Nigerian Journal of Clinical Practice最新文献

Background: Blood and blood products are life-saving interventions, preventing millions of deaths annually. However, they present ethical and clinical risks from transfusing wrong blood, near misses, and infectious and immunologic risks, which effective hemovigilance systems are designed to prevent. As African countries have a scarcity of such robust surveillance systems, why do hospital transfusion committees (HTCs) that can enable effective hemovigilance remain a rarity?

Aim: We aimed to assess the status, barriers, and opportunities for functional HTCs in Nigeria to improve national hemovigilance systems and blood transfusion outcomes.

Methods: A mixed-methods research study was undertaken, with quantitative data collected using interviewer-administered questionnaires and in-depth group and individual interviews. These were audio-recorded, transcribed verbatim, and inductive thematic analysis was undertaken to identify key themes.

Results: Ninety-eight health facilities across all 23 local government areas in Rivers State were assessed quantitatively, and 128 blood transfusion practitioners were assessed qualitatively. Routine reporting of blood transfusion adverse events occurred in 56.7% of facilities, whereas only 33.3% conducted audits. Only 12.5% of facilities had functional HTCs. Practitioners' responses revealed poor management commitment, blame culture, inadequate training on documentation and recognizing adverse events, limited funding, and heavy staff workload.

Conclusion: Effective hemovigilance in Nigeria remains challenged, and findings underscore the need for national mandates standardizing HTC operations. Developing adequate reporting and auditing systems that enhance blood safety requires exploring hindrances to functional HTCs. Vital approaches include high-level government and management commitment, resource mobilization, staff training, blame avoidance, and technology-enabled systems that alleviate task burdens on transfusion personnel.

Background: Muscle-invasive bladder cancer (MIBC) is associated with poor survival outcomes despite radical cystectomy (RC), creating a clinical need for simple and reliable prognostic biomarkers.

Aim: The CALLY index, a composite biomarker derived from serum C-reactive protein (CRP), albumin, and lymphocyte counts, reflects systemic inflammation, nutritional status, and immune function. Its prognostic utility in MIBC has not been fully elucidated. To evaluate the prognostic value of the CALLY index in predicting overall survival (OS) and disease-free survival (DFS) in patients undergoing RC for non-metastatic MIBC.

Methods: In this retrospective cohort study, 134 patients who underwent RC for non-metastatic MIBC between February 2014 and January 2024 were included. Patients who received neoadjuvant chemotherapy, had secondary malignancies, or active infections were excluded. The CALLY index was calculated as follows: (Albumin [g/dL] × Lymphocyte count [10⁹/L])/CRP [mg/dL] ×10⁴. Kaplan-Meier and receiver operating characteristic curve analyses were used to evaluate survival outcomes and the predictive performance of the index.

Results: Patients with a CALLY index of ≥1.33 had significantly longer OS (median 62 vs. 29 months, p < 0.001), and a cut-off of ≥1.11 was predictive of improved DFS (p = 0.004). The index demonstrated moderate discriminative ability (AUC: 0.682 for OS; 0.647 for DFS). CRP and albumin were independent prognostic factors, whereas lymphocyte count was not.

Conclusion: The CALLY index may serve as a valuable prognostic tool in patients with non-metastatic MIBC undergoing RC. Its incorporation into clinical risk stratification models could enhance individualized treatment planning. Prospective studies are warranted to validate these findings.

Background: Down syndrome (DS) also causes serious physiological impairments, musculoskeletal problems, and functional limitations. Especially during and after adolescence, a decrease in aerobic capacity, a tendency toward a sedentary lifestyle, low quality of life, low participation, and an increase in various health risks are observed.

Aim: To examine the anthropometric characteristics, physical performance levels, and quality of life of adolescents with DS and identify their need to better prepare them for healthier adulthood.

Methods: Thirty adolescents with DS and 28 typically developing (TD) peers participated in this study. Anthropometric measurements, lower extremity strength, and physical performance levels were assessed using the 30 secSit-to-Stand Test, timed up-and-go Test, Six-Minute Walking Test, Beighton hypermobility test, and physiological cost index. The Physical Activity Questionnaire for Adolescents (PAQ-A) and the Pediatric Quality of Life Questionnaire-Adolescent Form (PedsQL-A) were administered. Differences between groups were tested using an independent samples t-test. Pearson's correlation coefficient was calculated to examine the relationships between variables. The level of significance was set at P < 0.05.

Results: The study found that 83.33% of adolescents with DS were classified as obese or overweight. Adolescents with DS showed significantly lower lower extremity strength and physical performance levels but higher flexibility. The quality of life, except for emotional functionality, was higher in the TD group across all areas. Body mass index (BMI) in adolescents with DS was positively correlated with the PedsQL-A score and negatively correlated with the PAQ-A.

Conclusion: Targeted interventions are needed to improve physical performance and overall health outcomes of adolescents with DS.

Background: Large tumor size is associated with poor outcomes in patients with hepatocellular carcinoma (HCC). Although some studies have evaluated the treatment response of HCC to transarterial radioembolization (TARE), none of them used radiomics features with machine learning (ML) models in large tumors.

Aim: To assess the performance of ML models using radiomics to predict the treatment response of TARE in large HCC lesions.

Methods: This study included 49 patients with a large (>5 cm) HCC who underwent TARE. Treatment response was determined according to modified response evaluation criteria in solid tumors (mRECIST) criteria from the 3-month follow-up MR examinations. Complete or partial response was categorized as the responder group, while stable or progressive disease was classified as the non-responder group. Segmentation was performed on axial T2-weighted (T2W) and contrast-enhanced (CE) T1-weighted images. Classification learning models were used to create prediction models for TARE response.

Results: Forty-nine patients (9 female, 40 male; mean age 63.58 ± 8.77) were included. None of the clinical, laboratory, and radiologic characteristics except the neutrophil counts showed statistical significance. Radiomics models obtained from CE-T1 and T2W images demonstrated an accuracy rate of 79.6%, while the area under the curve (AUC) rates were 0.92 and 0.77, respectively. The clinical model showed an accuracy rate of 77.6% and an AUC of 0.65. No statistically significant difference was found among all the models (P = 0.092).

Conclusion: ML-based models constructed with radiomics features obtained from MR images before the TARE procedure might predict response in large HCC lesions.

Background: Video-based learning is used in surgical education due to its flexibility and cost-effectiveness. Endoscopic submucosal dissection (ESD) is a technically challenging procedure, and YouTube is an important source of educational videos on this topic. The laparoscopic video educational guide and scoring (LAP-VEGaS) system can objectively evaluate the educational quality of these videos.

Aim: To evaluate the educational quality of the most-viewed ESD videos on YouTube using the LAP-VEGaS score and to examine the relationship between quality and participation metrics.

Methods: On August 01, 2024, the 20 most popular videos were selected based on view count by searching for "endoscopic submucosal dissection" on YouTube. Two independent evaluators scored the videos using LAP-VEGaS (0-18). Videos scoring 9 or higher were classified as high quality (HQ; n = 12), while those scoring below 9 were classified as low quality (LQ; n = 8).

Results: The average number of views for the videos was 20,567 ± 38,269, the time elapsed since upload was 2751 ± 1264 days, the duration was 537 ± 301 s, and the average LAP-VEGaS score was 9.1 ± 5.2. HQ videos were longer (579 ± 295 s vs. 434 ± 190 s; P ≈ 0.08) and had a higher like rate (0.984 ± 0.02 vs. 0.94 ± 0.07; P < 0.05). Strong positive correlations were observed between likes and view rate (r = 0.979; P < 0.001) and video power index (r = 0.984; P < 0.001). Moderate correlations were found between the LAP-VEGaS score and duration (r = 0.515; P = 0.021) and similarity ratio (r = 0.492; P = 0.035).

Conclusion: The educational quality of popular ESD videos is heterogeneous, and unlike the number of views, interaction metrics, such as the like/view ratio and video duration, more reliably reflect educational value. Therefore, objective evaluation tools such as LAP-VEGaS are recommended to facilitate the selection of HQ content by educators and learners.

Background: Pediatric circumcision is a common procedure, and effective pain control is essential for recovery and comfort. The optimal anesthesia technique remains debated.

Aim: To compare the efficacy and safety of sedation-only anesthesia versus sedation combined with local lidocaine infiltration anesthesia in children undergoing circumcision.

Methods: In this prospective study, 140 boys aged 1-6 years were randomly assigned to receive either intravenous sedation alone (Group I) or sedation plus local anesthesia (Group II). Both groups received a standardized sedative regimen: midazolam, propofol, fentanyl, and ketamine. Postoperative pain was assessed at 1 and 3 hours using the FLACC scale. Complications were recorded.

Results: Median FLACC scores at both 1 hour (Group I: 2.0 [0-6], Group II: 2.0 [0-6]) and 3 hours (Group I: 1.0 [0-4], Group II: 1.0 [0-3]) showed no significant difference (P > 0.05). However, local complications such as ecchymosis and edema were more frequent in the group receiving local anesthesia (Group II: 7.1%) compared to the sedation-only group (Group I: 15.7%).

Conclusions: Sedation-only anesthesia using midazolam, propofol, fentanyl, and ketamine provides effective postoperative pain control for pediatric circumcision, with fewer local complications than when combined with local infiltration anesthesia.

Background: Edentulism remains a prevalent condition worldwide, significantly compromising masticatory efficiency, quality of life, and oral health. Various implant-retained and implant-supported prosthetic options have been developed to address mandibular edentulism, yet their biomechanical performance under functional loading remains incompletely understood.

Aim: To compare stress distribution among seven prosthetic designs for the edentulous mandible: two-implant bar and locator overdentures; four-implant bar and locator overdentures; an anterior fixed-posterior removable prosthesis retained with clasps; its precision-attachment variant; and an All-on-Four fixed prosthesis.

Materials and methods: A 3D finite element model of a D2-quality mandible (2-mm cortical, 1-mm mucosa, remaining cancellous bone) was created. Standard implants (4.3×11 mm) and distal-tilted (30°) long implants (4.3×14 mm) were simulated. A 100-N load was applied on the mandibular first molar vertically and obliquely. Literature-based material properties were assigned. Outcomes were implant von Mises stress and cortical bone maximum and minimum principal stresses.

Results: The lowest implant and bone stresses occurred in the anterior fixed-posterior clasp-retained design. Non-rigid connections (bar, locator, clasp) reduced implant stresses compared with precision attachments and fully implant-supported designs. Four-implant overdentures showed higher crestal stress than two-implant counterparts, likely due to greater framework rigidity and distal implant proximity to the load. Precision-attachment hybrid and All-on-Four configurations generated higher stresses at the implant neck and crestal cortical bone. Oblique loading produced higher stresses than vertical across all models.

Conclusion: Within the limits of an idealized, fully osseointegrated FEA, the anterior fixed-posterior clasp-retained prosthesis provided the most favorable stress distribution, supporting consideration of cost-effective, tissue-supported, non-rigid designs for selected mandibular edentulous cases. Increasing implant number did not uniformly reduce stresses; design rigidity and implant position were more influential than implant count. Clinical studies are warranted to validate these simulations.

Background: Thyroid hormones impact cardiac function and structure. Atherosclerosis, heart failure, and cardiac arrhythmias (especially atrial fibrillation) may occur depending on the degree of thyroid dysfunction. Asymmetric dimethylarginine is the main endogenous inhibitor of nitric oxide synthase, and it may increase in cardiovascular pathologies. The carotid intima media thickness is a predictive parameter for cardiovascular diseases.

Aim: This study assessed biventricular systolic and diastolic functions, the carotid intima media thickness, and asymmetric dimethylarginine levels in female adolescents with hypothyroidism.

Methods: The 71 participants were divided into a hypothyroid group (n = 37) and a control group (n = 34). All participants underwent laboratory blood tests (asymmetric dimethyl arginine [ADMA], complete two-dimensional, pulse, and tissue Doppler echocardiography examinations) and carotid intima-media thickness measurements.

Results: The hypothyroidism group had significantly higher total cholesterol (TC), low-density lipoprotein, glucose, homeostasis model assessment of insulin resistance, and ADMA values (0.47 ± 0.03 vs. 0.27 ± 0.03 µmol/L) than the control group. The control group's end-systolic and end-diastolic diameters of the left ventricle were larger, and the study group's ejection fraction was higher, but their ventricular global diastolic function and ventricular masses did not differ. The carotid intima-media thickness was significantly higher in the hypothyroidism group (0.39 ± 0.007 vs. 0.36 ± 0.003 mm). The hypothyroid group's global biventricular systolic and diastolic functions were normal, but the study group's ratio of the mitral peak early diastolic wave to the peak late diastolic wave (E/A) was significantly higher, while the control group had significantly higher tricuspid E/A ratios. The hypothyroid group showed a positive correlation of thyroid-stimulating hormone with TC, low-density lipoprotein cholesterol, and left ventricular ejection fraction, as well as a negative correlation with free thyroxine (r = 0.71, P = 0.01; r = 0.73, P = 0.01; r = 0.69, P = 0.01; and r = -0.58, P = 0.01, respectively).

Conclusions: Hypothyroidism in female adolescents may alter their myocardial geometry and function. Significantly higher asymmetric dimethylarginine levels and carotid intima-media thickness in patients with Hashimoto's thyroiditis may reflect endothelial dysfunction.

Background: C-shaped canals are a complex root canal variation, most frequently observed in mandibular second molars. Their atypical anatomy can make root canal treatment more difficult and may lead to complications if not properly identified. The use of Cone Beam Computed Tomography (CBCT) offers superior visualisation of canals morphology compared to conventional radiography. While the prevalence of C-shaped canals has been reported in various populations, there is limited data regarding their prevalence and configuration in the Malaysian's multiracial population. Understanding these morphological variations is essential for treatment planning and improving clinical outcomes.

Aim: This cone beam computed tomography (CBCT) study aimed to determine the prevalence and configuration of C-shaped canals in permanent mandibular and maxillary second molars among the Malaysian population using the Modified Melton's classification.

Methods: A total of 274 CBCT images involving 605 second maxillary (n = 269) and second mandibular molars (n = 336) were obtained from Oral Radiology Unit, Faculty of Dentistry, Universiti Sains Islam Malaysia. For each tooth, the canal configurations were evaluated at three different levels: 'coronal', 'middle', and 'apical'. The canal configurations were subsequently classified according to the Modified Melton's classification. The prevalence and canal configuration correlation between sex, ethnicities, and tooth positioning were determined using odds ratio (P = 0.05).

Results: The patients' ages ranged from 12 to 72 years old, with a mean age of 29.47 ± 11.53 years. The patients were female (76.6%) with Malays or Bumiputera (78.8%) predominance. The prevalence of C-shaped canals found was 10.1% (n = 44), and all were presented in second mandibular teeth. The most frequent C-shaped canals configuration found was C3-C3-C3 (29.5%). C-shaped canals were presented more likely when the patient is Chinese than other ethnicities with an odds ratio of 3.18 (95% CI, 1.562-6.488; P = 0.001) and in fused roots than multirooted roots (OR = 173.43; 95% CI, 65.077-462.195; P < 0.001). Sex was not associated with the prevalence of C-shaped canals in this study.

Conclusions: The prevalence of C-shaped canals of the mandibular second molar in the Malaysian subpopulation in this study was 10.1% with the most frequent configuration of C3-C3-C3 at 29.5%. The Chinese ethnicities and tooth with fused roots were more frequently associated with the incidence of C-shaped canals. Identification of the C-shaped canal morphology allows the clinician to modify the canal preparation and obturation techniques to obtain a good endodontic treatment outcome, while also preventing any iatrogenic or procedural errors.

Background: Head trauma was the significant public health issue and a common cause of emergency department visits. Cranial computed tomography (CT) was widely used in its evaluation; however, overuse-particularly in mild cases-raises concerns about patient safety and healthcare efficiency.

Aim: This study aimed to evaluate the appropriateness of cranial CT use in head trauma patients, its relationship with Glasgow Coma Scale (GCS) scores, and the prevalence of potentially avoidable imaging.

Methods: This retrospective study included 1,000 patients presenting with head trauma, who underwent cranial CT. Data collected included demographics, trauma mechanism, GCS score, CT findings, and indication for imaging. CT necessity was assessed using the Canadian CT Head Rule and New Orleans Criteria. CTs performed in patients with GCS 13-15, normal findings, and no guideline-based indications were classified as potentially avoidable.

Results: Of all patients, 65% were male, with a mean age of 42.1 ± 20.7 years. Mild trauma (GCS 13-15) was present in 77.5% of cases. Intracranial pathology was detected in 35.9% overall, with higher rates in patients with moderate and severe trauma. Unnecessary CT imaging was found in 57% of all cases, and in 80.2% of mild trauma cases. A statistically significant association was found between lower GCS scores and intracranial findings (P < 0.001).

Conclusion: Cranial CT was often overused in mild head trauma without adherence to clinical guidelines. Promoting the use of decision support tools and raising awareness among clinicians and patients are crucial for reducing potentially avoidable imaging, radiation exposure, and healthcare burden.