A 12-month prospective study of intra-abdominal hypertension and abdominal compartment syndrome incidence and outcomes at a tertiary hospital in Nigeria

Background: Peritoneal sepsis is a life-threatening emergency, more so in the low- and middle-income countries (LMICs) where immediate hospital presentation for much needed urgent surgical care is the exception rather than the norm. Continued research into the multifactorial aetiopathogenesis responsible for the high level of morbidity and mortality is necessary. We aimed to determine the incidence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in patients presenting with generalized peritonitis in a tertiary hospital in Nigeria. Methods: We conducted a prospective study involving recruitment of consenting patients managed for generalized peritonitis over 12 months. Results: Fifty-seven consenting and appropriate patients were recruited over the course of the study and managed as per study protocol. The duration of symptoms ranged between 11 hours and 7 days. All patients had varying degrees of IAH and ACS at presentation with generalized peritonitis. A laparotomy with definitive surgery was done in 51 patients (89%), with 6 patients (11%) having only a bedside peritoneal drain inserted for decompression. Significant improvement of the respiratory rate (P < 0.001), oxygen saturation (P = 0.041), and urinary output (P = 0.021) only occurred after decompression by laparotomy or tube drainage. The consecutive mean ± standard deviation (SD) intra-abdominal pressures measured, respectively, at presentation, immediately postsurgery, then postoperatively at 6 h, 24 h, and 72 h reflected significant improvement at each point (respectively in cmH2O: 11.4 ± 6.03, 6.58 ± 5.58, 5.78 ± 3.29, 4.73 ± 2.86, 6.72 ± 5.18; P < 0.001). Conclusions: IAH and ACS are not uncommon in our setting, and ACS at presentation is a significant predictor of mortality in patients with peritoneal sepsis. Surgical decompression invariably leads to an improvement in all clinical variables investigated. Keywords: intra-abdominal hypertension; abdominal compartment syndrome; peritonitis; laparotomy; percutaneous catheter decompression; Nigeria

Allele Frequencies of Apolipoprotein E in a South Western Nigerian population on HAART

Objective: Increasing evidence has shown that ApoE polymorphism is associated with the early onset of cardiovascular and neurological diseases in patients on HAART. The frequency of occurrence of the alleles and the genotypes vary by race and population. The study describes the pattern seen among adults in Ibadan, Nigeria. Methods: This cross-sectional study was conducted among 124 randomly selected HIV-infected persons on protease inhibitor therapy who receive care at the adult antiretroviral clinic of the University College Hospital (UCH), Ibadan. DNA was extracted from leucocytes using EDTA blood. ApoE genotypes were determined using the Seeplex ApoE ACE genotyping kit. The epidemiological distribution of apoE is figured with a pie graph. Results: About four-fifth (79%) of the participants were females while about two-thirds (68%) were below 50 years of age.  The most frequently occurring allele was the ε3 allele (82.2%) and the most common ApoE genotype observed was ε3/ε3. This genotype was present in 52 (41.9%) of the participants. At least one allele of Apo ε2, Apo ε3, and Apo ε4 was present in 28(22.5%), 102 (82.2%), and 50 (40.3) of the study participants respectively. Homozygosity for Apo ε2 and Apo ε4 was observed in 4.8% and 8.0% of participants respectively. Conclusions: Allelic frequency seen is similar to that described in other studied populations and the frequency of genotypes observed was also similar to those described among world populations with a higher observation of ApoE4 allele as seen in people of African descent

Effect of tranexamic acid on coagulation and fibrinolysis in women with postpartum haemorrhage (WOMAN-ETAC): protocol and statistical analysis plan for a randomized controlled trial.

Background: Postpartum haemorrhage (PPH) is a leading cause of maternal death. Tranexamic acid has the potential to reduce bleeding and a large randomized controlled trial of its effect on maternal health outcomes in women with PPH (The WOMAN trial) is ongoing. We will examine the effect of tranexamic acid on fibrinolysis and coagulation in a subset of WOMAN trial participants. Methods. Adult women with clinically diagnosed primary PPH after vaginal or caesarean delivery are eligible for inclusion in the WOMAN trial. In a sub-group of trial participants, blood samples will be collected at baseline and 30 minutes after the first dose of tranexamic acid or matching placebo.  Our primary objective is to evaluate the effect of tranexamic acid on fibrinolysis. Fibrinolysis will be assessed by measuring D-dimers and by rotational thromboelastometry (ROTEM). Secondary outcomes are international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, haemoglobin and platelets. We aim to include about 180 women from the University College Hospital, Ibadan in Nigeria. Discussion:  This sub-study of WOMAN trial participants should provide information on the mechanism of action of tranexamic acid in women with postpartum haemorrhage. We present the trial protocol and statistical analysis plan. The trial protocol was registered prior to the start of patient recruitment. The statistical analysis plan was completed before un-blinding. Trial registration: The trial was registered: ClinicalTrials.gov, Identifier NCT00872469 https://clinicaltrials.gov/ct2/show/NCT00872469; ISRCTN registry, Identifier ISRCTN76912190 http://www.isrctn.com/ISRCTN76912190 (Registration date: 22/03/2012)

Haematological and fibrinolytic status of Nigerian women with post-partum haemorrhage.

BACKGROUND: Early treatment with tranexamic acid reduces deaths due to bleeding after post-partum haemorrhage. We report the prevalence of haematological, coagulation and fibrinolytic abnormalities in Nigerian women with postpartum haemorrhage. METHODS: We performed a secondary analysis of the WOMAN trial to assess laboratory data and rotational thromboelastometry (ROTEM) parameters in 167 women with postpartum haemorrhage treated at University College Hospital, Ibadan, Nigeria. We defined hyper-fibrinolysis as EXTEM maximum lysis (ML) > 15% on ROTEM. We defined coagulopathy as EXTEM clot amplitude at 5 min (A5)  1.5. RESULTS: Among the study cohort, 53 (40%) women had severe anaemia (haemoglobin< 70 g/L) and 17 (13%) women had severe thrombocytopenia (platelet count < 50 × 109/L). Thirty-five women (23%) had ROTEM evidence of hyper-fibrinolysis. Based on prothrombin ratio criteria, 16 (12%) had coagulopathy. Based on EXTEM A5 criteria, 49 (34%) had coagulopathy. CONCLUSION: Our findings suggest that, based on a convenience sample of women from a large teaching hospital in Nigeria, hyper-fibrinolysis may commonly occur in postpartum haemorrhage. Further mechanistic studies are needed to examine hyper-fibrinolysis associated with postpartum haemorrhage. Findings from such studies may optimize treatment approaches for postpartum haemorrhage. TRIAL REGISTRATION: The Woman trial was registered: NCT00872469; ISRCTN76912190 (Registration date: 22/03/2012)

Demographic and epidemiological characteristics of HIV opportunistic infections among older adults in Nigeria

Background: In view of the maturing HIV epidemic in sub-Saharan Africa, better understanding of its epidemiology among older adults is necessary in order to design appropriate care and treatment programmes for them.Objectives: To describe the demographic and epidemiological characteristics of HIV opportunistic infections among newly enrolled patients aged 50 years and above in Ibadan, South-West Nigeria.Methods: Analysis of data extracted from electronic records of 17, 312 subjects enrolled for HIV/AIDS care and treatment between January 2006 and December 2014 at the ART clinic, University College Hospital, Ibadan.Results: Age of the patients ranged from 18 to 90 years with a mean of 36.4 years (SD= 10.3) with older adults constituting 12.0% (2075). Among older adults, about half (52.9%) were females. Majority (59.1%) were currently married while 25.9% were widowed. Prevalence of opportunistic infections was 46.6%. The commonest opportunistic infections (OIs) were: oral candidiasis (27.6%), chronic diarrhoea (23.5% and peripheral neuropathy (14.8%). Significant factors associated with opportunistic infections in older adults were: CD4 count less than 350 (OR=3.12, CI: 2.29-4.25) and hepatitis C virus co-infection (OR=2.17, CI: 1.14-4.13).Conclusion: There is need for prompt response to the peculiar challenges associated with the emerging shift in the epidemiology of HIV and associated infections in sub-Saharan Africa.Keywords: HIV/AIDS, older adults, epidemiological characteristics, opportunistic infections, Nigeri

Allele Frequencies of Apolipoprotein E in a South Western Nigerian population on HAART

Objective: Increasing evidence has shown that ApoE polymorphism is associated with the early onset of cardiovascular and neurological diseases in patients on HAART. The frequency of occurrence of the alleles and the genotypes vary by race and population. The study describes the pattern seen among adults in Ibadan, Nigeria. Methods: This cross-sectional study was conducted among 124 randomly selected HIV-infected persons on protease inhibitor therapy who receive care at the adult antiretroviral clinic of the University College Hospital (UCH), Ibadan. DNA was extracted from leucocytes using EDTA blood. ApoE genotypes were determined using the Seeplex ApoE ACE genotyping kit. The epidemiological distribution of apoE is figured with a pie graph. Results: About four-fifth (79%) of the participants were females while about two-thirds (68%) were below 50 years of age.  The most frequently occurring allele was the ε3 allele (82.2%) and the most common ApoE genotype observed was ε3/ε3. This genotype was present in 52 (41.9%) of the participants. At least one allele of Apo ε2, Apo ε3, and Apo ε4 was present in 28(22.5%), 102 (82.2%), and 50 (40.3) of the study participants respectively. Homozygosity for Apo ε2 and Apo ε4 was observed in 4.8% and 8.0% of participants respectively. Conclusions: Allelic frequency seen is similar to that described in other studied populations and the frequency of genotypes observed was also similar to those described among world populations with a higher observation of ApoE4 allele as seen in people of African descent

Effect of tranexamic acid on coagulation and fibrinolysis in women with postpartum haemorrhage (WOMAN-ETAC): a single-centre, randomised, double-blind, placebo-controlled trial

Background: Postpartum haemorrhage (PPH) is a leading cause of maternal death. The WOMAN trial showed that tranexamic acid (TXA) reduces death due to bleeding in women with PPH. We evaluated the effect of TXA on fibrinolysis and coagulation in a sample of WOMAN trial participants. Methods: : Adult women with a clinical diagnosis of PPH were randomised to receive 1 g TXA or matching placebo in the WOMAN trial. Participants in the WOMAN trial at University College Hospital (Ibadan, Nigeria) also had venous blood taken just before administration of the first dose of trial treatment and again 30 (±15) min after the first dose (the ETAC study).  We aimed to determine the effects of TXA on fibrinolysis (D-dimer and rotational thromboelastometry maximum clot lysis (ML)) and coagulation (international normalized ratio and clot amplitude at 5 min). We compared outcomes in women receiving TXA and placebo using linear regression, adjusting for baseline measurements. Results: : Women (n=167) were randomised to receive TXA (n=83) or matching placebo (n=84). Due to missing data, seven women were excluded from analysis. The mean (SD) D-dimer concentration was 7.1 (7.0) mg/l in TXA-treated women and 9.6 (8.6) mg/l in placebo-treated women (p=0.09). After adjusting for baseline, the D-dimer concentration was 2.16 mg/l lower in TXA-treated women (-2.16, 95% CI -4.31 to 0.00, p=0.05). There was no significant difference in ML between TXA- and placebo-treated women (12.3% (18.4) and 10.7% (12.6), respectively; p=0.52) and no significant difference after adjusting for baseline ML (1.02, 95% CI -3.72 to 5.77, p=0.67).  There were no significant effects of TXA on any other parameters. Conclusion: TXA treatment was associated with reduced D-dimer levels but had no apparent effects on thromboelastometry parameters or coagulation tests. Registration: ISRCTN76912190 (initially registered 10/12/2008, WOMAN-ETAC included on 22/03/2012) and NCT00872469 (initially registered 31/03/2009, WOMAN-ETAC included on 22/03/2012)

Demographic and epidemiological characteristics of HIV opportunistic infections among older adults in Nigeria.

Background: In view of the maturing HIV epidemic in sub-Saharan Africa, better understanding of its epidemiology among older adults is necessary in order to design appropriate care and treatment programmes for them. Objectives: To describe the demographic and epidemiological characteristics of HIV opportunistic infections among newly enrolled patients aged 50 years and above in Ibadan, South-West Nigeria. Methods: Analysis of data extracted from electronic records of 17, 312 subjects enrolled for HIV/AIDS care and treatment between January 2006 and December 2014 at the ART clinic, University College Hospital, Ibadan. Results: Age of the patients ranged from 18 to 90 years with a mean of 36.4 years (SD= 10.3) with older adults constituting 12.0% (2075). Among older adults, about half (52.9%) were females. Majority (59.1%) were currently married while 25.9% were widowed. Prevalence of opportunistic infections was 46.6%. The commonest opportunistic infections (OIs) were: oral candidiasis (27.6%), chronic diarrhoea (23.5% and peripheral neuropathy (14.8%). Significant factors associated with opportunistic infections in older adults were: CD4 count less than 350 (OR=3.12, CI: 2.29-4.25) and hepatitis C virus co-infection (OR=2.17, CI: 1.14-4.13). Conclusion: There is need for prompt response to the peculiar challenges associated with the emerging shift in the epidemiology of HIV and associated infections in sub-Saharan Africa