of infection despite their boiling practices. In contrast to reports from other communities in Nepal, risk awareness was sufficient in this region. Water boiling alone did not confer protection. Future efforts should target sanitation, screening, and other sources of contamination.

Incidence of skeletal deformities in endemic fluorosis

A, S., M, K., M, B. — 2008-09-26

An investigation was undertaken in three endemic fluorotic areas of Punjab State, India, to assess the prevalence of skeletal deformities. The concentration of fluoride in drinking water varies from 2.3 to 22.5 mg/L. The patients affected with skeletal fluorosis revealed joint pain in both upper and lower limbs, numbing and tingling of the extremities, back pains and knock-knees. Prevalence of skeletal fluorosis was found to be 29% of grade-I, 51% of grade-II and 20% of grade-III and was higher in males (63%) compared with females (37%).

Epidemiology of nosocomial infections in medicine intensive care unit at a tertiary care hospital in northern India

2008-09-26

This prospective observational study describes the rates of nosocomial infections (NI), the sites of infection, the pathogens involved, their antibiogram and the risk factors at a tertiary care hospital in northern India. In 62 of the 182 enrolled patients 95 episodes of NI were recorded (incidence rate 28.6/1000 person days): pneumonia (77%); urinary tract infection (24%) and blood stream infection (24%). All isolates of Acinetobacter, Pseudomonas and Klebsiella and 83.3% of Escherichia coli were resistant to the third generation cephalosporins. An increased duration of the time spent in intensive care units and days of intervention were associated with incident NI.

Does breast feeding provide protection against acute appendicitis? A case-control study

Alves, J. G. B., Figueiroa, J. N., Barros, I. — 2008-09-26

Breast feeding stimulates a more tolerant lymphoid tissue at the base of the appendix and this could provide protection against acute appendicitis. Two studies reported that children and adolescents with appendicitis were less likely to have been breast fed. In a case-control study of 200 children with histologically confirmed acute appendicitis matched by 200 siblings with the same sex and difference age – up to three-year-old – we found breast feeding in at least the first two months of life and for more than four months provides protection against acute appendicitis. These findings suggesting that breast feeding may possibly give protection against the development of appendicitis.

High-risk behaviours and associated factors among HIV-positive individuals in clinical care in southwest Ethiopia

Deribe, K., Woldemichael, K., Wondafrash, M., Haile, A., Amberbir, A. — 2008-09-26

A hospital-based cross-sectional survey was conducted among 705 HIV-positive individuals. The result showed that 24% of the participants reported unprotected intercourse in their most recent sexual episode. Nine percent of these events were with partners perceived to be HIV-negative and 39% with those of unknown HIV status. Protected sex at recent episode was independently associated with knowing a partner's HIV status, disclosing HIV status to a partner, receipt of antiretroviral treatment and perceiving HIV as less stigmatizing. This highlights the need for interventions among HIV-positive individuals that will assist them in attaining and maintaining safer sex practices.

Osteomyelitis of the ribs: a strategy for prompt diagnosis and effective management

Mohanty, D., Agrawal, V., Jain, B. K., Gupta, R., Rathi, V., Gupta, A. — 2008-09-26

Seven patients were treated for osteomyelitis rib (OR). Discharging sinuses and painful swellings were the presenting symptoms. An initial chest X-ray was unremarkable in all patients. Fine needle aspiration cytology and microscopy of pus did not reveal acid-fast bacillus in any patient. Computerized tomography (CT) of thorax was consistent with the diagnosis of OR in five patients. The patients underwent a subperiosteal excision of the affected part of the ribs or an excision biopsy of the unhealthy granulation tissue. Histopathological diagnosis was consistent with the diagnosis of tuberculosis (TB) OR in six patients. The patients received anti-TB drugs or appropriate antibiotics following surgery. All responded to treatment except one with a non-TB OR, who required further excision of the unhealthy rib ends. Inclusion of a CT of the thorax and an excision biopsy in the diagnostic process facilitates prompt diagnosis and effective management of OR.

A study of clinico-haematological profiles of pancytopenia in children

Gupta, V, Tripathi, S, Tilak, V, Bhatia, B D — 2008-09-26

We report on the clinico-haematological profile of pancytopenia in children from the Departments of Pediatrics and Pathology, Institute of Medical Sciences, Banaras Hindu University, India, over a period of 30 months. Pancytopenia was defined as: haemoglobin <10 g/dL, absolute neutrophil count 1.5 x 10⁹/L and platelet count <100 x 10⁹/L. A detailed history, clinical examination and haematological parameters were recorded. Bone marrow aspiration and trephine biopsy were carried out in all cases. One hundred and five cases aged 1.5–18 years, with a mean age of 8.6 years, were included in the study. Aplastic anaemia was the most common cause of pancytopenia (43%) followed by acute leukaemia (25%). Infections were the third most common cause of pancytopenia of which kala azar was the most common. Megaloblastic anaemia was seen in 6.7%.

Clinical patterns and major causes of infertility among Sudanese couples

Elussein, E. A, Magid, Y. M, Omer, M. M, Adam, I. — 2008-09-26

An understanding of the medical causes of infertility is crucial in order to reduce incidences of Infertility and for improving the clinical management of infertility. Although there were much data on infertility in other African countries, no data exist on infertility in Sudan. Seven hundred and ten Sudanese couples were investigated for the infertility in Khartoum Fertility Center, Sudan: 443 (62.4%) had primary infertility and 267 (37.6%) had secondary infertility. The mean (standard deviation) duration of the infertility was 5.2 (4.3) years. A positive male factor alone was found in 257 (36.2%) couples and a female factor in 350 (49.3%) couples: eleven (1.5%) couples had a combination of male and female factors: and the cause of infertility was unexplained in 92 (13.0%) couples. Oligozoospermia and asthenozoospermia were factors responsible for 16.8% and 17.5% of male infertility, respectively. Failure of ovulation (60.3%) was the most common cause of female infertility. The study revealed a high proportion of secondary infertility and a greater contribution of the female factors to infertility.

Fine needle aspiration cytology in the investigation of breast lumps at the University Teaching Hospital in Lusaka, Zambia

Bowa, K., Jewel, J., Mudenda, V. — 2008-09-26

The study was undertaken to determine the value of fine needle aspiration cytology (FNAC) in the investigation of breast lumps at the University Teaching Hospital (UTH) in Lusaka, Zambia. This technique, which has been shown to be cheap, simple and accurate has not been in common use at this institution. FNAC and open biopsy (OB) were performed on 56 patients who presented with a breast lump and the results compared, in order to determine the accuracy of FNAC. FNAC was found to have a sensitivity of 72% and specificity of 100%. This level of accuracy compares favourably with the quality assurance criteria set for breast FNAC by the Royal College of Pathologists in the British National Health Service (NHS).

The incidence of urinary tract infections in febrile children during a two-year period in Tehran, Iran

Panahi, Y., Beiraghdar, F., Moharamzad, Y., Matinzadeh, Z. K., Einollahi, B. — 2008-09-26

Of 433 febrile children examined in the paediatric clinics of two university hospitals in Tehran, Iran, 39 (9%) children (27 girls and 12 boys) were diagnosed as having urinary tract infection in which Escherichia coli was the most frequently detected pathogen (84.6%). According to the voiding cystourethrogram, nine (75%) boys and 17 (63%) girls had urinary tract abnormalities. This result is slightly higher than seen in other reports from developing countries.

Risk of hepatitis B virus in the slaughter house

Ola, S O, Otegbayo, J A, Yakubu, A, Odaibo, G N, Olaleye, D O — 2008-09-26

The study involved 180 Nigerian butchers and 180 traders (controls) selected by multistage stratified sampling who had their sera assayed for HBsAg (hepatitis B surface antigen) by enzyme-linked immunosorbent assay method. The butchers and the controls had an HBsAg sero-prevalence rate of 9.4% and 3.3%, respectively. Various risky practices were more common among the butchers but their hepatitis B antigenaemia was not related to the duration of their occupational exposure. The study shows that the butchers constitute a high risk occupation for hepatitis B viral infection.

Concomitant TB and cryptococcosis in HIV-infected patients

Rawat, D, Capoor, M R, Nair, D, Deb, M, Aggarwal, P — 2008-09-26

Four cases of concomitant tuberculosis and cryptococcosis infection in HIV-positive patients are described. As the HIV pandemic progresses and the proportion of patients with end-stage disease increases, a high suspicion of incidence and unusual forms of infections must always be kept in mind.

Crimean Congo hemorrhagic fever and diffuse alveolar haemorrhage

Doganci, L., Ceyhan, M., Tasdeler, N. F., Sarikayalar, H., Tulek, N. — 2008-09-26

Although the pathology of Crimean Congo haemorrhagic fever (CCHF) is mainly related to a haemorrhagic process with secondary cytokine storm, there have been no published reports of this fatal disease being a cause of diffuse alveolar haemorrhage (DAH). There are many aetiological factors emphasizing the direct role of endothelial injury on DAH. We present the case of a young adult Turkish man with diffuse bilateral alveolar haemorrhage without an episode of gross haemoptysis caused by the CCHF virus. Successful clinical results and a rapid clinical and radiological clearance were obtained within few days after starting daily oral ribavirin treatment. This fatal infection should be considered to exist in any patient presenting with DAH, and should rapidly be treated with ribavirin. Another very important factor which should always be borne in mind is the contagious character of the CCHF virus. It is one of the most dangerous microorganisms transmitted from person to person. Even the bronchoscopes contaminated with patient blood carry a high risk for nosocomial spread to medical staff and other patients.

Pyomyositis mimicking leptospirosis: two cases in a Brazilian tertiary care hospital in a non-tropical area

Luz, L. P., Dora, J. M., Goldani, L. Z. — 2008-09-26

Pyomyositis is a subacute, deep suppurative bacterial infection of skeletal muscle not arising from contiguous infection. It is presumably haematogenous in origin, and characterized by muscle pain and swelling. We report on two patients who presented with pyomyositis in a tertiary care hospital in temperate region located in southern Brazil with a clinical presentation, which was initially suggestive of leptospirosis. This report discusses the pathogenesis, clinical presentation, diagnosis and management of pyomyositis. Physicians living in non-tropical areas should note that pyomyositis might occur in those areas, and its initial clinical presentation may be similar to leptospirosis

Primary amoebic meningoencephalitis: a new case from Venezuela

Caruzo, G., Cardozo, J. — 2008-09-26

Primary amoebic meningoencephalitis (PAM) is not often seen. To date, less than 300 cases have been communicated to the medical literature since the disease was first discovered in 1965. Six of these reports originated in Venezuela. The authors describe a new spontaneous case of PAM in a 33-year-old previously healthy Western-Venezuelan man.

Childhood epilepsy and school absence

Ibekwe, R. C, Ojinnaka, N. C — 2008-09-26

Epilepsy is one of the most common diseases encountered among school children. Its effect on school attendance and academic performance is a major cause of concern to both parents and clinicians. In this communication, the absence rate and academic performance of 50 school children with epilepsy attending normal schools was compared with that of their age- and sex-matched classmates using the class attendance register and overall score of the 2001/2002 academic year. The mean and standard deviation of the number of days an epileptic child was absent in the 2001/2002 session was 15.3 + 13.8 days while that of the controls was 9.4 + 9.6 days (x2 = 3.4,df = 49, p < 0.001). There was no significant relationship between the rate of absenteeism and overall score among both epileptic children (x2 = 6.34, df = 2, p = 0.18) and the controls (x2 = 1.43, df = 2, p = 0.49). School absenteeism was therefore more common among epileptic children, though there was no observed negative effect of this increased absence on academic performance.

Unforeseen difficulties faced by a hospital in dealing with mass disaster victims

Dhar, S. A., Hamid, A., Khan, S. M. S., Butt, M. F. — 2008-09-26

Every major mass disaster challenges the health care services, especially in the third world. These challenges include the expected situations mainly pertaining to the overload of patients and the stretching of hospital facilities. We report our experiences about several unforseen challenges faced by our hospital in the 2005 earthquake that struck the Kashmir region.