EOSINOPHILIC MENINGITIS IN A 10-YEAR OLD NIGERIAN BOY: A CASE REPORT

Eosinophilic meningitis is rare, commonly caused by invasion of the central nervous system by helminthes. The present case is that of a 10–year–old boy who presented with history of generalized pruritus not associated with skin eruptions, followed by pain and weakness of the extremities and loss of consciousness. Patient did not receive BCG vaccination. Initial clinical evaluation was suggestive of tuberculous meningitis but cerebrospinal fluid analysis revealed eosinophilic meningitis. Patient made remarkable improvement with treatment with no sequel

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Relevance of the jaundice meter in determining significant bilirubin levels in term neonates at a tertiary hospital in Lagos State

Background and Aim: Jaundice is the yellowish discoloration of the skin and mucous membranes or the visible manifestation as a result of elevated serum bilirubin. With spectroscopic tools now available, it is possible to assess the skin's condition by quantitative measures and to access information from deeper layers of skin not visible to the eye. The aim of this study was to determine the relevance of the jaundice meter in determining significant bilirubin levels in term neonates at a tertiary hospital in Lagos State using the Konica Minolta JM-103. Materials and Methods: One hundred and fifty consecutive neonates who presented at the neonatal unit of the hospital were recruited for the study after checking them with set inclusion and exclusion criteria. The transcutaneous bilirubinometry (TcB) readings of the neonates were taken on the forehead, sternum, and abdomen of the calm neonate in a supine position, and blood samples for total serum bilirubin (TSB) estimation were drawn from a peripheral vein within 10 min of TcB measurement. Pearson's correlation analysis with linear regression was done to test the relationship between TSB and TcB values as well as for TcB measurements taken at different sites. Results: The difference between the bilirubin values measured with TcB and TSB was low, with 104 neonates (69.3%) having a difference that was 12 mg/dl was 45.2% compared with 56.8% obtained by TcB. In the present study, bilirubin levels measured with the JM-103 show a good agreement with TSB levels in the study neonates. A comparison of the extent of neonatal jaundice in our study at the different body sites using the Kramer's chart showed that there were similar mean recordings for TcB and TSB, with mean values of 10.27 ± 2.90 and 10.58 ± 2.90 for involvement of the face/neck and 18.34 ± 1.61 and 18.43 ± 1.42 for hand/feet obtained by TSB and TcB, respectively. Conclusion: The excellent correlation of TcB with TSB obtained from this study even at levels of bilirubin that necessitates the initiation of phototherapy is encouraging. The JM-103 device thus appears relevant in determining significant bilirubinemia in black neonates

Clinical and sociodemographic correlates of neonatal jaundice at a tertiary health facility in Lagos, Nigeria

Background: Varied aetiologies have been proposed for the prevalence of neonatal jaundice (NNJ) in different parts of Nigeria. The aim of this study was to determine the clinical and sociodemographic correlates of NNJ in a cohort of neonates presenting at a Tertiary health Facility in Lagos, Nigeria. Materials and Methods: One hundred and fifty consecutive neonates that presented at the neonatal unit of the hospital were enlisted for the study after checking them with set inclusion and exclusion criteria. The transcutaneous bilirubin (TcB) readings of the individuals were obtained on the forehead, sternum and abdomen of the calm neonate in a supine position and blood samples for total serum bilirubin estimation were drawn from a peripheral vein within 10 min of TcB measurement. Results: One hundred and fifty neonates were included in the study of which 89 (59.33%) were males and 61 (40.67%) were females. Mothers that had only a primary level of education had babies that presented with significantly higher bilirubin values (P = 0.000). Male neonates, those that presented after 48 h, those between 40 and 42 weeks' gestational age and those that were <2.5 kg birth weight also had higher values though it was not statistically significant. Those that were delivered at home or in a church, delivered by an auxiliary nurse or a traditional birth attendant and those with jaundice extending to the sole of the feet also presented with significantly higher mean bilirubin scores (P = 0.000). Conclusion: Majority of individuals in this study with NNJ were males, while those delivered at home or in a church or by traditional birth attendants and auxiliary nurses and had mothers that were poorly educated had higher mean bilirubin values. It is thus imperative that advocacy is increased to intervene on modifiable risk factors for this condition

Primary Caesarean Deliveries in a Private Hospital in Lagos

Context: Primary caesarean section increases the chances of subsequent operative delivery with its attendant problems. It is necessary to frequently review the indications for primary section in order to reduce rates. Objective: To examine the indications for primary caesarean section. Study Design, Setting and Subjects: A descriptive, fifteen-year report (1983 through 1997) of primary caesarean section from a private hospital in Lagos, Nigeria. Main Outcome Measures: Primary caesarean section rates in nulliparae and multiparae. Results: The overall primary caesarean section rate was 19.6%. It was higher for nulliparae than for previously parous women (32.0% Vs 11.5%, p < 0.0001) with cephalopelvic disproportion and poor progress in labour accounting for 72.2% of the difference in rates. About 90% and 80% of sections in nulliparae and multiparae respectively, were emergencies; cephalopelvic disproportion and poorly progressing labour accounted for twothirds and one-half of each subgroup respectively. Fetal malpresentation was the dominant indication for elective surgery in nulliparae (59.6%) and multiparae (32.6%). The incidence rates of cephalopelvic disproportion, failure to progress in labour, severe hypertension and fetal distress were all higher in nulliparae than in multiparae. but it was the reverse with antepartum haemorrhage Conclusions and Recommendations: Primary caesarean section is commoner in nulliparae than multiparae probably because previous successful vaginal delivery encourages more patient trial of labour in the latter group. A critical, individualised evaluation of cases of poor progress in labour is advocated to effect a decline in the incidence of this indication for surgery. Key Words: Primary Caesarean Section, Cephalopelvic Disproportion, Malpresentation. [Trop J Obstet Gynaecol, 2004; 21:156-159

Birth Asphyxia, Perinatal and Maternal Mortality Associated With Caesarean Section

Context: Caesarean section is sometimes required to improve maternal and neonatal outcome but adverse results occasionally occur. A review of associated adverse consequences is useful in identifying areas requiring improvement. Objective: To study the association between caesarean delivery and maternal/fetal outcome. Study Design, Setting and Subjects: A descriptive, fifteen-year report (1983 through 1997) from a private hospital in Lagos, Nigeria. The subjects were mothers delivered by caesarean section and their singleton babies. Main Outcome Measures: Perinatal asphyxia rate, stillbirth rate, early neonatal death rate, maternal mortality rate. Results: There were 1140 total deliveries. There were 240 cases (21.2%) of birth asphyxia and 16 early neonatal deaths (14.4/1000) among the 1113 live deliveries. There were 27 stillbirths (33.68/1000) and 3 maternal deaths (2.63/1000), all from emergency caesarean deliveries. Preterm delivery was associated with higher asphyxia rate (37.3% vs 22.8%, p < 0.05), while elective section had a lower asphyxia rate than emergency surgery (10.8% vs 24.3%, p < 0.05). Non-booked cases had significantly higher asphyxia rate (22.8% vs 3.9%), five-fold early stillbirth rate (95.54/1000 vs 18.24/1000), four-fold early neonatal death rate (42.25/1000 vs 10.40/1000) and a 12-fold higher maternal mortality rate (12.74/1000 vs 1.02/1000). Antepartum haemorrhage and hypertensive disease were the indications for surgery most frequently associated with perinatal mortality. Conclusions: The hazards of caesarean section are worse with emergency surgery but significant asphyxia occurs even following elective section. Early appropriate referral of high-risk cases will help to reduce perinatal/maternal morbidity and mortality. Key Words: Caesarean Section, Maternal, Neonatal, Mortality, Birth Asphyxia [Trop J Obstet Gynaecol 2002; 19: 25-29]

Caesarean Morbidity and Mortality in a Private Hospital in Lagos, Nigeria

Context: Nigerian patients have aversion to caesarean section. However, with better education and increasing safety of the procedure, the acceptability rate appears to be increasing. To sustain this acceptability, adverse outcome from caesarean section must be reduced to the barest minimum. Objectives: To determine the incidence, morbidity and mortality associated with caesarean section in our centre. Study Design, Setting and Subjects: A 2-year descriptive study (July 2000-June 2002) from a private hospital in Lagos Nigeria. All mothers that were delivered by caesarean section were included. Main Outcome Measures: Indications for surgery, Postoperative complications. Results: There were 391(34.6%) women who had caesarean sections out of 1129 deliveries in the hospital during the period. Postoperative complications occurred in 61 cases (15.6%). All reproductive age groups and parity were involved. The common complications were infectious morbidity (10.8%) postpartum haemorrhage (8.1%), prolonged hospital stay (6.8%)and postpartum anaemia (4.8%). The caesarean section related mortality rate in the hospital was 0.51%. Conclusion: Though the morbidity and mortality was less than previously reported in our environment, it is high when viewed in the context of the excellent facilities available in our centre and the nature of the patients who come there for treatment. Key Words: Caesarean Section, Maternal Mortality, Morbidity. [Trop J Obstet Gynaecol, 2002, 19: 97-100

Placenta Praevia: A Study of Risk Factors, Maternal and Fetal Outcome

Context: With the availability of ultrasound scan, most placenta praevia are detected before symptoms occur. However in most hospitals in Nigeria these facilities are not available and early detection of this condition is still not possible. Majority is diagnosed when symptoms occur. The only useful method of early diagnosis is the use of markers for this condition and early referral to centers were definitive diagnosis can be made. Objective: To determine the risk factors for placenta praevia in our environment and the associated morbidity and mortality. Methods: A hybrid, case control and descriptive study of all cases of placenta praevia seen at the Havana Specialist Hospital, Lagos, Nigeria over a period of 3 years (May 2000 April 2003) Results: The incidence of placenta praevia placenta praevia was 2.6% with 51.3% of cases being asymptomatic and 33.3% presenting as emergency. Some 59.0% were of minor degree. Majority of patients were delivered at between 34 and 38 weeks. No maternal death occurred, but the perinatal mortality rate was 76.9 per 1000 births. On univariate analysis, multiparity, advanced age, previous placenta praevia, caesarean section and early pregnancy bleeding were significantly associated with placenta praevia. However after multiple logistic regression, only early pregnancy bleeding and previous caesarean section retained their significant association with placenta praevia. Conclusion: With previous caesarean section and early pregnant bleeding identified as predictors of placenta praevia, early referral to center equipped with scan will not only confirm the diagnosis but will facilitate early and prompt management. Key Words: Placenta Praevia, Antepartum Haemorrhage [Trop J Obstet Gynaecol, 2004;21:131-134