Nigerian Journal of Clinical Practice最新文献

Cardiovascular diseases are the leading cause of death globally. As cardiovascular risk factors continuously rise to pandemic levels, there is intense pressure worldwide to improve cardiac care in preventive cardiology, cardio-diagnostics, therapeutics, and interventional cardiology. Artificial intelligence (AI), an advanced branch of computer science has ushered in the fourth industrial revolution with myriad opportunities in healthcare including cardiology. The developed world has embraced the technology, and the pressure not to be left behind is intense for both policymakers and practicing physicians/cardiologists in low to middle-income countries (LMICs) like Nigeria. This is especially daunting for LMICs who are already plagued with a high burden of infectious disease, unemployment, physician burnt, brain drain, and a developing cardiac practice. Should the focus of cardiovascular care be on men or machines? Is the technology sustainable in a low-resource setting? What lessons did we learn from the COVID-19 pandemic? We attempt to zero in on the dilemmas of AI in the Nigerian setting including AI acceptance, the bottlenecks of cardiology practice in Nigeria, the role of AI, and the type of AI that may be adapted to strengthen cardiovascular care of Nigerians.

Background: The isolation of pathogens using bronchoalveolar lavage (BAL) culture or endotracheal aspirate (ETA) culture may enhance the treatment success for secondary pneumonia due to COVID-19, thereby reducing the risk of morbidity and mortality.

Aim: This study aimed to retrospectively analyze the results of BAL and ETA cultures in intubated COVID-19 patients and to determine whether BAL has an advantage over ETA.

Methods: We routinely perform BAL culture via bronchoscopy or ETA culture within the first 48 h after intubation. We retrospectively reviewed cases that underwent BAL and ETA. The patients were divided into two groups: Group B (BAL) and Group E (ETA). Various parameters were evaluated and compared between the two groups.

Results: The demographic data and blood test results were similar between the two groups. However, ICU stay, duration of intubation, and culture positivity were significantly higher in Group B. Although not statistically significant, the mortality rate was higher in Group E. The most commonly isolated microorganisms were Candida species.

Conclusion: The observed mortality rates were consistent with the existing literature. Since the microorganism isolation rate is higher with BAL, leading to more effective antimicrobial treatment, early deaths were prevented, and ICU stay durations were prolonged. Conversely, these durations were shorter in the ETA group due to higher mortality. In intubated COVID-19 patients, a more effective treatment process can be achieved by clearing the airway with fiberoptic bronchoscopy and tailoring the treatment based on BAL culture results. This approach may positively impact prognosis and mortality rates.

Propofol is the most widely used short-acting intravenous anesthetic in clinical practice. Existing studies have shown that propofol has many effects on the cardiovascular system in addition to its anesthetic effect. Propofol can antagonize a variety of tachyarrhythmias and reduce the risk of recurrence, regulate autonomic balance of the heart, modulate circulatory dynamics, thereby increasing blood perfusion to vital organs such as the kidney, intestine, and brain, and exert myocardial protection and cerebral protection during ischemia-reperfusion injury. In this paper, we review the potential mechanisms of these effects and provide and ideas for future research and novel drug development of propofol and its derivatives in cardiac electrophysiology and circulatory dynamics.

Background: The near total absence of routine Hepatitis Delta Virus (HDV) screening in many countries in sub-Saharan Africa is a major challenge to understanding the burden of HDV in the region.

Aim: To evaluate Hepatitis Delta Virus screening practices and associated factors among clinicians in Nigeria.

Methods: A cross-sectional study was conducted in June-July 2022, in which a self-administered questionnaire that inquired about HDV awareness, screening practices, and treatment options was shared electronically with consenting clinicians practicing in Nigeria. At the end of the survey, data was analyzed using descriptive and inferential statistics. The level of significance was set at 0.05.

Results: At the end of the survey, 210 of the 213 responses retrieved from respondents were analyzed. The respondent's mean age was 38.60 ± 7.27 years with a male-to-female ratio of 1:2.5. They comprised 13.8% gastroenterologists and 86.2% respondents in other areas of clinical medicine. The study showed that 89.5% of the respondents knew that HDV infection occurs only in hepatitis B virus (HBV)-infected individuals. Most (91.4%) respondents do not screen for HDV in chronic HBV patients, mainly due to the non-availability of screening tools and lack of awareness of any screening test for HDV. Research interest was reported as the reason for screening among clinicians who had ever screened for HDV. Pegylated interferon was the main regimen used for treatment by 87.5% of respondents. About 2% did not know treatment options for HDV. A significant association between knowledge of HDV infection and area of specialty, as well as the nature of medical practice was noted (P = 0.008 and 0.013, respectively).

Conclusion: The study showed a high level of awareness of HDV dependency on HBV, for natural infection to occur. However, it documented very minimal HDV screening in clinical settings and factors affecting screening among clinicians.

Background: Aim to investigate the prognostic value of neutrophil to lymphocyte ratio (NLR) at the time of diagnosis, which is an inexpensive and easily accessible parameter, compared to factors known as prognostic value (such as R-IPI and NCCN-IPI) in patients with diffuse large B-cell lymphoma (DLBCL).

Aim: Prognostic value of NLR at diagnosis in DLBCL.

Methods: A hundred (100) newly diagnosed DLBCL patients were included. The correlations between the NLR with clinical characteristics, treatment response, and survival were analyzed. The NLR cut-off value was taken at 3.5 accordıng to the receiver operating characteristic curve.

Results: There were 53 patients with an NLR of 3.5 and 47 patients with an NLR < 3.5. Patients with NLR ≥ 3.5 had a complete response (CR) rate of 66.0% (n = 31/47), and patients with NLR < 3.5 had a CR rate of 98.1% (n = 51/52). The median progression-free survival (PFS) was 132.5 months (95%CI 103.1-162.0). PFS in the NLR ≥ 3.5 group (36 months) was significantly (P < 0.000) shorter than in the NLR < 3.5 group (185 months). The median overall survival (OS) for NLR ≥ 3.5 and NLR < 3.5 was 79.2 months (95% CI 51.6-106.8) and 197.8 months (95% CI 173.2-222.5), respectively. NLR ≥ 3.5 was associated with worse OS than NLR < 3.5 (P = 0.000). The high value of NLR (≥3.5) had lower treatment response rates, higher relapse, and death rates.

Conclusion: High NLR was associated with poor treatment response, PFS, and OS. NLR can be used as a cost-effective and easy-to-interpret prognostic marker in DLBCL patients.

Background: A new design, the Biblock appliance, was developed for the functional treatment of Class II malocclusions.

Aim: To compare the effects of Biblock appliance (BA) and Activator appliance (AA) on the skeleton, dentoalveolar, and soft tissue in Class II malocclusions.

Methods: Thirty-five patients with mandibular retrognathia caused by skeletal Class II malocclusion and normodivergent growth pattern were included in this study. After selecting the BA group (n = 17, 8 boys and 9 girls, mean age = 12.08 ± 0.37 years), we selected the active control group treated with AA (n = 18, 9 boys and 9 girls, mean age = 12.3 ± 0.27 years), which matched the BA group's development and gender. All patients were between PP2 = DP3u periods according to hand-wrist maturation. Cephalometric variables related to the skeletal, dentoalveolar, and soft tissue were measured.

Results: Treatment duration was 18.17 ± 1.45 months with BA and 16.92 ± 1.09 months with AA. Skeletal Class II malocclusion improved significantly in both groups. In the compared groups, the increase in ANS-Me was significantly higher in the AA group (P < 0.05). The Cd⊥SN and S-Cd increase in the compared groups was significantly higher in the BA group (P < 0.05). There was no significant difference in measurements between the groups in skeletal, dentoalveolar, and soft tissue measurements (P > 0.05).

Conclusion: The effects of AA, an appliance accepted by the orthodontic community, and BA, a new design, on the skeletal, dentoalveolar, and soft tissue were similar.

Background: Positive T-wave polarity in the augmented vector right lead (Tw-aVR) and ST-segment deviation in the augmented vector right lead (STaVR) have been identified as potential predictors of adverse outcomes in various cardiac conditions.

Aim: The aim of the study was to examine the effect of positive Tw-aVR and STaVR on in-hospital mortality after coronary artery bypass grafting (CABG) surgery in patients with heart failure with reduced ejection fraction (HFrEF).

Methods: A five-year retrospective study was conducted on 250 HFrEF patients who underwent CABG at a tertiary care hospital between January 2018 and December 2022. The primary outcome was in-hospital mortality, and the main exposures were positive Tw-aVR and STaVR on preoperative electrocardiograms. Logistic regression models were used to assess the factors associated with in-hospital mortality.

Results: Two hundred and fifty patients with a mean age of 67.4 ± 8.1 years were studied. Males constituted 68% of the participants. Among the participants, 60 (24%) had positive Tw-aVR, and 96 (38.4%) had STaVR. The overall in-hospital mortality rate was 7.6%, and patients with positive Tw-aVR and STaVR had significantly higher mortality rates than those without (odds ratio: 3.62 and 2.87, respectively, P < 0.01). These associations remained significant even after controlling for potential confounders such as age (adjusted odds ratio [AOR]: 1.11; 95% confidence interval [CI]: 1.03-1.20; P = 0.008), sex (AOR: 0.82; 95% CI: 0.31-2.18; P = 0.684), diabetes mellitus (AOR: 2.12; 95% CI: 0.88-5.12; P = 0.091), and chronic kidney disease (AOR: 1.79; 95% CI: 0.75-4.27; P = 0.194).

Conclusion: Positive Tw-aVR and STaVR were found to be associated with in-hospital mortality in HFrEF patients after CABG. These findings suggest that identifying patients with positive Tw-aVR and STaVR may help identify those at higher risk of adverse outcomes and facilitate closer monitoring and more aggressive interventions.

Background: Positive end-expiratory pressure (PEEP) is a crucial component of mechanical ventilation to improve oxygenation in critically ill patients with respiratory failure. The interaction between abdominal and thoracic compartment pressures is known well. Especially in intra-abdominal hypertension, lower PEEP may cause atelectotrauma by repetitive opening and closing of alveoli.

Aim: In this study, it was aimed to investigate the effect of PEEP adjustment according to the intra-abdominal pressure (IAP) on oxygenation and clarify possible harms.

Method: Patients older than 18 were mechanically ventilated due to hypoxemic respiratory failure and had normal IAP (<15 mmHg) included in the study. Patients with severe cardiovascular dysfunction were excluded. The following PEEP levels were applied: PEEPzero of 0 cmH2O, PEEPIAP/2 = 50% of IAP, and PEEPIAP = 100% of IAP. After a 30-minute equilibration period, arterial blood gases and mean arterial pressures were measured.

Results: One hundred thirty-eight patients (mean age 66.5 ± 15.9, 56.5% male) enrolled on the study. The mean IAP was 9.8 ± 3.4. Seventy-nine percent of the patients' PaO2/FiO2 ratio was under 300 mmHg. Figure 1 shows the change in PaO2/FiO2 ratio, PaCO2, PPlato, and MAP of the patients according to the PEEP levels. Overall increases were detected in the PaO2/FiO2 ratio (P < 0.001) and Pplato (P < 0.001), while PaCO2 and MAP did not change after increasing PEEP gradually. Pairwise analyses revealed differences in PaO2/FiO2 between PEEPzero (186.4 [85.7-265.8]) and PEEPIAP/2 (207.7 [101.7-292.9]) (t = -0.77, P < 0.001), between baseline and PEEPIAP (236.1 [121.4-351.0]) (t = -1.7, P < 0.001), and between PEEPIAP/2 and PEEPIAP (t = -1.0, P < 0.001). Plato pressures were in the safe range (<30 cmH2O) at all three PEEP levels (PEEPzero = 12 [10-15], PEEPIAP/2 = 15 [13-18], PEEPIAP = 17 [14-22]).

Conclusion: In patients with acute hypoxemic respiratory failure and mechanically ventilated, PEEP adjustment according to the IAB improves oxygenation, especially in the settings of the limited source where other PEEP titration methods are absent.

Background: Prolonged perinatal asphyxia (PA) may cause hypoxic-ischemic damage to the brain. The aim of this study was to investigate the brain diffusion changes of patients with PA and examine the relationship with brain damage.

Methods: This retrospective study included 55 patients diagnosed with PA, separated into mild and severe PA groups. For the evaluation of brain damage in all the study neonates, brain and diffusion MRI scans were performed using a 3T device. The scans were taken between 5 and 10 days postnatal, after completion of hypothermia treatment, in accordance with the standard clinical protocol of our institution. Apparent diffusion coefficient (ADC) values of the lentiform nucleus, thalamus, frontal white matter, and posterior limbs of the internal capsule were measured. Minitab package programs and SPSS version 20.0 software were used for statistical analysis and graphic drawing. Spearman's rank correlation analysis was used.

Results: The bilateral lentiform nucleus, thalamus, frontal white matter, and posterior limbs of the internal capsule ADC values were significantly higher in the severe PA group than in the mild PA group.

Conclusions: In neonates with severe perinatal asphyxia, brain damage can be evaluated on diffusion-weighted imaging (DWI) of the cerebral deep white matter and basal ganglia. DWI, imaging with conventional brain MRI comes to the fore in clinical importance in PA patients.

Background: The nasal cavity and paranasal sinuses are one of the most frequently anatomically varied regions. Their size and shape vary from person to person, and ethnic origin may have a role in this variety. Recognizing this variations is so important for ear nose throat (ENT) specialists because they predispose to sinonasal pathologies and affect the complication rate and success of endoscopic sinus surgery.

Aim: This study aimed to determine the frequency of sinonasal anatomic variations on paranasal sinus computed tomography (CT) in the Turkish population.

Methods: Patients who had undergone paranasal sinus CT with any complaints between 2013 and 2020 and aged over 18 years were included in the study. A total of 1209 patients who had undergone paranasal sinus CT were examined for coronal, axial, and sagittal plans retrospectively by two ENT professionals, and anatomical variations were evaluated. To assign the frequency of anatomic variations in a healthy population, patients who had previously undergone paranasal sinus and nasal surgery, who had nasal polyposis, and for whom CT evaluation was not possible due to intense sinusitis were excluded from the study.

Results: Among 1209 patients, 644 were male and 565 were female. The mean age of the patients was 33.7 years. The most common sinonasal anatomical variations were nasal septal deviation and agger nasi cells, while the least common variation is the supreme turbinate. No variation was found in 48 (3.9%) CTs.

Conclusion: Almost all patients had at least one sinonasal anatomical variation. These variations should be known by the professionals who have interest in sinonasal disease and surgery.