Management of Obesity: The Surgical Perspective

Background: Obesity which is one of the most prevalent diseases worldwide continues to increase with its associated complications. Bariatric surgeries have been described as the preferred method of treatment for morbidobesity. The objective of this review is to give an overview of bariatric surgical procedures and the possible outcomes.Method: Literature review was conducted using Goggle Search Engine and Highwire Press. Selected papers were taken and books from the author's collection were used for further reference.Results: Bariatric surgery is the most effective treatment for morbid obesity producing long lasting weight loss and remission of co-morbidities. Restrictive procedures are more commonly performed because they are simpler and achieve good weight loss in addition to the avoidance ofmetabolic complications associated with malabsorptive procedures.Conclusion: Specific criteria must be met and the patient must be motivated and fully informed before performance of bariatric surgery for obesity preferably with restrictive procedures.Key Words: Obesity; bariatric surgery; restrictive; malabsorptiv

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Hypertension detection and control in Port Harcourt: knowledge gap factor among primary care physicians

Background: Hypertension detection, awareness and control is low in Nigeria and Africa generally. Several factors, including Physicians' knowledge gap are responsible, but this is not usually emphasized. We sought to identify the role and the degree of knowledge gap in the control and management of hypertension by evaluating basic knowledge in hypertension diagnosis and treatment among a group of primary care physicians attending a continuing medical education program on hypertension. Methodology: A pre-test self-administered questionnaire on knowledge of hypertension diagnosis and treatment among physicians attending a workshop on continuing medical education on  hypertension in Port Harcourt, Nigeria was conducted in June 2013. Post test was also administered. Participants were drawn from both private and public medical practice. The questionnaire contained demographic data and knowledge of diagnosis and treatment of hypertension. The data was analysed with SPSS version  16.0.Results: A total of 30 physicians 8 females (26.7%) and 22 males (73.3%) filled and returned the administered questionnaires out of forty six participants. Age range was 33 to 56 years  mean age was 42.8±7.4 years. Sixteen (53.3%) had knowledge of cut off blood pressure for the diagnosis of hypertension, 10 (33.3%) knew about guidelines for diagnosis and treatment, 18 (60%) knew that diuretics was first line drug in blacks, 10 (33.3%) had knowledge of isolated systolic hypertension.Conclusion: Physicians' knowledge gap in hypertension detection and application of recommended guidelines in its management exist in the group of physicians surveyed and is an important impediment to the control of hypertension in Nigeria. Keywords: Hypertension, Hypertension control, Guidelines, Nigeri

The Diabetic Foot - A Review

OBJECTIVE: The aim of this paper is to highlight the epidemiology, aetiopathogenesis and management of this serious challenge in medical practice BODY: Foot lesions occur in both type 1 and 2, but 50% of the older type 2 patients have risk of foot lesions. These are more common in males over 60 years and also associated with social deprivation. 17% of all amputations in Nigeria are from Diabetis Mellitus constituting the second largest cause of amputations in the environment. About 40% of non trauma related amputations in British hospitals are from diabetic complications. The presence of foot ulcers in the diabetic increases the risk of lower extremity amputations, accounting for approximately 67,000 lost limbs annually. In the USA also, estimated total expenditure for treated diabetic foot ulcers was $16 million in a database of 7 million patients followed for 2 years. The presentation of diabetic foot spans the spectrum of sensory changes to frank gangrene. Skin changes range from bullae on the sole of the foot or blisters on the dorsum of the foot, and subsequent rupture due to scratching or trauma. Some toes may be involved, part or whole of the foot might get progressively involved. Dark coloration signifying ischaemic compromise might progress to frank gangrene. Symptoms of DM might include polyuria, polydypsia and polyphagia CONCLUSION: Careful annual foot review of diabetic patients should be done and reliance should not be on symptoms, because 50% of insensitive feet give no past history of neuropathic symptoms. Foot care education team, a multidisciplinary group, is established in some centres, which includes diabetologists, surgeons (vascular and/or orthopaedic), podiatrists, specialist nurses and shoe fitters. High risk patients should be advised to wash and inspect their feet daily, use creams and lotions to prevent dry skin and callus formation, use adequate foot wear, avoid barefoot gait and thermal injury, and seek early medical attention in the event of injury, however trivial. Pedicure must be done by another person Nig Jnl Orthopaedics & Trauma Vol.2(1) 2003:4-1

Cardiovascular burden of diabetes mellitus: a review

Background: The incidence of diabetes mellitus (DM) is rapidly on the increase worldwide and is gradually becoming a major public health problem for developing nations. Diabetes in all its forms is one of the main cardiovascular risk factors. Cardiovascular complications are a leading cause of death in diabetic patients and this has the potential to place a large social and economic burden on a developing country like ours, as cardiovascular diseases tend to strike those in their prime. Aim: To review the cardiovascular burden of diabetes mellitus.Methods:  A review of the literature was done using google search, hinari, pubmed and books from the author's collection. Keywords/ phrases used in the search included diabetes mellitus, cardiovascular diseases, cardiovascular complications of diabetes mellitus.Results: Diabetes mellitus affects the heart in four main ways; autonomic neuropathy, more severe coronary artery disease, diabetic cardiomyopathy and microangiopathy. DM increases the risk of coronary artery disease more in women than men. It negates the protective female hormonal advantage in cardiovascular disease so that the risk of cardiovascular death is equal in both sexes in diabetic patients. In type 2 diabetes autonomic dysfunction impairs exercise tolerance, reduces response in heart rate and blood pressure thus blunting the cardiac output in response to exercise. Cardiovascular autonomic neuropathy is associated with prolonged QT interval and may predispose to malignant ventricular arrhythmias. Left ventricular diastolic dysfunction characterised by increased ventricular stiffness, delayed relaxation of the left ventricle and increased left ventricular mass is also associated with an increased morbidity and mortality in diabetic patients.   Conclusions: Diabetes mellitus and related cardiovascular complications are a major public health burden worldwide and are especially on the increase in Africa even as the continent adopts a more westernised lifestyle. Keywords: Diabetes mellitus, Cardiovascular diseases,  Afric

Rheumatic heart disease in Port Harcourt, Nigeria: clinical, demographic and echocardiographic features

Background: Rheumatic heart disease is endemic in developing countries especially sub- Saharan Africa. However, there is a growing impression that this disease has been eliminated. Availability of echocardiography with colour flow Doppler facilities has significantly improved diagnosis of cardiac diseases. This study aims at documenting the clinical and echocardiographic pattern of rheumatic heart disease in adult patients in Port Harcourt.Methods: A one-year (April 2009 to March2010) prospective analysis of the clinical profile and echocardiographic features of all the patients who had echocardiographically confirmed rheumatic valvular heart disease from our cardiac laboratory was undertaken.  Trans-thoracic echocardiography was done using M-mode, two-dimensional, pulsed wave, continuous wave and colour flow Doppler techniques. Results: Twenty two cases of rheumatic valve disease were identified, thirteen males and nine females (M: F=1. 4:1). The age range was 17years to 68years with a mean age of 41.32 ± 16.14 years. The mean systolic blood pressure was 125.48 ± 26.46mmHg and mean diastolic blood pressure was 73.81± 18.57mmHg. The mitral valve was the most commonly involved valve (95.45%), one patient (4.54%)  had only aortic valve involvement, eight (36.36%) had aortic and mitral valve involvement while thirteen (59.09%) had only mitral valve involvement. Fifteen patients presented in heart failure, three presented with palpitation and four presented with recurrent praecordial chest pain.Conclusion: Rheumatic heart disease remains prevalent among adult Nigerians in Port Harcourt presenting with heart disease. Males predominate and they present commonly in heart failure

Influence of systolic blood pressure on outcomes in Nigerians with peripartum cardiomyopathy

Background: The relationship between blood pressure (BP) trajectories and outcomes in patients with peripartum cardiomyopathy (PPCM) is not clear. Aim: The study aimed to assess the clinical features and outcomes (all-cause mortality and unrecovered left ventricular [LV] systolic function) of PPCM patients grouped according to their baseline systolic BP (SBP). Patients and Methods: PPCM patients presenting to 14 tertiary hospitals in Nigeria were consecutively recruited between June 2017 and March 2018 and then followed up till March 2019. SBP at first presentation was used to categorize the patients into seven groups: <90, 90-99, 100-109, 110-119, 120-129, 130-139, and ≥140 mmHg. Unrecovered LV systolic function was defined as echocardiographic LV ejection fraction (LVEF) below 55% at the last profiling. Results: Two hundred and twenty-seven patients were recruited and followed up for a median of 18 months. Of these, 4.0% had <90 mmHg, 16.3% had 90-99 mmHg, 24.7% had 100-109 mmHg, 24.7% had 110-119 mmHg, 18.5% had 120-129 mmHg, 7.5% had 130-139 mmHg, and 4.4% had ≥140 mmHg of SBP at presentation. The highest frequency of all-cause mortality was recorded among patients with SBP ≤90 mmHg (30.8%) followed by those with 90-99 mmHg (20.5%) (P = 0.076), while unrecovered LV systolic function did not differ significantly between the groups (P = 0.659). In a Cox proportional regression model for all-cause mortality, SBP <90 mmHg had a hazard ratio (HR) of 4.00 (95% confidence interval [CI] 1.49-10.78, P = 0.006), LVEF had an HR of 0.94 (95% CI 0.91-0.98, P = 0.003, B = 0.06%), and use of angiotensin-converting enzyme or angiotensin receptor and/or β-receptor blockers had an HR of 1.71 (95% CI 0.93-3.16, P = 0.085). However, SBP was not associated with LV function recovery. Conclusion: In our cohort of PPCM patients, one-fifth was hypotensive at presentation. SBP <90 mmHg at presentation was associated with a four-fold higher risk of all-cause mortality during a median follow-up of 18 months

Disparities in clinical features and outcomes of peripartum cardiomyopathy in high versus low prevalent regions in Nigeria

Aims: The prospective, multicentre Peripartum Cardiomyopathy in Nigeria (PEACE) registry originally demonstrated a high prevalence of peripartum cardiomyopathy (PPCM) among patients originating from Kano, North-West Nigeria. In a post hoc analysis, we sought to determine if this phenomenon was characterized by a differential case profile and outcome among PPCM cases originating elsewhere. Methods and results: Overall, 199 (81.6%) of a total 244 PPCM patients were recruited from three sites in Kano, compared with 45 patients (18.4%) from 11 widely dispersed centres across Nigeria. Presence and extent of ventricular myocardial remodelling during follow-up, relative to baseline status, were assessed by echocardiography. During median 17 months follow-up, Kano patients demonstrated significantly better myocardial reverse remodelling than patients from other sites. Overall, 50.6% of patients from Kano versus 28.6% from other regions were asymptomatic (P = 0.029) at study completion, with an accompanying difference in all-cause mortality (17.6% vs. 22.2% respectively, P = 0.523) not reaching statistical significance. Alternatively, 135/191 (84.9%) of Kano patients had selenium deficiency (<70 μg/L), and 46/135 (34.1%) of them received oral selenium supplementation. Critically, those that received selenium supplementation demonstrated better survival (6.5% vs. 21.2%; P = 0.025), but the supplement did not have significant impact on myocardial remodelling. Conclusions: This study has shown important non-racial regional disparities in the clinical features and outcomes of PPCM patients in Nigeria, that might partly be explained by selenium supplementation

Incidence, clinical characteristics, and risk factors of peripartum cardiomyopathy in Nigeria : results from the PEACE Registry

Aims: The aim of this study was to describe the incidence, clinical characteristics and risk factors of peripartum cardiomyopathy (PPCM) in Nigeria. Methods and Results: The study was conducted in 22 hospitals in Nigeria, and PPCM patients were consecutively recruited between June 2017 and March 2018. To determine factors associated with PPCM, the patients were compared with apparently healthy women who recently delivered, as controls. Four hundred six patients were compared with 99 controls. The incidence and disease burden (based on the rate of consecutive recruitment of subjects) varied widely between the six geographical zones of Nigeria. From the North-West zone, 72.3% of the patients was recruited, where an incidence as high as 1 per 96 live births was obtained in a centre, while the disease was uncommon (7.6% of all recruited patients) in the South. Majority of the patients (76.6%) and controls (74.8%) (p = 0.694) were of Hausa-Fulani ethnic group. Atrial fibrillation, intracardiac thrombus, stroke, and right ventricular systolic dysfunction were found in 1.7%, 6.4%, 2.2%, and 54.9% of the patients, respectively. Lack of formal education (odds ratio [OR] 3.08, 95% confidence interval [1.71, 5.53]; P < 0.001), unemployment (OR: 3.28 [2.05, 5.24]; P < 0.001), underweight (OR: 13.43 [4.17, 43.21]; P < 0.001) and history of pre-eclampsia (OR: 9.01 [2.18, 37.75]; P = 0.002) emerged as independent PPCM risk factors using regression models. Customary hot baths (OR: 1.24 [0.80, 1.93]; P = 0.344), pap enriched with dried lake salt (OR: 1.20 [0.74, 1.94]; P = 0.451), and Hausa-Fulani ethnicity (OR: 1.11 [0.67, 1.84]; P = 0.698) did not achieve significance as PPCM risk factors. Conclusions: In Nigeria, the burden of PPCM was greatest in the North-West zone, which has the highest known incidence. PPCM was predicted by sociodemographic factors and pre-eclampsia, which should be considered in its control at population level. Postpartum customary birth practices and Hausa-Fulani ethnicity were not associated with PPCM in Nigeria