Evaluation of antimalarial chemotherapeutic practices and outcomes in the southwest region of Nigeria

With over 100 million cases of morbidity annually worldwide; control, elimination and eradication of malaria still remains a major challenge, particularly in sub-Saharan Africa. In some endemic countries, aggressive malaria control has reduced the malaria burden to a point where malaria elimination is becoming feasible. Nevertheless, sustained malaria control is crucial to prolong this downward trend for endemic countries. A major factor that affects the effective treatment of malaria is the lack of awareness of the recommended treatment guidelines and standardised protocols to routinely decipher the quality of the available drugs in the regions. Nigeria bears more than a quarter of the global burden of malaria, with 97% of the population at risk of the disease. The high rate of counterfeit and substandard drugs in Nigeria is therefore a barrier to effective case management of malaria. Therefore, this project proposes to qualitatively and quantitatively analyse chemotherapeutic practices and outcomes at an individual and community level in two selected states (Lagos and Osun) in the South West Region of Nigeria, in a bid to define barriers to effective case management. A quantitative approach, involving the use of questionnaires was used to explore the current pattern of malaria treatment and antimalarial drug use in Osun and Lagos State communities, pharmacies and hospitals. The study also investigated the different socio-economic factors affecting treatment behaviours in the communities. Commonly used antimalarial drugs, including Artemether combination drugs (ACTs) were also randomly sampled from the communities to check for substandard and counterfeits using in-vitro culture and FT-IR techniques. In Lagos and Osun urban regions of the study, ACTs contributed to primary treatment choice (60% and 59% respectively), although this was often a result of self-medication (50% and 46% respectively). The majority of the people in the rural regions (74% in Lagos and 57% in Osun) preferred non-ACTs, with a high level of self-medication. A strong significant association was found between employment, salary earned, hospital treatment and adherence to recognised malaria treatment recommendations (P < 0.001) in both urban regions. However, in the rural regions, only hospital treatment showed a significant association to recognised malaria treatment recommendations (P < 0.001). Also, there was also a strong association (P < 0.001) for self-medication and place where antimalarial was purchased in the Lagos rural region which was not observed in the Osun rural region. The gender of client also had a significant association (P < 0.001) with the type of store where treatment was received in Osun rural area but not in Lagos rural area. Hospital data further shows that the rural regions are the most challenging places to experience malaria infection. With already poor treatment practices in place, 81% of the suspected cases of malaria in Osun State rural area were confirmed positive. When compared to Lagos urban and Osun urban areas, where 65 % and 53% were confirmed to be positive, this shows the urgent need for improved intervention programmes to promote better treatment practices in the rural regions. However, low confirmation of malaria cases in the urban regions also illustrates the danger of self-medication that occurs when patients visit pharmacy stores and drug vendors since often no form of diagnosis is offered at these establishments prior to treatment. While all of the ACT samples tested with Fourier Transformed–Infrared spectroscopy showed consistency with ACT reference drugs, some chloroquine (22%) and sulphadoxine-pyrimethamine (20%), did not show consistency with reference samples; particularly if acquired from the rural regions. Moreover, some ACTs, primarily if acquired from the rural regions (65%), showed low efficacy against Plasmodium falciparum in vitro cultured parasites compared to reference samples. In addition to the ongoing intervention programmes creating awareness about effective malaria control and management of malaria, it is important to intensify efforts, especially in the rural regions, since this thesis work highlights that adherence to treatment practice is low and there is a high risk of treating malaria with either a counterfeit drug or a substandard antimalarial. Creating a platform for effective case management of malaria infections will require collaboration across international and national boundaries, bringing together intervention programs and influencing health policy

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Awareness, knowledge and perception of chronic kidney disease in a rural community of South‑West Nigeria

Background: Awareness and education on kidney disease impact on its effective management and will reduce the significant economic and public health burden. Knowledge of CKD and risk factors increases the perception of being at high risk and increasing health seeking behavior. We conducted a cross‑sectional descriptive study to assess the level of awareness, knowledge and conventional risk factors of CKD in the community to strategize on preventive modalities using the information gathered from this population.Methods: We used a pretested structured questionnaire to draw information on sociodemography, knowledge and risk factors of CKD from 563 residents aged &gt;18 years.Results: A total of 454 residents completed this study, mainly farmers, with a mean age of 45.8 ± 19.0 years and male: female ratio of 0.8:1. Only 33.7% had heard of kidney disease with 59.3% from the media and 35.3% from health workers; the level of knowledge of CKD was good in 27.1%. The majority (67.0%) do not know the correct location of the kidneys. Only 10.6% could mention at least one function of the kidneys with only 24.5% agreeing that NSAIDs can cause kidney disease. A laboratory test for kidney function was known by 4.4%; 45.9% and 47.8% believe that CKD can be cured by spiritual means and herbal concoctions respectively. Only 11.1% agreed that CKD can be hereditary. Abdominal obesity and cigarette smoking were seen in 14.6% and 16.6% respectively. Hypertension was seen in 26.5% while 17.8% actually knew they were hypertensive. Diabetes mellitus was found in 3.4%. None of the patients with CKD who had diabetes or hypertension was aware of kidney disease.Conclusion: There are a misconception and low level of awareness and knowledge of CKD, including those with risk factors, in the community. Efforts should be made to create awareness and educate people on CKD and prevention of its risk factors.Key words: Awareness, chronic kidney disease, knowledge, perceptio