Amalgam phase down: baseline data preceding implementation in Nigeria

Objective: The Minimata Convention on mercury includes amalgam phase-down and eventual phase-out from dentistry. To aid its subsequent evaluation it is important to have baseline data of amalgam use in a locality prior to implementing a phase-down. Methodology: Records of patients spanning 5 years from January 2011 to January 2016 were analysed to determine and the compare frequency of amalgam usage with other dental materials for carious teeth restorations in a Nigerian university teaching hospital. Classes of cavities restored and cadres of operators who employed the different materials were included. Institutional ethics committee approval was obtained prior to commencing the study. Results: 2,058 patients’ records were retrieved, 59% females and 41% males. Their ages ranged 19–80 years, mean 33.5 ± 12.7 years, young adults 20–39 years old were the majority (62.9%). Filling materials included 57.5% amalgam, 17.6% glass ionomer cement (GIC) and 24.9% resin composite. Class I restorations constituted 70.5% of amalgam restorations, while Class II restorations made up 29.4% and Class V restorations accounted for 0.1%. Undergraduate dental students placed most of the amalgam restorations (60.5%), and 78.9% of all their restorations were amalgam. Less experienced dentists used all materials equally; the more experienced dentists placed more composite resin and GIC (43.3%). Conclusion: Amalgam fillings constituted nearly 60% of the restorations of carious teeth. Training of dental students in placement of non-mercury alternatives to amalgam and Minimum Intervention Dentistry needs to be emphasized in dental schools. Phase-down of amalgam should be intensified in Nigeria with the ultimate aim of a phase-out in line with the Minamata Convention.Key words: Amalgam, phase-down, Nigeria, dental caries     

Vascular Access in Hemodialysis Patients with Central Venous Obstruction or Stenosis: One Center’s Experience

The purpose of this study was to evaluate the value of complex hemodialysis access procedures among patients with central venous obstruction who were running out of access sites. Between September 2002 and December 2003 we performed a total of 640 new hemodialysis access procedures in 3 renal units. Ten of these patients presented central vein stenosis or obstruction and were not suitable for peritoneal dialysis. Each of the 10 patients had 3 or 4 previous failed access procedures and numerous infected central lines and their dialysis catheters were not functioning adequately. Nine patients presented with a severely stenosed or occluded superior vena cava and 1 had both subclavian veins occluded. Three patients were diabetics, 2 were obese and 6 had hypertension. We performed 12 procedures on these 10 patients. Saphenous veins were used 6 times, twice as a loop to the femoral artery and 4 times as a transposition to the popliteal artery above the knee. Femoral vein transposition to the popliteal artery was carried out in 2 cases. We performed 3 axillary artery to popliteal vein polytetrafluoroethylene (PTFE) bypasses, 1 on an obese woman who had no saphenous vein and was not suitable for a femoral vein transposition, 1 on a diabetic woman whose saphenous vein loop clotted after 5 months and 1 on a female patient with severe peripheral vascular disease. The patient with bilateral subclavian vein occlusion had a brachial artery to internal jugular vein PTFE graft. The PTFE graft to the jugular vein has been patent and regularly needled with a follow-up of 4 months. Four saphenous vein fistulae were regularly used for dialysis; 2 were never used. Five saphenous fistulae clotted after an average life span of 4 months (range 3 weeks-9 months) and 1 is still patent and in use (5 months). Both femoral vein transpositions have been patent and have been needled 3 times a week with a follow-up of 10 and 4 months; one had to be revised surgically after 9 months. Of the 3 axillary artery to popliteal vein grafts, 1 had to be tied off after a week because of severe steal syndrome and 2 have been patent (20 months follow-up) and have been needled regularly ever since. Seventy percent of these patients have been dialyzed line-free through their fistula despite severe central vein stenosis or obstruction for periods of 9-18 months when this review was undertaken. Although the follow-up needs to be longer, we discuss the surgical, radiologic, and dialysis features of these patients and propose a management pathway for central vein stenosis or occlusion.     

Tumor necrosis factor alpha blockade with infliximab for refractory uveitis and scleritis

OBJECTIVE: To assess the efficacy and safety of the anti-tumor necrosis factor alpha agent infliximab in treatment-resistant uveitis and scleritis. DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: Seven patients with noninfectious ocular inflammatory disease that was refractory to alternative immunosuppression. These included one patient with idiopathic retinal vasculitis and panuveitis, one patient with intermediate uveitis, one patient with chronic juvenile anterior uveitis, three patients with scleritis, and one patient with scleritis and peripheral ulcerative keratitis. Four patients had an underlying systemic disease that was in remission in three cases. INTERVENTION: Infusions of infliximab, 200 mg, were given at 4-week to 8-week intervals, depending on the clinical response. MAIN OUTCOME MEASURES: Clinical response, including symptoms, visual acuity, degree of scleral vascular engorgement, corneal thinning, anterior chamber activity, and posterior segment inflammation, reduction in concomitant immunosuppression, and adverse effects. RESULTS: The mean patient age was 47 years (range, 24-78), and four patients were female. The mean number of infliximab infusions was seven (range, 2-19), and the mean follow-up period was 12 months (range, 4-22 months). Six patients experienced a clinical improvement, with five achieving remission and significant reduction in immunosuppression. One patient showed an initial response but developed a delayed hypersensitivity response that precluded further treatment. No other adverse effects occurred. CONCLUSIONS: Infliximab seems to be an effective and safe treatment for noninfectious uveitis and scleritis and may be indicated as rescue therapy for relapses of ocular inflammation or as maintenance therapy when conventional immunosuppression has failed. Further investigation of infliximab for treatment-resistant scleritis and uveitis is warranted.     

Proteinuria in atherosclerotic renovascular disease

Proteinuria is well described in atherosclerotic renovascular disease (ARVD), but the prevalence is unknown, and the pathogenesis may vary between patients. Substantial proteinuria (> 2 g/day) however, would be regarded by many as atypical of ARVD. We studied 94 patients (52 male) with ARVD, median age 67 years (range 49-87). Digital subtraction angiography was performed on all patients. Protein was assayed in 24-h urine samples and GFR derived using the Cockroft-Gault formula. Forty-nine patients (52%) had proteinuria < 0.5 g/24 h. Proteinuria increased with worsening renal function. Biopsies from seven non-diabetic patients with substantial proteinuria showed: minimal changes (1); glomerular sclerosis with marked ischaemic changes (3); focal glomerulosclerosis (2); and athero-emboli (1). Proteinuria, rather than being indicative of other pathology, is often a marker of severity of parenchymal disorder in atherosclerotic nephropathy, which itself is the major determinant of renal dysfunction in patients with ARVD.     

Subjective quality of life of Nigerian schizophrenia patients: sociodemographic and clinical correlates

Objective: Subjective quality of life (QOL) is dependent upon culture and its evaluation based on one’s particular belief system. This study aimed to examine the subjective QOL of Nigerian out‐patients with schizophrenia and its correlates. Method: Out‐patients with Schizophrenia (n = 99) completed the WHOQOL‐BREF as a measure of their subjective QOL. Sociodemographic, illness related and medication related details were also obtained. Results: Overall, 21 patients (21.2%) were categorised as having ‘good’ and 36 (36.4%) as having ‘poor’ subjective QOL. ‘Poor’ subjective QOL correlated with anxiety/depression symptoms (OR 4.88, 95% CI 2.93–11.48), comorbid medical problems (OR 4.75, 95% CI 1.43–16.33), unemployment (OR 3.75, 95% CI 1.25–11.72) and poor social support (OR 4.60, 95% CI 1.49–14.28). Conclusion: Efforts to improve the QOL of patients with schizophrenia in this environment should encompass the identified variables. Larger, longitudinal and multi‐centred studies are needed to adequately identify factors predicting QOL in this environment.     

Asymptomatic malaria parasitaemia in sickle-cell disease patients: how effective is chemoprophylaxis?

BACKGROUND & OBJECTIVES: Sickle-cell trait confers protection against malaria while homozygote sickle-cell disease (SCD) patients are at greater risk of malaria infection, hence the use of malaria chemoprophylaxis in SCD patients. The use of malaria chemoprophylaxis and asymptomatic parasitaemia were studied in SCD and non-SCD patients. STUDY DESIGN: A semi-structured questionnaire was administered to both patients and controls; a thick blood film was also examined in both the groups. RESULTS: Sixty-nine percent of patients use proguanil, 22% do not use any form of chemoprophylaxis, while 9% use pyrimethamine. There was no significant difference between level of parasitaemia in patients and controls (p = 0.1), a positive smear was found in equal numbers of patients on chemoprophylaxis and those not on chemoprophylaxis (p = 0.3). In the month preceding the study, 31% of patients vs 18% of controls had received treatment for malaria. There were no significant differences between patients and controls in frequency of malaria attacks (p = 0.06), last episode of malaria (p = 0.2). Ten percent of patients and 2% of controls use bednets. CONCLUSION: This study did not find any advantage in the use of malaria chemoprophylaxis in SCD patients over controls or SCD patients not on chemoprophylaxis. Vector control should also be considered in the fight against malaria. There is a need to look into why both patients and controls fail to use bednets in a malaria endemic country.     

Insomnia and role impairment in the community

BACKGROUND: Estimates of the occurrence of insomnia are not available in sub-Sahara Africa where demographic profile is different from that in developed countries. However, such estimates need to be considered along with associated functional role impairment in assessing the extent of public health burden due to insomnia. METHODS: Face-to-face interviews with a representative sample of persons aged 18 years and over (n = 6,752) in 21 of Nigeria's 36 states (representing about 57% of the national population) was conducted using the Composite International Diagnostic Interview, version 3. Role impairment, defined as proportion of lost work over the prior month, was assessed using the World Health Organization's Disability Assessment Schedule. RESULTS: Insomnia, defined as any sleep complaint lasting at least two weeks in the previous 12-months, was reported by 11.8%, with rates varying between 5.4% for early morning awakening, 7.7% for difficulty initiating sleep, and 8.5% for difficulty maintaining sleep. Increasing age was associated with higher rates of every type of insomnia but females were only more likely than males to report difficulty initiating sleep. Independently, chronic pain conditions, chronic medical conditions, as well as the presence of a DSM-IV mental disorder significantly increased the risk of having insomnia. Multivariate analysis suggests that, even though demographic factors and comorbid physical and mental conditions partly accounted for the association of insomnia with role impairment, a decrement of about 6% of estimated lost work in the prior month was probably attributable to insomnia. CONCLUSIONS: Findings indicate that insomnia is common even in this relatively young population. Its negative effect on role functioning is considerable, is not entirely accounted for by comorbid medical and mental conditions, and may be of public health significance.