Prevalence, correlates and in-hospital outcomes of kidney dysfunction in hospitalized patients with heart failure in Buea-Cameroon

Background Kidney dysfunction is common in patients with heart failure (HF) and has been associated with poor outcomes. This study aimed to determine the prevalence, correlates, and prognosis of kidney dysfunction in patients with HF in Cameroon, an understudied population. Methods We conducted a cross-sectional study in consecutive patients hospitalized with HF between June 2016 and November 2017 in the Buea Regional Hospital, Cameroon. Kidney dysfunction was defined as an estimated glomerular filtration rate < 60 ml/min/1.73m2. Prognostic outcomes included death and prolonged hospital stay (> 7 days). We also performed a sensitivity analysis excluding racial considerations. Results Seventy four patients (86.1% of those eligible) were included. Their median age was 60 (interquartile range: 44–72) years and 46.0% (n = 34) were males. Half of patients (n = 37) had kidney dysfunction. Correlates of kidney dysfunction included previous diagnosis of HF (adjusted odds ratio [aOR]4.3, 95% CI: 1.1–17.5) and left ventricular hypertrophy (aOR3.4, 95% CI: 1.1–9.9). Thirty-six (48.9%) had prolonged hospital stay, and seven (9.5%) patients died in hospital. Kidney dysfunction was not associated with in-hospital death (aOR 0.4, 95% CI: 0.1–2) nor prolonged hospital stay (aOR 2.04, 0.8–5.3). In sensitivity analysis (excluding racial consideration), factors associated with Kidney dysfunction in HF were; anemia (aOR: 3.0, 95% CI: 1.1–8.5), chronic heart failure (aOR: 4.7, 95% CI: 0.9–24.6), heart rate on admission < 90 bpm (aOR: 3.4, 95% CI: 1.1–9.1), left atrial dilation (aOR: 3.2, 95% CI: 1.04–10), and hypertensive heart disease (aOR: 3.1, 95% CI: 1.2–8.4). Kidney dysfunction in HF was associated with hospital stay > 7 days (OR: 2.6, 95% CI: 1–6.8). Conclusion Moderate-to-severe kidney dysfunction was seen in half of the patients hospitalized with HF in our setting, and this was associated with a previous diagnosis of HF and left ventricular hypertrophy. Kidney dysfunction might not be the main driver of poor HF outcomes in this population. In sensitivity analysis, this was associated with anemia, chronic heart failure, heart rate on admission less than 90 bpm, left atrial dilatation, and hypertensive heart disease. Kidney dysfunction was associated with hospital stay > 7 days.

The effects of major depression disorder on neurogenic thoracic outlet syndrome surgery outcomes

Objectives Thoracic outlet syndrome (TOS) is a group of disorders caused by impingement of the neurovascular structures at the thoracic outlet. Neurogenic TOS (nTOS), which is thought to be caused by a compression of the brachial plexus, accounts for more than 90% of the cases. Although treatment for nTOS is successful through physiotherapy and/or surgical decompression, little is known about the impact of psychosocial factors, namely, major depressive disorder (MDD), on postoperative outcomes such as non-routine discharge (NRD). Here, we assess whether MDD predicts the type of discharge following nTOS surgical intervention. Methods A retrospective analysis of the National Inpatient Sample database from the years 2005–2018 was performed. Using the International Classification of Diseases Clinical Modification, Ninth and Tenth revisions, patients who underwent a surgical intervention for nTOS were identified. Our primary outcome was to investigate the effects of MDD on nTOS patient disposition status after surgical management; secondary outcomes included analysis of total hospital charges and length of stay. NRD was defined as anything beyond discharge home without healthcare services. Univariate and multivariable logistic regression analyses were conducted to assess MDD and other potential independent predictors of NRD and prolonged hospital stay (> 2 days) following surgical intervention. Results A total of 6099 patients were identified: 596 (9.77%) patients with MDD and 5503 (90.23%) without MDD. On average, patients with MDD were older (39.6 ± 12.0 years vs. 36.0 ± 13.0 years; p < 0.001), female (80.7% vs. 63.5%; p < 0.001), white (89.6% vs. 85.6%; p = 0.030), and on Medicare (9.6% vs 5.2%; p < 0.001). Univariate and multivariable logistic regression models identified MDD as an independent risk factor associated with a higher risk of NRD (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI], 1.0–2.2). Additionally, chronic kidney disease (aOR, 2.60; 95% CI, 1.2–5.4), postoperative complications (aOR, 1.87; 95% CI, 1.2–2.9), and Medicare (aOR, 2.95; 95% CI, 1.9–4.7) were statistically significant predictors for higher risk of NRD. However, MDD was not associated with prolonged hospital stay (aOR, 1.00; 95% CI, 0.8–1.2) or higher median of total charges (MDD group: $27,867 vs. non-MDD group: $28,123; p = 0.799). Conclusion Comorbid MDD was strongly associated with higher NRD rates following nTOS surgical intervention. MDD had no significant impact on length of hospital stay or total hospital charges. Additional prospective research is necessary in order to better evaluate the impact of MDD in patients with nTOS.

Emerging spectrum of post-COVID-19 syndrome

‘Post-COVID-19 syndrome’ refers to symptoms in the convalescent phase following initial COVID-19 infection. This term encompasses a wide array of presentation involving lungs, heart and the neuromuscular system. Pulmonary manifestations include post-COVID-19 fibrosis, which is akin to post acute respiratory distress syndrome fibrosis and may reflect the permanent damage to the lungs following an initial bout of infection. Cardiovascular system is often involved, and the presentation can be in terms of acute coronary syndrome, myocarditis and heart failure. Clinical manifestations are often varied and non-specific, which entails a detailed workup and a multidisciplinary approach. Post-COVID-19 syndrome adds to the overall disease morbidity and leads to a prolonged hospital stay, greater healthcare utilisation and loss of productivity marring the country’s dwindling economy. Thus, it is imperative that post-COVID-19 syndrome be prevented and identified early followed by a prompt treatment.

Outcomes of management of intestinal obstruction at an urban tertiary hospital in sub Saharan Africa: a cross-sectional study

Background Intestinal obstruction (IO) is a common cause of acute abdomen globally, it remains challenging as it increases surgical financial expenditure while also causing major morbidity. Clinically it presents with nausea, vomiting, colicky abdominal pain and cessation of bowel movements or passage flatus and stool. Diagnosis, especially in resource limited settings, can be clinical but is usually confirmed radiologically. We studied the current diagnosis, management and outcomes of IO in Mulago Hospital. Materials and methods This was a prospective study done at all the surgical units of Mulago from January to May 2014 to assess general diagnosis and management of IO. Ethical approval was got in line with Helsinki declaration, we used pretested and validated questionnaires to collect data. Informed consent was got with eligible and consenting/assenting patients that fitted the inclusion criteria of age and presenting with suspected intestinal obstruction. Uni-variate and bi-variate variables analysis was done plus measures of association. Results We enrolled 135 patients, excluded 25 and recruited 110 patient. We had more males than females i.e. 71.8% males and 28.2% females. Colicky abdominal pain, abdominal distension, and vomiting were commonest symptoms, then abdominal distension, increased bowel sounds and abdominal tenderness were the commonest signs. Most patients’ (51%) were diagnosed radiologically with a lesser number clinically diagnosed. “Dilated bowel loops” was the commonest radiological sign. Surgery was the main stay of management at 72.7% while 27.3% were conservatively managed. Postoperatively the bowels opened averagely on the 3rd post-operative day (POD) with return of bowel sounds occurring on 5th POD. Most discharges (73%) occurred by the 7th POD. Unfavourable outcomes were prolonged hospital stay followed by wound sepsis (surgical site infection) and then Mortality. Conclusion This study noted that In Mulago we mostly diagnosed patients radiologically with most surgically managed and which is similar to regional practices. Postoperatively bowel opening happening on third POD with return of bowel sounds on fifth POD. Prolonged hospital stay followed by wound sepsis and then mortality were commonest unfavorable management outcomes.

Comparison of QSOFA and sirs scores for the prediction of adverse outcomes of secondary peritonitis among patients admitted on the adult surgical ward in a tertiary teaching hospital in Uganda: a prospective cohort study

Background SIRS and qSOFA are two ancillary scoring tools that have been used globally, inside and outside of ICU to predict adverse outcomes of infections such as secondary peritonitis. A tertiary teaching hospital in Uganda uses SIRS outside the ICU to identify patients with secondary peritonitis, who are at risk of adverse outcomes. However, there are associated delays in decision making given SIRS partial reliance on laboratory parameters which are often not quickly available in a resource limited emergency setting. In response to the practical limitations of SIRS, the sepsis-3 task force recommends qSOFA as a better tool. However, its performance in patients with secondary peritonitis in comparison to that of SIRS has not been evaluated in a resource limited setting of a tertiary teaching hospital in a low and middle income country like Uganda. Objective To compare the performance of qSOFA and SIRS scores in predicting adverse outcomes of secondary peritonitis among patients on the adult surgical wards in a tertiary teaching hospital in Uganda. Methods This was a prospective cohort study of patients with clinically confirmed secondary peritonitis, from March 2018 to January 2019 at the Accident and Emergency unit and the adult surgical wards of a tertiary teaching hospital in Uganda. QSOFA and SIRS scores were generated for each patient, with a score of ≥2 recorded as high risk, while a score of < 2 recorded as low risk for the adverse outcome respectively. After surgery, patients were followed up until discharge or death. In-hospital mortality and prolonged hospital stay were the primary and secondary adverse outcomes, respectively. Sensitivity, specificity, PPV, NPV and accuracy at 95% confidence interval were calculated for each of the scores using STATA v.13. Results A total of 153 patients were enrolled. Of these, 151(M: F, 2.4:1) completed follow up and were analysed, 2 were excluded. Mortality rate was 11.9%. Fourty (26.5%) patients had a prolonged hospital stay. QSOFA predicted in-hospital mortality with AUROC of 0.52 versus 0.62, for SIRS. Similarly, qSOFA predicted prolonged hospital stay with AUROC of 0.54 versus 0.57, for SIRS. Conclusion SIRS is superior to qSOFA in predicting both mortality and prolonged hospital stay among patients with secondary peritonitis. However, overall, both scores showed a poor discrimination for both adverse outcomes and therefore not ideal tools.

Posterior uterine rupture in early first trimester

Uterine rupture can be associated with severe maternal and neonatal morbidity and mortality. It should be considered as a differential diagnosis in all pregnant women who present with acute abdomen, haemoperitoneum and have specific risk factors, even during the first trimester. This is a case report of a 25-year-old woman who presented to emergency department with abdominal pain and vaginal bleeding at approximately 6–8 weeks gestation. She developed an acute surgical abdomen and required urgent surgical management. Despite intervention, she had massive haemorrhage, disseminate intravascular coagulation, admission to intensive care unit and prolonged hospital stay as complications. Posterior uterine wall rupture while rare, must be considered as a differential diagnosis as early intervention is crucial to prevent bad outcomes.

COVID-19 AND PNEUMOTHORAX: A CASE SERIES

Covid19 causing variant of pulmonary symptoms and complications, in this case series we reported about the observations made in 9 cases of COVID 19 associated with pneumothorax. Pneumothorax was predominantly seen in severe pneumonia patients with the mean age of 44.613.6 years, with male preponderance. Pneumothorax presented in different scenarios, 3 (33.3%) admitted with presentation of pneumothorax, 4 (44.4%) developed during the course of the illness and 2 (22.2%) after mechanical ventilation. The mean duration of hospital stays prolonged in all cases. Out of 9 cases, 3 were managed conservatively and 6 by intercostal chest tube drainage. Mortality was observed to be 55.5% among 9 patients. Pneumothorax acts as an independent risk factor for severe covid19 infection in worsening oxygen status, prolonged hospital stay leading to morbid outcomes. So early diagnosis, appropriate treatment modality and optimized ventilatory strategies can limit the morbidity and mortality in COVID19 patients with pneumothorax.

Clinical Predictors of Prolonged Hospital Stay in Patients with Myasthenia Gravis: A Study Using Machine Learning Algorithms

Myasthenia gravis (MG) is an autoimmune disorder that causes muscle weakness. Although the management is well established, some patients are refractory and require prolonged hospitalization. Our study is aimed to identify the important factors that predict the duration of hospitalization in patients with MG by using machine learning methods. A total of 21 factors were chosen for machine learning analyses. We retrospectively reviewed the data of patients with MG who were admitted to hospital. Five machine learning methods, including stochastic gradient boosting (SGB), least absolute shrinkage and selection operator (Lasso), ridge regression (Ridge), eXtreme gradient boosting (XGboost), and gradient boosting with categorical features support (Catboost), were used to construct models for identify the important factors affecting the duration of hospital stay. A total of 232 data points of 204 hospitalized MG patients admitted were enrolled into the study. The MGFA classification, treatment of high-dose intravenous corticosteroid, age at admission, treatment with intravenous immunoglobulins, and thymoma were the top five significant variables affecting prolonged hospitalization. Our findings from machine learning will provide physicians with information to evaluate the potential risk of MG patients having prolonged hospital stay. The use of high-dose corticosteroids is associated with prolonged hospital stay and to be used cautiously in MG patients.

Paediatric sickle cell disease at a tertiary hospital in Malawi: a retrospective cross-sectional study

IntroductionSickle cell disease (SCD) remains a major cause of childhood mortality and morbidity in Malawi. However, literature to comprehensively describe the disease in the paediatric population is lacking.MethodsA retrospective review of clinical files of children with SCD was conducted. Descriptive statistics were performed to summarise the data. χ2 or Fisher’s exact test was used to look for significant associations between predictor variables and outcome variables (case fatality and length of hospital stay). Predictor variables that were significantly associated with outcome variables (p≤0.05) in a χ2 or Fisher’s exact test were carried forward for analysis in a binary logistic regression. A multivariable binary logistic regression was used to identify covariates that independently predicted length of hospital stay.ResultsThere were 16 333 paediatric hospitalisations during the study period. Of these, 512 were patients with SCD representing 3.1% (95% CI: 2.9%- 3.4%). Sixty-eight of the 512 children (13.3%; 95% CI: 10.5% - 16.5%) were newly diagnosed cases. Of these, only 13.2% (95% CI: 6.2% - 23.6%) were diagnosed in infancy. Anaemia (94.1%), sepsis (79.5%) and painful crisis (54.3%) were the most recorded clinical features. The mean values of haematological parameters were as follows: haemoglobin (g/dL) 6.4 (SD=1.9), platelets (×109/L) 358.8 (SD=200.9) while median value for white cell count (×109/L) was 23.5 (IQR: 18.0–31.2). Case fatality was 1.4% (95% CI: 0.6% - 2.8%)and 15.2% (95% CI: 12.2% -18.6%) of the children had a prolonged hospital stay (>5 days). Patients with painful crisis were 1.7 (95% CI: 1.02 - 2.86) times more likely to have prolonged hospital stay than those without the complication.ConclusionAnaemia, sepsis and painful crisis were the most common clinical features paediatric patients with SCD presented with. Patients with painful crisis were more likely to have prolonged hospital stay. Delayed diagnosis of SCD is a problem that needs immediate attention in this setting. Although somewhat encouraging, the relatively low in-hospital mortality among SCD children may under-report the true mortality from the disease considering community deaths and deaths occurring before SCD diagnosis is made.