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   Table of Contents - Current issue
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January-March 2020
Volume 27 | Issue 1
Page Nos. 1-66

Online since Tuesday, January 14, 2020

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REVIEW ARTICLES  

Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa p. 1
Victor Alangibi Kiri, Aaron C Ojule
DOI:10.4103/npmj.npmj_141_19  PMID:32003355
Pubic health insurance schemes are usually set up by governments to provide cover for their insured populations against healthcare costs. These schemes are usually administered by a government agency and vary both in how they are funded and provide their services. A number of developing countries have introduced such schemes to minimise the impact of financial barriers to healthcare access by their populations. These schemes are expected to bridge the inequality in healthcare. A National Health Insurance Scheme has been in operation in Nigeria since 2005 to provide health cover for government employees and those in private institutions with no less than ten workers. There are similar schemes in a number of countries in sub-Saharan Africa. We conducted a literature review of publications on public health insurance schemes in sub-Saharan Africa to identify the challenges they encounter. We found 76 relevant publications. Although much have been published on these schemes, few have addressed the critical obstacles to effective implementation, management and sustenance in the unique environments we find in sub-Saharan Africa – where poor technological infrastructures, acts of forgery, counterfeiting and other forms of fraud are common. We highlight these challenges, using the scheme in Nigeria for reference. We discuss the potential role of robust electronic medical record (EMR) systems for sustainable schemes in such environments and describe some of the ways robust EMR systems could be used to mitigate the challenges posed by most of the peculiar problems associated with poor infrastructures.
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Genetic diversity of human immunodeficiency virus-1 in Nigeria: 2002–2017 – systematic review and meta-analysis p. 8
Mohammed Ibrahim Tahir, Maryam Aminu, Babangida Ahmed Suleiman, Ahmed Saraja Opaluwa, Abdurrahman El-Fulaty Ahmad
DOI:10.4103/npmj.npmj_64_19  PMID:32003356
Nigeria was ranked second highest country with human immunodeficiency virus (HIV) burden worldwide. HIV-1 subtypes and circulating recombinant forms genetic variability affect the protease and reverse transcriptase genes which code for viral enzymes and are the main targets for antiretroviral drugs. Therefore, this study was aimed at reviewing and pooling such HIV-1 subtypes in Nigeria to represent the collective prevalence of each subtype. Studies of HIV-1 subtypes in Nigeria published from 2002 to 2017 were retrieved and synthesised from different sources electronically. Sixteen studies were included for random effect meta-analysis for various subtypes in each study. The pooled prevalence was charted in forest plot and effect estimates from individual studies against some measure of study size or precision were presented in funnel plots. The pooled prevalence of Subtype G, CRF02_AG, CRF06_cpx, Subtype A and Subtype C were 38.27% (95% Confidence Interval [CI]: 21.27%- 55.98%), 37.81% (95% CI: 20.37%- 55.25%), 6.6% (95% CI: 7.10%-7.10%), 14.05% (95% CI: 9.06% - 19.04%) and 2.80% (95% CI: 2.70%- 8.30%) respectively. This study suggests HIV-1 subtypes G, CRF02_AG and A are the most prevalent in Nigeria.
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ORIGINAL ARTICLES Top

Comparative study of endoscopic band ligation versus injection sclerotherapy with 50% dextrose in water, in symptomatic internal haemorrhoids p. 13
Adekunle Adedapo Abiodun, Olusegun Isaac Alatise, Chukwuma Eze Okereke, Abudul-Rashid Kayode Adesunkanmi, Emmanuel Adewale Eletta, Alexander Gomna
DOI:10.4103/npmj.npmj_128_19  PMID:32003357
Background: Haemorrhoids are common anorectal conditions seen in surgical practice, with various treatment modalities. This study compared the short-term outcome of injection sclerotherapy with 50% dextrose in water and rubber band ligation in the management of second-and third-degree haemorrhoids, in terms of symptoms improvement, complications, recurrence rate, retreatment rate and acceptability. Methodology: This was a prospective comparative study that was carried out in the endoscopic unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, in southwestern Nigeria. Sixty consecutive patients with second- and third-degree haemorrhoids, who consented, were recruited into the study and were randomised into two groups. Group A had endoscopic injection sclerotherapy and Group B had endoscopic rubber band ligation. Results: With regard to anal protrusion, more patients consistently reported either complete (16 [64.4%]) or partial (9 [40.9%]) resolution of symptoms in Group B, compared to Group A which had 7 (28.0%) and 5 (22.7%) cases, respectively (P = 0.03). Resolution of anal bleeding was initially more in Group B than A (22 [95.7%] vs. 17 [77.3%] patients, respectively), in the first 24-h post-treatment; however, within the 1st week, this ratio was reversed (P = 0.07). The retreatment rate for Group A and B was 23.3% and 13.3%, respectively,P = 0.34. More patients in Group B experienced severe pain post-treatment compared to Group A (P = 0.01). Three-month post-treatment, two (11.8%) patients in Group A and one (4.5%) in Group B had recurrence of anal bleeding (P = 0.42). There was no recurrence in anal protrusion in both treatment groups. Conclusion: Endoscopic rubber band ligation had a significantly higher success rate than endoscopic injection sclerotherapy, in terms of resolution of anal protrusion, but with higher pain score.
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Naturalistic clinical and psychosocial outcome of incident cases of schizophrenia in Enugu Federal Psychiatric Hospital: A preliminary report at 4-month follow-up p. 21
Justus Uchenna Onu, Jude Uzoma Ohaeri
DOI:10.4103/npmj.npmj_127_19  PMID:32003358
Introduction: Longitudinal outcome studies based on incident and predominantly neuroleptic-naïve cases of schizophrenia are uncommon in the modern literature. Aims: To determine the proportion of persons with schizophrenia with different levels of clinical and functional outcome at monthly intervals of naturalistic treatment follow-up for 4 months: response, remission and recovery; and to examine the predictors of outcome. Subjects and Methods: Consecutive incident cases that fulfilled stringent criteria for schizophrenia were recruited into the study. After a baseline assessment, 160 incident cases of schizophrenia were followed up 4-weekly for indicators of symptomatic and functional outcome for 16 weeks. Standard rating scales were used to assess clinical and functional outcome. Sociodemographic and clinical variables were evaluated as predictors of outcome using multiple regression analysis. Results: The attrition rate at week 16 was 29.4%; hence, 113 subjects (out of 160) were available for assessment at the end of follow-up. Of the 113, 66.4%, by Brief Psychiatric Rating Scale (BPRS), met criteria for response (i.e., >50% reduction), while 20.3% could be judged to be clinically non-responsive to treatment (i.e., <20% decrease). Also, 60.2%, by BPRS, met the criteria for remission, while 44.5% met the criteria for recovery. The most important predictor, at week 16, of clinical and psychosocial outcome was social support (48.7%–51.8% of variance). Conclusion: Although as a preliminary report, the present findings are hypothesis-generating, the implication of the results is that, as a group, over a 4-month period of modern hospital treatment, schizophrenia patients who were incident cases progressively experienced significant reduction in psychopathology. The findings, therefore, support earlier international cross-cultural reports of relatively good clinical outcome from developing countries, thereby encouraging the idea of treatment optimism in schizophrenia in Africa.
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Antipsychotic prescription and polypharmacy among outpatients with schizophrenia in a Nigerian hospital p. 30
Ihechiluru Goodnews Anozie, Bawo O James, Joyce O Omoaregba
DOI:10.4103/npmj.npmj_93_19  PMID:32003359
Background: International guidelines recommend antipsychotic monotherapy as the ideal treatment option in pharmacotherapy for schizophrenia, though this yields modest outcomes in a third of patients. Antipsychotic polypharmacy (APP) has been tried in many patients with schizophrenia to improve outcomes in those with poor treatment response. Objectives: This study examined the pattern of antipsychotic prescription and polypharmacy among outpatient attendees with schizophrenia in a Nigerian psychiatric hospital. Methods: A cross-sectional study of 320 attendees with schizophrenia at the consultant outpatient department was undertaken. We administered a socio-demographic questionnaire, antipsychotic medication and health questionnaire to record the general health indices and the prescribed antipsychotic medication of participants and the Mini-International Neuropsychiatric Interview (MINI) Version 6.0 (psychosis module). Results: Oral second-generation antipsychotics (SGAs) monotherapy was most commonly prescribed. The prevalence of APP was 50.9%. Participants on simultaneous anticholinergic agents (P < 0.001), a twice-daily antipsychotic dosing interval (P < 0.001,) alcohol use (P = 0.02), antidepressant use (P = 0.02) and a current episode of schizophrenia on the MINI (P < 0.001) were more likely to be on an APP regimen. Conclusion: Although a preference for SGA monotherapy was observed, the prevalence of APP remained high. Clinicians, therefore, should be cautious regarding the clinical utility of APP and discourage its persistent use.
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Clinical, morphologic and histological features of chronic pyelonephritis: An 8-year review p. 37
Babatunde Lawrence Ademola, Akinfenwa T Atanda, Sani A Aji, Aliyu Abdu
DOI:10.4103/npmj.npmj_109_19  PMID:32003360
Background: Urinary tract infection (UTI), especially pyelonephritis when inadequately treated may culminate in end-stage renal disease. The study aims to evaluate the risk factors for and clinico-pathologic features of chronic pyelonephritis (CPN) among patients in Aminu Kano Teaching Hospital, Kano, in North-Western Nigeria. Materials and Methods: Data on cases diagnosed as CPN between 2010 and 2017 in the study centre were retrieved from archives and analysed for risk factors and clinic-pathologic features. Results: Forty-three cases of CPN were diagnosed in the study period and comprised 24 males and 19 females, with a male: female ratio of 1.3:1. The ages ranged from 3 to 80 years with a mean age of 37.0 ± 19.6 years. Urinary tract obstruction, poorly treated UTI, HIV infection and polycystic kidney disease were the risk factors in 21 (49%), 15 (35%), 6 (14%) and 1 (2%) cases, respectively. Proteinuria was seen in 10 (23.3%) of the patients, hypertension in 7 (16.3%) and haematuria in 3 (7.0%) of cases. Nephrectomy was done in 17 (39.5%) of the 43 CPN cases, indications for surgery were pus-filled, non-functioning kidneys. The diameters of the removed kidneys ranged from 10 to 28 cm and they weighed between 140 g and 2500 g. Scarring, reported in 79.0% of patients, was the most common pathological finding, followed by pus casts in 48.8% and focal segmental glomerulosclerosis in 27.9%. No statistically significant difference was found between age or gender and aetiology or risk factors of the disease (P > 0.05). Conclusion: CPN with pus-filled and non-functioning kidneys is a common indication for nephrectomy. Urinary tract obstruction, poorly treated UTI, and HIV infection were major risk factors seen in this environment. To prevent this complication there is a need for better training of clinicians in the diagnosis and adequate treatment of UTI.
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Choices and determinants of delivery location among mothers attending a primary health facility in Southern Nigeria p. 42
Ofonime Effiong Johnson, Precious Chizaram Obidike, Miriam Uzezi Eroh, Abasiono Augustine Okpon, Emmanuel Imeh Bassey, Paschal Christodiong Patrick, Princewill Edet Ebong, Emmanuel Ojumah
DOI:10.4103/npmj.npmj_150_19  PMID:32003361
Background: The delivery locations of pregnant women contribute greatly to their birth outcome. The objectives of this study were to determine the choices and determinants of delivery locations among mothers attending a primary health centre (PHC) in southern Nigeria. Research Methodology: This was a descriptive cross-sectional study among mothers attending PHC, West Itam, Itu, Nigeria. Data were collected using interviewer-administered questionnaire and analysed with STATA version 12.0. Level of significance was set at 0.05. Results: A total of 185 mothers participated in the study. The mean age of respondents was 27.6 ± 5.2 years. The delivery locations of last pregnancy were health facility (64.9%), traditional birth attendant's place (23.3%), respondent's residence (6.3%) and church (5.4%). The top five reasons that influenced the choice of delivery locations were distance (45.4%), cost (34.6%), skills of healthcare workers (30.3%), drug availability (27.6%) and attitude of healthcare workers (26.5%). Utilisation of healthcare facilities for delivery increased significantly with level of education and income of respondents and spouses (P < 0.05). Conclusion: Different non-institutionalised delivery locations were utilised by some of the respondents. Factors influencing women's choices of delivery locations included distance, cost and attitude of health workers. It is recommended that pregnant women be offered free or highly subsidised healthcare services to encourage their delivery at health facilities. Healthcare providers should endeavour to develop better relationship with clients who patronise their services. Female education should also be encouraged as this would empower them to make better choices about their health services options.
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Lower urinary tract symptoms in patients with advanced prostate cancer: What are the outcomes of androgen deprivation therapy? p. 49
Idorenyin Cletus Akpayak, Samaila I Shuaibu, Chimaobi G Ofoha, Nuhu K Dakum, Venyir M Ramyil, Victor E Onowa, Christian A Agbo, Lemech E Nabasu, Zingur Z Galam
DOI:10.4103/npmj.npmj_146_19  PMID:32003362
Background: Androgen deprivation therapy (ADT) is accepted as the first-line treatment of advanced prostate cancer. This study sets out to determine the outcomes of ADT in reducing lower urinary tract symptoms (LUTS) in patients with advanced prostate cancer and also to determine the quality of life (QoL) of the patients. Patients and Methods: This was a prospective study carried out at Jos University Teaching Hospital. All consecutive patients who had LUTS due to advanced prostate cancer were recruited into the study. All patients completed the international prostate symptom score (IPSS) questionnaire, including QoL assessment. Post-void residual (PVR) urine, maximum flow rate (Qmax), prostate specific antigen and total prostate volume (TPV) were assessed. The parameters before and at 12 months were compared. Results: Data from 65 patients were analysed. The mean age of the patients was 68.5 ± 8.67 years with an age range of 46–85 years. Four (6.2%) had mild LUTS before AD, and their symptoms remained mild at 12 months of ADT. Twenty-two (33.9%) patients had moderate urinary symptoms. Of this, 10 (18.5%) patients had symptomatic improvement at 12 months of ADT. Of 39 (60%) patients who presented with severe LUTS, 21 (32.3%) had improvement at 12 months of ADT. Before ADT and at 12 months of ADT, the mean IPSS score, mean TPV, Qmax, PVR and mean QoL score were 23 ± 8.8 and 15 ± 8.8 (P < 0.0001); 79.7 ± 51.4 and 73.4 ± 34.3 (P = 0.212); 8.0 ± 4.7 and 11.2 ± 4.4 (<0.001); 209.8 ± 127.8 and 163 ± 111.4 (<0.001); 4.23 ± 1.2 and 3.24 ± 1.2 (P < 0.001), respectively. Of the 39 patients (60%) with severe urinary symptoms, 18 (27.7%) of patients had urethral catheterization for either acute or chronic urinary retention before ADT. At 12 months on ADT, eight patients (12.3.7%) were still on catheter due to failed attempts at trial without catheter. Conclusion: ADT significantly improves urodynamic parameters, IPSS score and IPSS-related QoL. There remains a subset of patients, in whom LUTS persist with negative effects on QoL.
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Feasibility study of prospective audit, intervention and feedback as an antimicrobial stewardship strategy at the Lagos University Teaching Hospital p. 54
Alero Ann Roberts, Iretiolu Fajolu, Philip Oshun, Chioma Osuagwu, Opeyemi Awofeso, Edamisan Temiye, O Oyin Oduyebo
DOI:10.4103/npmj.npmj_115_19  PMID:32003363
Background: Antimicrobial resistance, a global problem, is mostly a consequence of misuse or overuse of antimicrobials. This study sought to audit the compliance to hospital antimicrobial policy and determine the ability of medical students to carry out audits. Methodology: This was a retrospective study to determine compliance with departmental policies in the preceding 2 months in the Children's Emergency Room (ChER) using a checklist. The primary outcome was to determine the rational use of antibiotics. The secondary outcomes were to determine whether the de-escalation of antibiotic, change from intravenous to oral or change in prescriptions were performed in line with culture results based on the departmental policy. Results: The records of 450 children who attended ChER of Lagos University Teaching Hospital in January and February 2018 were retrieved for this study, of which 279 (62.0%) were prescribed antimicrobials. A suspected or confirmed diagnosis of infection was made in 214 (76.6%) of the patients, significantly highest in the infant age group (P = 0.03). Cultures were taken from 94 patients (33.7%), and although not statistically significant, cultures were mostly taken from neonatal patients aged <28 days (20/49, 40.8%). Applying the criteria, compliance with departmental guidelines was found in 111 (39.8%) of the cases. Conclusion: We found that the use of antimicrobials was judged unnecessary in 17.2% of the patients seen in ChER. There was a poor practice of collecting samples for culture before prescribing antibiotics. Prospective audit and feedback is feasible and it can be done with medical students who will report their findings to consultants and other doctors knowledgeable in principles of antimicrobial therapy.
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CASE REPORTS Top

My flanks aches: Emphysematous pyelonephritis in a newly diagnosed case of diabetes mellitus p. 59
Bolanle Olajumoke Okunowo, Olubukola Abeni Omidiji, Emmanuel Ajibola Jeje, Olufemi Adetola Fasanmade
DOI:10.4103/npmj.npmj_162_19  PMID:32003364
Emphysematous pyelonephritis (EPN) is a rare, severe necrotising infection of the renal parenchyma and surrounding tissues. It is usually life-threatening and should be promptly treated. Here, we report a clinical case of a 54-year-old male who presented with the left flank pains of 3-week duration. The flank pain was described as dull, constant with associated fever. He was diagnosed with diabetes mellitus (DM) while on admission. A clinical diagnosis of the left pyelonephritis was made. The abdominopelvic computed tomography scan confirmed bilateral EPN by showing a thin film of perinephric fluid (13.2 ml) in the left lower pole. He was managed conservatively with fluid therapy, adequate glycaemic control and intravenous antibiotics with no percutaneous drainage done. This highlights the importance of early initiation of appropriate medical treatment to avoid interventional urological procedures of nephrectomy. It also highlights the importance of clinical suspicion of EPN in patients presenting with symptoms of urinary tract infection and DM.
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The role of immune restoration using highly active antiretroviral therapy in the management of AIDS-related Kaposi's sarcoma coexisting with pulmonary tuberculosis p. 63
Umar Abdullahi, Mukhtar Abdulmajid Adeiza
DOI:10.4103/npmj.npmj_102_19  PMID:32003365
A 35-year-old highly active antiretroviral therapy (HAART)-naïve woman diagnosed 2 years earlier presented with complaints of cough, fever and progressive weight loss of 5 months and skin rashes of 2 months. Clinical examination revealed a chronically ill-looking young woman who was wasted and pale, with purplish flat-topped papules and nodules on the skin of her neck, trunk, forearms and thighs. She also had a single lesion on the hard palate. Chest examination shows reduced breath sounds with crepitations. Sputum acid-fast bacilli were positive, and skin biopsy taken for histology confirmed Kaposi's sarcoma (KS). The patient recovered fully on antiretroviral and antituberculosis therapy without the need for any specific chemotherapy for KS. We report this case to elucidate the role of immune reconstitution as a treatment modality for AIDS-related KS, as well as to point out the possibility of multiple opportunistic conditions coexisting amongst patients with advanced HIV disease.
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