Determinants of Maternal Morbidity and Mortality Related to Anesthesia in Course of Cesarean Section in a Low-Income Country: Experience from the Centre Hospitalier Mère-Enfant Monkole

Objective: The role of anesthesia in maternal mortality is unknown in the Democratic Republic of Congo (DRC). This study was conducted with the objective of analyzing the determinants of morbidity and maternal mortality linked to anesthesia in course of cesarean section. Methods: This is a prospective, analytical and mono-centric study carried out on women who underwent cesarean section at the Centre Hospitalier Mère-Enfant Monkole from January 1st, 2011 to December 31st, 2018. The variables analyzed were socio-demographic, clinical, biological and anesthetic as well as the maternal issues. Data analysis was performed with SPSS 21.0 software. The determinants of mortality were sought by logistic regression with p Results: During this period, 1954 cesarean sections were performed. The mean age of the women was 31 years (range 14 to 47), 1549 women (79.3%) had completed prenatal consultation in Monkole and 405 (20.7%) elsewhere. The emergency was extreme in 192 cases (9.82%), absolute in 445 (22.77%) and relative in 1317 (67.4%). Locoregional anesthesia (LRA) was performed in 1811 cases (92.68%). The main complications were marked by arterial hypotension (22.9%) due to spinal anesthesia, and mortality was 0.56%. In multivariate analysis, only extreme emergency (aOR 7.62 95% CI: 2.80 - 71.23 p = 0.007), coma on admission (aOR 10.44 95% CI: 1.81 - 60.13 p = 0.009), general anesthesia (aOR 15.41 95% CI: 2.11 - 40.21 p = 0.007) and intraoperative transfusion due to anemia/hemorrhage (aOR 8.63 95% CI: 1.07 - 69.55 p = 0.043) persisted as determinants of maternal death. Conclusion: Maternal mortality (0.56%) in this series was relatively low for a low-income country and no death was directly related to anesthesia. General anesthesia, extreme urgency, intraoperative transfusion due to anemia/bleeding, and coma on admission were the major determinants of mortality.

Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach:7 years experience from a single surgical unit

AIM To determine percentage of patients of necrotizing pancreatitis(NP) requiring intervention and the types of interventions performed. Outcomes of patients of step up necrosectomy to those of direct necrosectomy were compared. Operative mortality, overall mortality, morbidity and overall length of stay were determined. METHODS After institutional ethics committee clearance and waiver of consent, records of patients of pancreatitis were reviewed. After excluding patients as per criteria, epidemiologic and clinical data of patients of NP was noted. Treatment protocol was reviewed. Data of patients in whom stepup approach was used was compared to those in whom it was not used. RESULTS A total of 41 interventions were required in 39% patients. About 60% interventions targeted the pancreatic necrosis while the rest were required to deal with the complications of the necrosis. Image guided percutaneous catheter drainage was done in 9 patients for infected necrosis all of whom required further necrosectomy and in 3 patients with sterile necrosis. Direct retroperitoneal or anterior necrosectomy was performed in 15 patients. The average time to first intervention was 19.6 d in the non step-up group(range 11-36) vs 18.22 d in the Step-up group(range 13-25). The average hospital stay in non step-up group was 33.3 d vs 38 d in step up group. The mortality in the step-up group was 0%(0/9) vs 13%(2/15) in the non step up group. Overall mortality was 10.3% while post-operative mortality was 8.3%. Average hospital stay was 22.25 d.CONCLUSION Early conservative management plays an important role in management of NP. In patients who require intervention, the approach used and the timing of intervention should be based upon the clinical condition and local expertise available. Delaying intervention and use of minimal invasive means when intervention is necessary is desirable. The step-up approach should be used whenever possible. Even when the classical retroperitoneal catheter drainage is not feasible, there should be an attempt to follow principles of step-up technique to buy time. The outcome of patients in the step-up group compared to the non stepup group is comparable in our series. Interventions for bowel diversion, bypass and hemorrhage control should be done at the appropriate times.

A Study on Risk Factors for Venous Thromboembolism and the Requirement of Thromboprophylaxis in Pregnancy and Postpartum Period in a Tertiary Care Centre in South Asian Country: A Cross Sectional Study

Introduction: Thrombosis is a major cause of maternal death worldwide. During pregnancy, the risk of venous thromboembolism (VTE) increases fourfold to five-fold and contributes towards maternal morbidity and mortality. Sri Lanka does not have a proper assessment tool to detect and manage it in the antenatal care. Objectives: To identify risks factors for VTE among pregnant mothers, postpartum mothers according to RCOG (Royal College of Obstetricians) risk categorization and to assess the requirement of thromboprophylaxis. Method: A cross sectional study was conducted at the antenatal clinics and obstetrics and gynaecology wards (ward 2, 5, 8) of De Soysa Hospital for Women in 2021. Obstetric thromboprophylaxis risk assessment tool recommended by the RCOG was used for the risk assessment of pregnant mothers during the antenatal and postpartum period. Results: In antenatal period, obesity (BMI > 35), age more than 35 years and parity more than 3 were the commonest risk factors. Out of 404 mothers, 67.33% did not have any risk factors. Among others, 18.56%, 0.40%, 2.72%, 0.99% had a score of 1, 2, 3 and 4 respectively. Patients with intermediate (0.99%) and high risk (2.72%) were commenced on thromboprophylaxis from 28 weeks. The low-risk category was not started on any treatment (28.96%, n = 97). Approximately 96% of mothers did not require any thromboprophylaxis during antenatal period. Another 404 postnatal mothers were recruited for the study group. Elective caesarean section and caesarean section during labour were the main risks identified other than pre-existing antenatal risks. 39.95 % of mothers did not have any risk factors and 37.22% of mothers had a score of 1. Conclusions: VTE risk assessment tool can be implemented at national level to detect patients at risk of VTE and improve maternal care.

Association between Placenta Malaria Parasites and Preeclampsia/Eclampsia among Parturient Mothers in Alex Ekwueme Federal University Teaching Hospital Abakaliki

In tropical countries, malaria and preeclampsia/eclampsia are common diseases of pregnancy;and placenta have been implicated in the pathophysiology of both disease processes. The two diseases have pathophysiologic similarities in the placenta such as placenta ischaemia, endothelial dysfunction and production of pro-inflammatory cytokine. Yet, there is paucity of studies on the association of these two disease processes. Determining the association between the two disease processes may help to unravel the pathogenesis of preeclampsia and also help in its prevention and patient management. Objective: Determined the association between placenta malaria parasitemia and preeclampsia/eclampsia among parturients at Alex Ekwueme Federal University Teaching Hospital Abakaliki. Materials and Methods: This was a case control study that was conducted in the Labour wards of department of Obstetrics and Gynaecology, Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA) and Mile 4 Missionary Hospital Abakaliki, a comprehensive health care centre in Abakaliki, Ebonyi state. It was conducted over a period of 6 months between 1st October 2021 and 31st March, 2022. The cases in this study were parturients that developed preeclampsia/eclampsia in the course of pregnancy, while the controls were parturient without preeclampsia/eclampsia. Interviewer-administered questionnaires were used to collect data on socio-demographic characteristics, obstetrics and medical histories. Histological examinations were conducted to isolate plasmodium falciparum parasites from placenta samples obtained from the maternal surface of the placenta. The data was processed using Epi Info software. Categorical variables were analyzed using Mc Nemar X2 test, with a p-value of 0.05 considered statistically significant. Logistic regression models were used to estimate the odds ratios (OR) and 95% CI of the association between placenta malaria parasites and preeclampsia/eclampsia was conducted. Relative risk with 95% CI was used to determine both fetal and maternal outcomes. Results: The prevalence of preeclampsia during the study period was 2.9%. Placenta malaria was positive in twenty one (21) of the 67 cases of preeclampsia/eclampsia analyzed, giving a prevalence of 31.3% and in eleven (11) out of 68 controls (normotensive) patients analyzed, giving a prevalence of 16.2%. The presence of placenta malaria significantly increased the odds of developing preeclampsia/eclampsia among parturients (OR = 2.4, 95% CI = 1.0 - 5.4, P value = 0.04). Presence of placenta malaria in mothers with preeclampsia/eclampsia was associated with adverse pregnancy outcomes such as cerebrovascular accident (RR = 19.2, 95% CI = 1.1 - 341.7, P value = 0.04), DIC (RR = 10.9, 95% CI = 1.4 - 88.0, P value = 0.02), abruptio placenta (RR = 2.4, 95% CI = 1.2 - 4.8, P value = 0.01), pulmonary edema (RR = 2.7, 95% CI = 1.1 - 25.9, P value = 0.03), IUGR (RR = 2.1, 95% CI = 1.1 - 4.5, P value = 0.03) and IUFD (RR = 3.8, 95% CI = 1.3 - 11.7, P value = 0.02). Presence of placenta malaria also increased the risk of NICU admission (RR = 2.6, 95% CI = 1.1 - 6.0, P value = 0.03), Low 1st minute APGAR score (RR = 2.7, 95% CI = 1.2 - 6.1, P value = 0.02) and Low 5th minute APGAR score (RR = 3.0, 95% CI = 1.0 - 8.6, P value = 0.04) among neonates delivered by mothers with preeclampsia/eclampsia. However, presence of placenta malaria did not significantly increase maternal and perinatal mortalities. Conclusion: There is a higher prevalence of placenta malaria among mothers with preeclampsia/eclampsia when compared with normotensive controls and this was associated with increased risk of certain maternal and perinatal morbidities. Placental malaria was not associated with increased risk of either maternal or perinatal mortality.

Surgical Management of Perforated Colon Tumours in Yaoundé: A Multicentre Retrospective Review of 30-Day Postoperative Outcome

Introduction: Colon cancer is often diagnosed late in our context and there is a high prevalence of complicated forms, this including perforation. The optimal surgical treatment remains controversial. The aim of this study was to improve the short-term postoperative outcomes of patients operated upon for perforated colon cancer, by identifying factors associated with complications occurring within 30 days after surgery. Patients and methods: We carried out an analytical observational study, with a retrospective collection of data from the files of patients operated upon for an in situ tumoral colon perforation. This was done in four referral hospitals in the city of Yaoundé. The period was from the 1st of January, 2012 to the 31st of December, 2021. Cox regression identified the factors associated with postoperative morbidity and mortality. Results: We collected files of 46 patients. The mean age was 54.7 ± 19.9 years with a sex ratio of 1.4. The clinical presentation on admission was dominated by the presence of signs of peritoneal irritation (91.3%) and bowel obstruction (28.3%). The diagnosis was made preoperatively in 16 cases (34.8%). The surgical procedures consisted of colectomy with anastomosis in 28 cases (60.9%) and without anastomosis in 14 cases (30.4%). Postoperative morbidity was 60.9% dominated by surgical site infection (37%). Postoperative mortality was 39.1%. The existence of generalized peritonitis was associated with the occurrence of postoperative complications (p = 0.019). The main factors associated with postoperative mortality were resection with primary anastomosis (p = 0.027), enterocutaneous fistula (p = 0.005). Conclusion: Colic resection with primary anastomosis or ideal colectomy is associated with an increased risk of mortality and should therefore not be performed in this setting.

Short-term and middle-term evaluation of laparoscopic hepatectomies compared with open hepatectomies: A propensity score matching analysis

AIM To compare short-term results between laparoscopic hepatectomy and open hepatectomy using a propensity score matching. METHODS A patient in the laparoscopic liver resection(LLR) groupwas randomly matched with another patient in the open liver resection(OLR) group using a 1:1 allocated ratio with the nearest estimated propensity score. Patients of the LLR group without matches were excluded. Matching criteria included age, gender, body mass index, American Society of Anesthesiologists score, potential co-morbidities, hepatopathies, size and number of nodules, preoperative chemotherapy, minor or major liver re-sections. Intraoperative and postoperative data were compared in both groups.RESULTS From January 2012 to January 2015, a total of 241 hepa-tectomies were consecutively performed, of which 169 in the OLR group(70.1%) and 72 in the LLR group(29.9%). The conversion rate was 9.7%(n = 7). The mortality rate was 4.2% in the OLR group and 0% in the LLR group. Prior to and after propensity score matching, there was a statistically significant difference favorable to the LLR group regarding shorter operative times(185 min vs 247.5 min; P = 0.002), less blood loss(100 m L vs 300 m L; P = 0.002), a shorter hospital stay(7 d vs 9 d; P = 0.004), and a significantly lower rate of medical complications(4.3% vs 26.4%; P < 0.001). CONCLUSION Laparoscopic liver resections seem to yield better short-term and mid-term results as compared to open hepatectomies and could well be considered a privileged approach and become the gold standard in carefully selected patients.

A Modified Surgical Approach of Hepatopancreatoduodenectomy for Advanced Gallbladder Cancer:Report of Two Cases and Literature Review

Gallbladder cancer（GBC） is the most common cancer of the biliary tract, constituting 80%–95% of malignant biliary tract tumors. Surgical resection is currently regarded as the sole curative treatment for GBC. Hepatopancreatoduodenectomy（HPD） has been adopted to remove the advanced gallbladder tumor together with the infiltrated parts within the liver, lower biliary tract and the peripancreatic region of GBC patients. However, patients who underwent HPD were reported to have a distinctly higher postoperative morbidity（71.4%, ranging from 30.8% to 100%） and mortality（13.2%, ranging from 2.4% to 46.9%） than those given pancreatoduodenectomy（PD） alone. We present two patients with advanced GBC who underwent a modified surgical approach of HPD： PD with microwave ablation（MWA） of adjacent liver tissues and the technique of intraductal cooling of major bile ducts. No serious complications like bile leakage, pancreatic fistula, hemorrhage and organ dysfunction, etc. occurred in the two patients. They had a rapid recovery with postoperative hospital stay being 14 days. Application of this approach effectively eliminated tumor-infiltrated adjacent tissues, and maximally reduced the postoperative morbidity and mortality. This modified surgical method is secure and efficacious for the treatment of locally advanced GBC.

Risk stratification of renal transplant recipients using routine parameters: Implication of learning from SARS-CoV-2 into transplant follow-up program

BACKGROUND Severe acute respiratory syndrome coronavirus-2(SARS-CoV-2)infection is a global pandemic that is associated with a high risk of morbidity and mortality among recipients of solid organ transplantation.In the course of acute SARS-CoV-2 infection,various laboratory markers have been identified as predictors for high risk of mortality.AIM To risk stratify renal transplant recipients(RTxR)using general demographic parameters,comorbidities and routine laboratory markers for the severity of the disease and its outcomes.We believe that learning about these routinely monitored parameters can help us plan better strategies for the RTxR follow-up program.METHODS This present study includes RTxR who acquired SARS-CoV-2 infection from March 2020 to February 2021.We recorded the basic demographics,comorbidities and routine laboratory markers.We investigated the impact of SARS-CoV-2 infection on RTxRs and risk-stratified the progression of disease severity and outcomes in terms of recovery or mortality.RESULTS From 505 RTxRs in our renal transplant follow-up program,29(7.75%)RTxRs had PCR-positive SARS-CoV-2 infection.We recorded 8 deaths from SARS-CoV-2 infection giving an overall mortality rate of 1.6%but a significant 27.6%mortality in SARS-CoV-2 positive recipients.Age more than 68 years,non-Caucasian ethnicity and male gender were associated with a significant drop in survival probability;P≤0.001.<0.001 and<0.0001 respectively.87.5%of the deceased were diabetic;P≤0.0.0001.Estimated glomerular filtration rate of less than 26 mL/min/1.73 m2,serum albumin less than 20 g/L,Hemoglobin less than 9.6 g/L and serum calcium less than 1.70 mmol/L were all associated with significantly increased risk of mortality;P=0.0128,<0.001,<0.0001 and 0.0061 respectively.CONCLUSION This study has identified some routinely used modifiable parameters in predicting a higher risk of mortality and morbidity.This knowledge can be used in RTxR follow-up programs by addressing these parameters early to help reduce the morbidity and mortality in RTxRs.

Two case reports of novel syndrome of bizarre performance of gastrointestinal endoscopy due to toxic encephalopathy of endoscopists among 181767 endoscopies in a 13-year-university hospital review: Endoscopists, first do no harm!

BACKGROUND Although deficient procedures performed by impaired physicians have been reported for many specialists,such as surgeons and anesthesiologists,systematic literature review failed to reveal any reported cases of deficient endoscopies performed by gastroenterologists due to toxic encephalopathy.Yet gastroenterologists,like any individual,can rarely suffer acute-changes-inmental-status from medical disorders,and these disorders may first manifest while performing gastrointestinal endoscopy because endoscopy comprises so much of their workday.CASE SUMMARIES Among 181767 endoscopies performed by gastroenterologists at William-Beaumont-Hospital at Royal-Oak,two endoscopies were performed by normally highly qualified endoscopists who manifested bizarre endoscopic interpretation and technique during these endoscopies due to toxic encephalopathy.Case-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps,and absurdly“pressed”endoscopic steering dials to“take”endoscopic photographs;Case-2-endoscopist repeatedly insisted that had intubated duodenum when intubating antrum,and wildly turned steering dials and bumped endoscopic tip forcefully against antral wall.Endoscopy nurses recognized endoscopists as impaired and informed endoscopy-unit-nurse-manager.She called Chief-of-Gastroenterology who advised endoscopists to terminate their esophagogastroduodenoscopies(fulfilling ethical imperative of“physician,firstdo-no-harm”),and go to emergency room for medical evaluation.Both endoscopists complied.In-hospital-work-up revealed toxic encephalopathy in both from:case-1-urosepsis and left-ureteral-impacted-nephrolithiasis;and case-2-dehydration and accidental ingestion of suspected illicit drug given by unidentified stranger.Endoscopists rapidly recovered with medical therapy.CONCLUSION This rare syndrome(0.0011%of endoscopies)may manifest abruptly as bizarre endoscopic interpretation and technique due to impairment of endoscopists by toxic encephalopathy.Recommended management(followed in both cases):1-recognize incident as medical emergency demanding immediate action to prevent iatrogenic patient injury;2-inform Chief-of-Gastroenterology;and 3-immediately intervene to abort endoscopy to protect patient.Syndromic features require further study.

Surveillance for highly pathogenic avian influenza in wild birds in the USA

As part of the USA’s National Strategy for Pandemic Influenza,an Interagency Strategic Plan for the Early Detection of Highly Pathogenic H5N1 Avian Influenza in Wild Migratory Birds was developed and implemented.From1April2006 through 31 March 2009,261946 samples fromwild birds and 101457 wild bird fecalsamples were collected in the USA;no highly pathogenic avian influenza was detected.The United States Department of Agriculture,and state and tribal cooperators accounted for 213115(81%)of the wild bird samples collected;31,27,21 and 21%of the samples were collected from theAtlantic,Pacific,Central and Mississippi flyways,respectively.More than 250 species of wild birds in all 50 states were sampled.The majority of wild birds(86%)were dabbling ducks,geese,swans and shorebirds.The apparent prevalence of low pathogenic avian influenza viruses during biological years 2007 and 2008 was 9.7 and 11.0%,respectively.The apparent prevalence of H5 and H7 subtypes across all species sampled were 0.5 and 0.06%,respectively.The pooled fecal samples(n=101539)positive for low pathogenic avian influenza were 4.0,6.7 and 4.7%for biological years 2006,2007 and 2008,respectively.The highly pathogenic early detection system for wild birds developed and implemented in the USA represents the largest coordinated wildlife disease surveillance system ever conducted.This effort provided evidence that wild birds in the USA were free of highly pathogenic avian influenza virus(given the expected minimum prevalence of 0.001%)at the 99.9%confidence level during the surveillance period.