The High Dependency Unit in the Management of Critically Ill Obstetric Patients in Low Resource Countries

The care of the obstetric population requiring critical care at the intensive care unit is associated with challenges that have made the establishment of obstetric high dependency units (HDU) a priority in the developed, unlike low resource countries.The objective was to evaluate the need to establish obstetric HDUs in low-resource countries.The study was a retrospective descriptive study of obstetric patients admitted in the intensive care unit of the University of Ilorin Teaching Hospital from 1st January 2010 to30th June 2013. Those that were suitable for management at HDUs were compared with those who needed ICU care. The statistical analysis was with SPSS version 20 with p-values, x2, and odds ratio; p-value <0.05 was considered significant.All the 52 patients were postpartum; 16(30.8%) were suitable for HDU care. Of the HDU eligible patients, 11(68.8%) were of low social class, 12(75%) were booked, 11(68.8%) had no further complication at ICU and mortality was 1(6.25%). Compared to those who needed ICU care, there were no statistical significance in maternal age, parity, duration of ICU admission and total cost of ICU care. There were more cases with statistical significance of organ involvement (p<0.001), severity of Glasgow coma score at admission (p<0.001), further complications at ICU (p<0.001) and maternal mortality (p<0.001) among those needing ICU care compared tothose needing HDU care.In conclusion, the establishment of the HDU will reduce cost and the burden on the few ICUs in low-resource countries without increasing maternal mortality

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Packed cell volume in rheumatoid arthritis patients at first presentation

Anaemic syndrome is a common manifestation of rheumatoid arthritis. Both anaemia of chronic disease and iron deficiency anaemia are present in patients with rheumatoid arthritis. Patients with active rheumatoid arthritis are more like to be anaemic with a high impact on the quality of life. The diagnosis of anaemia of chronic disease is made by exclusion. Treatment of the anaemia consists merely of anti-rheumatic treatment. This was a retrospective study of 34 patients diagnosed of rheumatoid arthritis between July 2013 and June 2016. These were the patients that satisfied the 1987 revised diagnostic criteria of the American College of Rheumatology for the diagnosis of rheumatoid arthritis. Anaemia was diagnosed based on the packed cell level and laboratory analysis of red blood cell morphology. Patients with rheumatoid arthritis were divided into 3 groups; rheumatoid arthritis patients without anaemia, rheumatoid arthritis patients with anaemia of chronic disease, and rheumatoid arthritis patients with iron deficiency anaemia. The laboratory results for packed cell volume (PCV), mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), and mean corpuscular haemoglobin concentration (MCHC) were noted and analyzed. Erythrocyte sedimentation rate and rheumatoid factor results were documented. Five hundred and two rheumatology patients were seen over a period of three years (July 2013 –June 2016). Thirty-four rheumatoid arthritis patients were diagnosed (F-26, M-8) with a female to male ratio of 3.3:1. The age range was 18 to 65 years with a mean age of 45 ± 6yrs. The mean duration of onset at presentation was 5 ±2.6 years, and the mean early morning joint stiffness was 3 ±1.2 hours. The mean swollen and tender joint count was 14 ± 2. Erythrocyte sedimentation rate was uniformly elevated with a mean value of 78 ± 5mm/hr. Rheumatoid factor was positive in 27 patients. Anaemia was predominant in age group 41 to 50 years. The prevalence of anaemia was 70.6%, and anaemia of chronic disease was predominantly seen (70.8%). Among patients with rheumatoid arthritis, the prevalence of anaemia was found to be relatively high. Anaemia of chronic disease was the leading cause of anaemia. The degree of anaemia was closely related to the age and duration of the disease.Keywords: Haemoglobin, iron deficiency, mean corpuscular haemoglobin, anti-rheumatic drugs, rheumatoid arthriti

Critically ill obstetric admissions into a tertiary hispital's intensive care unit

No Abstract

Exploring the practice and attitude of circumcisers in the eradication of female genital mutilation/cutting

Background: Female Genital Mutilation/Cutting (FGM/C) remains a form of violence against women despite efforts aimed at its eradication.Objectives: To explore the practice and attitude of circumcisers towards eradication of FGM/C.Methods: A descriptive (pilot) study involving local circumcisers in Kwara State, Nigeria using interviewer-administered questionnaire; analysis was done using SPSS version 21.0 and p &lt;0.05 was significant.Results: There are 57 circumcisers including 36(63.2%) males, 49(86%) acquire the skill for circumcision as a family tradition, 3(5.3%) practice circumcision as sole occupation and 49(79%) derive higher average monthly income from other sources. Forty-two (73.7%) have a dedicated knife used for multiple clients, 44(77.2%) clean the instrument before use, 17(29.8%) wear protective gloves, 55(96.5%) apply substances to the wound mostly iodine 15(26.3%) and shea butter 11(19.3%) while 27(47.4%) have encountered complications previously. Among circumcisers, 44(77.2%) believe FGM/C prevent sexual promiscuity while 26(45.6%) think it is for culture/tradition. Thirty (52.6%) are aware of government activities to stop FGM/C, 53(93.0%) are willing to stop the act if support is provided in form of money to establish a trade 33(57.9%) or new employment 12(21.1%).Conclusions: Circumcisers are willing to discontinue FGM/C if necessary support including vocational skill acquisition, credit facilities to start a trade or new employments are provided. Efforts should be expedited to support their rehabilitation to achieve the eradication.Keywords: Female genital mutilation, Female circumcision, Circumcisers, Violence against wome

Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology

Background: The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a ‘delayed’ operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease. Methods: Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost–utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model. Results: Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0–120 000). Conclusion: Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background: The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals. Methods: Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results: Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals. Conclusion: Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care

Population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background: The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all-cause 30-day readmissions and complications in a prospective population-based cohort. Methods: Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all-cause 30-day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results: Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion: Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics