Diagnosis of tuberculosis: urgent need to strengthen laboratory services

Tuberculosis (TB) is of great public health concern globally, and the impact is most felt in developing countries of Asia and Africa, where 95% of cases and 98% of deaths are attributable to the disease, The disease is poverty-driven and the situation is further worsened by absence of rapid diagnostic tools to facilitate early diagnosis of the illness, thus leading to widespread of the disease. While attention is being focused on the HIV/AIDS pandemic, little is being heard of TB, especially in the areas of laboratory diagnosis despite the fact that the disease is the commonest cause of death in people living with HIV/AIDS. The importance of a diagnostic laboratory in a TB control program cannot be overemphasized. Smear microscopy, which is the cornerstone of World Health Organization (WHO) 'DOTS' strategy for the treatment of TB, has many drawbacks among which is its inability to detect latent infection and the dependency of its sensitivity on a trained and motivated microscopist. Therefore, there is a need for a more reliable, sensitive and rapid diagnostic test to facilitate early diagnosis of cases and prompt initiation of therapy for a TB control program to have a meaningful impact in the community.     

Extracorporeal shock wave lithotripsy as monotherapy for staghorn calculi--is reduced renal function a relative contraindication?

Extracorporeal shock wave lithotripsy as monotherapy for staghorn calculus is not without complications. We describe a case in which, due to markedly reduced renal function following lithotripsy for a staghorn calculus, broken fragments of calculi forming steinstrasse became cemented together to form a solid calcified tube extending from the renal pelvis to the ureteric orifice. This resulted in further loss of kidney function. The patient eventually required nephro-ureterectomy. Extreme care should be taken when using extracorporeal shock wave lithotripsy to treat staghorn calculi in kidneys with markedly diminished function to prevent further loss of function due to treatment.     

Medical ethics in sub-Sahara Africa: closing the gaps

Background

Health care providers are expected to have the skills and knowledge relevant to their field and should also be familiar with the ethical and legal expectations that arise out of the standard practices.

Objectives

To elucidate the practice of the health care providers in relation to healthcare ethics in Nigeria.

Methods

A self-administered structured questionnaire was devised and distributed to staff of two tertiary health care facilities in Northern Nigeria. The questionnaire comprised of detailed questions regarding day-to-day aspects of Medical ethical issues.

Results

A total of 307(76.2%) out of 403 health care providers responded to the questionnaire. The median age of the respondents was 34 years. More than half 168(54.7%) of the respondents disagreed as to whether “Ethical conduct is important only to avoid legal action. Many respondents 135 (44.0%) agreed to adhering to “patient''s wishes”, on the other hand over two-third of the respondents 211 (68.7%) agreed that “doctor should do what is best” irrespective of the patient''s opinion. There were significant differences (p<0.05) between the perception of physicians and non-physicians on many ethical issues.

Conclusion

This study has shown gap in knowledge and practice of healthcare ethics among health care providers. There is a need for periodic education on clinical ethics in our hospitals.     

Multidrug resistance to Mycobacterium tuberculosis in a tertiary hospital

OBJECTIVE: The magnitude of drug-resistant Mycobacterium tuberculosis infection (MDR-TB) in Nigeria, the most populous country in sub-Saharan Africa, is largely unknown. This information would assist policymakers to develop intervention strategies against tuberculosis (TB) in the country. MATERIALS AND METHODS: This is a one-year laboratory-based study. Specimens from suspected new TB patients sent to the TB laboratory of the Department of Medical Microbiology, University College Hospital Ibadan, Nigeria from May 1, 2005 to April 27, 2006 were processed and analyzed. The specimens were stained with Ziehl-Neelsen (Z-N) reagents and cultured on Lowenstein-Jensen medium, incubated at 37 degrees C for 6-8 weeks. Isolates were confirmed as MDR-TB by Z-N reactions and biochemical methods. Drug susceptibility to streptomycin, ethambutol, rifampicin and isoniazid was done using Bactec 460 TB radiometric method. RESULTS: Of the 1,120 specimens processed, 80 (7.1%) were smear positive, while 56 (5.0%) were culture positive, even though the association was not statistically significant (p > 0.05). Culture contamination rate was 8.8%. Thirty (53.6%) of the culture positive isolates were resistant to both isoniazid and rifampicin, while 26 (46.4%) were susceptible. About half--53.3%--of the resistant isolates were from the antiretroviral clinic, while 10 (33.4%) were from peripheral centers. CONCLUSION: This study shows that MDR-TB is emerging in Nigeria. Further studies on MDR-TB are urgently needed in the country to ascertain the magnitude of the problem and to proffer solutions to it.     

Vesical calculus formation on non-absorbable sutures used for open inguinal hernia repair

INTRODUCTION

Iatrogenic injuries to the urogenital tract are rare, with the bladder being the organ most affected. We describe a case of a vesical calculus that formed on non-absorbable sutures that were used to repair an inguinal hernia.

PRESENTATION OF CASE

A 45-year-old male presented with frank haematuria and dysuria 2 years following an open left inguinal hernia repair. A CT urography showed a vesical calculus adherent to the left anterio-lateral wall of the bladder. Cystoscopy revealed that the calculus formed on non-absorbable sutures. Cystolapaxy was performed followed by cystoscopic excision of the sutures. The patient''s post-operative course was uneventful.

DISCUSSION

Foreign bodies in the urinary bladder always act as a nidus for formation of a calculus. Iatrogenic bladder injuries are common during hernia repair. It is however rare for sutures used to repair an inguinal hernia to involve the urinary bladder wall. The patient most likely had a full bladder at the time of hernia repair or the bladder was part of the contents of the hernia sac.

CONCLUSION

This case illustrates the need to ensure that the bladder is empty prior to pelvic surgery and for surgeons to have a good understanding of inguinal anatomy to avoid injuring the contents of the hernia sac.     

Outcome of endoscopic treatment for vesicoureteral reflux in children using polydimethylsiloxane

PURPOSE: We reviewed the outcome of subureteral injection of polydimethylsiloxane as a bulking agent for endoscopic treatment for vesicoureteral reflux in patients younger than 12 years. MATERIALS AND METHODS: A total of 40 children (59 ureters) with primary grades II to IV vesicoureteral reflux were treated with a single subureteral injection from 1997 to 2001 and followed an average of 26 months (range 4 to 45). Results in 38 patients (55 ureteral units) were available for review. Each child underwent preoperative voiding cystourethrography, renal ultrasound, dimercapto-succinic acid scan and urine culture. Treatment was done on an outpatient basis. With the patient general anesthesia polydimethylsiloxane implant was injected transurethrally below the ureteral opening of the affected renal unit. Renal ultrasound at 1 week and voiding cystourethrography at 2 months were done to rule out obstruction at the injection site and/or persistent reflux, respectively. Cure was defined as absent vesicoureteral reflux on voiding cystourethrography 2 months after injection. RESULTS: After a single injection polydimethylsiloxane cured vesicoureteral reflux in 45 ureteral units (81.8%), while in 5 (9.1%) the condition was improved. The remaining 5 ureteral units (9.1%) showed no change in reflux grade. In 1 patient (1.9%) with unilateral grade IV vesicoureteral reflux contralateral reflux developed. None of the cured patients had recurrent reflux during followup. In 1 patient ureteral obstruction was successfully treated with ureteral reimplantation. CONCLUSIONS: Endoscopic subureteral injection of polydimethylsiloxane implant in children with primary grades II to IV vesicoureteral reflux appears to be an effective, safe and minimally invasive technique.     

Prostate cancer metastatic to the omentum

A 76-year-old man presented with palpable omental metastasis and gross ascites due to prostate cancer. Within 3 months of surgical castration, the ascites resolved completely, the omental mass was reduced by more than 75%, and serum PSA fell to 4.24 ng/ml from 368.4 ng/ml. Worthwhile palliation can be achieved in patients with massive effusions secondary to metastatic prostate cancer using hormone manipulation.     

Allopurinol provides long-term protection for experimentally induced testicular torsion in a rabbit model

OBJECTIVE: To assess the effect of five antioxidants on exocrine function of rabbit testes retained in situ for 24 h and 3 months after experimental torsion. MATERIALS AND METHODS: The left testes of peripubertal rabbits were clamped for 60 min, after which the clamps were removed and the testes allowed to reperfuse. The right testes served as internal controls. There were eight rabbits in each of the following experimental groups: (a) sham; (b) 60-min ischaemia followed by reperfusion; (c) 60-min ischaemia followed by left orchidectomy. In five further groups, rabbits were exposed to 60-min ischaemia followed by reperfusion, but received one of the following antioxidants before reperfusion: acetyl salicylic acid, ascorbic acid, allopurinol, quercetin or superoxide dismutase. Both testes were excised at 24 h or 3 months. The degree of lipid peroxidation, a measure of free radical damage, was assessed in testicular tissue homogenates by measuring the tissue levels of malondialdehyde (MDA). The Johnsen score was used to assess the morphological damage at 24 h and 3 months for each group. RESULTS: At 3 months twisted viable testes allowed to reperfuse had higher MDA levels than controls; the left testes of rabbits treated with allopurinol had significantly lower MDA levels than untreated rabbits and rabbits given other antioxidants. Rabbits given quercetin, ascorbic acid or superoxide dismutase had lower (but not significantly) left testicular MDA levels than untreated rabbits, while rabbits given acetyl salicylic acid had even higher levels. Allopurinol-treated rabbits had a Johnsen score of > 7.6 and those given other antioxidants had scores of < 7.6 at 3 months. CONCLUSION: The twisted viable testis treated by orchidopexy contains high free radical levels at 3 months. Of the antioxidants studied, only allopurinol had a beneficial long-term effect, by significantly reducing testicular MDA levels at 3 months.