Epidemiology of death in the emergency department of a tertiary health centre south-south of Nigeria

Background

The emergency department (E.D) of any hospital is an important entry point of critically ill patients. The initial management of these patients is often challenging, and for valuable lives to be saved, the in fracture and manpower should be up to date.

Objective

To analyze the epidemiology of death in our Emergency Department within 72hours after admission, the death rate, and to establish any contributory factors.

Method

Demographic data, time of arrival at the ED, physical finding, the Glasgow coma scale(GCS), the injury severity score(ISS), the diagnosis, investigations done, treatment offered, the time of death and the autopsy report, were entered into a Proforma. These data was analyzed using EPI-Info statistical programme version 3.4.3 of 2007.

Results

Four thousand and eleven (4,011) patients were seen in the E.D during the period. A total of three hundred and fifty five (355) mortalities were recorded. Their ages ranged from 4–87years, with an average of 34.5years. The male: female ratio was 2.1:1. The overall mortality in the hospital during the period was 859: the E.D mortality figure representing 41.3%. Fifteen patients were brought in dead. The 355 deaths fell into two categories: trauma and non-trauma. One hundred and forty-seven (41.4%) persons died from trauma; road traffic accidents (RTAs) accounting for 118 (80.3%). Two hundred and eight (58.6%) persons died from nontrauma related causes, with chronic cardiovascular disorders been the most frequent cause of death 52[25.0]. Majority of the mortalities were between 26–50 years age range. 86.2% of the mortalities presented late, greater than 6hours after the incidence. Within the 72 hours period, only 129(36.3%) were able to do the requested tests. Out of the 355 deaths, only 4[1.1%] were autopsied. An in-hospital 72hours death rate of 8.6 was recorded.

Conclusion

Road traffic accidents and cardiovascular disorders are the common causes of emergency death in UCTH. A recorded death rate of 8.6% is high, suspected contributory factors include systemic deficiencies such as the lack of a trauma system, prehospital care; late presentation, the role of chemist operators, traditional healers, and delayed referral systems.     

A prospective study evaluating the lowering of hemoglobin standards for blood donors

Strict regulations exist for the selection of blood donors. These include minimum hemoglobin (Hb) standards of 13.5 and 12.5 g/dL for males and females respectively. In Canada 2% of all blood donors, or approximately 25,000 individuals annually attempt to make a blood donation but are deferred because their Hb level does not meet these minimum accepted standards. In a previous study we provided a biostatistical approach to ascertain objectively the optimal minimum Hb standards for blood donors to best discriminate between iron deficient and non iron deficient individuals. The derived values were lower than the existing minimum Hb standards and because of concern that blood donors accepted using these lower Hb standards might have asymptomatic disease, the proposed new levels were not adopted. This present prospective study was undertaken to assess the impact on the blood donors of the new Hb standards. Over 26 months we evaluated 1,558 donors (695 males and 863 females). On entry into the study they were screened for a variety of medical conditions which could result in asymptomatic anemia and 6 months later they answered a health questionnaire. Blood donors were entered into 1 of 3 groups. Group I were donors accepted by the existing criteria. Group II were donors who did not meet the existing Hb criteria but satisfied the newly derived standards. Group III were donors deferred even by the new Hb standards.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of oxygenated sterol compounds on human bone marrow granulocytic progenitor cells

Oxygenated sterol compounds are potent inhibitors of sterol and DNA synthesis in mammalian cells. We studied the effects of oxygenated sterols on human marrow granulocytic progenitor cells in vitro (CFU-C). 25-Hydroxycholesterol was found to be a potent inhibitor of sterol synthesis in marrow mononuclear cells, with 50% inhibition occurring at approximately 10(-7) M. This compound, as well as 6-ketocholestanol, 7- ketocholesterol, and 20 alpha-hydroxycholesterol, also demonstrated marked inhibition of CFU-C proliferation. The latter effect, which was not a result of direct cytoxicity of the compounds, was reversible by cholesterol, but not by mevalonic acid. We conclude that inhibition of sterol synthesis by oxygenated sterol compounds may be insufficient to explain their suppression of CFU-C proliferation.     

Predictors of maternal mortality in institutional deliveries in Nigeria

Background

Maternal mortality in poor countries reflects the under-development in these societies. Global recognition of the burden of maternal mortality and the urgency for a reversal of the trend underpin the Millenium Development Goals (MDGs).

Objective

To determine risk factors for maternal mortality in institutional births in Nigeria.

Method

Twenty one health facilities in three states were selected using stratified multi-stage cluster sampling strategy. Information on all delivered mothers and their newborn infants within a three-month period was culled from medical records.

Results

A total of 9 208 deliveries were recorded. About one-fifth (20.5%) of women had no antenatal care while 79.5% had at least one antenatal visit during pregnancy. Four-fifths (80.5%) of all deliveries were normal deliveries. Elective and emergency caesarean section rates were 3.1% and 11.5% respectively. There were 79 maternal deaths and 8 526 live births, giving a maternal mortality ratio of 927 maternal deaths per 100 000 live births. No antenatal care, parity, level of education, and mode of delivery were significantly associated with maternal mortality. Low maternal education, high parity, emergency caesarean delivery, and high risk patients risk independently predicted maternal mortality.

Conclusion

Meeting goal five of the MDGs remains a major challenge in Nigeria. Multi-sectoral approaches and focused political will are needed to revert the high maternal mortality.     

Overview of reviews: Mechanical interventions for the treatment and management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by a progressive and non‐reversible airflow limitation and symptoms of breathlessness, sputum production and cough. COPD is the fourth most common cause of mortality worldwide and represents a significant social and economic burden. As such, effective strategies that might be employed to treat COPD and manage symptoms need to be investigated. This overview aimed to summarize the existing evidence available in the Cochrane Library regarding the use of mechanical interventions used for the treatment and management of COPD. Systematic reviews that included adult participants with diagnosed COPD who received a mechanical intervention were included. Five reviews were included, and due to the heterogeneity of these reviews, direct and indirect comparisons of the effects of the intervention were not possible. Instead, data of the effectiveness of each intervention were extracted and summarized in tables and discussed as a narrative summary. Interventions included non‐invasive positive pressure ventilation (NPPV), positive airway pressure (PEP) devices and neuromuscular electrical stimulation (NMES). Evidence regarding the effectiveness of NPPV was limited, and available data do not support the use of NPPV for patients with stable COPD. NPPV might, however, be of benefit as a weaning strategy for intubated patients and for patients experiencing respiratory failure; however, more research is required. Although PEP devices are considered as a safe airway clearance technique, data do not reveal a clear clinical benefit to their use. NMES is also regarded as safe for patients with COPD, and might also be beneficial in improving exercise tolerance and improving quality of life for patients with COPD.     

The emerging syndrome of envenoming by the New Guinea small-eyed snake Micropechis ikaheka

The New Guinea small-eyed or Ikaheka snake, <it>Micropechis ikaheka</it>, which occurs throughout New Guinea and some adjacent islands, is feared by the indigenes. The first proven human fatality was in the 1950s and this species has since been implicated in many other cases of severe and fatal envenoming. Reliable attribution of envenoming to this species in victims unable to capture or kill the snake recently became possible by the use of enzyme immunoassay. Eleven cases of proven envenoming by <it>M. ikaheka</it>, with two fatalities, were identified in Papua New Guinea and Irian Jaya. Five patients showed no clinical signs of envenoming by other Australasian elapids: mild local swelling, local lymphadenopathy, neurotoxicity, general myalgia, spontaneous systemic bleeding, incoagulable blood and passage of dark urine (haemoglobinuria or myoglobinuria). Two patients developed hypotension and two died of respiratory paralysis 19 and 38 h after being bitten. <it>In vitro</it> studies indicate that the venom is rich in phospholipase A2, is indirectly haemolytic, anticoagulant and inhibits platelets, but is not procoagulant or fibrinolytic. It shows predominantly post-synaptic neurotoxic and myotoxic activity. Anecdotally, Commonwealth Serum Laboratories' (CSL) death adder antivenom has proved ineffective whereas CSL polyvalent antivenom may be beneficial. Anticholinesterase drugs might prove effective in improving neuromuscular transmission and should be tested in patients with neurotoxic envenoming.      

Pals-associated tight junction protein functionally links dopamine and angiotensin II to the regulation of sodium transport in renal epithelial cells

Background and purpose:

Dopamine inhibits renal cell Na⁺,K⁺-ATPase activity and cell sodium transport by promoting the internalization of active molecules from the plasma membrane, whereas angiotensin II (ATII) stimulates its activity by recruiting new molecules to the plasma membrane. They achieve such effects by activating multiple and distinct signalling molecules in a hierarchical manner. The purpose of this study was to investigate whether dopamine and ATII utilize scaffold organizer proteins as components of their signalling networks, in order to avoid deleterious cross talk.

Experimental approach:

Attention was focused on a multiple PDZ domain protein, Pals-associated tight junction protein (PATJ). Ectopic expression of PATJ in renal epithelial cells in culture was used to study its interaction with components of the dopamine signalling cascade. Similarly, expression of PATJ deletion mutants was employed to analyse its functional relevance during dopamine-, ATII- and insulin-dependent regulation of Na⁺,K⁺-ATPase.

Key results:

Dopamine receptors and components of its signalling cascade mediating inhibition of Na⁺,K⁺-ATPase interact with PATJ. Inhibition of Na⁺,K⁺-ATPase by dopamine was prevented by expression of mutants of PATJ lacking PDZ domains 2, 4 or 5; whereas the stimulatory effect of ATII and insulin on Na⁺,K⁺-ATPase was blocked by expression of PATJ lacking PDZ domains 1, 4 or 5.

Conclusions and implications:

A multiple PDZ domain protein may add functionality to G protein-coupled and tyrosine kinase receptors signalling during regulation of Na⁺,K⁺-ATPase. Signalling molecules and effectors can be integrated into a functional network by the scaffold organizer protein PATJ via its multiple PDZ domains.     

Spontaneous abortion and psychosomatics. A prospective study on the impact of psychological factors as a cause for recurrent spontaneous abortion

A group of 36 patients who had had at least two consecutive spontaneous abortions and who desired to have children was subjected to a psychosomatic investigation before a biomedical diagnostic screening programme was started. A semi-structured interview regarding sociodemographic data, current relationship, social support, education, occupation and medical anamnesis was carried out. In addition, all women completed four standardized questionnaires on the topics of anxiety, somatization disorder, life satisfaction and depression. A control group of 36 women, matched for age and occupation, was subjected to the same psychosomatic investigation. The findings of the diagnostic screening programme showed that 16 women had abortions because of physical abnormality, and 15 women had no physically confirmed cause (in five women, the investigations were not completed). Following recurrent spontaneous abortion, 18 women had a successful pregnancy within 2 years, and 18 women were still childless. The comparison between patients and the control group revealed that patients with recurrent abortion were significantly more satisfied with their life quality regarding leisure time, financial situation and occupation. No significant differences were observed in any other variables. Patients who suffered spontaneous abortions due to a physical disorder showed partner relationship of longer duration, and more frequent miscarriages. Women with successful pregnancy within 2 years after recurrent miscarriage were significantly younger and had fewer physically related abortions compared with women who remained childless. In summary, psychological factors seem to be of subordinate importance as a cause for recurrent spontaneous abortion. Moreover, physical abnormalities in the reproductive system have a predominant impact on the prediction of a future successful pregnancy.      

Renal pericytes: multifunctional cells of the kidneys

Pericytes have become a hot topic in renal biology. They play a critical physiological role in vessel development, maintenance and remodelling through active communication with their vascular partners—endothelial cells—and modulation of extracellular matrix proteins. Multiple functions for renal pericytes have been described; specialised perivascular populations participate in glomerular filtration, regulate medullary blood flow and contribute to kidney fibrosis by differentiation into collagen-generating myofibroblasts. Interestingly, the origin of renin-producing cells of the juxtaglomerular region is attributed to the perivascular cell lineage; we have observed the coincidence of renin and pericyte marker expression during human kidney development. Finally, pericytes have been shown to share features with mesenchymal stem cells, which places them as potential renal progenitor cell candidates. Since renal diseases are often associated with microvascular complications, renal pericytes may emerge as new targets for the treatment of kidney disease.