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Challenges Facing Surgical Training in the Great Lakes Region in SubSaharan Africa: a Review Article
M. Galukande, S. Luboga, E. Elobu
A One Decade Trend of Transforming Medical Doctors to Surgeons in
Tanzania: The Leaking Trough.
O.V Nyongole, N. Siril, A. Kiwara
Age at First Child Birth as a Risk Factor of Breast Cancer among
Ugandan Women at a Tertiary Hospital: a Case Control Study
V. Mukasa, M. Galukande, J. Jombwe, O.J. Fualal
Hydrocoele: A Silent Disability Affecting Quality of Life in Katakwi District in
Uganda.
N. Kakembo, S. Kirunda, J. Yiga, I. Kikwabanga.
Treatment Options and Outcomes of Urethral Stricture in Dar Es
Salaam,Tanzania. Have we utilized all the Options?
O.V. Nyongole, L. O. Akoko, A.H. Mwanga, C. Mkony
The Role of Abdominal Ultrasound and |Chest Radiography in
Management of Breast Cancer Patients in a Low Resource Country: A
Case of Tanzania.
L. Sakafu, R. Kazema, C. Kahesa, J. Mwaiselage, L. Akoko, T. Ngoma
An Audit of Perforated Peptic Ulcer Disease in a Tropical Teaching Hospital.
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O. Afuwape, D.O. Irabor, O. Ayandipo
Snake Bite; A review of Current Literature
S.B. Dreyer, J.S. Dreyer
Extended Debridement and Skin Graft as Local Treatment of Cobra
Snake Bite Injury: A Case Report.
G. Mari , J. Abonga, P. Romano, L. Ojom, J.C.O. Olin, M. Komakech, A.
Costanzi, P. Brown
Pattern of Neonatal Surgery at a Teaching Hospital in Nigeria: A Review
of 101 Cases.
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E. Aiwanlehi, E. Ogbaisi
Levels and Trends of Occupational Hazards among Surgical Residents at
Tikur Anbessa Hospital, Addis Ababa Ethiopia
A. Bekele, S. Shiferaw, D. Gulilat
Demograpics of Patients Admitted with Traumatic Intracranial Bleeds at
Kenyatta National Hospital in Nairobi, Kenya.
V.D. Wekesa, J.A. Ogengo, C.V. Siongei, H. Elbusaidy, M. Iwaret.
Reasons Why Trauma Patients Request for Discharge against Medical
Advice in Wesley Guild Hospital Ilesha.
E.A. Orimolade, O.O. Adegbehingbe, L.M. Oginni, J.E. Asuquo, O. Esan
Results of Operative Fixation of Fractures of the Ankle at a Tertiary
Hospital in a Developing Country.
O.J. Ogundele, A.I. Ifesanya, O.A. Oyewole, O.O.Adegbehingbe
Hand Tumours in Lagos, Nigeria: A Clinicopathologic Study
B.O. Mofikoya, C.C. Anunobi, A.O. Ugburo.
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Uterine Stone : A Case Report
T. Negussie, P. Kidane
The Prevalence of HIV Infection among Pregnant Women at Kabutare
District Hospital - Rwanda
Kabera R, King L
The Umbilical Artery Resisitive Index and the Cerebro-Placental Ratio as a
Predictor of Adverse Foetal Outcome in Patients with Hypertensive Disorders of
Pregnancy during Third Trimester.
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L.P. Parmar, G.N. Mwango, M.N. Wambugu, J.O. Ong’ech
Ileosigmoid Knotting in Pregnancy: A case Report Seen in Uganda.
D. Mutiibwa, G. Tumusiime
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Challenges Facing Surgical Training in the Great Lakes Region in Sub-Saharan Africa: a
Review Article
M. Galukande1, S. Luboga2, E. Elobu1
1
Department of Surgery, College of Health Sciences, Makerere University, Kampala, Uganda,
2
Department of Anatomy, College of Health Sciences, Makerere University.
Correspondence to: Moses Galukande, Email: mosesg@img.co.ug
Background: There is a severe shortage of health workers in sub-Saharan Africa yet this subcontinent experiences a significant proportion of the world’s disease burden. This shortage is
further reflected in the lack of personnel for surgical sub specialities such as orthopaedics,
paediatrics, neurology and urology to mention but a few.
Objective: This review therefore sought to summarize the current literature on the state of surgical
training in sub Saharan Africa, discuss the challenges faced and the possible ways to overcome
these challenges
Methods: We performed online searches of electronic databases i.e. PUBMED, MEDLINE and
African Journals online that feature many African Journals not index by the ‘regular’ databases.
Results: The searches returned 88 articles and 24 of which were included in the review, we present
results focused on; training capacity and methods, scope of practice, technology and surgery, and
low research capacity and output.
Conclusion: The future of surgical training in Africa will depend on the ability of the leadership to
create or and adopt innovative educational technologies, recruit and retain trainers and attract
trainees on one hand and on the other, the growth of demand for quality surgical care in the great
lakes regions. For those that have excelled in training need to build on those successes and share
their stories.
Keywords: Surgical Training, challenges, sub- Saharan Africa
Introduction
There is a severe shortage of health workers in sub-Saharan Africa yet this sub- continent experiences
a significant proportion of the world’s disease burden1. This shortage is reflected in lack of personnel
for sub-specialities of Surgery such as plastics, general, orthopaedics, paediatrics, neurology and
urology to mention but a few2,3. Many patients in sub-Saharan Africa who require surgical
intervention go unattended to and Africa contributes the biggest proportion of the surgical DALY’s in
the world4. A host of factors may be responsible for this shortage which includes but not limited to
brain drain, inadequate training, poor funding of training institutions, few or inexistent training
institutions, leadership and mentorship gaps5,6,7.
There is a population explosion with growth rates of up to 3% in many African countries yet there
isn’t an equivalent growth in numbers of trained health workers8. This lack of Human Resources for
Health (HRH) ultimately impacts negatively on equitable delivery of surgical services. Previous
reports and anecdotal observations have shown that surgical training in sub-Saharan Africa was
inadequate and that the surgical output in some parts of the region notably Eastern Africa has
stagnated at levels well below other more resourced countries.
There have been several calls in the recent past to improve surgical training through increase of
surgical training programs, trainee numbers including efforts to retain the trained surgeons9-13.
This review therefore seeks to summarize the current literature on state of surgical training in the
great lakes region in sub Saharan Africa, discuss the challenges faced and possible ways to address
these challenges.
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Study context
The great lakes region is made up of 10 countries all categorised as low income by World Bank
defined standards14. Together, it is home to an estimated population of over 370 million people15,
about the population size of the USA but with physician density of 0.019 per 1,000 for Malawi the
lowest to 0.181 per 1,000 for Kenya16 as the highest. The region has 52 medical schools of which 30
(approximately 60%) are found in Ethiopia and DR Congo and the rest 22 spread among the 9
countries; few offer speciality training in surgical disciplines. The term “African Great Lakes Region”
when used in a narrow sense for the area lying between northern Lake Tanganyika, western Lake
Victoria, and lakes Kivu, Edward and Albert. This comprises Burundi, Rwanda,
northeastern Democratic Republic of Congo, Uganda and northwestern Kenya and Tanzania. When
used in a wider sense it includes all of Kenya and Tanzania, for the purposes of this paper it goes as
far south as Zambia, Malawi and Mozambique and - north to include Ethiopia, these four countries
border one of the Great Lakes17,18.
Methods
We performed online searches of electronic databases i.e. PUBMED, MEDLINE and African Journals
online that feature many African Journals not index by the ‘regular’ databases. We used educational
articles for surgical disciplines in 10 sub-Saharan Africa countries (The Great Lakes countries). Only
English language articles were considered. No limits of type of articles and dates of publication were
set. We excluded any duplicate articles and those papers not describing training in the great lakes
region.
We used the key word terms, ‘challenges of surgical training’, ‘Africa’ for all searches and added
‘review’ as a limiting term. These searches returned a combined 76 articles/titles/abstracts and finally
12 which we reviewed for face value relevancy. To supplement the search we searched several sites
including the SAMSS project (sub Saharan Medical Schools Study), MEPI (Medical Education
Partnership Initiative) but also snowballed all cited references using terms; surgical skills training,
specialist surgeons, competence based training for surgery, and research capacity. We found an
additional 12 articles, therefore 24 articles were assessed.
Results
There was a paucity of papers on challenges of surgical training in particular; however several articles
concerning human resources for health were available. Training capacity for surgical training and
competence based curricula are neglected. Research capacity is thoroughly described for Africa in
general; but use of technologies to enhance it is neglected too. In this paper, we present results
focused on; training capacity, training methods and scope of practice, technology and surgery, low
capacity and output. The searches returned 88 articles and 24 were reviewed (Figure 1).
Training Capacity
In general terms as an example Uganda has one of the lowest densities of researchers among the most
scientifically advanced nations in sub Saharan Africa: only 25 researchers per million inhabitants and
has no science Ministry. Kenya has made strides in publications output but mostly skewed to crop
science/agricultural19. There are few medical training institutions for undergraduate courses and even
fewer for speciality training; in fact for many countries on the sub-Saharan Africa have limited
capacity to offer most sub-speciality training such as neurosurgery or plastic surgery20,21,22. There is
also a shortage of trainers at most institutions of higher learning, and the few that are available are
overwhelmed with work in mostly challenging work environments due to lack of funding, inadequate
infrastructure and lack of funding for research23.
Internal funding from governments for training and health service delivery is inadequate at best and
yet external donor funding is skewed to infectious diseases such as HIV, TB and Malaria4. Though a
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wakeup call for NCDs including surgical conditions and Health systems strengthening has been
sounded and much attention has now been aroused24, 25.
In the region for the most part training in surgery takes on two pathways: the Masters of Medicine
(M.MED) offered by University Medical Schools and Colleges and the Fellowship in Surgery
(offered by the College of Surgeons of East, Central and Southern Africa – COSECSA) and they are
described elsewhere10, 26. The trainers are mostly subject specialists with no training in curriculum
development and pedagogical skills.
Records identified through data
base searching
n=76
Additional records
identified through other
sources
n=12
Records after duplicates removed
n=86
Records screened
n=86
Records excluded
n=64
Full text articles assessed
n=24
Studies included in analysis
n=24
Figure 1. A Flow Chart Showing Search Results
Training methods and scope of practice
Whereas the scope and frequency of the surgical procedures performed at the district hospitals in the
region are well documented27, the same is not true for teaching /referral hospitals, this knowledge may
be important if training and assessment (examination) capacities are to be maximally leveraged. Most
curricula follow an apprentice model but it’s fraught with the lack of consistent supervision by the
trainers and the uncertainty of finding the required cases to practice on, therefore adding to the
uncertainty of acquisition of the required skills and competences upon graduation.
The most relied upon methods of training are lectures, bedside teaching, operating room OR
demonstrations, Projects and groups work.
Technology and Surgery
There is a general lack of exposure and practice in Minimal Invasive Surgery (MIS) and use of
Information Technology (IT). In 2006, Aminu noted that the Surgery in Nigeria and most of Africa
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had not maximised the benefit of computers28. Although there is demonstrable effort to encourage the
practice of MIS despite the numerous challenges of lack of supplies, training and high costs to
patients 29, 30.
Low research capacity and output
Despite some efforts, the research capacity and output of countries remain low. Whereas available
data show progress, many nations have big gaps to overcome. The African Innovation outlook 2010
survey showed that only 3 nations Malawi, Uganda and South Africa spent above the 1% of the GDP
recommended for research and development. No data was available in this search that delineates
investment in research and training in the area of surgery and surgical services. Other issues
confronting the region; many laboratories are poorly equipped and science students get little: practice,
and practical research training because research centres are often separate from Universities19.
By using published articles and grants as a proxy for research, there is low output and update among
surgeons and surgery as a discipline in general31,32. The countries of the Great Lakes region no
collective data was found. Whereas there is increasing commitment to foster research surgery by
COSECSA and Universities33, there are very few surgeons with PhD training and few with ready
facilitation, time and interest the regularly and consistently engage in research.
Discussion
In this paper we set out to highlight the challenges facing training of surgeons in the great lakes region
and the opportunities that lie ahead. We performed a review and found that surgical training in the
region is fraught with low numbers of trainees2, 11 (despite recent increases), and trainers with poor
working environment and poor pay12. In addition there is low research capacity and output. Training
methods and philosophy have not kept up with recent innovations in surgical training missing out on
for example simulation advancements and Quota based (log book) training2, 11, 13. The gaps in the
availability of speciality surgeons: Opportunities therefore now exist to train more, take advantage of
availability of new simulation technologies, internet communication, globalization, international
travels and increasing access to grant funding from development partners and governments.
Training capacity
There is a severe shortage of trainers, the few that there are, have their time split among
administrative work, consultancies and patient care2, 34,35,36. The solution is to train more, pay better
salaries and improve the working conditions as is regularly articulated33,37.
Whereas this may be the more desirable solution to the problem, it requires long periods and resources
for training surgeons and mentoring them to become competent trainers of surgery.
International collaborations have been advocated for as measure to plug the gaps in numbers of
trainers and the actual training process38. Across sub Saharan Africa (SSA) international
collaborations have been documented to have improved service delivery, and increased the training
and research capacity of partner institutions e.g. Makerere University/University of California San
Francisco Global Partners in Anaesthesia and Surgery (MU/UCSF GPAS) in Uganda, Vanderbilt and
Kijabe in Kenya, Weill Cornell University and Bugando Medical Centre in Tanzania to mention but a
few38, 39. Such collaborations may include faculty and student exchanges, a variety of training skills
transfer workshops and sandwich models for fellowships in various surgical sub specialties40, 41.
The Royal College of Surgeons of Ireland through COSECSA have in the recent past conducted a
Trainer of Trainees course for faculty to make them more effective and efficient motivating trainers of
surgeons. These partnerships should be leveraged for mutual learning based on overlapping priorities
and interest. As most collaborations seem to be initiated by the foreign partners, it behoves the local
institutions to be clear of their priorities and needs as they develop memoranda of understanding.
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Training methods and scope of practice
Surgical training has traditionally been modelled on an apprenticeship system, where trainees learn by
direct instruction from their seniors, combined with long term observation and assessment from those
same seniors. This is accompanied by ‘the gradual absorption into a community practice’ where
participants learn as much from their peers42.
The process of new skills training techniques is based on established theories of the ways in which
motor skills are acquired and expertise developed. Fitts and Posner’s three stage theory of motor skill
acquisition is widely accepted in both the motor skills literature and the surgical literature. In the
cognitive stage (the first stage) the learner intellectualizes the task; at this stage performance is erratic,
and the procedure is carried out in distinct steps. However, with practice and feedback, the learner
reaches the integrative stage (the second stage) in which knowledge is translated into appropriate
motor behaviour. The learner is still thinking about how to move the hands and execute the task with
fewer interruptions. In the third and last stage, (the autonomous stage), practice gradually results in
smooth performance. The learner no longer needs to think about how to execute this particular task
and can concentrate on other aspects of the procedure43, 44. What we are currently missing in training
is developing skills based on a pre determined list of competencies and following through to ensure
that the minimum numbers of supervised procedures are stipulated and seen to be done before the
trainee is allowed to graduate.
How much operating time is needed to develop competence, what skills are transferable and which
ones are not? What about simulation technology, in the situations where there isn’t enough procedures
to go round for teaching and practice? There is sufficient evidence that simulation has a role in the
development of technical competence during surgical training42.
Technology and Surgery
With the fast pace of globalization, technology is permeating all aspects of life including the practice
of surgery and communication. The modern surgeon even in SSA needs to be “tech savvy” to catch
up with the technological advances in minimally invasive surgery (MIS), take advantage of more
efficient communication technologies, and use the internet and other electronic resources.
Although there is a general lack of exposure and practice in minimally invasive surgeries there may
be innovative ways around some of these challenges. For example simulation boxes are becoming
more readily available for surgeons starting out in the learning of these laparoscopic skills.
Interestingly, several centres have used ordinary cardboard or plastic boxes fitted with a simple
webcam and computer to create their own effective and cheap training boxes. A cost cutting technique
for laparoscopic appendectomy has been described29. Although not in sub Saharan Africa, a report
from India documented innovative use of homemade devices and other basic equipment adapted to
use in MIS45.
In the future, the application of computers in surgery would make surgical knowledge and practice
simplified with increased productivity, even for the more technically challenging procedures and in
this era of global surgery and international collaborations, such technology will be key28. The uptake
and utilization of Minimally Invasive Surgery in much of the developing world has been fraught with
challenges and gross disparities. By 2003, the Aga Khan teaching hospital in Kenya had reported
tremendous steps towards use of laparoscopy with no mortality, low complication rates (< 1%) and
conversion rates of 1.96%30. In 2011 in Uganda, laparoscopy was deemed feasible at a teaching
hospital with low major complication rates of 1.7% and 2.2% conversion rates29. It suffices to say that
MIS in SSA is riddled with challenges of acquisition of equipment, repair and maintenance, as well as
supply of related consumables. Also there are challenges with training of surgeons, nurses and
biomedical technicians in the use and maintenance of this equipment.
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Partnerships have been formed to improve training e.g. skills transfer workshops with teams from
developed countries where MIS is more routine45. Teaching models for Fundamentals of laparoscopic
surgery including tele-simulation have been evaluated and found relevant to training46, 47. Also several
surgeons at a particular centre may form a group where they support each other e.g. after these
workshops. Another possibility would be to engage manufactures of MIS equipment and supplies to
invest in training the surgeons who are in effect their consumers. As is the case of Ethicon Johnson &
Johnson and Nairobi Surgical Skills centre in Nairobi.Electronic resources are increasingly becoming
more available for training and research e.g. the Ptolemy project of University of Toronto in
conjunction with COSECSA48. The ‘School for Surgeons’ portal offers valuable resources for surgical
trainees under the COSECSA track. Surgery in Africa reviews, HINARI, and several University
libraries among others, offer access to useful texts for the surgical trainee. . However it remains
unknown to what extent these resources are being utilized by the intended users
Low research capacity and output
Many of the published articles are of low levels of evidence and with poor adherence to reporting
standards as was demonstrated in the analysis of articles published in the African Journal of Paediatric
surgery, a publication of APSON/PAPSA49. Such articles may not contribute much to informing
decisions of patient care or other areas of service delivery. There is generally lower funding for
surgical research and even internationally fewer grants are won by people in surgical than in
infectious disease disciplines31. It has been argued that in part this is a reflection of low grant
applications in the first place50. However, there has for long time been an international focus on
communicable disease. Opportunity maybe at the surgeons’ door as non-communicable diseases start
to take centre stage in global health. Cancer, trauma and aspects of patient safety that are increasingly
becoming of public health concern and do involve significant amounts of surgical input.
There is evidence that Africa’s future is in strengthening indigenous educational systems and
institutions for generating and applying knowledge by assuring public support with emphasis on
research capacity. In addition to individual skills developed in research work, research capacity
includes quality of research environment, funding, adequate infrastructure, research incentives and
time availability for the researcher50. In most African countries, conditions for research are severally
compromised36, 51, 52.
The lack of interest from potential trainees
Surgery is perceived as ‘hard’ fraught with hardships including the risk of catching HIV from needle
stick injuries, plus the perceived lack of heavily funded research as is the case with other disciplines,
such as internal medicine , paediatrics and public health13.
The gaps and opportunities
We do need
• more numbers of specialists to provide a service and leadership in surgical care delivery and
research
• Better quality education, focusing on acquisition of predetermined competences with
supervision and mentorship by the more trained and experienced surgical specialists.
• To know what the needs of the communities are through assessment of the surgical disease
burden, against which we can measure our successes.
• Collaborations that are mutual and equitable, where resources are shared for the mutual
benefit of the rich and poor countries.
• To strengthen the platforms we have already, the pre- practice training opportunities22, to
better structured surgical camps and leverage the in-service training opportunities.
• To utilize better the advocacy opportunities that exist through the various associations to
enhance political will and civil society activism
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Conclusion
The future of surgical training in Africa will depend on the ability of the leadership to create and or
adopt innovative educational technologies, recruit, retain trainers, attract trainees on one hand and on
the other hand the growth of demand of quality surgical care as the middle class in the great lakes
regions grows. For those that have excelled in training need to build on those successes and share
their stories.
References
1. Scheffler R. M J. X. Liu, et al. Forecasting the global shortage of physicians: an economic- and
needs-based approach. Bull World Health Organ 2008; 86(7): 516-523B
2. Ozgediz D, Galukande M, Mabweijano J, Kijjambu S, Mijumbi C, et al. The neglect of the global
surgical workforce: Experience and evidence from Uganda. World J Surg 2008; 32: 1208–1215
3. Chirdan LB, Ameh EA, Abantanga FA, Sidler D, ElhalabyEA.Challenges of training and delivery
of pediatric surgical services in Africa. J Pediatr Surg. 2010 Mar; 45(3):610-8.
4. Debas H, Gosselin RA, McCord C, Thind A (2006) Surgery. In: Jamison DT, Breman JG,
Measham AR, Alleyne G, Claeson M, et al. eds. Disease Control priorities in developing
countries. 2nd edition. New York: Oxford University Press. pp 1245–1259. Available:
http://www.dcp2.org/pubs/DCP/67/FullText. Accessed August 2013.
5. Linden AF, Serufusa Sekidde F, Galukande M, Knowlton LM, Chackungal S , McQueen KAK.
Challenges of Surgery in Developing Countries: A Survey of Surgical and Anesthesia Capacity in
Uganda’s Public Hospitals. World J Surg DOI 10.1007/s00268-012-1482-7
6. Jackie Wicz W, Tulenko K. Increasing community health work force productivity and
effectiveness: a review of the influence of the work environment. Human Resources for health
2012; 10:38
7. Luboga S, Macfarlane SB, von Schreeb J, Kruk ME, Cherian MN, Bergström S, Bossyns PBM,
Denerville E, Dovlo D, Galukande M, et al: Increasing Access to Surgical Services in SubSaharan Africa: Priorities for National and International Agencies Recommended by the Bellagio
Essential Surgery Group. PLoS Med 2009, 6:e1000200.
8. World Review. Africa’s Population Boom. www.worldreview.info/content/africas-populationboom accessed 31 July 2013.
9. Luboga S, Macfarlane SB, von Schreeb J, Kruk ME, Cherian MN, Bergström S, Bossyns PB,
Denerville E, Dovlo D, Galukande M et al. Increasing Access to Surgical Services in Sub-Saharan
Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential
Surgery Group. PLOS Medicine. 2009 Dec; 6(12): e1000200. doi:10.1371/journal.pmed.1000200
10. Kakande I, Mkandawire N, Thompson MW. A review of surgical capacity and surgical education
programmes in COSECSA region. ECAJ Surg 2011; 16(3): 6-34
11. Surgical Training in Africa Collaboration Programme. www.resi.ie/cosecsa accessed August
2013.
12. Strategies to increase access to surgical services in resource-constrained settings in sub saharan
Africa.
Bellagio
Esential
Surgery
group
July
2008.
essentialsurgery.org/bellagio/docs/background-strategies-to-increase.pdf
13. Galukande M, Luboga S, Kijjambu SC. Improving Recruitment of surgical trainees and Training
of Surgeons in Uganda. East and Central African Journal of Surgery. April 2006; 11(1): 17 – 24
14. The World Bank. Working for a World Free of poverty. http:///data.worldbank.org/about/countryclassification accessed, 1 August 2013.
15. The World: Population (2013) – Top 100+ www.geoba.se/population.php?pc=wor accessed, 1
August 2013.
16. WHO. Global Health Observatory. Density of physicians (total number per 1000 population,
latest available per year) www.who.int/gho/health_workforce/physicians_density/en/index.html
accessed, 1 August 2013.
9
COSECSA/ASEA Publication -East and Central African Journal
(3))
Journal of Surgery. November/December 2013 Vol. 18 (3
ISSN 2073
2073073-9990 East Cent. Afr. J. surg
17. The African Great Lakes http://en.wikipedia.org/wiki/African_Great_Lakes accessed, 1 August
2013.
18. The African Great Lakes Region: An End to Conflict? Research paper 06/51
www.parliament.uk/breifing-papers/RP06-51pdf accessed, 1 August 2013.
19. Irifefe V, Vaidyanathan G, Nordling L, Twahirwa A, Nakkazi E, Monastersky R. Africa’s nations
are achieving some success in building their science capacity, but the foundations remain
unsteady. Nature 2011; 474: 556-559
20. Bagan M. The Foundation for International Education in Neurological Surgery. World Neuro
Surgery 2010; 73 (4): 289
21. Fagan JJ. Developing world ENT: a global responsibility. J Laryngolotol 2012; 126 (6): 544-7
22. Aswani J, Baidoo K, Otiti J. Establishing a head & Neck unit. J Laryngolotol 2012; 126(6): 552-5
23. The
medical
workforce
problems
in
sub-Saharan
Africa
www.samss.org/samss.upcoad/documents/126.pdf accessed, 1 August 2013.
24. Bryan L, Conway M, Keesmaat T, Mckenna S, Richardson B. A practical approach to health
system
strgethening
in
sub
Saharan
Africa.
www.touchfoundation.org/uploads/assets/documents/Health%20international-nMvrM152.pdf
accessed on August 1, 2013
25. Marquez PV, Farrington JL. The challenge of non-communicable diseases and road traffic
injuries
in
sub
Saharan
Africa:
an
over
view.
www.documents.worldbank.org/curated.eu/2013/ob/17997739 accesses on August 7, 2013
26. Galukande M, Ozgediz D, Elobu E, Kaggwa S. Pre-training Experience and Structure of Surgical
Training at a Sub-Saharan African University. World Journal of Surgery: 2013; 37 (8):1836-1840
27. Galukande M, von Schreeb J, Wladis A, Mbembati N, de Miranda H, et al. Essential Surgery at
the District Hospital: A Retrospective Descriptive Analysis in Three African Countries. PLoS
Med 2010 7(3): e1000243. doi:10.1371/journal.pmed.1000243
28. Aminu MB, Ameh EA, Mai A. Computer Technology and the Surgeon: what the resident needs to
know. Nigeria J Med 2006; 15(2):119-23
29. Galukande M, Jombwe J. Feasibility of Laparoscopic surgery in a resource limited setting: cost
containment, skills transfer and outcomes. ECAJS 2011; 16 (2): 111 - 116
30. Parkar RB, Thagana NG, Baraza R, Otieno D. Experience with laparoscopic surgery at the Aga
Khan Hospital, Nairobi. East Afr Med J 2003; 80(1): 44-50
31. Mann M, Tendulkar A, Birger H, Howard C, Ratcliffe MB. National Institutes of health funding
for surgical research. Ann Sug 2008; 247 (2): 217-21
32. Nankinga Z, Kutyabami P, Kibuule D, Kalyango J, Goves S, Bollinger RC, Obua C. An
assessment of Makerere University College of Health Sciences: optimizing health research
capacity to meet Uganda’s priorities. BMC International Health and Human Rights 2011 (11):
Suppl S12Poenaru D, Steffes B. Developing world perspective on mimally invasive surgery and
training. www.mastri.umm.edu/NIH-Book/wprld-perspective.html accessed August 12, 2013
33. The College of SECSA www.who.int/workalliance/mentorslist/COSECSA/Index.html
34. Greysen SR, Dovlo D, Oluwabunmi E, Jacobs M, Sewankambo NK, Mullan F. Medical
Education in sub Saharan Africa: a literature review. Medical Education 2011; 45: 973-986
35. Luboga S, Galukande M, Ozgediz D. Recasting the role of the surgeon in Uganda: a proposal to
maximize the impact of surgery on public health. Tropical medicine & international health : TM
& IH 2009, 14(6):604-608.
36. Beveridge M. Surgical training in East Africa. Education and practice. Lancet 2004: 363; 2196
37. Ozgediz D, Roayalek K, Debas H, Checter W, Farmer D. Surgery in developing countries:
essential training in residency. Arch Surg 2005; 140: 795-800
38. Riviello R, Ozgediz D, Hsia RY et al. Role of collaborative academic partnerships in surgical
training, education and provision, World J Surg 2010; 34(3): 459 – 65
39. Mitchell KB, Giiti G, Kotecha V, Chandika A, Pryor OK, Roger Härtl R, Gilyoma J. Surgical
education at Weill Bugando Medical Centre: supplementing surgical training and investing in
local health care providers. Mitchell BK, Can J Surg, 2013; 56(3): 199-203
10
COSECSA/ASEA Publication -East and Central African Journal
(3))
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ISSN 2073
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40. Mkandawire NC. Surgical education collaboration between high and low income countries.
www.surgicon.org/wp-content/uploads/2013/07/surgicon-2013_session
4_N-Mkandawire.pdf
Accessed October 2013
41. Kassam F, Damji KF, Kiage D, Carruthers C, Kollmann MKH. The Sandwich Fellowship: A
Subspecialty Training Model for the Developing World. Academic Medicine, 2000; 84(8): 115260
42. Thomas MP. The role of simulation in the development of technical competence during surgical
training: a literature review. Int Journal of Medical Education. 2013; 4:48-58
43. Fitts PM, Posner MI. Human performance. Belmont CA; Brooks/Cole, 1967
44. Kopta JA. The development of motor skills in Orthopeadics education. Clin Orthop 1971; 75: 805
45. Poenaru D, Steffes B. developing world perspective on minimally invasive surgery and training.
www.mastri.umm.edu/NIH-Book/world-perspective.html. Accessed August 12, 2013.
46. Okrainec A, Henao O, Azzie G. Telesimulation: an effective method for teaching
the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc. 2010 Feb;
24(2):417-22.
47. Okrainec A, Smith L, Azzie G. Surgical simulation in Africa: the feasibility and impact of 3day fundamentals of laparoscopic surgery course. Surg Endosc. 2009 Nov; 23(11):2493-8
48. Derbew M, Beveridge M, Howard A, Byrne N. Building surgical Research capacity in Africa:
The Ptolemy project. PLoS Med. 2006; 3(7): e305
49. Nasir AA, Ameh EA. Fate of abstracts presented at Association of Paediatrtic surgeons of Nigeria
annual meetings. Afri J Paediatric Surg 2012; 9:132-6
50. Sawyer A. African Universities and the challenge of research capacity development. JHEA/RESA
2004; 2(1): 211 – 240
51. Kakande I. Is General Surgery on the Verge of Demise? East Central Journal of Surgery. 2012;
17(1): 3-8
52. Whitworth JAG, Kokwaro G, Kinyanjui S, Snewiu V, Tanner M, Walport M, Sewankambo NK.
Strengthening capacity for Health research in Africa. Lancet 2008: 373 (9649): 1590-1593
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A One Decade Trend of Transforming Medical Doctors to Surgeons in Tanzania: The Leaking
Trough.
O.V Nyongole1, N. Siril2, A. Kiwara2
1
Department of Surgery, School of medicine, Muhimbili University of Health and Allied Sciences.
2
Department of Development Studies, School of Public Health and Social sciences
Corresponding to: Obadia V Nyongole, Email address: onyongole@yahoo.co.uk
Background: A major emphasis in the ongoing health sector reforms in Tanzania is to increase the
number of graduates in medical field in all aspects. Tanzania development vision 2025 set quality
livelihood for all as one of its principle objectives. For this to be realized not only Human resource
for Health (HRH) in all Medical fields are required but a highly trained calibre HRH is of
paramount. Whether it has worked or not is a subject of speculation. This paper sets out to examine
to what extent number of produced medical doctors (MDs) has turned positively the number of
surgeons for the past one decade in Tanzania.
Methods: Retrospective analysis of reports from five health Universities in Tanzania with a
focus on graduated Medical Doctors and those trained to become surgeons for the period 2001
to 2010.
Results: Between 2001 and 2010 five institutions trained these graduate Human Resource for
Health (HRH). Combined local training institutions produced a total of 2,022 Medical Doctors.
These Institutions included a public institution Muhimbili University of Health and Allied
Sciences (MUHAS), Private faith based (Kilimanjaro Christian Medical Centre (KCMC) and
Bugando University College of Health Sciences (BUCHS) and private for profit (International
Medical and Technology (IMTU) and Hurbert Kairuki Memorial University (HKMU).
MUHAS alone trained 1,285 MDs or 64% of these graduates. Faith based produced 287 and
the rest (450) were produced by the private for profit institutions. Out of 1285 MDs trained at
MUHAS in the mentioned period, only 25(1.9%) became surgeons, and out of all 2022 Medical
Doctors locally trained in that period only 51(2.5%) trained to become general surgeons. This
is a major challenge for the profession.
Conclusion: If only 2.5% (51 out of 2,022) of all locally trained Medical Doctors trained to
become Surgeons in a period of ten years realization of vision 2025 health sector goals is
questionable. The major question which remain unanswered is why this trend? It is the
authors’ view that Marshall Plan need to be adapted to redress the situation.
Introduction
Highly trained Human Resource for Health (HRH) in all cadres is inevitable for quality health
services of any Nation. In Tanzania from 1963 to late 1990s only one graduate level health training
institution existed. This Institution was responsible for producing both the first degree graduates and
also for specialization cadres. This resulted into the country to have very low HRH in the highly
trained cadres while the population growing rapidly.
The health sector reform which was introduced in 1991 like to other sectors called upon the public
private partnership (PPP) in the health sector. This among other things aimed at expanding the
provision of health services to the increased population and increasing number of trained HRH from
both public and establishment of private training Institutions. This opened doors for establishment of
private health training institutions and hence increasing production of graduate level HRH. By 2012 a
total of eight (08) graduate level health training institutions existed.
In 2000 Tanzania launched its development vision 2025 which set direction towards desired condition
by 2025. This vision among other targets it set in the quality livelihood for all Tanzanians by 2025.
For this quality livelihood to be attained the HRH should be among other things adequately trained
and well deployed at all levels. For the past one decade the total number of Medical Doctors
graduating from the local Universities has increased from less than 100 in 2000 to more than 400 in
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20101. This increase was expected to turn up to increase the number of graduate Specialists in all
Medical fields and in Public health. Our eye is on the number of surgeons that have been produced in
the past one decade.
In spite of this increase in number of Medical Doctors, the number of graduating surgeons has not
increased accordingly hence leaving a big gap of unmet needs in the country. Working in a
specialized National hospital we observed that the country is having only one centre with 4 surgeons
offering specialized neurosurgical services for a population of 45 million people. Urology is another
area with a big gap with longer waiting lists of Patients waiting for surgery. With this great demand,
there have been complaints on decline in surgical output in our hospitals, especially at Muhimbili.
In dealing with the shortage of Human Resource for Health (HRH) in the country the Ministry of
Health and Social welfare (MoHSW) has set in HRH strategic plan 2008-2015 with main focus on
scaling up the number of well trained HRH in the country. However the challenge faced realization of
this plan is the low funding capacity of the country. Another deliberate effort undertaken by MoHSW
is the strategic plan III 2009-2015 which again underscores the importance of HRH for realization of
not only the vision 2025 but also the MDGs 2015 2.
The overall disease burden associated with surgical conditions in sub-Saharan Africa is estimated at
38 DALYS (disability adjusted life years) lost per 1,000 population3. This estimate is higher than in
other regions of the world, and is mainly due to injuries (15/1,000), obstetric complications (6/1,000),
malignancies (3/1,000), perinatal conditions (3/1,000), congenital anomalies (3/1,000), and cataracts
and glaucoma (2/1,000). The estimated cost per surgical DALY gained at a district hospital is in the
range of US$19–102/DALY. By comparison, the basic immunization program in Africa costs under
US$10/DALY averted, malaria prevention and treatment costs US$2–24/DALY averted and oral
rehydration therapy for diarrheal disease can cost around US$1,062/DALY averted. Antiretroviral
therapy for HIV infection in sub-Saharan Africa is estimated to be in the range of US$350–
1,494/DALY averted. Yet, the global health community has largely neglected surgical diseases when
supporting health interventions in sub-Saharan Africa.
Sub-Saharan Africa faces the greatest challenges. It has been documented that 57 African countries
have critical shortage of 2.4 million doctors and nurses and that, on average, Africa has 2.3 health care
workers per 1000 populations, (the minimum required to achieve an 80% coverage rate for deliveries
by skilled birth attendants or for measles immunization (WHO Report, 2006), compared to America
that has 24.8 health care workers per 1000 population. Additionally, while Africa has 25% of global
disease burden, it only has 1.3% of the world’s experienced health care workers4-5.
It has also been documented that a recent situational analysis indicates that the College Of Surgeons
in East, Central and Southern Africa (COSECSA) region has as few as 1,390 trained surgeons for 273
million inhabitants in 9 of the lowest income countries in the world. In this analysis some of the
reasons for shortage of Surgeons were highlighted including low medical school output, training
capacity limited to university hospitals, international “brain drain”, and low remuneration3,6-7.
Sub-Saharan African medical schools in 22 countries have trained approximately 5334 physicians
practicing in the USA. Nigeria, with more than twice the population of any other country in the region
and with16 medical schools, has lost 2158 physicians who were practicing in the USA by 2002; South
Africa, with eight medical schools, has lost 1943 physicians; and Ghana, with three medical schools,
has lost 478 physicians to the USA. By region, West Africa lost 2697 physicians and Southern Africa
1943. It is also suspected there are many more physicians from these countries working in the USA,
although they are not licensed as physicians8-9.
With the increased surgical conditions and the depicted deficit of Surgeons it is clear that more
Surgeons are needed now than any other time in sub-Saharan Africa in which Tanzania is based. A
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deeper understanding of the contribution of the increased production of Medical Doctors and as to
what extent this has turned the number of Surgeons is called upon by this study.
Subjects and Methods
This was a descriptive, retrospective cross-sectional study; the main study population was the Medical
doctors locally trained in Tanzania. This was a systematic review of documents from the five training
institutions that produce graduate Medical Doctors and four training Institutions that produce
Surgeons in Tanzania. The documents reviewed were the graduation books from 2001-2010.Data
were analyzed manually, the output summarized and presented in tables. Permission to conduct this
study was obtained from the ministry of health and social welfare and verbal informed consent was
sought from respective institutions.
Results
A total of 2022 Medical Doctors graduated in the internal training institutions from 2001-2010.
MUHAS produced 1,285 (63.55%) the rest institutions producing the remaining. Private faith based
(KCMC and BUCHS) combined produced a total of 287 MDs (14.19%) and private for profit (IMTU
and HKMU) combined produced 450 MDs (22.26%) in that period (Table 1). During this period,
MUHAS trained Medical doctors throughout the decade with almost tripling the output at the end of
the decade. Though IMTU started producing Medical Doctors in 2001 it was not able to produce them
throughout the decade as it was barred by MoHSW in 2003, 2004 and 2008 due to failure to conform
to some requirements set by regulatory bodies for Universities in East Africa and Tanzania. The other
institutions started to produce MDs as shown in table 1 above. From the table above it is clear also
that BUCHS was at its infancy.
Number of Surgeons graduated in Tanzania from 2001-2010
A total number of 51 (2.5%) General surgeons were trained in four institutions. Out of these 25
(49.0%) were trained at MUHAS however the number of surgeons who originated from MUHAS in
that period is very less compared to total number of MDs graduated from MUHAS in that period.
Table 1. Medical Doctors graduated in Tanzania from 2001-2010
Doctor of Medicine
Institution
MUHAS
KCMC
IMTU
HKMU
BUCHS
Total
2001
56
04
60
02
61
15
12
88
03
105
11
04
120
04
103
11
12
126
05
122
11
39
20
192
06
134
27
34
08
203
07
175
24
27
26
252
08
201
24
42
09
276
09
173
39
26
50
24
312
10
155
71
76
70
21
393
Total
1,285
233
218
232
54
2,022
Table 2. Number of Surgeons graduated in Tanzania from 2001-2010
Surgeons Graduates
Institution
MUHAS
KCMC
HKMU
BUCHS
Total
14
2001
1
1
2002
2
2
2003
1
2
3
2004
4
1
5
2005
1
1
2006
3
3
2007
3
2
5
2008
3
1
1
5
2009
5
2
1
3
11
2010
6
3
3
3
15
Total
25
15
5
6
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From table 2 above, in 2005 and 2006 MUHAS did not produce surgeons; the reason for this was lack
of qualified Students for enrolment or graduation as surgeons. It is also clear that with exceptional to
KCMC which started to produce surgeons in 2003 the rest two institutions were still at infancy.
Discussion
The trend of training medical doctors has been on ascending order for the past one decade, however
this have not been reflected in real life contributing to quality livelihood as it is stated in development
vision 2025 and not even in the number of graduating Surgeons. This finding conforms to what
Munga and Mbilinyi in 2009 documented. In the so mentioned study they commented that, “Tanzania
is unable to attract and retain an adequate and qualified health workforce to effectively implement
health interventions, reverse the negative health status trends and ultimately achieve Millennium
Development Goals (MDGs)” (p.3)10. When documenting unfavourable direction towards MDGs.
Production of 51 surgeons out of 2,022 MD graduates in 10 years for a population of 45 million
people is not a favourable direction towards fulfilling the health care sector goals of the vision 2025
with one of the principle targets as quality livelihood for all. These findings are not also in favour of
the National health policy objective 2.4.4 (2003) which states,’ Train and make available competent
and adequate number of health staff to manage health services with gender perspective at all levels.7
Capacity building of human resource at all levels in management and health services provision will be
addressed’11-12.
The situation is not unique to Tanzania according to an article released by PSI (Population services
International) in 2012 most sub-Saharan countries are facing the same problem, for instance in
Zambia PSI documented; ‘Zambia has only 44 fully licensed surgeons to serve its population of 13
million..” PSI further added that more than 56 Million People in sub-Saharan Africa need surgery
ranging from caesarean section to cataract surgery13-14.
This study shows that there is brain drain within the profession whereby out of 2022 trained medical
doctors only 51(2.5%) specialized in General Surgery. Robinson in 2007 describes two categories of
brain drain of health care workers, the “International brain drain (involving) the transfer of human
resources across national borders, typically from a developing to a developed country which could
imply a reduction (net loss) in aggregate welfare for the 'donor' country and an addition or
improvement (net gain) in the social welfare of the 'recipient' country (and) the Internal brain drain
(that) merely involves a re-allocation of existing human resources in the same country and implies no
welfare loss in the aggregate, to that country, although at the micro-level, some groups may be made
better off at the expense of others’’ 6, 15-18.
Mills, Kanters and Hagopian (2011) noted that Sub-Saharan African countries that invest in training
doctors have ended up losing $2 billion as the expert clinicians leave home to find work in more
prosperous developed nations 15. The movement of Doctors away from their home country may partly
explain why there is small number of Doctors joining post graduate studies to become Surgeons in
Tanzania10, 14. The HSSP III (2009) documented that a large number of professional workers are
needed. The same document acknowledge that there is higher attrition rates for health workers which
has been contributed by among other things, health workers’ migration, in addition to the competition
between the private and public health facilities over scarce health workers in Tanzania. On top of
competition between private and public sector for Health care workers, there is a competition between
public health facilities with NGOs, Health Training/Research Institutions, and urge for further studies
and other health related agencies12, 14.
With regard to rural-urban dynamics we observed that major towns compared with other regions were
mainly having a good number of those trained Surgeons mainly Dar es salaam, Mwanza, Kilimanjaro
and few in Mbeya. Although this may not give a clear picture of rural-urban dynamic of health
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workers, it can depict the staffing levels of health care workers in major town compared to other
regions. Concentration in major towns is attributed to presence of Medical Training or Research
institutions in these towns. Again, this may reflect the absence of medical doctors’ training institutions
in the underserved regions with public facilities being major source of employment14.
Decentralization of medical doctors’ training institutions may result in even distribution of health
workers throughout the country. While there is marked improvement in number of graduate Medical
Doctors in this decade the question that remain unanswered is as to why they have not turned
positively to become Surgeons.
Conclusions
The training of surgeons has not been synergized by the number of medical doctors trained for the
past one decade. The big question that remain unanswered and which call for another big study is as
to why this small number of Medical doctors showed up to become Surgeons. Tanzania progress
towards realization of the vision 2025 with principal target of quality livelihood for all becomes a day
dream if the HRH in its nut shell is not well addressed. It is the authors’ opinion that a well articulated
strategy taking into consideration the production of specialized HRH is devised to revert this trend.
Acknowledgement
The Authors would like to thank all executives of various institutions for participating in this study
and the registrar of the Medical council of Tanganyika. Special thanks to the ministry of health and
social welfare for giving a permission to conduct this study without any competing interest. Many
thanks to MUHAS for their sponsorship to this study without competing interest.
References
1. Kiwara A .Human Resource for Health in Tanzania 2012-unpublished report.
2. MoHSW. (2008).The Health Sector Strategic Plan III (2009-2015)
3. Luboga S, Macfarlane SB, von Schreeb J, Kruk ME, Cherian MN, et al. Increasing Access to
Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies
Recommended by the Bellagio Essential Surgery Group. PLoS Med.2009; 6(12).
4. Naicker S Plange-Rhule J, Tutt RC, Eastwood JB. Shortage of health care workers in
developing countries-Africa Ethnicity & Disease. 2009. Volume 19; Section1; 60-64.
5. WHO. (2006). Health workers: A global profile. Chapter 1.
6. Robinson R. The costs and benefits of health worker migration from East and Southern Africa
(ESA). 2007. A literature review. EQUINET DISCUSSION PAPER49.
7. O'Flynn, J .Addressing Surgical Manpower in Sub Saharan Africa: An Intercollegiate
Partnership between RCSI and COSECSA. 2012
8. Hagopian A, Thompson MJ, Fordlyce M,Johnson KL,Hart LG. The migration of physicians
from sub-Saharan Africa to the United States of America: measures of the African brain
drain. Human Resource for Health Journal .2004(2);17
9. Africa’s Heath care Brain Drain Report,New York Times.2004,August 13
10. Munga MA, Mbilinyi DR .Non-financial incentives and retention of health workers in
Tanzania: Combined evidence from literature review and a focused cross-sectional
study,'.2008. EQUINET Discussion Paper Series 61. NIMRI, ECSA-HC, EQUINET: Harare.
11. MoHSW (2007). Primary Health Sector Development Plan
2007-217.Available at
http://www.moh.go.tz/documents/FINAL%MMAM%2026.11.2007.pdf
12. MoHSW. The Health Sector Performance Profile 2011. (2012)
13. Population Services International (PSI) .Surgery Gap in Sub-Saharan Africa Threatens
Progress. 2012
14. Sikika.
(2011).
HRH
Tracking
study
2010.
Available
at;
http://www.sikika.or.tz/en/cms/functions/files/publication69.pdf
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15. Hagopian A, Mills K, Kanters M. The financial cost of doctors emigrating from sub-Saharan
Africa: human capital analysis. BMJ 2011;343:d7031
16. Michael D, Conway etal Addressing Africa’s Health Workforce Crisis. 2007
17. The HRH Crisis, as per Global Health Trust Report. 2004
18. WHO (2008). World Health Statistics Available at
http://www.who.int/gho/publications/world_health_statistics/EN_WHS08_Full.pdf
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Age at First Child Birth as a Risk Factor of Breast Cancer among Ugandan Women at a
Tertiary Hospital: a Case Control Study
V. Mukasa1, M. Galukande2, J. Jombwe1, O.J. Fualal1
1
Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda.
2
Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda.
Correspondence to: Victo Mukasa, Email: vmnassaka@gmail.com
Background: Breast Cancer in Uganda is the third commonest cancer in women after cancer of the
cervix and Kaposi’s sarcoma.
The incidence of Breast Cancer in Uganda has nearly tripled from 1961 to 2006. It has been
considered a neglected disease but the reasons to why there is an increase in its incidence have not
been fully explained.
Studies show that age at first full term child birth has been associated with risk of developing breast
cancer in the Caucasian population.
Objective: To establish whether age at first full term child birth is associated with development of
breast cancer among Ugandan women.
Method: A case control study was conducted over a six months period from November 2011 to
April 2012 with patients confirmed with breast cancer as cases and controls without breast cancer.
The sampling were convenient and interview questionnaire were administered, and clinical
examinations done .The main predictor were age at first full term child birth and the outcome were
histologically confirmed breast cancer. Data were analysed using stata 10; using logistic regression
models, p-value of less than 0.05 was considered significant.
Results: Over all, 183 women were enrolled, (93 cases and 93 controls). The mean age at first full
term child birth was 19.8 years. The histological subtype was ductal carcinoma. No association
were found between age at first full term child birth and risk of breast cancer adjusted OR 0.3 (0.12.4), p=0.239.
Conclusion: No associations were found between age at first term child birth and risk for breast
cancer disease among this group of Ugandan women.
Key words: Breast Cancer, Age at First Birth, Uganda
Introduction
Breast cancer is the most common diagnosed cancer and the leading cause of cancer death in women
worldwide, with an estimated 1.4 million new breast cancer cases and 458,000 deaths in 20081. The
incidence and mortality rates vary internationally by more than 5-fold however, the highest incidence
rates are found in Switzerland, U.S. whites, Italy, and many other European countries, whereas low
rates are found in Africa, Asia, and South America2,3. Generally, the incidence of Breast cancer in
some high-income countries is stabilizing, and death rates are falling, but both appear to be increasing
in developing countries4. According to Stewart, the majority of new cases now occur in women from
low- and middle-income countries, in which the incidence is increasing by as much as 5% per year
and three-fourths of global breast cancer deaths occur5,6.
The actual cause of breast cancer is unknown however; studies have attributed it to various factors
including lifestyle, anthropometric, reproductive and demographic characteristics7,8. Several studies
have identified a woman’s reproductive history as an important determinant of her breast cancer risk.
Factors that protect against breast cancer in the general population include a late age of onset of
menarche, multiparity, breastfeeding, and an early age at menopause9. Conversely, late age at birth of
first child has been reported as one of the major determinants of breast cancer incidence10 and has
been attributed to 28% of its incidence11.
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Little is known about the influence of age at first full term child birth on the risk of breast cancer in a
Ugandan setting and especially Mulago Hospital. This study was therefore to generate information on
whether AFFB is associated with the risk of developing breast cancer among Ugandan women.
Patients and Methods
This study was a matched case control study conducted at the Endocrine and Breast Clinic, 3C
surgical ward and at the Uganda Cancer Institute Solid Tumour Centre at Mulago hospital. It was
aimed at determining the association between ages at first full-term child birth with development of
breast cancer.
The breast clinic receives an average of five cases of incident breast cancer from the screening
program per week. The clinic receives referrals from all over the country of both confirmed and
suspected cancer of the breast. The target population consisted of women histologically confirmed to
have breast cancer who sought treatment from Mulago Hospital. The controls included women
without breast disease who attended surgical outpatients’ clinic for other medical conditions during
the study period. The controls were matched with cases by age and parity status. The cases were
identified from the surgical wards and the endocrine/breast clinic. Clinical breast examination was
done by the Principal investigator for every control to exclude those with asymptomatic breast cancer.
Women aged 18 years and above with or suspected to have breast cancer were identified. Those who
had histologically confirmed diagnosis of breast cancer, able and willing to give relevant information
and had ever given birth to a child were included. Convenience sampling method was used to select
the cases. Core biopsies were taken using a BARD MAGMUM gun. The controls in the same age
category as cases and who had given birth to at least a child were conveniently selected from the
general clinic, plastic clinic, endocrine clinic, and orthopaedic clinic. Clinical breast examination was
done for every control to exclude those with asymptomatic breast cancer.
Breast cancer subtype namely ductal, lobular, mixed ductal-lobular, mucinous, medullary, tubular and
solid and Age at first full term child birth. Age at menarche, Use of oral contraceptives ,Age at
menopause ,Breast feeding habits, Breast cancer screening history , Personal and family history of
cancer, Lifetime physical activity , Smoking status and Alcohol intake.
Procedure
An informed consent was sought first after explaining the nature and purpose of the study. The
patients were divided into 2 groups; women with a histological diagnosis of breast cancer were
recruited in the study as cases while those with no breast disease were recruited in the study as
controls. Data were collected by the principal investigator and a trained research assistant over a six
month study period. All information was recorded in a data collection form.
The controls were recruited from the surgical clinics including the general clinic. The cases were
matched by age and parity.
Data collection and management
Case or control status of the patients was concealed to the Interviewers as much as possible. The
questionnaires were pretested among five controls and equal number of cases drawn from outpatients
department and the wards. The completed questionnaires were evaluated for consistency; accuracy
and comments obtained from the RAs and the volunteers were incorporated accordingly. The
completed questionnaires were collected on daily basis for data entry as well as safe storage. Data
were double entered in Epidata 3.1 and transferred to Stata 10.1 for analysis.
Summary statistics were obtained for each histological subtype identified, clinical features and the
independent variables. Bivariate analysis were done for risk factors of BCA including age at first full
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term child birth. Variables found to be significantly associated were included in a multivariate logistic
regression model. The strength of association were determined using odds ratios and their
corresponding confidence intervals.
Results
The study were conducted among 183 female participants of whom 90 were cases of breast cancer
with 42 post menopausal and 48 premenopausal. 93 were the study controls of whom 34 were post
menopausal and 59 were premenopausal. We administered questionnaires to assess what factors in the
cases absent in the controls could have contributed to their risk for breast cancer. Participants were of
different nationality, the majority being Ugandans 95.1% from the nearby districts. The mean age of
the respondents among cases was 48 and 46 in the controls.
Table 1. General Characteristics of the Study Population and Associated Risk Factors.
Risk factor
First pregnancy age category
≤ 25 years
>25 years
Use of oral contraceptives
Yes
No
Age categories at menopause
Before 55 years
After 55 years
Months of breastfeeding
<24
24-48
49-72
73-96
>96
Breast cancer family history
Yes
No
Alcohol intake
Yes
No
Smoking
Yes
No
Body mass index
Normal
Overweight
Obese
Risk factors for breast cancer
Odds (CI)
Crude OR (CI)
Adjusted OR (CI)
P-value
0.98 (0.72-1.32)
0.75 (0.26-2.16)
0.8 (0.3-2.3)
0.3 (0.1-2.43)
0.239
0.2 (0.1-0.4)
1.7 (1.2-2.4)
8.2 (3.7-18.3)
16.7 (1.2-226)
0.032
1.4 (0.8-2.2)
0.3 (0.1-1.7)
0.3 (0.1-1.3)
0.16 (0.1-1.5)
0.108
0.5 (0.3-1.0)
1.1 (0.6-1.9)
1.6 (0.7-3.5)
3.3 (1.1-9.9)
0.7 (0.4-1.3)
Reference
2.2 (0.9-5.2)
3.2 (1.1-9.2)
6.5 (1.7-24.3)
1. 5 (0.6-3.5)
Reference
0.9 (0.1-6.2)
5.6 (0.3-92.4)
1.5 (0.0-24.4)
0.3 (0.1-1.5)
0.945
0.225
0.762
0.136
1.1 (0.5-2.6)
0.95 (0.70- 1.30)
0.9 (0.4-2.2)
0.2 (0.1-2.2)
0.193
1.0 (0.6-1.7)
0.9 (0.7-1.3)
0.91 (0.5-1.7)
1.6 (0.4-5.6)
0.495
1.5 (0.4-5.3)
0.9 (0.7-1.3)
0.6 (0.2-2.3)
1.1 (0.1-8.3)
0.958
1.1 (0.7-1.7)
1.4 (0.8-2.3)
0.3 (0.1-0.7)
Reference
1.2 (0.6-2.4)
0.3 (0.1-0.7)
Reference
1.6 (0.4-6.4)
0.3 (0.1-1.9)
0.513
0.178
Table 1 summarizes the distribution of the risk factors between the cases and the controls so that we
are able to establish the contribution of age at first child birth to the risk of breast cancer disease.
The distribution of risk factors in both the cases and the controls in almost the same. However
significant differences were noted in body mass index, months of breast feeding and oral
contraceptive use, age when menstrual period begun. Very few cases than controls were obese. Fewer
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cases than controls breastfed for less than 24 months whereas fewer controls than cases breastfed for a
period of 73-96 months. Oral contraceptive use was greater in the control group than the cases.
No one was ever diagnosed with breast cancer only. One participant reported to have ever been
diagnosed with benign breast disease and this were among the controls p-value of difference in
proportions = 0.324.
Table 2. Association between Breast Cancer and Chosen Risk Factors
Risk factor
First pregnancy age category
≤ 25 years
25 years
Use of oral contraceptives
Yes
No
Age categories at menopause
Before 55 years
After 55 years
Months of breastfeeding
<24
24-48
49-72
73-96
>96
Breast cancer family history
Yes
No
Alcohol intake
Yes
No
Smoking
Yes
No
Odds (CI)
Crude OR (CI)
Adjusted OR (CI)
P-value
0.98 (0.7-1.3)
0.75 (0.3-2.2)
0.8 (0.3-2.3)
0.3 (0.1-2.4)
0.239
0.2 (0.1-0.4)
1.7 (1.2-2.4)
8.2 (3.7-18.3)
13.2 (1.3-138)
0.032
1.4 (0.8-2.2)
0.3 (0.1-1.7)
0.3 (0.1-1.3)
0.2 (0.1-1.5)
0.108
0.5 (0.3-1.0)
1.1 (0.6-1.9)
1.6 (0.7-3.5)
3.3 (1.1-9.9)
0.7 (0.4-1.3)
Reference
2.2 (0.9-5.2)
3.2 (1.1-9.2)
6.5 (1.7-24.3)
1.45 (0.6-3.5)
Reference
0.9 (0.1-6.2)
5.6 (0.3-92.4)
1.5 (0.1-24.4)
0.3 (0.0-1.54)
0.945
0.225
0.762
0.136
1.1 (0.5-2.6)
0.9 (0.7- 1.3)
0.9 (0.4-2.2)
0.2 (0.1-2.2)
0.193
1.0 (0.6-1.7)
0.9 (0.65-1.3)
0.9 (0.5-1.7)
1.6 (0.4-5.6)
0.495
1.5 (0.4-5.3)
0.9 (0.7-1.3)
0.6 (0.2-2.3)
1.1 (0.1-8.3)
0.958
Total number of pregnancies represented as means (SD)
Overall: 5.31(4.53)
Among controls: 5.81(5.64)
Among the cases: 4.8 (2.92)
Mean age at first pregnancy, mean (SD)
Overall: 19.81(3.82)
Among the cases: 19.88 (3.68)
The difference in means between the cases and control was not statistically significant (p=0.8133).
The difference in proportions between the cases and controls was statistically significant (p= 0.009).
There were more cases that had their menstruation at age 14 years than the controls. The differences
in proportions between the cases and controls was statistically significant (p =0.009
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Discussion
Contrary to those previous studies, in our study the risk of having breast cancer was 0.20 times less in
those who used oral contraceptives compared to a high risk which were 1.65 times in the control
group. The reasons which could probably explain this could be smaller sample size which were
hospital based compared to larger sample sizes which were population based, the duration when oral
contraceptives were used; at what age they were used.
Several studies have identified a woman’s reproductive history is an important determinant of her
breast cancer risk. Of particular importance is the age at which a woman completes her first full term
pregnancy26. From the numerous studies of reproductive history and breast cancer risk, there is a
consensus that an early first birth is associated with a long term reduction in risk. An early age at first
child birth (i.e. before the age of 20) has been reported to reduced a woman’s risk of developing
breast cancer by up to one half20, whereas a late age at first child birth (e.g. at age 30 or older)
increases her risk. Various studies have shown that the risk associated with a late first term pregnancy
may be as great as or higher than the risk associated with nulliparity12.
In our study it were found out that the risk of breast cancer has 0.98 times higher in woman who gave
their first full term child at age 25 years and below compared to those who gave their first full term
child at age greater than 25 years (OR 0.75) however this were not statistically significant as shown
by the p value of 0.239. A study by LiCI29, found that age at first full term pregnancy were inversely
associated with breast cancer risk. In this study, women who had full term pregnancy at age 19 or
younger compared with those who had that first full term pregnancy at age 35 or older had a 2.0 fold
(95% C I, 1.1-3.7) increased risk of invasive breast cancer in our case control study done in Mulago
national referral hospital, no statistical significance were found between age at first full term child
birth with risk of breast cancer. This could be due to genetic, environmental, ethnical and racial
variations as far as cancer breast is concerned.
Breast cancer is considered to be associated with various documented risk factors. In our study oral
contraceptive use were found to be associated with breast cancer. The risk of breast cancer has been
found to be increased with use of oral contraceptives as supported by previous studies which were
population based38. In these studies, the risk were highest for women who started using oral
contraceptives as teenagers, however , 10 or more years after women stopped using oral
contraceptives, their risk of developing breast cancer had returned to the same level as if they had
never used birth control pills regardless of family history of breast cancer, reproductive history
geographic area of residence, ethnic background, differences of family history of breast cancer, and
type of hormone (s) used duration of use39.
Among the different histological types of breast cancer, ductal with productive fibrosis (infiltrating
ductal) is the commonest form of cancer of the breast appropriately 80%. A retrospective study done
in Bugando medical Center in Tanzania, which looked at 328 case reports of histologically confirmed
cancer breast, showed that majority of patients had invasive ductal carcinoma (91.5%) followed by
mucinous carcinoma (5.2%), invasive lobular carcinoma (31%) and in situ ductal carcinoma (0.3%).
Other studies also showed almost similar findings with percentages of up to 80. In agreement with
previous studies, our study also found out that majority of cases had invasive ductal carcinoma
(94.4%), invasive lobular 4.4% and papillary 1.1%.
The mean age at first full term pregnancy among the cases was19.9 and among controls, it was 19.8.
The difference in means between the cases and controls were not statistically significant.
Conclusion
There was no association between age at first full term child birth and risk of developing breast
cancer.
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References
1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of
cancer in 2008: GLOBOCAN 2008. International Journal of Cancer. 2010;127(12):2893-917.
2. Parkin DM, Fernández LMG. Use of statistics to assess the global burden of breast cancer. The
breast Journal. 2006;12:S70-S80.
3. Zahl PH, Maehlen J, Welch HG. The natural history of invasive breast cancers detected by
screening mammography. Archives of Internal Medicine. 2008;168(21):2311.
4. Peto R, Boreham J, Clarke M, Davies C, Beral V. UK and USA breast cancer deaths down 25%
in year 2000 at ages 20–69 years. The Lancet. 2000;355(9217):1822.
5. Stewart BW, Kleihues P. World cancer report: IARC press; 2003.
6. Parkin DM, Nambooze S, Wabwire-Mangen F, Wabinga HR. Changing cancer incidence in
Kampala, Uganda 1991- 2006. International Jouranl of Cancer. 2010; 126(5):1187-95
7. Cancer CGoHFiB. Familial breast cancer: collaborative reanalysis of individual data from 52
epidemiological studies including 58 209 women with breast cancer and 101 986 women without
the disease. The Lancet. 2001;358(9291):1389-99.
8. Ravdin PM, Cronin KA, Howlader N, Berg CD, Chlebowski RT, Feuer EJ, et al. The decrease in
breast-cancer incidence in 2003 in the United States. New England Journal of Medicine.
2007;356(16):1670-4.
9. Key TJ, Verkasalo PK, Banks E. Epidemiology of breast cancer. The lancet oncology.
2001;2(3):133-40.
10. Colditz GA, Rosner B. Cumulative risk of breast cancer to age 70 years according to risk factor
status: data from the Nurses' Health Study. American Journal of Epidemiology.
2000;152(10):950.
11. Pisani P. Avoidable cancer in Europe: estimating avoidable fractions. Lyon: Europe Against
Cancer Programme. 2000.
12. Layde PM, Webster LA, Baughman AL, Wingo PA, Rubin GL, Ory HW. The independent
associations of parity, age at first full term pregnancy, and duration of breastfeeding with the risk
of breast cancer. Journal of Clinical Epidemiology. 1989;42(10):963-73.
13. Ma H, Bernstein L, Pike MC, Ursin G. Reproductive factors and breast cancer risk according to
joint estrogen and progesterone receptor status: a meta-analysis of epidemiological studies. Breast
Cancer Res. 2006;8(4):R43.
14. Parkin D, Whelan S, Ferlay J, Teppo L, Thomas D. Cancer incidence in five continents. Lyon:
International Agency for Research on Cancer. Vol VIII IARC Scient Publ. 2002(155).
15. Althuis MD, Dozier JM, Anderson WF, Devesa SS, Brinton LA. Global trends in breast cancer
incidence and mortality 1973–1997. International Journal of Epidemiology. 2005;34(2):405.
16. Hortobagyi GN, de la Garza Salazar J, Pritchard K, Amadori D, Haidinger R, Hudis CA, et al.
The global breast cancer burden: variations in epidemiology and survival. Clinical Breast Cancer.
2005;6(5):391-401.
17. Mathers C, Fat DM, Boerma J. The global burden of disease: 2004 update: World Health
Organization; 2008.
18. Omar S, Khaled H, Gaafar R, Zekry A, Eissa S, El-Khatib O. Breast cancer in Egypt: a review of
disease presentation and detection strategies. East Mediterr Health J. 2003;9(3):448-63.
19. Vorobiof DA, Sitas F, Vorobiof G. Breast cancer incidence in South Africa. Journal of clinical
oncology. 2001;19(suppl 1):125.
20. Adesunkanmi A, Lawal O, Adelusola K, Durosimi M. The severity, outcome and challenges of
breast cancer in Nigeria. The Breast. 2006;15(3):399-409.
21. Hisham AN, Yip C-H. Overview of Breast Cancer in Malaysian Women: A Problem with Late
Diagnosis. Asian Journal of Surgery. 2004;27(2):130-3.
22. Gakwaya A, Galukande M, Luwaga A, Jombwe J, Fualal J, Kiguli-Malwadde E, et al. Breast
cancer guidelines for Uganda (2008). African Health sciences. 2008;8(2):126.
23. Gondos A, Brenner H, Wabinga H, Parkin D. Cancer survival in Kampala, Uganda. British
Journal of cancer. 2005;92(9):1808-12.
23
COSECSA/ASEA Publication -East and Central African Journal
(3))
Journal of Surgery. November/December 2013 Vol. 18 (3
ISSN 2073
2073073-9990 East Cent. Afr. J. surg
24. Newcomer LM, Newcomb PA, Trentham-Dietz A, Longnecker MP, Greenberg ER. Oral
contraceptive use and risk of breast cancer of histologic type. International Journal of Cancer.
2003; 106(6):961- 4
25. Li CI, Malone KE, Porter PL, Weiss NS, Tang MTC, Daling JR. The relationship between
alcohol use and risk of breast cancer by histology and hormone receptor status among women 65–
79 years of age. Cancer Epidemiology Biomarkers & Prevention. 2003;12(10):1061-6.
26. Chie WC, Hsieh C, Newcomb PA, Longnecker MP, Mittendorf R, Greenberg ER, et al. Age at
any full-term pregnancy and breast cancer risk. American Journal of Epidemiology.
2000;151(7):715.
27.
MacMahon B, Cole P, Lin T, Lowe C, Mirra A, Ravnihar B, et al.
Age at first birth and breast cancer risk. Bulletin of the World Health Organization.
1970;43(2):209.
28. Phipps AI, Li CI, Kerlikowske K, Barlow WE, Buist DSM. Risk factors for ductal, lobular, and
mixed ductal-lobular breast cancer in a screening population. Cancer Epidemiology Biomarkers &
Prevention. 2010;19(6):1643.
29. Li CI, Littman AJ, White E. Relationship between age maximum height is attained, age at
menarche, and age at first full-term birth and breast cancer risk. Cancer Epidemiology Biomarkers
& Prevention. 2007;16(10):2144-9.
30. Okobia M, Bunker C, Zmuda J, Kammerer C, Vogel V, Uche E, et al. Case–control study of risk
factors for breast cancer in Nigerian women. International Journal of Cancer. 2006;119(9):217985.
31. Park SK, Kim Y, Kang D, Jung EJ, Yoo KY. Risk Factors and Control Strategies for the Rapidly
Rising Rate of Breast Cancer in Korea. Journal of breast cancer. 2011;14(2):79.
32. Grethe A, Ivar H, Steinar T. Histological type and grade of breast cancer tumors by parity, age at
birth, and time since birth: a register-based study in Norway. BMC Cancer.10.
33. Zanetti-Dällenbach RA, Krause EM, Lapaire O, Gueth U, Holzgreve W, Wight E. Impact of
hormone replacement therapy on the histologic subtype of breast cancer. Archives of gynecology
and obstetrics. 2008;278(5):443-9.
34. Kotsopoulos J, Chen WY, Gates MA, Tworoger SS, Hankinson SE, Rosner BA. Risk factors for
ductal and lobular breast cancer: results from the nurses' health study. Breast Cancer Research.
2010;12(6):R106.
35. Li CI, Daling JR, Malone KE, Bernstein L, Marchbanks PA, Liff JM, et al. Relationship between
established breast cancer risk factors and risk of seven different histologic types of invasive breast
cancer. Cancer Epidemiology Biomarkers & Prevention. 2006;15(5):946-54.
36. Li CI. Risk of Mortality by Histologic Type of Breast Cancer in the United States. Hormones and
Cancer. 2010;1(3):156-65.
37. Dirier A, Burhanedtin-Zincircioglu S, Karadayi B, Isikdogan A, Aksu R. Characteristics and
prognosis of breast cancer in younger women. Journal of BU ON: official Journal of the Balkan
Union of Oncology. 2009;14(4):619.
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Hydrocoele: A Silent Disability Affecting Quality of Life in Katakwi District in Uganda.
N. Kakembo1, S. Kirunda1, J. Yiga1, I. Kikwabanga 2.
1
Department of Surgery, School of Medicine, Makerere College of Health Sciences, Kampala
Uganda.
2
Medical Officer, Katakwi General Hospital, Eastern Uganda
Correspondence to: Nasser Kakembo, Email: kakembon@ymail.com
Background: Katakwi district is one of the rural districts in eastern Uganda in Teso Sub Region.
The district is heavily infested with filarial worms a major cause for hydrocoele and elephantiasis if
the infection is left untreated. Hydrocoele in Katakwi district are still a big cause of silent morbidity
though it’s an operable condition with good outcome. Individuals affected with large hydrocoele
are socially withdrawn, with inability to walk and work, leading to severe poverty to the extent that
they cannot afford to pay for surgery and basic needs in their lives This is also associated with a
negative impact on their sexual lives with broken marriages
Methods: Between 12th and 16th August 2013, a surgical camp was organized in Teso Sub Region
during which free surgery was offered to patients suffering from surgical conditions.
Results: A total of 400 patients reported and were screened. Of these, 90 patients were booked for
surgery but only 57 patients were operated during the camp. Their ages ranged from 5 to 75 years,
of the 57 patients who were operated on, 23 had hydrocoele 5 of them presenting with had bilateral
hydrocoele while 3 patients had concurrent hydrocoele and hernia.
Conclusion: The prevalence of hydrocoele in Katakwi district is high and it’s a big ccausese of
silent morbidity and disability’
Key words: Hydrocoele, Surgical camp
Background
Katakwi district is one of the rural districts in eastern Uganda in Teso Sub Region. The population is
majorly of subsistence farmers that grow rice, sorghum and millet in water logged low lying areas.
The district is heavily infested with filarial worms a major cause for hydrocoels and elephantiasis if
the infection is left untreated. The worms are called Wuchereri bancrofti and are spread by
mosquitoes1, 3. Hydrocoele is a scrotal condition that grows steadily but painless. It may become
excessively big with affected individuals being socially withdrawn, with inability to walk and work2,6.
If un-operated there is a remote association of chronic hydrocoel wit testicular and Para testicular
cancer though more studies are required in black Africans5.
Patients and Methods
The patients were worked on during the Assocition of Surgeons of Uganda (ASOU) surgical camp
held in Teso Sub Region from 12th /08/2013 to 16th /08/2013. The camp was held in the ten districts
making the sub region Katakwi being one of them. The patients were screened as they came and
prepared for surgery.
Results
A total of 400 patients were screened, these included children with congenital anomalies, women with
gynaecological conditions and some patients with purely medical conditions, 90 cases were booked
for surgery and 57 patients were operated during the five days the camp lasted depending on the
severity of the condition. The age range for patients operated was 5 to 75 years. Of the 57 patients
worked on at Katakwi hospital, 23 patients had hydrocoele operated under spinal anaethesia and of
those, 5 had bilateral hydrocoele, 3 had concurrent hydrocoele with at least an inguinal hernia, 1
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patient had bilateral inguinal hernias and bilateral hydrocoele. Other cases included 13 inguinal
hernias, lipomas, keloids abscesses and cysts.
B
A
C
Figures 1A,B,C. Photos of some of the patients who were operated for hydrocoele
Table 1. The Distribution Surgical Conditions among Operated Patients
Surgical condition
Unilatera Hydrocoele (one side)
Bilateral Hydrocoele
Concurrent Hydocoele and Hernia
Bilateral Hydrocoele and Bilateral Hernia
Unilateral Inguinal Hernia
Others
(lipomas, ganglion, cysts, in growing toenails and abscesses)
Total
26
Number of patients
14
5
3
1
13
21
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During the hydrocelectomy about 500 to 1000ml of serous fluid was drained from either hem side and
most of them had stayed with hydrocoele for over 5years. Operated patients were reviewed by the
local doctor in Katakwi hospital, and by three weeks after the camp, all the patients had been healed
un eventfully except two individuals. One patient with a giant hydrocoele developed wound sepsis
with dehiscence of the scrotal suture line that was successfully managed with dressing. The other, was
a patient with bilateral hydocoel and bilateral hernias who developed urinary retention 24 hours after
surgery that was managed with an indwelling urethral catheter for one week. No scrotal haematomas
was reported probably due to meticulous haemostasis.
Discussion
Hydrocoeles are common in this region because they are of infectious cause and the place has a lot of
water bodies with swamps used for cultivation of rice. The water bodies are infested with filarial
worms that cause hydrocoele 3. Hydrocoele in Katakwi district is still a big cause of silent morbidity
though it’s an operable condition with good outcome4.
Once one develops a giant hydrocoele the reaction is to get withdrawn from the public and social
gathering for fear of stigmatization and resort to excessive abuse of alcohol and lack of self care,
though some sections of the population believe that it’s prestigious for man to have big hydrocoele.
The patients tend to abandon work places and become less productive because of the excessive weight
of the scrotum. The problem is compounded by poverty to the extent that they cannot afford to pay
for the surgeries and basic needs in their lives5 .This is also associated with a negative impact on their
sexual lives because of the inconvenience caused by the masses and most of the time the penis is
swallowed in the hydrocoele with broken marriages2. Because the penis is swallowed up patients find
it difficult to clean themselves after urinating in that the urine just flows over the scrotum without
penile support and soils their clothes.
As noted during the surgical camp, most of the hydrocoele were more than 5 years in existence, it s of
paramount importance to closely follow up the patients for fear of the cancers associated with long
standing hydrocoele5.
Conclusion
The prevalence of hydrocoele in Katakwi district is high and it’s a big cusse of silent morbidity and
disability.
Recommendations
We recommend the following:
! To conduct regular case specific surgical camps in the district to operate on the patients with
such giant hydrocoele.
! To strengthen the mass treatment for the filarial worms that causes hydrocoele
! .Health education in order to reduce on stigmatization and encourage early surgery.
! Building capacity for local doctors to develop skill in performance of hydrocoelectomy.
! Integrating hydrocoele surgery in programs like mass circumcision that are already running in
the distinct.
! Strengthen the use of insect repellants and reduce on mosquito bites.
References
1. Neglected diseases targeted in Katine village. Joseph Mugisha, theguardian.com Tuesday
21 April 2009.
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2. E. E. Akpo. Giant hydrocoel –an epitome of neglect. African health sciences 2005
December, 5(4); 343-344.
3. Simonsen P.E., Meyrowitsch D.W., Makunde W.H., Magnussen P. Bancroftian filariasis
;the pattern of microfilaraemia and clinical manifestations in three endemic communities
of northeastern Tanzania. Acta Tropica 1995; 60(3):179-187).
4. Thomas G, Richards FO Jr, Eigege A et al. Apilot program of mass surgery weeks for
treatment of hdrocoel due to lymphatic filariasis in central Nigeria. The American Journal
of Tropical Medicine and Hygiene 2009; 80(3): 447-451.
5. Chukwud O. Okorie, Louis L.Pisters, and Pig Liu. Long standing hydrocoel in adult
Black Africans;Is preoperativescrotal ultrasound justified? Niger Med J.2011 Jul-Sep;
52(3):173-176
6. Mwobobia I.K., Munju E.M, Kombe Y, Wamae C.N. Hydrocelectomy: a proxy for
hydrocoele prevalence in coastal Kenya. Ann Trop Med 2000 Jul; 94(5):479-84
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Treatment Options and Outcomes of Urethral Stricture in Dar Es Salaam,Tanzania. Have we
utilized all the Options?
O.V. Nyongole, L. O. Akoko, A.H. Mwanga, C. Mkony
Department of Surgery, School of Medicine, Muhimbili University of Health and Allied Sciences
Correspondence to: O.V. Nyongole, E-mail: onyongole@yahoo.co.uk
Background: The historical management of urethral strictures constituted regular dilations of the
scar tissue but this inevitably failed for long strictures or subjected to secondary trauma, ischemia,
scarring and further reduction of luminal caliber. A urethral stricture would best be managed by
taking into account its etiology, site, length and caliber as well as applying the right procedure.
Length, patient’s age and co morbid factors play significant roles in the choice of treatment.
Therefore this study was set to document treatment options and early treatment outcomes of urethral
stricture among patients seeking urological services in Dar es Salaam.
Methodology: This was a hospital based descriptive, prospective study which involved all patients
presenting to urology clinics confirmed to have urethral strictures during the period of study from
March 2011 to December2011.
Results: A total of 111 patients with urethral strictures were recruited into the study, all were male
with age range of 10 – 97 years with a mean of 52.7. DVU was the most performed procedure
accounting for 73 (65.8%) of all patients followed by primary urethroplasty at 31 (27.9%) and
multistage urethroplasty at 7 (6.3%). DVU was the commonest procedure in all age groups.
Conclusions: Three treatment options of urethral stricture DVIU, primary urethroplasty, multistage
urethroplasty including clean intermittent catheterization (cic) were adopted as modes of treatment of
patients with urethral stricture seeking urological services at Muhimbili National hospital and
Tumaini hospital in Dar es Salaam, DVIU being the commonest mode treatment. Primary
urethroplasty and DVIU had better treatment outcome during the follow up of 3months.
Key words: Treatment options, urethral stricture, outcome.
Introduction
The historical management of urethral strictures constituted regular dilations of the scar tissue but this
inevitably failed for long strictures and subjected them to secondary trauma, ischaemia, scarring and
further reduction of luminal calibre. A urethral stricture would best be managed by taking into account
its aetiology, site, length and calibre, patients’ age, and co morbid factors.1-5 With the passing of time,
more objective ways of approaching the management of urethral strictures were instituted.6 Pre
operative preparations should enable selection of patients for optimal management so that they are
offered the most beneficial procedure.
Conservative management is for patients who either are medically unfit for elaborate surgical
interventions or on their own choice prefer it over surgery. Urethral stents get incorporated into the
urethral wall and are contraindicated in those with previous reconstructive procedures or those with
dense strictures as at the end prostheses cause tissue proliferation. They are best reserved for short
bulbar strictures. Other conservative management options include use of Suprapubic catheterization,
dilatation and Direct Visual Internal Urethrotomy (DVIU)6-7. DVIU is best suited for strictures less than
one centimetre in length independent of the aetiology or location. The principle is to have one DVIU or
dilatation before resorting to Urethroplasty but primary Urethroplasty is cost effective if a DVIU
success rate is estimated at less than 35%8-9. Urethroplasty forms the modern urethral stricture
management and is best for recurrent strictures and those greater than one centimetre in length. 10, 11
Urethroplasty may be a single or staged procedure and may or may not involve the utilization of tissue
transfer techniques. The tissue transfer may be in the form of free tissue graft or pedicled island flaps
that may be tubularised or onlay12 -17.
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Success in the management is considered to be the absence of obstructive voiding symptoms5,18. Early
treatment outcomes include relieving obstructive symptoms without complications within the study
period from the treatment date. Strictures in the distal portion like the fossa navicularis will require
cosmetic consideration besides the assumption of effective voiding8-9. This study was therefore
conducted to document the treatment options used at MNH and Tumaini Hospital and early treatment
outcome of urethral stricture.
Patients and Methods
This was a hospital based descriptive, prospective study that involved all patients treated for urethral
stricture from March-December 2011. Patients with urethral stricture and consented to be involved in
the study were recruited.
Data was collected through personal interviews and patient case notes where treatment options and
outcome were documented. Patients were assessed for urine flow rate before and three months after
treatment to document an improvement. Patients who had DVIU had catheter removed 24 hours post
procedure while post urethroplasty the catheter was removed after 21 days. Urine flow rate was
assessed at removal of catheter and three months later. Those who could not void at removal of catheter
were considered to have persistence of stricture while those who showed improvement at removal of
catheter but had difficulty at three months were considered as having a recurrence. The flow rate was
determined by checking the volume of urine voided against time. Information collected was entered
into a structured questionnaire.
All the collected data were recorded into the checklist for storage of information and were checked by
the research team for completeness and consistency. Data collected were analyzed by Statistical
Package for the Social Sciences (SPSS) 18 for the Windows program where cross-tabulations were
performed. Ethical approval was obtained from MUHAS Research and Publications Committee. No
patient was denied appropriate and adequate treatment upon not consenting. All patients’ information
was kept confidential.
Study limitations
Duration of follow up to assess the treatment outcome was less than 1 year as the success in the
stricture management can only be claimed after many years, patients can fare on well for 10 years or
more before suffering recurrence.13-14
Results
A total of 111 patients with urethral strictures were recruited into the study, all were male with age
range of 10 – 97 years with a mean of 52.7. DVIU was the most performed procedure accounting for 73
(65.8%) of all patients followed by primary Urethroplasty at 31 (27.9%) and multistage Urethroplasty at
7 (6.3%). Most patients were > 60 years of age accounting for 47 (42.3%) followed by those between
45 – 60 years at 27 (24.3%), those <30 years at 22 (19.8%) and the least were aged 31 – 44 years at 15
(13.5%). Overall, DVIU was the commonest procedure in all age groups (Table 1).
Table 1: Shows age distribution by procedure done
Treatment Given
AGE GROUPS
<30
31-44
45-60
No
%
No
%
No
%
12 54.5 11 73.3 19 70.4
DVU
7 31.8 4 26.7 5 18.5
Primary urethroplasty
3 13.6 0
0
3 11.1
Multistage Urethroplasty
Total
22 19.8 15 13.5 27 24.3
30
Total
No
31
15
1
47
>60
%
66.0
31.9
2.1
42.3
No
73
31
7
111
%
65.8
27.9
6.3
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Most patients received DVIU as the primary treatment of choice, 70 (63.1%) followed by primary
urethroplasty at 28 (25.2%) and multistage was least at 5 (4.5%). Two patients underwent all the three
procedures and one patient received primary Urethroplasty and DVIU. [Figure 1]
Figure 1. Shows treatment options offered
Multistage
urethroplast
y
Dropout - 3
0
0
2
1
DVIU
Primary
urethroplast
y
Table 2. Treatment Options and Outcomes
_________________________________________________________________________
Treatment (n=108)
Failure Rate (%)______________
Direct Vision Internal Urethrotomy (5/71)
7
Multi Stage Urethroplasty (4/7)
57
Primary Urethroplasty (3/30)
10
____________________________________________________________________________
Three patients were lost to follow up of which 2 were treated by DVIU and one by primary
Urethroplasty. Multistage Urethroplasty had the highest failure rate at 57% (Table 2).
Discussion
DVIU is best suited for strictures less than one centimetre in length independent of the aetiology or
location. DVIU constituted 65.8% of the provided treatments followed by primary (one stage)
urethroplasty (27.9%) in this study. This is similar to what has been reported from other centres and at
KCMC19 DVIU was used in 50% followed by urethroplasties in
43.2%2,5,19. The principle is to have
one DVIU or dilatation before resorting to urethroplasty but primary urethroplasty is cost effective if a
DVIU success rate is less than 35% 8 or in more than a single recurrence after DVIU and in young
patients6,14. In this study 71 patients were treated by DVIU, (93%) were symptom free at follow up of
three months. DVIU and urethroplasty are primary methods of managing urethral stricture with excision
of stricture and primary anastomosis for stricture management with intent to cure2, 5.
In this study multistage urethroplasty was done in those patients with longer or multiple strictures
accounting for 6.3% of the provided treatments this was complemented by clean intermittent
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catheterization (CIC) 20. This is similar to what was reported by Webster et al that the most important
consideration in stricture management is length with multistage repairs being reserved for long or
multiple strictures10, 21.
Success in the treatment of urethral stricture is considered to be absence of obstructive symptoms13. In
7 patients treated by Multi stage urethroplasty in 57% patients symptoms recurred during follow up
period while in 30 patients who were treated by Primary Urethroplasty the success rate was of 90%
with three patients having persistence of symptoms despite the treatment given in the three months
follow up although successful DVIU depends on a length less than 1cm, single site, stricture on original
as opposed to a neourethra and a calibre more than 15F5.
Failed urethral stricture repair complicates management due to fibrosis, impaired vascularity and
limited urethra available for mobilization21-23. This could be the same in those patients treated by multi
stage urethroplasty and had recurrent stricture or persistent stricture in this study. The duration of
follow up of three months was short to assess the treatment outcome. This also could probably explain
why few patients reported complications24-27. It was observed that the number of patients with urethral
stricture who were awaiting treatment at MNH was high; this could be explained by shortage
resources such as urethroplasty kits but also limited number of operating days of patients with urethral
stricture. This was contrary to Tumaini Hospital where despite having a small bed capacity it serves a
significant number. This may be due to good hospital policy and administration including having
motivated and committed staff.
Conclusion
Three treatment options of urethral stricture DVIU, primary urethroplasty, multistage urethroplasty
including clean intermittent catheterization (cic) were adopted as modes of treatment of patients with
urethral stricture seeking urological services at Muhimbili National hospital and Tumaini hospital in
Dar es Salaam. DVIU remains the commonest mode treatment of patients with urethral stricture
seeking urological services at Muhimbili National Hospital and Tumaini Hospital in Dar es Salaam.
Primary urethroplasty and DVIU had better treatment outcome during the follow up of 3months.
Acknowledgement
The Authors would like to thank all the Consultants, Specialists, Residents, Registrars and Nurses at
Muhimbili National Hospital and Tumaini Hospital for all the invaluable assistance and support they
offered us during all the stages in the preparation of this work.
References
1. Figueroa JC, Hoenig DM.Use of flexible paediatric cystoscope in the staging and
management of urethral stricture disease. J Endourol.2004; 18(1):119-21.
2. Greenwell TJ, Castle C, Andrich DE et al. Repeat urethrotomy and dilatation for the
treatment of urethral stricture neither clinically effective nor cost effective. J Uro.2004;
173(1):275-7.
3. Das Shusrata S of India, the pioneer in the treatment of urethral stricture. Sur.Gyn. and
Obstet (1983), 157:6,581-582.
4. Smith AL, Ferlise VJ, Rovner ES. Female urethral strictures: Successful management with
long term clean intermittent catheterization after urethral dilation. BJU Int. 2006; 98(1):96-9.
5. Pansadoro V, Emilozzi P. Internal urethrotomy in the management of anterior urethral
strictures: Long term follow up. J Uro.1996; 156(1):78-9.
6. Rourke KF, McCammon KA, Sunfest JM et al. Open reconstruction of paediatric and
adolescent urethral strictures: long-term follow up. J Urol.2003; 169(5):1818-21
32
COSECSA/ASEA Publication -East and Central African Journal
(3))
Journal of Surgery. November/December 2013 Vol. 18 (3
ISSN 2073
2073073-9990 East Cent. Afr. J. surg
7. Smith D. Disorders of the penis and male urethra in General urology Ed:Lange Medical
Publications:1988; 10th edition :485-497
8. Wright JL, Wessels H, Nathens AB et al. What is the most cost effective treatment for 1 to
2cm bulbar urethral strictures; societal approach using decision analysis.Urology.2006;
67(5):889-93.
9. Ogbonna BC. Managing patients with a urethral stricture; a cost benefits analysis of
treatment options. Br J Urol.1998; 81(5); 741-4.
10. Webster GD, Koefoot RB, Sihelnik SA. Urethroplasty management in 100 cases of urethral
strictures: a rationale for procedure selection. J Urol.2003; 169(5):1818-21
11. Nabi G, Dogra PN. Endoscopic management of post traumatic prostatic and supra prostatic
strictures using Neodymium-YAG Laser.Int J Urol.2002; 9(12):710-4.
12. Zinman L. Optimal management of 3 to 6 centimeter anterior urethral stricture. Curr Urol
Rep.2000; 1(3):180-9.
13. Husmann DA, Rathbun SR. Long term follow up of visual internal urethrotomy for
management of short(less than 1 cm) penile urethral strictures following hypospadias repair.
J Urol.2006; 176(4):1738-41.
14. Hafez AT, EL-Assmy A, Dawaba MS et al. Long term outcome of visual internal
urethrotomy for the management of paedriatic urethral strictures. J Urol.2005; 173(2):595-7.
15. Griffith HB. An operation for urethral stricture. E.Afr.Med.J.1962; 39(9): 580-585
16. Klonsia JW, Madden DL, Fucillo DA, Traub RG, Mattson JM, Kreslewicz AG. The etiology
of non-specific urethritis in active duty marines.J.of Urol.1978; 120:67-69
17. Kirei B. Operative management of urethral strictures in Muhimbili Medical Center, Dar es
Salaam: A three year experience. Proc.of the .A.Assoc.of.Surg.1987; vol.9.
18. Macleod DAD. Anterior urethral injuries. Injury 8 (1):25-30.
19. Mteta KA, Musau PM, Kategile AM, Kaali S. The profile and Management of urethral
strictures at Kilimanjaro Christian Medical Center (K.C.M.C), Moshi, Tanzania. BJUI.2009;
934(5): 73.
20. Piechota H, Bruehl P, Gertke L, Siejekabd J. Catheter drainage of the bladder today
Deutsches Aerteblatt 2000; 4:168-174
21. Mchembe MD, Kategile AM, Yongolo CMA. Balanitis Xerotica Obliterans; An experience
with Buccal Mucosa On lay Flap Graft. East and Central Africa Journal of surgery.2011;
16(2)
22. Modgar I, Hertz M, Gold Wasser B, Ora H, Manim and Jonas P. Urethral strictures in
boys.Urol.1987; 30: 46-49
23. Blandy JP: Urethral Stricture. Postgraduate. Med J. 1980; 56: 383-418.
24. Mkony CA. The endoscopic management of urethral stricture in Dar es Salaam. East and
Central Afr.J.Surg .1999; 5(1): 39-42.
25. Zango B, Kambou T. Internal endoscopic urethrotomy for stricture at the
hospital of
Bob-Dioulasso: Feasibility of the technique in precarious situations and short-term results.
Bull Soc Pathol Exot.2003; 96(2):92-5.
26. Kulkarni SB, Barbagli G, Kulkarni JS, Romano G, Lazzeri M. Posterior urethral stricture
after pelvic fracture urethral distraction defects in developing and developed countries, and
choice of surgical technique. J Urol. (2010); 183(3):1049-54.
27. Baskin LS, McAninch JW: Childhood urethral injuries: perspectives on outcome and
treatment. Br J Urol. 1993; 72: 241-6.
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The Role of Abdominal Ultrasound and |Chest Radiography in Management of Breast Cancer
Patients in a Low Resource Country: A Case of Tanzania.
L. Sakafu1,2, R. Kazema3, C. Kahesa2, J. Mwaiselage2, L. Akoko4, T. Ngoma1,2.
1
Department of Clinical Oncology, School of Medicine, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
2
Department of Medical services, Ocean Road Institute, Dar es Salaam, Tanzania
3
Department of Radiology, School of Medicine, Muhimbili University of Health and Allied Sciences,
Dar es Salaam, Tanzania
4
Department of Surgery, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar
es Salaam, Tanzania
Correspondence to: Lulu Sakafu, E-mail: willymeena2007@yahoo.com
Background: Breast cancer is among the commonest cancers affecting women in Tanzania. Most of
them seek hospital treatment when the disease has reached an advanced stage. Hence widely
available modalities like ultrasound (LUS) and chest radiograph (CXR) can be used to establish
metastasis in newly diagnosed patients. The main objective of this study was to determine the role of
abdominal ultrasound and chest radiography in detection of liver and lung metastasis in newly
diagnosed breast cancer patients.
Methods: This was a descriptive cross sectional study in which 103 new breast cancer patients
attending Ocean Road Cancer Institute (ORCI) were recruited consecutively. All participants were
investigated for liver and lung metastases using abdominal ultrasound and chest x-ray respectively.
Standardized questionnaires were used to obtain socio-demographic and to document examination
findings.
Results: Participants were aged between 26 – 77 years, with a mean of 48±11.22. The prevalence of
metastasis to the liver and lungs were 18.4% and 20.4% respectively. Majority of patients with breast
cancer had locally advanced breast cancer disease that is either TNM stage three (59.2%) or four
(32%) disease upon arrival to ORCI.
Conclusion: This study has demonstrated a high detection rate of LUS and CXR for liver and lung
metastasis in patients with locally advanced breast cancer.
Introduction
Breast cancer is a disease with high prevalence in females worldwide, contributing to a substantial
public health burden. Although breast cancer was once known to affect highly affluent communities, it
has been realized that disadvantaged communities now are facing the heaviest disease burden. It is
estimated that more than 1.3 million cases of breast cancer are diagnosed each year. This disease
accounts for 10.9% of all cancers and 22.8% of all cancers in women worldwide1. In USA one out of
eight women will be diagnosed of breast cancer in her lifetime. Breast cancer is the leading cause of
mortality and morbidity in Asia and Latin America2.
Cancer of the breast is among the commonest cancer affecting women in Tanzania. It is estimated that
approximately 1307 women with breast cancer register in different hospitals in Tanzania each year3.
Majority of women who are diagnosed with breast cancer seek hospital treatment when the disease has
reached an advanced stage, at which point metastasis to the lungs or liver are most likely4.
Lack of knowledge about breast cancer among the general population and lack of regular systematic
breast cancer screening program are some of the factors for late presentation at Ocean Road Cancer
Institute (ORCI)5. A study done in 1996 at Muhimbili National Hospital (MNH) found that more than
90% of breast cancer patients had stage III or more disease, with high probability of a distant metastasis
to the lungs or liver4. Liver metastasis is a primary clinically significant contributor to mortality
associated with breast cancer, and present in about two-thirds of women with metastatic disease. At the
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same time sixty to seventy percent of patients who die of breast cancer eventually have metastasis in
their lungs6.
In Tanzania, where resources are limited, widely available modalities like ultrasound (LUS) and chest
radiograph (CXR) can be used to establish early overt metastasis in breast cancer patients.They are
reliable, fast, cheap and easy modalities in detecting liver and lung metastasis and for predicting
prognosis in breast cancer patients. However, in case of microscopic liver metastasis LUS maybe
normal hence complementary examinations like, computed tomography (CT scan), Magnetic
Resonance Imaging (MRI) and Positron emission tomography (PET) should be done where resources
are available7. On the other hand, CXR is very beneficial since it can upgrade patient who had stage I or
II to stage IV, and hence determine the appropriate treatment plan8. In situations where CXR
interpretations maybe inconclusive advanced radiological investigations like Computed tomography
(CT) scan may be needed.
The aim of this study was therefore to show that in a low resource country like Tanzania, LUS and
CXR are very beneficial in staging, treatment planning, follow up and prognosis determination of breast
cancer patients.
Patients and Methods
This was a six months hospital based descriptive cross sectional study carried out between June and
Dec 2010 at Ocean Road Cancer Institute (ORCI) in Dar es Salam Tanzania. ORCI is the only
specialized centre for cancer treatment in Tanzania, handling cancer patients from all over the country
of 45million people. Its treatment modalities range from chemotherapy, radiotherapy by external beam,
hormonal therapy and to a lesser extent immunotherapy. Patients are either referred for neo/adjuvant
therapy or palliative options using the above and the cancer surgery is done by the referring hospitals.
The centre receives about 4,000 new cancer cases every year, two thirds of whom are women. Breast
cancer cases comprise 10%- 14% of all new cancer cases seen at the institute. The confirmation of
diagnosis was done by the referring hospitals, including TNM staging for those that have undergone a
mastectomy. All patients come to ORCI with results from pathology laboratories either with a
Histopathology (HP) or histocytology (HC) number.
Male patients were excluded from this study along with those who did not have tissue reports
confirming the diagnosis. A total of 103 patients were therefore recruited into this study. Each
underwent an abdominal ultra sound and chest x-ray evaluation to check for evidence of metastasis.
Structured questionnaire was used to collect information regarding patient’s socio-demographic details,
abdominal ultrasound and chest x-ray findings. Abdominal ultrasound was done using a PHILIPS HD
4000 system with broadband curve-linear transducers of 2MHz to 5MHz range (Best, Eindhovern, The
Netherlands) which is in a routine use at the Radiology department. Metastasis was defined as any
lesion in the liver which its echotexture was heterogeneous, hypoechoic, or isoechoic be it solitary or
multiple with irregular margins and had a size of more than 1cm.
A high KV technique chest radiograph postero-anterior (PA) view was obtained by a Radiographer
using PHILIPS HD 30 system (Best, Eindhoven, The Netherlands). All chest x-rays were reported by
the Researcher then re-reported by a qualified Radiologist. Lung metastasis was defined as presence of
solitary or multiple lung nodules with irregular margins, reticulo-nodulations, or presence of pleural
effusion
The limitation to this study was that neither tissue confirmation was performed to confirm that the
lesions seen were indeed metastasis from the breast nor a follow up to document on the response to
therapy offered. Ethical clearance was sought from ethical clearance board (IRB) of the Muhimbili
University of Health and Allied Sciences (MUHAS) which is also an ethical clearing body for ORCI.
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Permission to conduct the study was sought from Ocean Road Cancer Institute to use the subjects for
the Study. Data analysis was done using Statistical Packages for Social Science (SPSS) version 15.
Results
A total of 103 women with breast cancer were recruited into the study, aged between 26 – 77, with 64
(61.5%)of them being 45 years and with a mean of 48±11.22. Fifty (48.5%) of the patients had primary
level of education. The majority (64%) of the patients were married. Fifty six (53.8%) had no formal
source of income(Table 1). Overall, the majority of newly diagnosed patients had locally advanced
breast cancer with either TNM stage three 61(59.2%) or four 33(32.0%) disease, very few had stage II
and none had stage I. There is a trend of decreasing in stage 3 with increasing age, while there is an
increasing trend of stage 4 with increasing age (Figure 1). A total of 38.8% (40/103) of the breast
cancer patients had LUS and Chest X-ray detectable metastasis. Those aged 45 years and above had the
highest prevalence of metastasis at 44.3%, the least being in those between 25-34 years of age. Lung
metastasis was most commonly observed at 20.4% (21/103)
(Table 2).
Table 1.Demographic and baseline characteristics of study population (N=103)
Characteristics
Age in Years
25-34
35-44
45 and above
Mean age(SD), years
Marital status
Single
Married
Divorced
Education level
No formal education
Primary education
Post primary education
Occupation
Formal and informal occupation
No occupation
Number
Percentage
10
29
64
48±(11.22)
9.6%
27.9%
61.5%
10
66
27
9.7%
64.0%
26.2%
25
50
28
24.3%
48.5%
27.2%
47
56
46.2%
53.8%
Figure 1.Distribution of Study Sample by Age and TNM Stage
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Table 2.Prevalence of Liver and Lung Metastasis According to Age ( n = 103)
Age (Yrs)
Liver
Lung
Total
25-34 (10)
2(20%)
1(10%)
30%
35-44 (24)
4(13.8%)
6(20.7%)
34.5%
>45 (61)
13 (21.3%)
14 (23%)
44.3%
Total (103)
19(18.4%)
21(20.4%)
38.8%
Discussion
Lung and liver metastasis contributes to morbidity and mortality in women with breast cancer disease
making both clinical and radiological staging to be of paramount importance in patient management
plan. The purpose of staging in resource constrained settings is to rule out overt metastasis, with
resultant treatment and prognostic implications. In this study, the findings of breast cancer TNM stages
do not differ with studies done in other parts of Africa whereby more than 90% had locally advanced
breast cancer which was either stage III or IV disease at the time of diagnosis and none presented with a
stage one disease4. These findings have remained the same in spite of more recent campaigns to create
awareness of breast cancer among women conducted by Medical Women Association of Tanzania
(MEWATA) in almost the whole country5.
The reasons for these late presentations might be multifactorial but were beyond the scope of this study.
More than half of the studied women had no any kind of work that generated income. This lack of
economic independence has been shown to limit access to information and access to early care seeking
behaviour. This is also aggravated by a lack of formal education which might lead to holding of
traditional beliefs hence seeking other help outside the formal health care setting before finally
presenting with an advanced disease9. But study by MEWATA had sited that a lack mammography at
primary health care facilities, poverty, difficult referral system, myths and misconceptions were among
the factors accounting for advanced disease at presentation5.
In South Africa a similar study was done about TNM stage of newly diagnosed breast cancer patients
and compared blacks and white patients. Findings were similar to what was seen in this study whereby
stages III and IV of breast cancer were the most prevalent in black women (77.7%) compared to white
women (30.7%). The reasons given were that for blacks having Locally Advanced Breast Cancer
(LABC) at the time of diagnosis was interpreted as a reflection of conflicts, particularly in social
relationships. Many patients with cancer believed that a special witchcraft caused their cancer; hence
the first priority was to reverse the sorcery by seeking help from tradition healers before presenting to
hospital10.
Moreover locally advanced breast cancer is the most common form of presentation for breast cancer
patients in countries of limited resources, and, along with stage IV disease, it represents up to about
80% of new patients at presentation in Arabic and African communities11. This means that our patients
have poor prognosis in comparison to breast cancer patients in developed world who are usually picked
up with an early breast cancer disease stage I/II. Furthermore death occurring due to breast cancer
shows significant differences among stages: only 5% to 12% of Stage I/II patients die in the first 10
years after diagnosis, compared with over 60% of Stage III patients and over 90% of Stage IV
patients12. In this study the detection rate of lung and liver metastasis in newly diagnosed breast cancer
was 20.4% and 18.4% respectively. This is high compared to what was seen by other researchers
elsewhere.
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In Toronto Canada they found out that the prevalence of metastatic disease in locally advanced breast
cancer (LABC) was 13.2%. This supports the continued need for full routine staging tests for patients
with LABC as compared with those women with earlier stage disease. The Canadian study subjected all
women who had LUS and CXR negative to more complex studies like computed tomography, magnetic
resonance imaging (MRI) and/or positron emission tomography (PET), where an additional 2.8%
metastasis was found13. In our setting, though CT scanning and MRI are available, they are largely
expensive and will delay timely intervention hence was not considered. This implies that there was a
possibility that we missed about 2.8% distant metastasis but still our breast cancer metastasis detection
rate was still very high.
In the Netherlands in 2002, wherein 399 breast cancer women underwent LUS and CXR, the
prevalence of liver and lung metastasis were 1.5% and 1% respectively14. This was similar to an Italian
study finding, thus suggesting that these investigations are largely unnecessary in early breast cancer
patients15. But the two studies only involved early breast cancer patients hence their conclusions might
not have sound implications in this series where the detection rate has been demonstrated to be high.
The ability to accurately stage patients has many benefits. Firstly, clinicians will be better able to advise
patients on their prognosis. Secondly, appropriate palliative measures can be introduced at an earlier
opportunity. Finally, clinicians will be able to better individualize treatment to their patients.
Conversely, in those who present with metastatic disease, a more balanced, quality-of-life oriented
approach can be utilized. It is, however, considered beneficial for the accurate staging of disease to be
known when decisions regarding adjuvant systemic therapy are made13. To aide this, our study has
provided evidence that abdominal ultra sound and chest x-ray should be performed routinely on every
patient presenting with LABC who are majority at the ORCI.
Conclusion
This study has demonstrated a high detection rate of LUS and CXR for liver and lung metastasis in
patients with locally advanced breast cancer.
Acknowledgement
For the financial support from the Tanzania government through Ministry of Health and Social welfare
grant for post-graduate dissertation work.
References
1. Soroptimist International of the Americas. Early Detection of Breast Cancer. Philadelphia 1709
2.
3.
4.
5.
6.
38
spruce st; June 2007 [cited ]; Available from: www.soroptimist.org. last accessed on August 2011
Singletary SE, and Connolly JL, Breast Cancer Staging: Working With the Sixth Edition of the
AJCC Cancer Staging Manual. Cancer J Clin 2006;56:10.
GLOBOCAN 2008, WHO, International Agency For Research on Cancer, Cancer Incidence and
Mortality
Worldwide
2008,
[cited
];
Available
from:
http://globocan.iarc.fr/factsheets/populations/factsheet.asp?uno=834, accessed on August
2011
Amir H, Azizi MR, Makwaya CK, Jessani S, TNM classification and breast cancer in an African
population: a descriptive study, . Cent Afr J Med . 1997 Dec; 43. (12 ):3.
Magandi JL, Breast Cancer Screening and Awareness Project In TANZANIA. MEWATA. 2009
11/10. .
Reilly
O,
A
Guide
to
Living
with
Metastatic
Disease
1998, Available from: http://www.patientcenters.com/breastcancer. last accessed on August
2011 .
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7. Klaeser B, Wiederkehr O, Koeberle D, Mueller A, Bubeck B, Thuerlimann B, Therapeutic
impact of 2-[fluorine-18]fluoro-2-deoxy-Dglucose positron emission tomography in the preand postoperative staging of patients with clinically intermediate or high-risk breast cancer
Annals of Oncology 2007 ( 18: ):5
8. Chen EA, Carlson GA, Coughlin BF, Reed WP, Garb JL, Frank JL, Routine Chest
Roentgenography Is Unnecessary in the Work-Up of Stage I and II Breast Cancer J Clin Oncol
2000 (18 ):4.
9. Peres RS, Santos MA, Breast cancer, poverty and mental health: emotional response to the disease
in women from popular classes. Rev Latino-am Enfermagem 2007 setembro-outubro. 2007:5.
10. Vorobiof DA, Sitas F, and Vorobio G, Breast Cancer Incidence in South Africa. Journal of
Clinical Oncology, 2001 September 15 Vol 19, ( 18):2.
11. Eniu A, Carlson RW, El Saghir NS, Bines J, Bese NS, Vorobiof D, Masetti R, Anderson BO,
Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries: Treatmen
Resource Allocation. CANCER Supplement. 2008;113( 8).
12. Singhal H, Gohel MS, Kaur K, Thomson S, Breast cancer evaluation, web MD profesional.
2010 Nov 17,.
13. Al-Husaini H, Amir E, Fitzgerald B, Wrighty F, Denty R, Fralicky J, Clemons M, Prevalence
of Overt Metastases in Locally Advanced Breast Cancer. Clinical Oncology. 2008;20:5.
14. Ravaioli A, Tassinari D, Pasini G, Polselli A, Papi M, Fattori PP, Pasquini E, Masi A,
Alessandrini F, Canuti D, Panzini I, Drudi G, Staging of breast cancer: What standards should be
used in research and clinical practice? Annals of Oncology 1998.;. ( 9):4.
15. Puglisi F, Follador A, Minisini AM, Cardellino GG, Russo S, AndreettaC, Di Terlizzi S, Piga A,
Baseline staging tests after a new diagnosis of breast cancer: further evidence of their limited
indications Annals of Oncology 2005(16 ):4
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An Audit of Perforated Peptic Ulcer Disease in a Tropical Teaching Hospital.
O. Afuwape, D.O. Irabor, O. Ayandipo,
Department of Surgery, College of Medicine / University College Hospital Ibadan Nigeria
Correspondence to: Afuwape Oludolapo, Email: dolafpe@yahoo.co.uk
Background: Perforated peptic ulcer (PPU) is associated with high morbidity and a mortality rate.
Thus it requires urgent surgical intervention. Recently a reduction in the rate of peptic ulcer
perforation in young men with a relative increase in the elderly and in women has been documented.
This study is an audit of perforated peptic ulcer surgical emergencies treated by the gastrointestinal
surgery division of a teaching hospital in Nigeria. It also reviews the early complications and the
average duration of admission of these set of patients.
Method: This was a retrospective five-year audit of patients admitted by the gastrointestinal surgery
division of a tertiary teaching hospital in Ibadan Nigeria. The data extracted from the patients’
records included the bio-demographical data, the duration of symptoms prior to admission, the
patients’ vital signs at presentation and the results of the haematological investigations. Other
information includes the duration from admission to surgery, the intra-operative findings and the
outcome of the treatment.
Results: Forty patients consisting of thirty three male and seven female were treated. The ages
ranged from 20 years to 70 years. The peak incidence was in the fifth decade. None of the patients
was seen within 6 hours of the onset of symptoms however fifteen patients were seen within twenty
four hours of the onset of symptoms. Twelve patients (30%) had history of significant ingestion of
non-steroidal anti-inflammatory drugs, nine (22.5%) had a significant history of alcohol ingestion,
while one (2.5%) had a recent history of fasting prior to the onset of symptoms. The distribution of
the sites of perforation, revealed a pattern of 9(22.5%), 21(52.5%) and 10(25%) in the body of the
stomach, pre-pyloric region and the first part of the duodenum respectively. There were six
mortalities.
Conclusion: The outcome is excellent when prompt and adequate resuscitation and surgical repair of
perforation are done. Health education may increase patient awareness which may translate to early
presentation. Risk scores may be helpful in predicting the outcome but an experienced clinical
opinion is still essential
Introduction
The development of new drugs for the treatment of peptic ulcer disease, better knowledge about its
aetiology and eradication of Helicobacter pylori have reduced the incidence of peptic ulcer and its
complications1. Consequently the role of surgery in the treatment of the disease has also reduced1,2.
Similarly the frequency of duodenal or gastric perforations in this disease condition has reduced3.
Although there is a reduction in the rate of peptic ulcer perforation in young men there is a relative
increase in the elderly and in women4. Perforated peptic ulcer (PPU) is associated with high morbidity
and mortality rates. Thus it requires urgent surgical intervention5.
The first documentation of surgical repair of PPU by a simple closure technique was in 18176. Shortly
after this, Johan Mikulicz-Radecki, another surgeon was quoted to have said ‘Every doctor, faced with a
perforated duodenal ulcer of the stomach or intestine, must consider opening the abdomen, sewing up
the hole, and averting a possible inflammation by careful cleansing of the abdominal cavity7. This
principle of treatment still applies in modern surgery today. The current surgical principles of
management still consist of primary closure of the perforation by suturing and a convenient tag of
adjacent omentum on top of this or an omental plug. Although this therapy sounds very simple PPU
still remains a surgical condition, associated with high morbidity and mortality8.
40
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This study is an audit of perforated peptic ulcer surgical emergencies treated by the gastrointestinal
surgery division of tertiary teaching hospital in Ibadan Nigeria. It also reviews the early complications
and the average duration of admission of these set of patients.
Patients and Methods
This was a retrospective audit of patients admitted by the gastrointestinal surgery division of a tertiary
teaching hospital in Ibadan Nigeria. It is a five year review of patients admitted, with an operative
diagnosis of perforated peptic ulcer disease. Patients with peritonitis secondary to other conditions apart
from perforated peptic ulcer disease were excluded from the study.
All the patients were admitted through the emergency department of the hospital. They were
resuscitated with normal saline infusion until adequate urinary output was established. All the patients
had nasogastric tubes introduced, urethral catheterization, parenteral analgesics and pre-operative
administration of broad spectrum antibiotics. The base line investigations included Complete blood
count, Urea and electrolytes, urinalysis as well as radiology of the chest and abdomen.
The data extracted from the patients’ records included the bio-demographical data, the duration of
symptoms prior to admission, the patients’ vital signs at presentation and the results of the
haematological investigations. Other retrieved information included the duration from admission to
surgery, the intra-operative findings and the outcome of the treatment.
Results
The total number of patients in this study was 40 consisting of thirty three male and seven female
patients with a male female ratio of 4.7:1. The ages ranged from 20 years to 70 years. The mean age
was 42.5years with a standard deviation of 13.239.The peak incidence was in the fifth decade (35%).
None of the patients presented in the emergency room within six hours of the onset of symptoms.
Fifteen patients (37.5%) were seen within twenty four hours after the onset of symptoms while the rest
of the patients presented after twenty four hours. Thirty seven patients (92.5%) presented with
generalized abdominal pain. Other features were abdominal distention (47.5%) and fever
(35%).Nineteen patients (47.5%) had previous history of peptic ulcer disease. Twelve patients (30%)
had history of significant ingestion of non-steroidal anti-inflammatory drugs, nine (22.5%) had a
significant history of alcohol ingestion, while one (2.5%) had a recent history of fasting prior to the
onset of symptoms. Serum chemistry analysis revealed elevated potassium, urea and acidosis in
7(17.5%), 25(62.5%) and 21(52.5%) patients respectively.
90
80
70
60
East
50
West
40
North
30
20
10
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Figure 1.
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Figure 2.
Figure 3.
The anatomical distribution of the sites of perforation, revealed a pattern of 9(22.5%), 21(52.5%) and
10(25%) in the body of the stomach, pre-pyloric region and the first part of the duodenum respectively.
The diameters of these perforations ranged from about 5mm to 20mm with 5mm being the highest
frequency (62.5%).The method of closure was determined by the operating surgeon. Simple closure
was performed in 10 (25%), pedicled omental plug done in 24 (60%) and primary closure with an onlay omentum in 6(15%) of the patients.
The duration of admission ranged from three days to forty two days. Patients with blood group ‘O’
constituted 45% (eighteen) of the population. Eighteen patients developed post-operative complications.
Eight developed post-operative wound infection, five had intra-abdominal abscesses, and four had
pleural effusion, while one had a burst abdomen. There were six mortalities. The average follow up
period was six months. Many of the patients defaulted from follow up clinic attendance.
Discussion
Although the role of surgery in the treatment of peptic ulcer disease is on the decline1. visceral
perforation remains as one of the most dreaded complications of peptic ulcer disease. Early presentation
with aggressive treatment reduces the associated morbidity and mortality of this disease condition. In
this study of forty (40) patients there were thirty-three (82.5%) male and seven (17.5%) female (M: F
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ratio of 4.7:1) patients with an age range of twenty (20) to seventy (70) years. The mean age was
42.5+/_ 13.2years. Compared with studies from India9and the Arab Emirates10 respectively there is a
similarity of male preponderance in all three studies although the Indian male female ratio is much
higher (10.3:1).There is a similarity in the average age in the Indian population(43.4 years) however the
Arab population demonstrates a relatively younger population of about 35 years. Despite a time span of
about thirty years delayed presentation as well as blood group distribution remains the same as previous
studies11.
Previous studies described fasting, ingestion of non-steroidal anti-inflammatory drugs(NSAID) and
alcohol ingestion as risk factors for perforated peptic ulcer disease1, the percentage of patients in this
study with significant history of fasting, ingestion of NSAID or alcohol ingestion was 2.5%, 30%, and
22.5% respectively. Some determinants of survival are still controversial. Predictive scoring models
such as the ‘APACHE Score’ and the ‘Boey Score’ may be poor predictors of mortality12. On the other
hand, the duration of visceral perforation prior to admission and the physiological derangement in
serum biochemistry such as shock, septicaemia, biochemical parameters suggestive of renal impairment
and pre-operative metabolic acidosis13,14 are also predictors of mortality. A high index of suspicion
facilitates reduction delays in diagnosis when there are x-ray controversies in the absence of
computerized tomogram. Consequently the clinical acumen of the managing physician plays a crucial
role in environments without readily available computerized tomography.
At presentation serum chemistry revealed hyperkalemia and hypokalemia in seven (17.5%) and four
(10%) respectively. There was acidosis and elevated urea levels in twenty-one (52.5%) and twenty-five
(62.5%) patients respectively. These subtle derangements have been previously enumerated as
prognostic factors which affect the outcome significantly. The approximate size of the perforations in
terms of the widest diameter observed at surgery ranged between 0.5 cm and 2cm. However more than
60% of the perforations were 0.5cm in size. The distribution of sites of perforation is as shown in figure
1 with a preponderance of gastric pre-pyloric perforations. The surgical technique of repair was
determined by findings at surgery and the site of the perforation. The range of procedures included
simple closure with interrupted silk or vicryl suture following excision of the edges of the perforation
for gastric body perforations, simple closure with omentum laid over the repair or an omental plug for
duodenal and prepyloric perforations. Where the omentum was shrunken, a simple closure of the
perforation or a serosa patch was considered. The mean hospital stay was 15.75 days with a range of six
to forty two days.
Our mortality rate after surgery was 15%.Variable mortality rates have been reported in literature
ranging between 11.8%(15) and 17%14. Our mortality rate is based on patients who had surgery.
Patients who were unfit for surgery were not included. In many instances when patients are not fit for
surgery, less radical conservative treatment modalities such as mini-laparotomy for peritoneal toileting
may be considered16. Although laparoscopic surgery has its limitations15 closure of perforations
diagnosed early is comparable with open surgery in outcome17. The limitations are the lack of expertise
for laparoscopic surgery and the frequent lack of CT for early diagnosis in many centres in Africa. In
absence of the CT clinical examination with the demonstration of abdominal pain, distention and
pneumo-peritoneum with a sensitivity of 90% 18 are pathognomonic of PPU in developing countries.
The pattern of post-operative complications is as shown in figure 2. The most frequent complications
are wound infection and intra-abdominal abscess. These figures are high when compared with similar
studies with wound infection rate of 5.8%15.
Conclusion
PPU is a surgical emergency with a high risk of mortality. The outcome is excellent if prompt
and adequate resuscitation and surgical repair of perforation are done. Risk scores may be
helpful in predicting the outcome but an experienced clinical opinion is still essential.
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Reference
1. Hermansson M, Ekedahl A, Ranstam J, Zilling T. Decreasing incidence of peptic ulcer
complications after the introduction of the proton pump inhibitors, a study of the Swedish
population from 1974-2002. BMC gastroenterology. 2009; 9:25.
2. Irabor DO. An audit of peptic ulcer surgery in Ibadan, Nigeria. West African journal of
medicine. 2005 Jul-Sep; 24(3):242-5.
3. Hermansson M, Stael von Holstein C, Zilling T. Peptic ulcer perforation before and after the
introduction of H2-receptor blockers and proton pump inhibitors. Scandinavian journal of
gastroenterology. 1997 Jun; 32(6):523-9.
4. Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis.
World journal of surgery. 2000 Mar;24(3):277-83.
5. Lee CW, Sarosi GA, Jr. Emergency ulcer surgery. The Surgical clinics of North America. 2011
Oct;91(5):1001-13.
6. Crampton J. Rupture of the Stomach and escape of its Contents into the Cavity of the
Abdomen. Medico-chirurgical transactions. 1817;8:228-31.
7. Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment.
Digestive surgery. 2010 Aug; 27(3):161-9.
8. Conservative management of perforated peptic ulcer. Lancet. 1989 Dec 16; 2(8677):1429-30..
9. Arveen S, Jagdish S, Kadambari D. Perforated peptic ulcer in South India: an institutional
perspective. World journal of surgery. 2009 Aug; 33(8).
10. Torab FC, Amer M, Abu-Zidan FM, Branicki FJ. Perforated peptic ulcer: different ethnic,
climatic and fasting risk factors for morbidity in Al-ain medical district, United Arab Emirates.
Asian journal of surgery / Asian Surgical Association. 2009 Apr;32(2).
11. Ajao OG. Perforated duodenal ulcer in a tropical African population. Journal of the National
Medical Association. 1979 Mar; 71(3):271-3.
12. Buck DL, Vester-Andersen M, Moller MH. Accuracy of clinical prediction rules in peptic ulcer
perforation: an observational study. Scandinavian journal of gastroenterology. 2012 Jan;
47(1):28-35.
13. Moller MH, Adamsen S, Thomsen RW, Moller AM. Preoperative prognostic factors for
mortality in peptic ulcer perforation: a systematic review. Scandinavian journal of
gastroenterology. 2010 Aug;45(7-8):785-805.
14. Nuhu A, Kassama Y. Experience with acute perforated duodenal ulcer in a West African
population. Nigerian journal of medicine : journal of the National Association of Resident
Doctors of Nigeria. 2008 Oct-Dec;17(4):403-6.
15. Durai R, Razvi A, Uzkalnis A, Ng PC. Duodenal ulcer perforation: a district hospital
experience. Acta chirurgica Belgica. 2011 Jan-Feb;111(1):23-5.
16. Ishida H, Ishiguro T, Kumamoto K, Ohsawa T, Sobajima J, Ishibashi K, et al. Minilaparotomy
for perforated duodenal ulcer. International surgery. 2011 Jul-Sep;96(3):194-200.
17. Thorsen K, Glomsaker TB, von Meer A, Soreide K, Soreide JA. Trends in diagnosis and
surgical management of patients with perforated peptic ulcer. Journal of gastrointestinal surgery
: official journal of the Society for Surgery of the Alimentary Tract. 2011 Aug;15(8):1329-35.
18. Ashindoitiang JA, Atoyebi AO, Arogundade RA. The value of plain abdominal radiographs in
management of abdominal emergencies in Luth. Nigerian quarterly journal of hospital
medicine. 2008 Jul-Sep;18(3):170-4.
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Snake Bite: A review of Current Literature
S.B. Dreyer, J.S. Dreyer
Department of Surgery, Dumfries & Galloway Royal Infirmary, Dumfries, United Kingdom
Correspondence to: Stephan B Dreyer, Core surgical trainee, West of Scotland Deanery
Email: stephan_1908@hotmail.com
Snake bite is a significant public health problem in rural areas of many parts of the world1.
Venomous snakes are found worldwide, except for a few islands and the frozen environments. Snake
bite most commonly affects those living in the tropical and sub-tropical areas of Africa, Asia, the
Americas and Oceania. The morbidity and mortality resulting from bites are significant. Huge
variation in management, coupled with many patients’ traditional cultural beliefs and lack of
resources contribute to a huge disease burden from snake bites2. The World Health Organisation
(WHO) recently recognised snake bite as a neglected tropical disease and this has led to a global
snake bite initiative to improve clinical outcome following snake bites3.
The aim of this paper is to review current literature on the incidence, pathophysiology and
management of snake bite. The aim is to help clinicians to a better understanding of the
management of bites, especially when in situations with minimal resources and lack of anti-venom,
which is where most snake bites occur. This review discusses a safe approach to clinical management
in a field with limited evidence. A treatment guide to use of anti-venom is included to facilitate rapid
decision making in stressful clinical situations.
Surgeons in rural hospitals in low and middle income countries are often involved in the
management of snake bite patients due to the nature of tissue damage caused by venom or wrong
primary management, or because surgeons might be amongst the more senior staff available to help
manage critically ill patients in such district hospitals. Most surgeons are outside their comfort zone,
however, when they have to manage a snake bite patient, and this paper attempts to provide a
structured approach to management.
Burden of Disease
Snake bite has recently been recognised by the World Health Organisation as a neglected tropical
disease1. An exact estimation of the incidence of snake bite has not yet been achieved and remains an
epidemiological challenge2,4 . Estimates vary greatly and no accurate morbidity and mortality data exist.
Swaroop and Grabb5 first attempted to quantify the global burden of snakebite but admitted that their
data was flawed. Their study suggested that the global annual mortality from snakebite is between 30
000 and 40 000. This was calculated mostly from hospital data and the authors recognised the gross
inaccuracy from these results since most bites go unreported or take place in regions where data is not
accurately collected5.
More recent attempts to determine the annual global deaths from snake bite vary between 20 000 and
125 0001,6,7. Estimates are that the number of bites may be around 5 million per year with more than 2.5
million envenomings6,7. The highest incidences appear to be in Latin America, sub-Saharan Africa,
South and South-East Asia6,7. Interestingly, mortality rates were less in Latin American countries than
Africa and Asia with similar incidences of bites7. The reason for this is unclear, but has been suggested
to be due to increased availability and better developed local anti-venom, or better local guidelines on
management of bites7.
There remains very little evidence detailing the extent of morbidity, long term disability and major
psychological impact from snakebite. This is of particular importance since many victims are
agricultural workers and a return to work will likely provide significant psychological stress. Disability
may also hamper the victim’s functional ability to work.
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Some studies suggest permanent disfigurement or disability in 18-19% of victims8,9. This is mostly due
to local tissue necrosis resulting in debridement, amputation or permanent scarring. Hypoxic brain
injury secondary to neurotoxic bites or haemorrhagic complications from envenoming are also causes
of long term disability2. Significant renal injury can lead to dependence on dialysis following
envenoming and is common after bites from Russell’s viper in South Asia10. Permanent disability and
disfigurement is of particular concern to the majority of snakebite victims, since most bites occur in
regions with poor access to healthcare or income support such as Sub-Saharan Africa and South East
Asia7.
Pathophysiology
Bites occur most commonly on the lower extremity as a result of accidentally stepping close to the
snake11. This is particularly so in low and middle income countries where victims use rural footpaths,
often at night. In regions where it is customary to sleep on the ground or on low beds, bites occur at
night as cold blooded snakes search for a warm environment. There has been growing reports of exotic
venomous snake bites in the Western world due to increasing numbers being kept as pets. Here victims
are often bitten on the upper extremity when attempting to handle the snake, often while intoxicated11.
Most venomous bites occur from species with anteriorly located fangs, such as the Viperidae and
Elapidae species. Envenoming from posterior fanged snakes is rare, yet can be highly dangerous, as
with bites from species such as the boomslang (Dispholidus typus). Snake venoms are complex
collections of peptides, enzymes and other toxins that vary greatly even amongst sub-species2,11. This
allows the venom to induce several systemic responses in potential prey. The most clinically significant
toxins are those that cause tissue necrosis and adversely affect the neurological, cardiovascular and
coagulation systems2.
Snake venoms contain multiple compounds that cause systemic effects. These vary from neurotoxic
pre- and post synaptic blockers, to cytotoxic compounds such as Phospholipase A2 that cause severe
local necrosis2,12,13. The toxicology of snake venom is complex and there remains great heterogeneity
amongst species, making development of anti-venom difficult and challenging14.
Probably the most common clinical effect of snake bite is tissue necrosis that can cause extensive soft
tissue destruction. Envenoming by a wide range of species, particularly the Viperidae such as the puffadder and rattlesnake species are responsible for tissue necrosis through cytotoxic compounds. Cell
lysis, increased vascular permeability and thrombosis within the micro-circulation lead to cell death,
severe local inflammation and ischaemia2,12. The systemic inflammatory response syndrome is triggered
to varying degree and can result in severe local and systemic sepsis. Debridement is often required2,11,12.
Compartment syndrome and the requirement for fasciotomy are not as common as previously thought,
and can be prevented by good medical management15. Snake bite induced nephropathy is a common
sequel to cytotoxic envenoming leading to acute renal failure12. Rhabdomyolysis, cardio-vascular
compromise, changes within the micro-circulation and coagulopathy all contribute to nephropathy12.
Pathological changes that can be seen in the kidney include acute tubular necrosis, glomerulonephritis
and vasculitis, producing a range of clinical manifestations12.
Snake venom is thought to cause neurotoxicity exclusively by affecting the peripheral nervous system
with almost no penetrance into the central nervous system2,16. Toxicology is complex, affecting both
pre- and post-synaptic receptors. The clinical effects vary greatly, with the most feared that of
respiratory depression and neurogenic shock2. In certain species such as the black mamba (Dendroaspis
polylepis), symptoms of neurotoxicity start with metallic taste, ptosis and gradual bulbar paralysis2,15 .
These patients carry a high risk of death and should be treated with great urgency (see management
section).
Patients with significant envenoming can have profound cardio-vascular compromise leading to a
variety of clinical manifestations with multi-factorial causes. Increased vascular permeability and
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dilatation is thought to be implicated, and may be due to the release of cytokines such as bradykinin2,17.
Cardiogenic shock is seen in severe bites secondary to cardiac specific myotoxic compounds and
venom induced conduction defects. This can be further complicated by ischaemia secondary to
coronary artery thrombosis secondary to coagulopathy18.
Snake bite induced coagulopathy is a complex and diverse clinical problem. It is responsible for a large
proportion of snake bite mortality and can be lethal due to complex pathophysiology which is often
only reversed with anti-venom13,15. Venom heterogeneity results in disruption of the coagulation
pathway at various stages. A range of haemostatic disturbances can be seen due to vessel damage due to
cytokines and trauma, reduced coagulability, disseminated intravascular coagulation and the
development of pro-thrombotic states 13. Disintegrins, lectins and phospholipases are examples of
substances that are thought to inhibit haemostasis2,13. In some species snake venom contain procoagulant factors, such as factor V, X, XIII and pro-thrombin activators resulting in a pro-thrombotic
state2,13. Platelet aggregation can be either inhibited or induced depending on the venom sub-type.
Laboratory results of patients are often dramatically deranged without correlating clinical
manifestation13. It is important that snake bite coagulopathy is managed differently to the more common
causes of deranged clotting, as usual treatments can be ineffective and dangerous (see management
section).
Management
The management of venomous snake bite remains a challenge for even the experienced clinician. Lack
of emergency transport and rural location of most bites result in patients often presenting late after the
clinical effects of envenoming is well established2, 19. The cultural beliefs of many rural populations
further exacerbate the problem with traditional healers often attempting to manage the bite using
traditional methods 2, 8. Poor education amongst rural populations and healthcare professionals alike
result in poor first aid measures that often worsen the effects of envenoming 8, 19. Some studies in Africa
have suggested that late presentation is not associated with worse outcome 4, 8. These conclusions can be
challenged: with neurotoxic bites late presentation can result in respiratory failure and hypoxic death
while haemotoxic envenoming can lead to fatal coagulopathy if untreated.
A major obstacle in snake bite treatment is the correct identification of the responsible snake. Snake
bite species vary greatly from one geographic region to another, even within countries. This makes
developing a national or regional treatment strategy problematic. In 40% of cases the patient does not
identify the snake and mistaking for a different species is common15, 20. Even expert herpetologists can
misidentify the snake, resulting in inappropriate treatment with anti-venom2, 20. Attempting to kill or
capture the snake that caused the bite further endangers the individual attempting this, as well as being
detrimental to the local eco-system. Capturing the snake responsible for identification should therefore
be discouraged.
The difficulties facing clinicians treating snake bite is further exacerbated by the lack of availability of
anti-venom and modern medical equipment. Most bites occur in the rural tropics and sub-tropics in low
and middle income countries where access to health care is difficult and resources are limited7.
Clinicians often face treating patients with advanced stages of envenoming without anti-venom. A
systematic approach to managing the clinical syndromes resulting from snake bite is an effective and
safe strategy for clinicians even with limited resources15, 20.
First Aid
Suggestions for initial treatment of snake bite vary greatly 2, 15. Most important are to avoid the use of a
tourniquet and transport the patient to medical care as soon as possible 2, 15. Attempts to clean or incise
the wound and to suck out any venom are ineffective and should be discouraged15. The Sutherland
technique of pressure immobilisation involves compression bandaging of the affected limb along a
splinted support 21. This has been widely taught to reduce venom transport but there is no evidence that
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this is indeed successful 10, 15, 22, 23. It may be effective in treatment of bites in which the venom is
mainly transported via the lymphatics 15. Direct pressure pad application, on the other hand, has been
shown to reduce venom uptake in experimental settings, although the evidence for the clinical benefit of
this technique is limited 10, 23. Educating health care professionals and first aiders in these techniques is
fraud with difficulty and inaccuracy; patients are more likely to be harmed by over-tight bandaging
resulting in a tourniquet effect 15, 23. Tourniquets should be discouraged for use in immediate care
except for bites with neurotoxic venom (e.g. mamba species) that are confidently identified; tourniquets
should be removed within 90 minutes of application 15, 24, 25. Tourniquet use as a first aid measure is
associated with increased hospital stay and worse outcome 8. The ischaemic effects of tourniquet use
can greatly increase the tissue damage resulting from cytotoxic envenoming which accounts for 90% of
bites in Africa 15.
All patients that suffer venomous snake bite should be resuscitated as per Advanced Trauma Life
Support (ATLS®) guidelines 26. The most rapid threat to life is with neurotoxic bites in which
respiratory depression secondary to muscle paralysis is a frequent cause of mortality2, 15. The airway
must be secured while ensuring adequate oxygenation. Patients may become hypotensive due to direct
neurotoxicity, cardiogenic shock, bleeding or sepsis. Shock must be urgently treated with IV fluid
therapy with appropriate monitoring. Avoiding hypoglycaemia and hypothermia are important
resuscitative adjunct measures prior to definitive treatment. All patients should receive tetanus
vaccination.
Syndromic Management
The shortage of anti-venom globally, particularly in the rural tropics, provides a major challenge to
snakebite management. Management of the specific clinical syndrome caused by envenoming can be
effective, whether anti-venom is available or not 15,20. As described previously, snake venom produces
different clinical syndromes depending on the venom constituents and varies greatly 14, 15.
Local Necrosis / Painful Progressive swelling
Bites from Viperidae (e.g. puff-adder, diamondback rattlesnake) and some Elapidae (e.g. kraits, cape
cobra) species are associated with severe cytotoxic effects 14, 15. This is the most common presentation
associated with snake bite in many parts of the world, particularly Africa. The cytotoxic effects of the
venom progress rapidly and may be severe in patients presenting late. Due to local tissue necrosis and
the chemical nature of cytotoxic venom, the administration of anti-venom can be fairly ineffective once
tissue damage has occurred 14. Clinical management of these bites can be very effective dealt with in a
systematic fashion 15.
Patients presenting with progressive tissue necrosis should be resuscitated as stated above. It is worth
keeping in mind that some snakes such as the African spitting cobras can have neuro- and cytotoxic
venom and progressive paralysis is a greater initial threat to life 15.
The affected limb should be elevated and patients should receive adequate analgesia. Fluid resuscitation
is an important aspect of management. The cytotoxic effects of the venom can cause fluid loss and
patients are at risk of acute kidney injury from processes causing myoglobinuria 14. The affected limb
should be monitored closely for tissue necrosis. If debridement is required, it is recommended that this
is performed 5-7 days after the bite 15. This allows adequate demarcation margins to develop and can
avoid unnecessary returns to the operating theatre in an unstable patient. Anti-biotic therapy is only
indicated if signs of sepsis are present.
Complications of cytotoxic envenoming include compartment syndrome, rhabdomyolysis,
myoglobinuria and acute renal failure. Compartment syndrome is uncommon and should be managed
with fasciotomy, if required on clinical grounds 15. Femoral vessel entrapment by the inguinal ligament
can occur rarely, resulting in an ischaemic lower limb 27. Carpal tunnel syndrome from bites to the
upper limb usually recovers with elevation and analgesia 15.
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Not all patients suffering from cytotoxic bites require anti-venom. The indications include compartment
syndrome or serious associated complications such as coagulopathy or adult respiratory distress
syndrome (Table 1). This is required in less than 10% of cytotoxic bites 15.
Table 1
Indications for Anti-Venom
Always use anti-venom with appropriate medical staff and monitoring available. Treat reactions
appropriately and ensure adrenaline, cortico-steroid and anti-histamine are available prior to
administration
Airway/Breathing
• Swelling affecting airway
• Bulbar paralysis affecting breathing / swallowing
• Respiratory distress (ARDS) after cytotoxic bite
Circulation
• All confirmed envenoming from species with haematoxic venom e.g. boomslang
• Systemic bleeding
• Signs of intra-cerebral bleeding
• Significant deranged clotting measurements eg APTT/PT, TEG
• Shock not responsive to fluid therapy
• Cardiac arrhythmias
Disability
• Triad of Pins and needles, profuse sweating and excessive salivation with metallic taste
[suggest severe neurotoxic envenomation]
• Evidence of severe/progressive neurotoxicity (low threshold in species known for neurotoxicity
such as black mamba)
• Seizures / reduced conscious level / severe headache [suggesting intra-cerebral haemorrhage]
• Severe local swelling
! More than ½ of limb within 24 hours
! Significant swelling involving digits
! Rapid extension within few hours
! Compartment syndrome / vessel entrapment
Repeating Anti-Venom
• Continued bleeding 1-2 hours after initiating anti-venom
• Deteriorating neurological function after 1-2hours
• Continued coagulopathy as per laboratory measurements after 6 hours
Progressive Paralysis
Neurotoxic envenoming can cause rapid deterioration and death. This is commonly caused by Elapidae
such as the black mamba in southern Africa and cobra species 14, 15, 20. Some patients may have minor
local tissue damage or they may have severe necrosis and associated coagulopathy.
In neurotoxic envenoming the application of an arterial tourniquet is indicated whilst awaiting hospital
transfer, as the initial risk to life is much greater from neurotoxicity than tissue necrosis 15. Initial
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management of neurotoxic envenoming is appropriate resuscitation with primary attention to Airway
and Breathing. This is crucial in order to prevent respiratory failure secondary to bulbar and respiratory
paralysis. Patients with severe envenoming will require intubation and full respiratory support and this
should not be delayed if indicated during primary survey. Muscle-relaxants should be avoided, unless
absolutely required for initial intubation 15.
These patients require anti-venom in almost all cases. Lack of information regarding the snake
responsible should not delay anti-venom administration if clinical signs and symptoms are highly
suggestive of neurotoxicity. This includes difficulty in swallowing, peri-oral paraesthesiae, metallic
taste, excessive salivation and respiratory failure. If patients are supporting their own respiratory
function but a rapid onset generalised weakness occur, then anti-venom administration is required to
prevent respiratory complications 15. Early intubation should be considered as this allows respiratory
support prior to inevitable respiratory failure. Unlike in cytotoxic envenoming, anti-venom is very
successful in reversing synaptic neurotoxicity 14, 24. If patients are ventilated and anti-venom
administrated then recovery can be excellent, unless the venom also had significant cytotoxic or
coagulopathic effects.
Coagulopathy
Coagulopathy can be the primary venomous effect of some bites, or in conjunction with neurotoxic or
cytotoxic venom. The coagulopathic effects vary greatly depending on the venom and the
haematological interference it produces. It is worth remembering that even if the coagulopathic effects
of venom can produce extremely abnormal laboratory results, these do not always transpire into clinical
morbidity or mortality. Most snake bite coagulopathy result in haemorrhagic tendency, but can rarely
result in pro-thrombotic events and overall is a major source of snakebite mortality globally, causing as
many as 50% of deaths 13.
As discussed previously, underlying mechanisms of coagulopathy vary greatly. Unlike other more
common clinical causes of coagulopathy, those resulting from snake bite are not successfully treated
using standard treatment strategies. The only successful treatment is administration of anti-venom. The
indications for anti-venom include persistent bleeding from minor skin wounds, clinical evidence of
intra-cranial haemorrhage, systemic bleeding or significantly deranged laboratory measurements of
coagulation13, 15. Patients may require repeated administration of anti-venom depending on clinical
response. Blood coagulation profiles should be rechecked six hours after administration of anti-venom
and, if still abnormal, a repeat dose is indicated 2. The clinician should keep in mind that coagulopathy
is often associated with concurrent cyto- or neurotoxic envenoming. These patients should be
resuscitated and managed as required for all the clinical sequelae of the bite.
Anti-venom
Anti-venom was first developed by Calmette in the late 19th century 2, 14. Immunoglobulins are extracted
and purified, usually from animal serum after previous immunization to that specific venom. Antivenom can be mono- or polyspecific, depending on whether it is effective against a single or multiple
species’ venom. Polyvalent anti-venom is usually created geographically to cater specifically for the
most common bites in that particular region. The large variability in inter- and intra-species venom
constitution makes development of anti-venom challenging. This is compounded by the requirement of
having venom from all the particular species available to manufacturing companies. Economical and
distribution difficulties result in anti-venom being unavailable to large populations that are at particular
risk of snake bite.
Anti-venom reactions are common, with more than 10% of patients developing a reaction. These vary
from early Type I hypersensitivity reactions to late serum sickness type reactions. Hypersensitivity is
due to the use of animal serum and patients with previous exposure to animal serum are at particular
risk. The use of pre-administration sensitivity testing is inaccurate, wastes time in patients that are
critically ill and should therefore be avoided 2. Anti-venom should always be administered, resources
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permitting, with suitable monitoring and resuscitation equipment available. Intra-muscular adrenaline is
the treatment of choice in patients with immediate reactions. Corticosteroids and anti-histamines are
indicated as in other causes of anaphylaxis. Patients who receive anti-venom must be monitored for at
least 2 hours post-administration.
The lack of anti-venom availability and the risks of its administration must always be considered by the
clinician treating a patient with snakebite. The majority of bite victims can be managed safely and
successfully without anti-venom. Administration must, however, not be delayed in cases in which antivenom is indicated (Table 1). Clinicians must familiarise themselves with regional anti-venom
availability and whom to contact to obtain these in case of a venomous bite.
Conclusions
Snake bite is a huge public health concern, mostly affecting those in rural areas in low and middle
income countries with poor access to healthcare. This is further complicated by a lack of availability of
anti-venom, and no good quality evidence base on how to manage bites most effectively. This paper
helps to provide clinicians who might have to treat snake bite patients with information on the
identification and management of the syndromic sequelae of snake bites, with or without the
availability of anti-venom. It is essential that the evidence base for effective snake bite treatment is
expanded in order to reduce the devastating public health impact of this neglected tropical disease.
References
1. World
Health
Organisation.
Neglected
Tropical
Disease:
Snakebite.
[http://www.who.int/neglected_diseases/diseases/snakebites/en/] Accessed 08/09/2013.
2. Warrell DA (2010). Snake Bite. Lancet 375:77-88.
3. Williams D, Gutierrez JM, Harrison R et al (2010). The Global Snake Bite Initiative: an
antidote for snake bite. Lancet 375: 89-91.
4. Chippaux JP (2011). Estimate of the burden of snakebites in sub-Saharan Africa: a metaanalytic approach. Toxicon 57: 586-599.
5. Swaroop S, Grab B (1954) Snakebite mortality in the world. Bull World Health Organ 10: 35–
76.
6. Chippaux JP (1998). Snake-bites: appraisal of the global situation. Bull World Health Organ
76: 515-524
7. Kasturiratne A, Wickremasinghe AR, de Silva N et al (2008). The Global Burden of Snakebite:
a literature analysis and modelling based on regional estimates of envenoming and deaths.
PLoS Med 5 (11): 1592 – 1604.
8. Godpower MC, Thatcher TD, Shehu M (2011). The effect of pre-hospital care for venomous
snake bite on outcome in Nigeria. Trans Roy Soc Trop Med Hyg 105: 95-101.
9. Pugh RN, Theakston RD, Reid HA (1980). Malumfashi Endemic Diseases Research Project,
XIII. Epidemiology of human encounters with the spitting cobra, Naja nigricollis, in the
Malumfashi area of northern Nigeria. Ann Trop Med Parasitol 74: 523–30.
10. Tun-Pe, Phillips RE, Warrell DA, et al (1987). Acute and chronic pituitary failure resembling
Sheehan’s syndrome following bites by Russell’s viper in Burma. Lancet 2: 763–67.
11. Norris RL, Auerbach PS, Nelson EE, Bites and Stings (2008) In: Saviston Textbook of Surgery,
Saunders-Elsevier, Philadelphia, p. 586 – 601.
12. Sitprija V (2006). Snakebite nephropathy. Nephrology 11: 442-448.
13. White J (2005). Snake venoms and coagulopathy. Toxicon 35: 951-967.
14. Gutierrez JM, Leon G, Burnouf T (2011). Antivenoms for the treatment of snakebite
envenoming: The road ahead. Biologicals 39: 129-142
15. Blaylock RS (2005). The identification and syndromic management of snakebite in South
Africa. SA Fam Pract 2005 47(9): 48-53
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Journal of Surgery. November/December 2013 Vol. 18 (3
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16. Gubensek F, Ritonja A, Cotic V, et al (1982). Distribution of vipera ammodytes toxic
phospholipase A in the cat and its ability to cross the blood–brain barrier. Toxicon 20: 191–94.
17. Rocha e Silva M, Beraldo WT, Rosenfeld G (1949). Bradykinin, a hypotensive and smooth
muscle stimulating factor released from plasma globulin by snake venoms and by trypsin. Am J
Physiol 156: 261–273.
18. Ducancel F (2005). Endothelin-like peptides. Cell Mol Life Sci 62: 2828–2839.
19. Gutierrez JM, Theakston RDG, Warrell DA (2006). Confronting the neglected problem of
snake bite envenoming: the need for a global partnership. PLoS Med 3(6): 727 - 731
20. Ariaratnam CA, Sheriff MHR, Arambepola C et al (2009). Syndromic approach to treatment of
snake bite in Sri Lanka based on results of a prospective national hospital-based survey of
patients envenomed by identified snakes. Am J Trop Med Hyg 81(4): 725-731
21. Sutherland SK, Coulter AR, Harris RD (1979). Rationalisation of first-aid measures for elapid
snakebite. Lancet 1: 183-186.
22. Anker RL, Straff on WG, Loiselle DS et al (1982). Retarding the uptake of ‘mock venom’ in
humans: comparison of three first-aid treatments. Med J Aust 1: 212–14.
23. Canale E, Isbister GK, Currie BJ (2009). Investigating pressure bandaging for snakebite in a
simulated setting: bandage type, training and the effect of transport. Emerg Med Australas
2009; 21: 184–90.
24. Warrell DA (1999). WHO/SEARO Guidelines for the clinical management of snake bites in the
Southeast Asian region. SE J Trop Med Publ Hlth 30 (suppl 1): 1–85.
25. Gold BS, Dart RC, Barish RA (2002). Bites of venomous snakes. N Eng J Med 347(5): 347356.
26. American College of Surgeons Committee on Trauma (2008). Advanced trauma life support
for doctors [8th Edition], American college of Surgeons, Chicago.
27. Blaylock RSM (2003). Femoral vessel entrapment and compartment syndromes following
snakebite. S Afr J Surg 41 (3) : 72 – 3
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Extended Debridement and Skin Graft as Local Treatment of Cobra Snake Bite Injury: A Case
Report.
G. Mari , J. Abonga, P. Romano, L. Ojom, J.C.O. Olin, M. Komakech, A. Costanzi,
P. Brown
Saint Joseph Hospital, Kitgum District. Kitgum Uganda.
Correspondence to: Giulio Mari, Department of General Surgery Desio Hospital (Italy),
Email: giul_mari@yahoo.it
Snakebite is a serious issue in rural areas of developing countries as Uganda. In children above all
snakebite seems to be more common. Availability of anti-venoms is very poor. Local tissue damage
caused by snake venom, either cytotoxic or necrotic, can continue even after systemic crisis has
expired. We report the case of a 5 years old male child, born in Kitgum district, Northern Uganda,
carried in hospital for a Cobra snake bite on the right foot who could not receive anti-venom.
Debridement of the bite site, wound lavage, amputation and skin graft were required. Progression of
the local infection associated to the reappearance of high fever induced us to bring the debridement
up to the leg almost at the level of the knee in order to prevent unset of tibial Osteomyelitis and to be
able to perform skin grafting.
Keywords; Snakebite, Cobra, surgical treatment, debridement, skin graft, osteomyelitis.
Introduction
Snakebite is a serious issue in rural areas of developing countries. In children above all snakebite seems
to be more common1. In Northern Uganda referrals to Health Centers or Outpatients department for
such events are weekly reported. Because of the distances patients have to cover in order to reach
hospitals and because of the still common first step referral to traditional doctors, many cases of
snakebite die before practitioners can start any treatment. Anti-venoms are unfortunately not widely
available in Uganda1,2,3. Patient who are admitted to hospital are mostly those who survived the
systemic problems venom causes. It is particularly the local injury that brings patients in fact to
hospital. Local tissue damage caused by snake venom, either cytotoxic or necrotic, can continue even
after systemic crisis has expired4. Tissue necrosis and local infection often times need surgical
management to be solved5. Debridement of the bite site, wound lavage, amputation and skin graft are
some of the procedures snake bite treatment require5. Osteomyelitis is a severe complication observed
in the experience of our Hospital. Preventing it is a concern surgeon has when.
We report the case of a 5 years old male child, born in Kitgum district, Northern Uganda, carried in
hospital for a Cobra snake bite on the right foot happened early in the morning during the rainy season.
Systemic and local treatment was required. Delayed necrosis and the fear for the onset of osteomyelitis
requested extension of the debridement.
Case Report
A 5 years old boy weighing 19 kg, was brought by the parents to the Outpatients Department of Saint
Joseph Hospital, Kitgum District, in Northern Uganda. The child had been referred with a history of
sudden pain in the right foot while he was sleeping in his hut. Intense pain, swelling and edema of the
foot started immediately followed by high fever, weakness and loss of consciousness. Two other people
had also been attacked by a snake and one died. Witnesses described with a certain amount of certainty
that the snake was a Cobra.
On admission his blood pressure was 90/60. Other findings included a temperature of 38.5oC, heart rate
122 bpm and respiratory rate of 125. The right leg was warm, swollen with signs of oedema and
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swelling. Features of inflammation and bacterial infection were present together with cutaneous
necrosis involving the whole surface of the foot.
Since in our Hospital no anti-venom was available, the medical treatment we could provide to this case
included intra-venous administration of crystalloids, hydrocortisone and ceftriaxone antibiotics. After
48 hours from time of admission, systemic parameters were stabilized and landmarks of the initial
necrosis of the tissues of the food became evident.
A decision was taken to perform surgical debridement. Under general anesthesia we drained 250 ml of
pus from the soft tissues of the foot and right leg. A total of 20% of the skin of the foot which was
necrotic was removed. Toes were temporary left in place even though there were early features of
necrosis. Debridement and lavage were done every 48 hours initially until extension of necrosis was
definitely evaluated. Warm saline plus Iodiopovidone 5% were used to wash the wound; Hydrogen
peroxide solution was used to clean the tissue before performing amputation. Amputation of the toes
first and afterward of the first metatarsus was required. Later when early contracture of the Achilles
tendon was noted we applied an open cast to keep the right foot extended. No bacterial examination
from a wound sample was done due to insufficient means.
After we noticed a progression of the local infection associated to the reappearance of high fever, in
order to prevent onset of tibial osteomyelitis we decided to bring the debridement up to the leg almost
to the level of the knee. Several lavages were performed with pus and necrotic tissue evacuation from
the distal third of the leg. Total cleaning of the region was achieved. After 19 lavages, tibial bone was
not presenting signs of infection and soft tissues of the leg were granulating properly. After 1 week
from total resolution of the infective process we performed skin graft. We divided the grafting in three
steps. Grafts were taken from the thighs and applied to the granulating tissue. Very few stitches were
used to keep the grafts in place. The skin took well. Patient kept cast in place also after discharge and
was referred to an orthopedic workshop for customized shoes for the amputated foot.
On discharge patient was not presenting signs of residual infection or necrosis. White cell count was
within normality rates. Right foot was warm and clean with good skin graft implant.
Discussion
Mortality associated to poisoned snake bite in Northern Uganda is difficult to be quantified.
Nevertheless in our institution we weekly reported referrals for such an event. Survived patient often
referred to have received second or third bite from a snake attack on more than one person. It’s
reasonable to think that poison load is lower after the first bite. In our experience it was rare to hear of a
survived patient from a single person Cobra snake attack, above all among children. As other authors
report, snake bite occurred in the case we describe, happened within the shelter of a house while the
child was sleeping, during the rainy season1. Other two children were involved in the attack. At
patient’s arrival surgeon’s behavior is crucial. Bite site evaluation is the starting point together with
stabilization of systemic parameters. Absence of anti-venom and the lack of supply is an issue we have
to daily deal with. Crystalloid fluid load and i.v. cortisone are indicated in our experience. We usually
associate also antibiotic therapy and tetanus prophylaxis6,7 when disposable. If there’s n evidence of
compartment syndrome8, debridement should be delayed until pus is present below the external tissues
and the edges of the necrotic area are at least initially delimitated9. In Northern Uganda anti-venom is
not available so patients have to recover from hematologic and neurologic toxicity basically by
themselves. After the first pus evacuation and necrotic tissue debridement chances to develop delayed
necrosis are still high10. Observation and repeated medication are needed to enquire whether or not
starting necrotic processes are developing also far from the initial site11.
Another main concern to have is osteomyelitis onset. The pour hygienic conditions people live in and
the lack of immediate primary wound disinfection are a risk factor for developing septic bone
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processes. Since consequences of such an onset over a poisoned site can be extremely severe, surgical
follow up of the debrided wound in mandatory12,13. In the case we report decision for a pushed
extension of the debridement came after temperature re-increased even when in our opinion the surgical
site was clean14. Detecting any possible focus of tibial osteomyelitis or residual necrotic tissue far from
the infection starting site became then necessary. This aspect is crucial even in order to perform a safe
skin graft. Complete resolution of the infection also distally from the grafted site occurs to achieve a
good graft acceptance. Necrosis of soft tissues of the foot can bring to tendons injury. Retraction of the
Achilles tendon, if not corrected can cause additional functional problems. We fashion an open cast
meant to extend Achilles tendon in order to recover an acceptable extension of the foot. Physiotherapy
should be proposed where possible to restore the strength of the remnant muscular mass.
Conclusion
Cobra snake bite is a life threatening event unfortunately common in Northern Uganda. Systemic
toxicity can be difficult to treat where anti-venom is not available. The treatment of snake bite site
necrosis and infection is challenging and long lasting but it is mandatory for saving patient functional
outcome. Delayed extensive use of debridement can be required to prevent the onset of osteomyelitis.
References
1. Gutiérrez JM. Improving antivenom availability and accessibility: science, technology, and beyond.
Toxicon. 2012 Sep 15;60(4):676-87.
2. Del Brutto OH, Del Brutto VJ. Neurological complications of venomous snake bites: a review. Acta
Neurol Scand. 2012 Jun;125(6):363-72.
3. Churi S, Ramesh M, Bhakta K, Chris J. Prospective assessment of patterns, severity and clinical
outcome of Indian poisoning incidentsChem Pharm Bull (Tokyo). 2012;60(7):859-64.
4. Dramé BS, Dabo M, Diani N, Cissé B. Assessment of the availability and use of antivenom in the
district of Bamako, Mali, West Africa Bull Soc Pathol Exot. 2012 Aug;105(3):179-83.
5. Laohawiriyakamol S, Sangkhathat S, Chiengkriwate P, Patrapinyokul S. Surgery in management
of snake envenomation in children. World J Pediatr. 2011 Nov;7(4):361-4.
6. Van de Velde S, De Buck E, Vandekerckhove P, Volmink J. Evidence-based African first aid
guidelines and training materials. PLoS Med. 2011 Jul;8(7):e1001059.
7. Adehossi E, Sani R, Boukari-Bawa M, Niaouro S Snake bites in the emergency unit of Niamey
National Hospital, Niger Bull Soc Pathol Exot. 2011 Dec;104(5):357-60.
8. Kemparaju K. Snakebite management: time for strategic approach. Curr Top Med Chem.
2011;11(20):2493
9. Appiah B. Snakebite neglect rampant in Africa CMAJ. 2012 Jan 10; 184(1):E27-8
10. Williams DJ, Gutiérrez JM, Calvete JJ, Wüster W. Ending the drought: new strategies for
improving the flow of affordable, effective antivenoms in Asia and Africa. J Proteomics 2011 Aug
24;74(9):1735-67
11. Abubakar SB, Habib AG, Mathew J. Amputation and disability following snakebite in Nigeria.
Trop Doct. 2010 Apr;40(2):114-6.
12. Chippaux JP. Estimate of the burden of snakebites in sub-Saharan Africa: a meta-analytic
approach. Toxicon. 2011 Mar 15;57(4):586-99
13. Loro A, Franceschi F, Dal Lago A. The reasons for amputations in children (0-18 years) in a
developing country. Trop Doct. 1994 Jul;24(3):99-102.
14. Chippaux JP. Local complications of snake bites Med Trop (Mars). 1982 Mar-Apr; 42(2):177-83.
15. Pietrangiolillo Z, Frassoldati R, Leonelli V, Freschi R. Compartment syndrome after viper-bite in
toddler: case report and review of literature. Acta Biomed. 2012 Apr;83(1):44-50.
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Pattern of Neonatal Surgery at a Teaching Hospital in Nigeria: A Review of 101 Cases.
E. Aiwanlehi1, E. Ogbaisi2
1
Department of Surgery, Irrua Specialist teaching Hospital, Irrua, Edo State and Department of Surgery,
University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.
2
Department of Surgery, Medical Centre, Yenogoa, Nigeria.
Correspondence to: E. Aiwanlehi, Email: eighemhenrioehi@yahoo.com
Background: Neonatal surgeries are a particularly challenging aspect of paediatric surgery
following the peculiar physiologic and metabolic demands of neonates. Surgery in the neonates
therefore will require specific anaesthesia, analgesia, intraoperative and postoperative monitoring.
There are a wide range of surgical conditions requiring surgery in the neonates.
Methods: The study was a retrospective study of neonates who underwent various surgeries from
2010-2012.The study was carried out at the University of Benin Teaching Hospital, Benin City,
Nigeria. A total of 101 neonates had various surgeries during this period.
Results: A total of 53 males and 48 females were seen with a male to female ratio of 1.1:1. The ages
at presentation of the neonates ranged between few hours to 28 days. A wide range of clinical
conditions involving various systems of the body were seen requiring surgery. These varied from
neurosurgical plastic to gastrointestinal conditions. Most of the cases were congenital anomalies
involving the gastrointestinal system (87.1%). Adequate analgesia was achieved with use of
intravenous paracetamol in our patients. This does not require monitoring unlike in the case of
opiods. Active postoperative monitoring is crucial to achieving good outcome in neonatal surgery.
Key words: Neonatal, Congenital, Surgery
Introduction
The surgical neonate poses significant test to the expertise of the pediatric surgeon. This is because the
neonate has a peculiar demand in terms of their physiology and metabolic requirements that can be
deranged in the presence of a surgical need. A thorough understanding of neonatal physiology and
metabolism is needed to achieve success in neonatal surgery. Specific considerations include
anesthesia, analgesia temperature control, intra-operative and post-operative monitoring. The
management of neonatal surgical problems continues to pose considerable challenges especially in low
resource settings1.
Surgery in neonates is commonly an open procedure mainly due to the small size of their body frame.
However increasing success is being recorded in the field of laparoscopic neonatal surgery2. Surgery
for neonates is mostly for congenital anomalies for which they present early in life.
Patients and Methods
The study was a retrospective study of neonates who underwent various surgeries from 2010-2012.The
study was carried out at the University of Benin Teaching Hospital, Benin City, Nigeria. The hospital is
one of the major teaching hospitals in Nigeria. The neonates were on admission at the Special Care
Baby Unit (SCBU) of the hospital. The SCBU has a capacity for about 50 neonates and it is equipped
with neonatal incubators, phototherapy machines, resuscitators and other equipments for the proper care
of neonates.
Patients are admitted into the SCBU from the obstetrics and gynaecology department of the hospital
and from referrals from every part of the state (Edo state).The SCBU of the hospital also frequently
receive patients from adjoining states like Delta, Kogi and Ondo states. Neonatal surgeries are mainly
handled by the paediatric surgeons and occasionally by the paediatric neurosurgeons and plastic
surgeons.
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Neonates who had surgeries for various conditions were analyzed over the 3 year period. Data was
obtained from the admission register in the unit and from case notes of the patients. The case notes were
retrieved from the medical records department of the hospital. Relevant data retrieved included the
names, sex, age at presentation, diagnosis and type of surgery.
The data was analyzed using simple statistical methods and also application of SPSS version 10.
Results
A total of 101 neonatal surgeries were done over the 3 year period (2010-2012).The surgeries mainly
performed by the paediatric surgeons, paediatric neurosurgeons and plastic surgeons. A total of 53
males and 48 females were seen with a male to female ratio of 1.1:1. The age at [presentation of the
neonates were between few hours to 28 days. The distribution of the age at presentation and
corresponding number of patients is shown in Figure 1. A wide range of clinical conditions involving
various systems of the body were seen requiring surgery. These range from neurosurgical plastic to
gastrointestinal conditions. Table1 show the distribution of cases. Table 2 show the distribution of
cases.
Gastrointestinal cases form a very large percentage (87.1%) of surgeries done in neonates. These
gastrointestinal conditions cut across a wide range of congenital anomalies. Distributions of the
gastrointestinal cases are shown in Table 2.
Figure 1. Age at Presentation
33
21
16
16
15
5
.Table 1. Distribution of Cases by System
System
Neurosurgery
Plastic
Gastrointestinal
Genitourinary
Thoracic
Tumours/Oncology
57
Number
2
2
88
4
2
3
Percentage
1.9
1.9
87.1
3.9
1.9
2.9
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Table 2. Distribution of GIT Cases
Diagnosis
Anorectal Malformation
Omphalocele
Gastroshcisis
Hirschsprung’s disease
Intestinal Atresia/Stenosis
Hernia
Gastric Outlet Obstruction
Necrotizing Enterocolitis
Malrotation
Total
Number of Cases
18
5
12
8
20
6
7
4
8
88
Percentage
20.4
5.6
13.6
9.1
22.7
6.8
7.9
4.5
9.1
100
Table 3. Colostomy Rate
Diagnosis
Anorectal malformation
Hirschsprung’s disease
Necrotizing enterocolitis
Number of cases
12
5
1
Percentage
66.6
62.5
25.0
Exteriorization of a portion of the bowel (small intestine and colon) and creation of a stoma is an
acceptable temporary way of managing some neonatal conditions like anorectal malformation,
Hirschsprung’s disease and necrotizing enterocolitis. In this study 18 patients had one form of
colostomy or the other as shown in Table 3.
Discussion
A total of 101 neonatal surgeries were recorded between 2010 and 2012 at the SCBU in our centre. The
male to female ratio was almost equal with ratio of 1.1:1.Most of the conditions seen were congenital
anomalies of the different systems of the body. Few neonates were observed to have multi-systemic
involvements. In these categories only the system for which surgery was done in the neonatal period
was recorded in this study. Congenital anomalies are the commonest cause of surgical intervention in
neonates as clearly shown in this study. The age at presentation range from the day of delivery to 28
days of life. This distribution is shown in Table 1.
A total of 14.8% of the neonates presented on the day of delivery. It was observed that a majority of
these patients presented with anterior abdominal wall defects (gastroschisis and omphalocele). These
are very obvious deformities for which the newborns are not usually taken home after delivery. About
a third (32.6%) presented between 2nd day and 7th day of life, while 20.7% presented between 8th and
14th day of life. Many of these patients had intestinal obstruction from varying causes. very but quickly
referred to the paediatric surgeons.
They presented with episodes of vomiting and abdominal distention which had progressively worsened.
It was observed that a majority (32.6%) of all our patients presented between 2nd and 7th day of life.
There was a wide spectrum of disease conditions recorded in the period of the study. Gastrointestinal
cases had the highest contribution with 87.1%
Neurosurgery: 2 (1.9%) cases were seen over the period that was admitted into the SCBU. Both cases
were that of frontal encephalocele that was repaired.
Plastic surgery: 2(1.9%) cases of burn injury that required surgery were seen .The patients presented at
the 22nd and 26th day of life.
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Genitourinary surgery: 4 (3.9%) neonates with genitourinary conditions were seen during the period.
The male to female ratio was 1:1.The 2 female neonates seen presented with progressive lower
abdominal distention from hydrometrocolpos and imperforate hymen as well vaginal atresia. One of the
male neonates presented with posterior urethral valves while the other had bilateral pelvi-ureteric
junction obstruction.
Thoracic surgery: 2(1.9%) of thoracic cases were seen and both were oesophageal atresia and
tracheosophageal fistula. Both had right posterolateral thoracotomy with primary anastomosis.
Tumour surgery: Two cases of sacroccocygeal teratoma Type1 were seen over the period and one case
of cervical cystic hygroma with obstructive symptoms. All the three cases had excision of the masses
during the neonatal period.
Gastrointestinal surgery: This accounted for the highest contribution with 87.1%.Intestinal
atresia/stenosis accounted for the largest cause of neonatal surgeries from gastrointestinal system with
22.7%.This was followed by anorectal malformations (ARM) with 20.4%.Others are gastroschisis
13.6%, Hirschsprung’s disease 9.1% and gastric outlet obstruction 7.9%. Infantile hypertrophic pyloric
stenosis (IHPS) was responsible for all the cases of gastric outlet obstruction. It has been observed in
the hospital that there has been a progressive decline in the incidence of IHPS since the introduction of
baby friendly practice in the hospital.
The other contributions were from malrotation (9.1%), omphalocele (5.6%), obstructed hernias (6.8%)
and necrotizing enterocolitis (4.5%). Of the 5 patients with omphalocele, 3 were ruptured and 2 had
primary skin cover following omphalocele minor. Six neonates presented with symptomatic
inguinoscrotal hernia requiring emergency groin exploration. Most of the neonates had primary repair
for their anomalies.
Colostomy was done for 18 of the neonates with anomalies like anorectal malformation (ARM),
Hirschsprung’s disease (HD) and necrotizing enterocolitis (NEC). These included 12 patients with
ARM, 5 patients with HD and 1 with NEC. Creation of colostomy is a palliative and acceptable way of
initial treatment of these conditions to allow the neonate to grow. The colostomy rate for ARM was
66.6%, HD 62.5% and NEC 25%. Creation of colostomy is a temporary and acceptable way of initial
treatment of these conditions to allow time for the neonates to grow.
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Safe and effective analgesia for neonates undergoing major surgery remains a challenge particularly in
institutions where resources are limited. Effective pain relief for neonates is considered essential as it is
only humane but may play a role in surgical outcome3, 4. In this review adequate postoperative analgesia
was achieved by paracetamol administration at 10mg/kg/dose 6 hourly. This was observed to have good
control of pain.
The use of intraoperative and postoperative opiods has been shown to have respiratory depressive
effects on the neonates causing apnoeic attacks. Intraoperative opiods and subsequent continuous
postoperative infusions are widely used but usually mandate ventilatory support and/or close
monitoring and supervision following major surgery3, 5, 6.Postoperative opiods are not usually given in
our center to neonates to avoid untoward side effects in the absence adequate monitoring.
Acknowledgement
Dr Daniel Okosun of Department of surgery UBTH, Benin City for helping in collecting data
References
1
2
3
4
5
6
60
Lohfa B Chirdan, Petronila JN, Essam A Elhalaby. Neonatal surgery in Africa.Seminars in
Pediatric surgery.May 2012; 21(2),151-159
T.Fujimoto, O.Segawa, G.J Lane, S.Esaki, T.Miyano. Laparoscopic surgery in newborn
infants.Surg Endosc;1999,13:773-777
Adrian T, Bosenberg FFA. Epidural analgesia for major neonatal surgery .Paediatric
Anaesthesia 1998; 8(6): 479-483
Annad KJS, Hickey PR. Pain and its effects in the human neonates and fetus .N.Engl J .Med
198; 317: 1321-1329.
Goresky VG, Klassen K , Waters JH. Postoperative pain management for children.Aaesth Clin
N Am 1991; 9: 801-819
Lloyd-Thomas AR. Pain management in paediatric patients .Brit J .Anaesth 1990 ,64 (85),pg
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Levels and Trends of Occupational Hazards among Surgical Residents at Tikur Anbessa
Hospital, Addis Ababa Ethiopia
A. Bekele1, S. Shiferaw2, D. Gulilat1
Tikur Anbessa Hospital, Addis Ababa Ethiopia
Correspondence to: Abebe Bekele, Email: abebesurg@yahoo.com
Background: A previous study conducted four years ago among surgeons-in-training at the Addis
Ababa University revealed that work-related accidents among surgical trainees were enormous, and
there was huge under reporting to the occupational health unit (OHU) of the hospital. The aim of
this study was to evaluate the impact of the strengthened OHU of the hospital and what the current
status of work-related accidents is like at the same hospital three years later.
Methods: A cross-sectional study was conducted to investigate the prevalence and context of all
work-related accidents that resulted in contamination with blood and blood products inside the
operating theatre, among surgical residents at the Tikur Anbessa teaching specialized referral
hospital, in Addis Ababa University, Ethiopia. Data was collected from all 76 surgical residents who
were at different stages of their specialty training in 2011.
Results: Seventy- two (94.7%) of the residents were males and 26 (34.2%) were in their 3rd and 4th
year of training. Of the 76 respondents, 53 (69.8%) had sustained a needle-stick injury inside the
operating theatre at least once during their residency (Range=1-15 times). For 20 (26.3%), the
accidents involved a high risk patient at least once. Cut with a sharp object, contact of blood to an
unprotected skin and splash of blood to the eyes and face were reported by 9 (11.7%), 39(51.3%) and
28(36.9%) of the respondents respectively. Information concerning the most recent injuries inside the
operating theatre revealed that 46(69.7%) of the residents sustained accidents in the 6 months
preceding the survey, 7(9.2%) of which involved a high risk patient. All of the 7 (100%) of the recent
high risk injuries and 10(27.7%) of the low-risk injuries were reported to the OHU and all the high
risk injury victims were commenced on HIV prophylaxis.
Conclusions and Recommendations: Overall, the study revealed that work-related accidents among
surgical trainees are still unacceptably high, even though there is a decline in the number of sharp
object cut, and blood splash accidents. However, there is a positive trend towards reporting of
injuries, particularly those which are high risk. More is expected from the hospital to create a safe
working environment and to encourage reporting of all form of injuries.
Introduction
By virtue of their profession, surgeons and surgical residents have the greatest risk of exposure to
blood-borne pathogens, given their numerous encounters involving the use of sharp instruments on
patients and the increased propensity for injury while learning new technical skill sets1, 2. In surgery
residents, the type of exposures are mainly needle stick injuries and cuts, and they tend to occur during
operative procedures 1, 2, 3.
A previous study conducted in 2007 among surgeons-in-training at the Addis Ababa University,
department of surgery had revealed that work-related accidents, (needle sticks, blood splash to the face,
contact of blood to the skin and mucus membranes) among surgical trainees were enormous, and there
was huge under reporting to the occupational health unit (OHU) of the hospital4. The study also
identified a number of existing problems that predisposed the residents to such accidents. The authors
further recommended that every possible effort has to be done to popularize the already existing OHU
in the hospital unit, the OHU must be placed in a more accessible site and there should be a standard
reporting protocol.
After the study was published, the hospital, already engaged in major restructuring of the OHU,
undertook some vital measures to strengthen the existing unit. Measures taken included the provision of
a free 24 hours testing, counselling and prophylaxis medication provision service, the OHU space was
expanded and placed at a more accessible site, focal contact person was identified in the operating
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theatre and 24 hours contact was established, many awareness creation actions were undertaken such as
posters all over the hospital and fliers circulated. In this study, we wanted to assess the impact of the
newly strengthened OHU with regards to the occurrence of the work related accidents and the observed
change in reporting behaviour in similar study subjects.
Methods
All surgical residents in General Surgery (N=76) were included in the study. Data were collected using
a structured questionnaire that included questions about the postgraduate year of residency, the sex of
the respondents and the total number of needle sticks, cut by sharp instruments, contact with blood to
the unprotected skin and splash to the face and eyes that occurred during their residency training in the
operating theatre with emphasis on how many of the above accidents involved a high risk case.
Respondents were also asked about the most recent injuries involving a high risk patient. For the
purpose of the study, a high-risk patient was defined as a confirmed or strongly suspected case of HIV
infection. The questions about the most recent needle stick included whether it involved a high risk
patient, the perceived causes and circumstances of injury, whether it was reported, reasons for not
reporting it if applicable, and whether anyone else knew of the injury.
Data entry, cleaning and analyses was performed using SPSS version 14. P-values (less than 0.05) and
95 % confidence levels were used to assess the statistical significance of the observed changes on
selected indicators between the previous and present study.
Results
A total of 76 respondents were included in the study. As shown in Table 1, 72 (94.7%) were males and
50 (65.8%) were senior surgical residents in their 3rd and final year (4th year) of training. SeventyTwo (94.7%) claimed to put on double gloves during most of major operations while only 4 (5.3%)
were vaccinated against hepatitis.
Of the 76 respondents, 53 (69.7%) had sustained a needle stick inside the operating theatre at least once
during their residency (Range=1-10 times) compared to 77.8% 3 years ago. For 20(26.3%: 95% CI:
16.1, 35.9), the accidents involved a high risk patient at least once showing a decline, though
insignificantly, from the previous study of 36.1 percent (95% CI: 20.3, 51.7). Cut with a sharp object,
contact of blood to an unprotected skin and splash of blood to the eyes and face were reported by
9(11.7%), 37(48.7%) and 28(36.9%) of the respondents respectively. In agreement with the previous
study, the likelihood of having needle stick increased as the number of postgraduate years of training
increased (Figure 1).
Information concerning the most recent occupational injury inside the operating theatre revealed that 46
(60.5%) of the residents sustained work-related accident in the 6 months preceding the survey,
7(15.2%) of which involved a high risk patient. Of these injuries, 31(67.3%) of the respondents
reported that the injury was self-inflicted, 27(58.6%) by a solid needle and 32 (83.8%) during suturing.
The residents were 1st assistants when they sustained the injury during 28(60.8%) of the surgeries and
they were the operating surgeons in 4(8.7%). Lack of/improper use of operating material and a feeling
of being "rushed" was identified by 40 (86.9 %) and 30 (65.2%) of the respondents as major
contributing cause of the injury. 40 (88.2%) believed that the injury was preventable. (Table 2)
From the 46 recent accidents, 10 (21.7) were reported to the OHU showing some improvement
compared to no reporting of recent injuries in the previous survey. All the 7 high risk injuries were
reported to the occupational health unit and the injured residents were started with HIV prophylaxis
medication. However, only 3(7.6 %) of the non-high risk injuries were reported in the year 2010,
compared to one individual with non-high risk injury reported in the year 2007. The most frequently
cited reasons for not reporting were not knowing if the unit exists in the hospital 8 (22.2%) versus 15
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(50%) in 2007 and the fact that the process takes a long time 14 (38.8 %) versus 6 (20%) in 2007 (Table
3).
Of these most recent injuries that were not reported (N=36), 34 (94.4%) were known to others while a
colleague resident was aware in 20 (55.5%). When asked whether they will report if they sustain injury
in the future, 27(73.7%) of all the participants said yes. As shown in Table 4, there has been a relative
declining trend of occupational injuries, except for contact of blood to an unprotected skin, among
surgeon-in-training over the preceding three years. Similarly, the percentage of residents who reported
the accidents (particularly high risk injuries) to the Occupational Health Unit increased between the two
surveys.
Figure 1. Percentage of residents who sustained needle stick according to their year of training, TAH
2011 as compared to a similar study in 2007.
Table 1. Profiles of Surgical Residents at the Tikur Anbessa Hospital, Addis Ababa, Ethiopia, 2011 as
compared to the a similar study in 2007
Characteristics
N (36)
Year of study
1
2
3
4
2007
%
N (76)
2010
%
13
6
9
8
36.1
16.7
25.0
22.2
33
17
9
17
43.4
22.4
11.8
22.4
32
4
88.9
11.1
72
4
94.7
5.3
Sex
Male
Female
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Table 2. Trends in the Characteristics of the Most Recent needle stick among Surgical Residents, Tikur Anbessa
Hospital, Addis Ababa, Ethiopia 2011 as compared to the a similar study in 2007.
2007
Variable
2010
No=31
Characteristics of injury
Self induced
Inflicted by someone else
Nature of injury
Solid needle
Hollow needle
Sharp instrument
Unclear
Type of procedure
Suturing
Cutting
Instrument exchange
Unclear
Cause of recent injury *
Lack of assistance
Lack of required skills
Lack of appropriate operating equipments
Fatigue/hunger
The feeling of being rushed
Accident avoidable?
Yes
No
During the most recent injury, you were the:
Surgeon
1st assistant
2nd assistant
%
No=46
%
27
4
87.1
12.9
31
15
67.3
22.7
26
1
4
-
83.8
3.2
12.9
27
7
1
11
58.6
15.2
2.1
23.9
26
4
-
83.8
12.9
-
32
1
6
7
69.5
2.1
13.0
15.2
2
14
5
12
6.4
45.1
16.1
38.1
14
6
40
7
30
30.4
13.0
86.9
15.2
65.2
28
8
90.3
9.7
40
6
88.2
7.9
11
13
-
41.9
35.4
4
28
14
8.7
60.8
30.4
Key: *: More than one response was possible.
Table 3. Characteristics of the Most Recent Injury among Surgical Residents, Tikur Anbessa Hospital, Addis
Ababa, Ethiopia, 2011 as Compared to a Similar Study in 2007.
Characteristic
The main reasons for not reporting to OHU
Don’t know whether it exists or not
Process takes a lot of time
Don’t want to take the prophylactic drugs
No use in reporting it
Don’t want to know result
Who knew about recent injury
No one
Colleague resident
A consultant
Significant others
Other Theatre staff e.g. Anaesthetist
Will report in the future
Yes
No
64
2007
(N=36)
%
2010
(N=36)
%
12
6
2
3
2
50.0
20.0
6.4
9.6
6.4
8
14
6
6
2
22.2
38.8
16.6
16.6
5.5
5
20
1
5
16.1
64.5
3.2
16.1
2
20
8
3
3
5.5
55.5
22.2
8.3
8.3
25
11
69.4
30.6
27
9
73.7
23.7
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Table 4. Trends in the Prevalence of Work-related Injuries, Tikur Anbessa Hospital, Addis Ababa,
Ethiopia, 2011 as Compared to a Similar study in 2007
2007
Characteristic*
2010
Needle stick injury
N
28
%
77.8
N
53
%
69.7
Cut by sharp instrument
11
30.6
9
11.8
Contact of blood to an unprotected skin
27
75.0
60
78.9
Splash of blood to the eyes and face
27
75.0
48
63.2
Reported total recent injuries to the OHU
-
-
10
21.7
Reported recent high risk injuries
1
4.4
7
100
* - None of the observed changes between 2007 and 2010 were statistically significant apparently
because of the small number of residents in each subcategory
Discussion
This study tried to re-focus at assessing the level and trend of occupational injuries among residents in
Tikur Anbessa hospital with the ultimate aim of identifying modifiable exposure risk factors and
behaviours that need to be addressed. It was encouraging to note that there is crude but not statistically
significant decline in the prevalence of important forms of injuries such as needle stick injury (from 78
to 70 percent), sharp injuries (from 31% to 12%), and splash of blood to the eyes and face (from 75 to
63 percent) following the re-organization of the OHU. Such a positive trend is encouraging and needs
to be strengthened.
The residents also mentioned their perceived reasons of injury such as lack of appropriate operating
equipments, lack of proper assistance during surgery and lack of the required surgical skills to conduct
a safe procedure. It was also interesting to note that similar reasons were mentioned in the previous
study with a similar frequency. If a significant decline in the occurrence of occupational injuries is
expected, the medical school and the department of surgery in particular should pay attention to this and
due emphasis should be put in the training and set up of the operating procedures. Responsible hospital
and school administrators should again look into this and find ways of improving the working
environment.
Interestingly, the pattern and nature of injuries remains the same between the two surveys. The
prevalence of injury increases as the risk of exposure increases with each year of training. Likewise,
self induced needle injuries which were often encountered while suturing are the predominant forms of
injuries in both rounds of surveys pointing to the need to specifically target such procedures for
preventive interventions. It is also interesting to note that most residents believe that they are suffering
from injuries which are completely avoidable
The study also revealed that only 5.3% of the residents were vaccinated against Hepatitis B. Such a low
prevalence of vaccination is also reported from other developing countries such as Nigeria 5 and India6,
and developed countries like Japan7. Though this is not the main objective of this study, we believe this
is unacceptable by all standards and deserves mention. Review of the literature shows that among
healthcare workers, sero-prevalence for hepatitis B is two to four times higher than that of the general
population6,7.
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Other studies have also shown that among physicians and dentists, those in specialties with more
frequent blood or needle-stick exposures (e.g., surgeons, obstetrician-gynaecologists,
anaesthesiologists) have a significantly elevated risk compared to those in specialties such as
paediatrics or psychiatry8. An additional risk factor for acquisition of HBV infection is the underlying
prevalence of HBV infection in the population, which is very high in the developing countries9. We
believe such a low vaccination rate among our surgical residents may be due to various reasons
including awareness, risk assessment, lack of opportunity and low priority given by the health
managements of hospitals.
Worth mentioning is the fact that residents have made some progress as far as reporting the injury to the
Occupational Health Unit is concerned, although it is still insufficient. Finally, although the present
study showed commendable progress in the incidence as well as reporting of occupational injuries in
the operating theatre, most of the findings were not statistically significant perhaps as a result of the
small number of study participants in both surveys. Drawing a strong conclusion about the cause effect
relationship between the institution of the OHU and the improvements subsequently seen is also limited
by the fact that there was no control population to account for secular changes that may have occurred
between the two surveys.
References
1. Martin A. Makary, Ali Al-Attar, Christine G. Holzmueller, J. Bryan Sexton, Dora Syin, et al.
Needlestick Injuries among Surgeons in Training. NEJM, Volume 356:2693-2699 June 28,
2007 Number 26.
2. Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR
personnel. AORN J 1998;67:979-81, 983.
3. Rele M, Mathur M, Turbadkar D Risk of needle stick injuries in health care workers - A report.
Indian Journal of Medical Microbiology Year : 2002 Volume : 20 Issue : 4 Page : 206-207
4. Abebe Bekele, Berhanu Kotisso and Solomon Shiferaw.Work-Related Operating Theatre
Accidents Among Surgical Residents in Addis Ababa, Ethiopia. East and Central African
Journal of Surgery Volume 13 Number 1 – March / April 2008.
5. Ibekwe RC, Ibeziako N. Hepatitis B vaccination status among health workers in Enugu,
Nigeria. Niger J Clin Pract. 2006 Jun; 9 (1):7-10.
6. Varsha Singhal, Dhrubajyoti Bora, and Sarman Singh. Hepatitis B in Health Care Workers:
Indian Scenario. J Lab Physicians. 2009 Jul-Dec; 1(2): 41–48.
7. Nagao Y, Matsuoka H, Kawaguchi T, Ide T, Sata M. HBV and HCV infection in Japanese
dental care workers. Int J Mol Med. 2008;21:791–9.
8. West DJ. The risk of hepatitis B infection among health professionals in the United States: A
review. Am J Med Sci. 1984;287:26–33.
9. US Public Health Service. Centers for Disease Control and Prevention. Updated U.S. Public
Health Service Guidelines for the Occupational Exposures of HBV, HCV, and HIV and
Recommendations for Post exposure Prophylaxis. MMWR. 2001;50:1–52.
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Demograpics of Patients Admitted with Traumatic Intracranial Bleeds in Kenyatta National
Hospital in Nairobi, Kenya.
V.D. Wekesa1, J.A. Ogengo2, C.V. Siongei3, H. Elbusaidy4, M. Iwaret4.
1
Department of Surgery, Division of Neurological Surgery, University of Nairobi (UoN).
2
Department of Human Anatomy, University of Nairobi.
3
Department of Nursing, Kenya Methodist University.
4
Medical Student, University of Nairobi.
Correspondence to: Vincent D. Wekesa, dvwekesa@yahoo.com, vwekesa09@gmail.com
Background: This study was designed to describe the demographics of patients presenting with
traumatic intracranial bleeds at the Kenyatta National Hospital (KNH).
Methods: A descriptive cross sectional analysis of consecutive patients who had traumatic
intracranial bleeds, and admitted at the KNH between December 2010 and March 2011 was
performed. A total of 51 patients with traumatic intracranial bleeds were recruited in the study with a
male: female ratio of 24:1.
Results: The age of patients ranged from 4-82 years with a mean of 34.3 (+/- 18.5). Ninety six point
one (96.1) percent of the patients were males, with a male to female ratio of 24:1. Majority of the
patients only had primary school education, 56.9%, while a few had tertiary level education, 3.9%.
Eleven point eight (11.8%) percent of the patients did not have any form of education. Most of the
patients were in some form of employment, 47.1%, while 7.8% of patients had no employment. A
clear majority of these patients were married, 51%, while 47.1% were single. Thirty five point three
(35.3%) percent of these patients were alcohol consumers, while 21.6% were cigarette smokers. A
number of these patients had other co-morbidities. Only 7.8% of the patients were hypertensive while
2% had HIV infection.
Conclusion: From the foregoing, the population greatly affected by traumatic brain injury involves
the young and productive segment of the population. Specific interventions by policy makers and
clinicians, based on findings of patient demographics can help prevent some of these preventable
causes of traumatic brain injury.
Introduction
The study of the epidemiology of head trauma, and traumatic brain injury has been a noted challenge1.
The challenges have ranged from difficulties in reporting mild head trauma, especially those who do not
present to hospital, to reporting of polytrauma fatalities, where traumatic brain injury is not factored.
Patients who also die at the accident scene from brain injury may be lost to documentation. Whereas
CTscan is the main radiological diagnostic modality in traumatic brain injury, it remains beyond reach
of most third world countries2, 3. This makes diagnosis and documentation, the more difficult among
patient populations in most countries with emerging economies.
Other common radiological changes further complicate the study of the epidemiology of traumatic
brain injuries. These include ‘spat-apoplexie’, a condition characterized by delayed posttraumatic
intracerebral hemorrhage, or other evolving small intracerebral clots like epidural hematomas2,4,5. These
changes usually contribute to missed in diagnoses of traumatic brain injury related intracranial bleeds
and pathology.
Above challenges notwithstanding, the reported incidence of traumatic brain injury is estimated at 200
per 100,000 populations at risk per year1. This estimate again is based on hospital records from
admissions. This potentially omits patients who do not present to hospital and thus affects the
subsequent estimates. There has been scarcity of data and literature from our part of the world on
traumatic brain injury, especially on epidemiology. This is as opposed to most parts of the world, where
extensive studies have been done on this important topic. Fife6 studied head injury in the US, over a 4
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year period from 1977-1981. He noted the incidence to be approximately, 825 per 100,000 populations
in 1980. In a population based study in the Netherlands, Meerhoff et al7. Reported the incidence of
traumatic brain injury to be 836 per 100,000 population. Further studies in China and South Africa
described various incidences and important aspects of epidemiology of traumatic brain injury. In a
randomized population study in six urban areas of China, Wang et al8 noted an incidence of 56 per
100,000 populations. Nell9, described the epidemiology of traumatic brain injury in Johannesburg South
Africa, where he noted an incidence of 360 per 100,000 populations among the 15-24 year old age
group. In all these epidemiological studies, the incidence of traumatic brain injury tends to decline with
increasing age, but starts to rise again among the oldest in the populations.
Patients and Methods
This descriptive cross sectional study was conducted at the Kenyatta National Hospital (KNH), between
December 2010 and March 2011. This is a national referral and teaching hospital. Though being a
national referral hospital, it is the main hospital for the populous Nairobi suburbs, including the
populous Kibera slums, and Nairobi’s East lands. It largely caters for the middle class and the lower
socio-economic groups of the population who can’t afford private care. The hospital has a fully
functional neurosurgical service with an independent ward and a neurosurgical intensive treatment area,
within the ward. There are three general surgical wards, and a paediatric surgical ward where all head
trauma patients admitted within 24 hours of injury, are managed by the neurosurgical service.
All head trauma patients admitted after 24 hours of injury, are admitted in the neurosurgical ward. All
critically head injured patients (GCS less than 8), are admitted and managed from the main hospital
Intensive care unit. Once improvement is noted clinically, they are upgraded to the neurosurgical
intensive treatment area, in the neurosurgical ward. Patients admitted with head injury were clerked,
and upon confirmation of the diagnosis, were recruited in the study after signing the informed consent
to participate in the study. Relatives and guardians signed consent on behalf of those patients who could
not do so on account of clinical condition. Data on socio-demographic characteristics, pattern and
causes was collected using a questionnaire administered to patients who met the inclusion criteria.
Data collected was analyzed using statistical package for social sciences (SPSS) version 16.0. Approval
for the study was granted by Kenyatta National Hospital/ University of Nairobi Research and Ethics
Committee.
Results
The ages of the patients ranged from 4 to 82 years with a mean of 34.3 (± 18.5). Forty nine (96.1%) of
the patients were males. The majority (56.9% of the patients only had primary education while only 2
(3.9%) had tertiary education, 3.9% (n=2) (Table 1).
Occupation, Marital Status and Social Habits
Twenty four (47.1%) of the patients were employed, 7 (13.7%) were students while the rest were either
self employed or did not have any form of employment (Figure 1). Twenty six (51%) of the patients
were married, while 47.1% were single (n=24). Regarding the social habits, 18 (35.3%) of the patients
were alcohol consumers while 11 (21.6%) were cigarette smokers.
Table 1: Education levels among patients admitted with intracranial bleeds
Level of education
Primary
Secondary
Tertiary
No education
68
Frequency
29
12
2
6
Percentage
56.9%
23.5%
3.9%
11.8%
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Figure 1. Occupational Distribution
Co-morbidities
Four (7.8%) of the patients were hypertensive while one (2.0%) was HIV infected. .Three of the 4
hypertensive patients had a previous history of spontaneous intracranial bleeding.
Discussion
The epidemiology of traumatic brain injury (TBI) has been studied extensively globally. There however
exists a tremendous knowledge gap on this crucial subject in the region. In all the studies reported,
males have been noted to be generally more affected than women. Kraus et al10 noted a male to female
ratio of 2:1. The highest male to female ratios have been noted by various studies to involve mainly the
young adults, who tend to involve themselves in potentially risky activities.
Studies in the United States which involved emergency department evaluations revealed male to female
ratios of 1.5:111 and 1.7:112. Studies among South African adults revealed among the highest male to
female ratio of greater than 4:1. The noted gender difference was noted to peak among young adults9.
The findings in our study recorded among the highest male: female ratios globally of 24.5:1. This
however, may not represent the exact findings in the population, because this was a hospital based
study. The study may have excluded some patients, especially those discharged from the outpatient
department with mild head injury, thus having an impact on overall result. The population covered in
our study was mainly black and indigenous, so racial differences could not be ascertained.
While level of education has not been documented exclusively as a factor affecting the epidemiology of
traumatic brain injury, it does contribute especially when associated with low socio-economic status.
Majority of the patients studied in our series had primary level education. These were mainly low
income earners, slum dwellers with high unemployment and poverty levels. They were generally
associated with high interpersonal violence. A multicenter study from 1992 to 1994 in the US,
involving mainly emergency department evaluations, revealed racial differences in the incidence of
traumatic brain injury. Traumatic brain injury per 100,000 populations was noted highest among blacks,
582, whites 429, and 333 for other racial groups12. In these studies, findings were closely related to
socio-economic status where blacks were generally noted to be poorer. A study in South Africa’s
Johannesburg city revealed the highest race specific differences in TBI ratios. The rate of sustaining
TBI compared to whites was 3.3 in Africans, 2.7 in coloured and 1.9 among Asians9.
The findings in our study revealed 47.1% of patients had some form of employment. These were
however poor paying jobs due to the low level of education among the majority of patients studied. This
reflected the high levels of poverty, especially the slum dwellers. Though majority of patients were
married, this was not observed to contribute to the rate of TBI. In our study, 4 patients were known
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hypertensives, while one patient was HIV infected. These, clearly are not known risk factors for TBI,
but were studied as part of the general patient epidemiology. Hypertension and tachycardia have been
an observed phenomenon in the acute phase of TBI, but usually as a consequence of13. Alcohol intake,
especially excessive alcohol intake has been a known factor in TBI causation. Thirty five point five
percent of our patient series were known alcohol consumers. In a study of alcohol use at the time of
TBI, Chen et al, noted that the risk of TBI related to alcohol use significantly affects outcome and need
not be overlooked14.
Conclusion
The study of epidemiology of traumatic brain injury forms a major basis for intervention in the control
and management of TBI patients. Whereas not many studies have not been noted from the region, this
will be a major entry point for subsequent studies. These will include population based, and multicenter
based studies to give a true reflection of the disease burden.
References
1. John B Jr, W Allen H. The epidemiology of Traumatic Brain Injury: A Review. Epilepsia.
2003; 10: 2-10.
2. Thompson DO, Hurtado TR, Liao MM et al. Validation of the Simplified Motor Score in the
Out of Hospital Setting for the Prediction of Outcomes After Traumatic Brain Injury. Ann
Emerg Med. 2011(11); 58(5): 417-25.
3. Lee B, Newberg A. Neuroimaging in traumatic brain imaging. NeuroRx. 2005; 2(2): 372-83.
4. Alvarez-Sabin J, Turon A, Lozano-Sanchez M et al. Delayed post traumatic hemorrhage. ‘Spatapoplexie’ Stroke. 1995; 26(9): 1531-5.
5. Topal NB, Hakyemez B, Erodan C et al. MR imaging in the detection of diffuse axonal injury
with mild traumatic brain injury. Neurol Res. 2008; 30(9): 974-8.
6. Fife D. Head injury with and without hospital admission: Comparison of incidence and shortterm disability. Am J Public Health 1987; 77: 810-12.
7. Meerhoff SR, de Kruijk JR, Rutten J et al. Incidence of traumatic head or brain injuries in
catchment area of Academic Hospital Maastricht in 1997. Ned Tijdschr Geneeskd 2000;
144:1915-8.
8. Wang CC, Schoenberg BS, Li SC et al. Brain injury due to head trauma in urban areas of the
Peoples Republic of China. Arch Neurol 1986; 43:570-2.
9. Nell V, Brown DS. Epidemiology of traumatic brain injury in Johannesburg II: Morbidity,
mortality and etiology. Soc Sci Med 1991; 33: 289-96.
10. Kraus JF, Black MA, Hessol N et al. The incidence of acute brain injury and serious
impairment in a defined population. Am J Epidemiol. 1984; 119(2): 186-201.
11. Guerrero JL, Thurman DJ, Sniezek JE. Emergency department visits associated with traumatic
brain injury: United States, 1995- 1996. Brain Inj 2000; 14:181-6.
12. Jager TE, Weiss HB, Cohen JH et al. Traumatic brain injuries evaluated in US emergency
departments, 1992- 1994. Acad Emerg Med 2000; 7:134-40.
13. Tadahiko S. Hypertension and Head injury. Current Hypertension Reports 2005; 7: 450-453.
14. Chen CM, Yi Hy, Yoon YH et al. Alcohol use at time of injury and survival, following TBI:
Results from the National Trauma Data Bank. J Stud Alcohol Drugs. 2012; 73(4): 531-41.
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Reasons Why Trauma Patients Request for Discharge against Medical Advice in Wesley Guild
Hospital Ilesha.
E.A. Orimolade1, O.O. Adegbehingbe1,L.M. Oginni1,J.E. Asuquo2, O. Esan1
1
Department of Orthopaedic Surgery and Traumatology Obafemi Awolowo University, Ile-Ife
2
Department of Orthopaedic Surgery and Traumatology Obafemi Awolowo University Teaching
Hospitals’ Complex (OAUTHC) Ile- Ife.
Correspondence to: Dr Orimolade E.A, Email: ayodeleorimolade@yahoo.com
Background:The aim of this study was to find out the reasons why trauma victims with Orthopaedic
injuries take their discharge against medical advice.
Methods: This was a prospective study conducted on Trauma victims presenting to the Wesley Guild
Hospital Ilesha who took their discharge against medical advice (DAMA) over a 2 year period. A
questionnaire was designed that was used to retrieve information on the patients biodata, their
injuries and the reasons why they DAMA.
Results: A total of 49 patients were interviewed over this period. The mean age of the patients was
36.7 years. Students (22.4%), traders (20.4%) and artisans (24.5%) were commonly involved in this
practice. Eighteen (36.7%) of the respondents claimed to have taken DAMA due to hospital cost, 18
(36.7%) also DAMA because of their believe in Traditional Bone Setters. Eleven patients (22.4%)
simply said they want treatment near home while one patient each gave the fear of amputation and
hospital protocol as their reasons for DAMA.
Conclusion: Cost of treatment and believe in traditional bone setters were the 2 main reasons why
most patients with fracture DAMA. Measures to reduce the cost of treatment and patient’s education
about the dangers with unorthodox treatment of fractures and dislocations should help to reduce this
behaviour.
Introduction
Discharge against medical advice (DAMA) describes a situation in which a patient chooses to leave the
hospital before the treating physician recommends discharge1. Research shows that against medical
advice discharges represent as many as 2 percent of all hospital discharges1,2.Those patients represent
an at-risk group for both morbidity and mortality3-6.A patient is said to discharge against medical advice
when the patient has been well informed of the diagnosis, options of treatments and the risks, the
patient should be mentally competent to take his or her decision without any coercion.
There are many reasons why a patient may want to discharge against medical advice. This may be due
to financial problems especially in countries where patients pay for medical services on their own
without medical insurance coverage. Some patients on treatment for chronic illnesses without hope of a
cure or who have not seen remarkable changes in their condition may wantDAMA. Patients on
medications which have serious side effects or severe reactions may end with DAMA6-11. The reasons
for DAMA among patients in different subspecialties show similarities and differences. Information on
the reasons why patients go for DAMA will help in working out the strategies to reduce this undesirable
action.The aim of this study is to find out the reasons why trauma victims with Orthopaedic injuries
take their discharge against medical advicewith a view to minimizing this deleterious action.
Patients and Methods
This was a prospective study conducted on trauma victims presenting to the wesley Guild hospital
Ilesha who took their discharge against medical advice over a 2 year period (July 2004-June
2006).Patients presenting with orthopaedic injuries were managed in line with the Advanced Trauma
Life support protocol. After the patients were well resuscitated, investigated and in stable clinical
conditions, they were informed about their diagnosis, our treatment plans and other options of treatment
and the possible complications. Those patients who decided to DAMA during the course of treatment
despite our counsel, were recruited into this study by filling questionnaire on them. A questionnaire was
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designed that was used to retrieve information on the patients’ biodata, their injuries and the reasons
why they took their discharge against medical advice. Data analysis was done using SPSS version 19.
Results
Forty nine patients were interviewed over this period; the mean age of the patients was 36.7 years.
Thirty three were males while 16 were females with a M: F 2:1. Majority of the patients, 83.7% were
Yorubas. Twenty six patients (53.1%) took DAMA within 24 hours of admission. Up to 77.6% (37) of
the patients who discharged against medical advice did so within 72 hours. While the remaining (11)
22.4% discharged themselves after 72 hours. The patients often waited to be well rescuscitated before
taking AMA discharges.
Thirty seven of the 49 patients had their educational level recorded 17 had primary education, 15 had
secondary school education while 5 patients had tertiary education. In 12 patients the level of education
were not recorded. The injuries were sustained most often from motor vehicular accidents, Motor cycle
accidents and pedestrians hit by motor vehicles or motor bikes as shown in Figure 1.
Table 1. Occupation of Patients Discharged Against Medical Advice (DAMA)
Occupation
Artisans
Students
Traders
Civil Servant
Others
Total
72
Frequency (%)
12 (24.5)
11 (22.4%)
10 (20.4)
6 (12.2)
6 (12.2)
49 (100)
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Table 2. Distribution of Fractures and Dislocations
Parts involved in injury
Femur
Tibia
Humerus
Radius and Ulnar
Complex Hand injuries
Joint Dislocations
Frequency
14
19
5
6 (2Galleazi, 1Monteggia)
2
2 Hips, 2 Elbows
Table 3.Reasons Given for Requesting DAMA.
Reason
Hospital cost
Believes TBS treatment is
Orthodox
Wants treatment near home
Hospital protocol
Fear of amputation
TOTAL
better
than
Frequency (%)
18 (36.7)
18 (36.7)
11 (22.4)
1(2.04)
1(2.04)
49 (100)
Figure 2. Place Where DAMA Patients Wanted to go after Leaving Hospital.
Twenty three patients had closed fracture, 24 had open fracture while 2 presented with elbow
dislocation. Among patients with open fractures 54.2% of them had Gustillo Anderson type 3 injuries.
Most of the fractures were in the lower limbs involving the femur and the tibia. Two patients with
fractures had associated Hip dislocations which were reduced prior to taking discharge against medical
advice. Fifteen of the patients (30.6%) had associated head injury.The reasons given for taking DAMA
is as presented in Table 3.We were interested in the post discharge plan of the patients or relatives and
they were asked about where the discharged patients will be treated. The responses were captured in
Figure 2.
Discussion
Discharge against medical advice is seen in our practice and involves people of different ages and strata
in the society. The average age of 36.7 years among people that DAMA is in keeping with the peak age
that are most often involved in trauma. The active and productive age group where most often involved
in trauma and this may explain the predominance of students,artisans,traders and civil servants among
the patients that DAMA. Also males were found to be twice more involved in this act than females.
This may be due to the fact that males are more involved in trauma12. it may also mean that female
patient are more cooperative and more concern about their health than the male counterpart. Some
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studies have reported Younger age, male sex, poor social support, lack of health care coverage,
psychiatric illness, drug or alcohol abuse to be frequently associated with discharge Against Medical
Advice6,7,9-11,13-16.
Motor vehicular accidents and motorbicycle accidents were the cause of most injuries. Contrary to the
believe that most patients with open fractures recieve treatment in the hospital because these group of
patients are most likely to suffer infective complications of fracture in addition to other complications.
We however, observe that patients with open fractures were equally involved in DAMA; as nearly half
of the patients with fracture that DAMA had open fractures majority of which were severe grades
(Gustillo-Anderson type III).Cost of treatment was the reason given for discharge against medical
advice in 36.7% of the patients. In our practice there is no provision for free treatment of trauma
victims. Medical insurance is not available to most injured patients. Treatments are paid for by the
patients and their relatives. The difficulty of sourcing for unplanned expenses or inability to secure
funds for treatment is the reason why some patients discharge themselves from the hospital prematurely
against the wish of the Doctor. Provision of medical insurance to care for trauma victims will reduce
DAMA among this group of patients.
Another 36.7% of the patients that DAMA claimed they prefer treatment with the Traditional Bone
Setters. While the fear of amputation was advanced to be the reason for DAMA in one patient who also
discharged to recieve treatment with the TBS. The reasons why some patients opt for treatment with the
TBS is multifactorial, payment for treatment is easier as they pay in bits over time, some due to fear of
operation, some believe their treatment is faster, some believe their treatment is more wholistic caring
for both the physical and spiritual aspect of their treatment.In our environment, traditional bone setters
after destroying the limbs of injured patients with obvious gangrene send them to the hospital to have
amputation, when such patients eventually are amputated by the Orthopaedic surgeon. Such patients are
often used to discourage patients with fractures from seeking orthodox treatment because only
Orthodox Doctors does amputation. Hence the fear of amputation is used by TBS to recruit patients to
their own practice.
Adequate education of the populace on the advantages of Orthodox treatment and the dangers inherent
in receiving treatment with TBS while making provision for medical insurance coverage for all trauma
victims will reduce the number of patients taking discharge against medical advice.Patients who want
treatment near home constituted 22.4% of the patients taking DAMA. Some patients have obligations
which they have to fulfil. Receiving treatment in a distant place may make this impossible. Also in our
setting there is still strong family support system for patients, Patient relatives help with funding,
feeding and caring for the family of the injured to some extent. This support is always better when
patient is being treated near his place of abode or home. If treatment is made easier for victims, fewer
patients will press for DAMA due to distance away from home.
Only one patient gave hospital protocol as the reason for discharge. Though this constituted a small
proportion of patient that DAMA, simplifying hospital protocol and making it patient friendly will
make it easier for patients to access treatment and reduce the practice of DAMA.
Where DAMA becomes inevitable, the Doctor should discuss the likely harms of premature discharge,
the benefits of inpatient treatment, and all possible options of treatment with the patient. Where possible
a follow up plan like collecting the patient’s telephone number may help reduce complications which
often follow this practice. This is particularly important as signing of DAMA form does not completely
protect the Doctor against litigation.17
Conclusion
Cost of treatment and believe in traditional bone setters were the 2 main reasons why most patients with
fracture take their discharge against medical advice.Measures to reduce the cost of treatment so as to
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make orthodox treatment affordable as well as patients’ education about the dangers with unorthodox
treatment of fractures and dislocations should help to reduce this behaviour.
References
1. Alfandre DJ. ‘’I’ m Going Home’’ : Discharges Against Medical Advice. Mayo Clin Proc.
2009; 84(3): 255–260.
2. Taqueti VR. Leaving against medical advice. N Engl J Med. 2007; 357(3):213-215.
3. Carrese JA. Refusal of care: patients' well-being and physicians' ethical obligations: “but
doctor, I want to go home”. JAMA 2006; 296(6):691-695.
4. Berger JT Discharge Against Medical Advice: Ethical Considerations and Professional
Obligations Journal of Hospital Medicine. 2008;3(5):403-408.
5. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital
against medical advice? CMAJ 2003; 168(4):417-420.
6. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who
leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol.
2007; 119(4):924-929.
7. Fadare JO, Jemilohun AC. Discharge against medical advice: Ethico-Legal implications from
an African Perspective. S. Afr J BL.2012;5(2):98-101.
8. Moy E, Bartman BA. Race and hospital discharge against medical advice. J Natl Med Assoc.
1996; 88(10):658-660.
9. Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA):
factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse 2004; 30(2):489-493.
10. Nwokediuko SC,Arodiwe EB, DischargeAgainstMedicalAdvice In Enugu, South Eastern
Nigeria – Some Ethical and Legal Aspects. Journal of College of Medicine 2008; 13(1):34-38.
11. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial
perspectives. Int J Clin Pract. 2002; 56(5):325-327.
12. Elias A, Tezera C. Orthopaedic and Major Limb Trauma at the Tikur Anbessa University
Hospital, Addis Ababa Ethiopia. East and Central African Journal of Surgery 2005; 10 (2):4350.
13. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity
predictors? J Gen Intern Med. 2006; 21(9):955-960.
14. Saitz R. Discharges against medical advice: time to address the causes. CMAJ
2002;167(6):647-6
15. Long JP, Marin A. Profile of patients signing against medical advice. J Fam Pract. 1982;
15(3):551, 556.
16. Wylie CM, Michelson RB. Age contrasts in self-discharge from general hospitals. Hosp
Formul. 1980; 15(4):273, 276-277.
17. Devitt P, et alDoes Identifying a Discharge as Against Medical Advice Confer Legal
Protection,J Family Practice, 2000; 49(3):224.
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Results of Operative Fixation of Fractures of the Ankle at a Tertiary Hospital in a Developing
Country.
O.J. Ogundele1, A.O. Ifesanya1, O.A. Oyewole1, O.O.Adegbehingbe2
1
Department of orthopaedics and Trauma, University College Hospital, PMB 5116, Ibadan, Oyo state,
Nigeria.
2
Department of orthopaedics and traumatology, Obafemi Awolowo University, PMB 5538, Ile-Ife,
Osun state, Nigeria.
Correspondence to: O.J. Ogundele, Email: ogunjosh@yahoo.com, ogunjosh128@gmail.com.
Background: Operative fixation of ankle fractures is becoming popular in developing countries. The
concern however is the outcome of care. The objective was to evaluate the results of open reduction
and internal fixation (ORIF) of fractures of the ankle in our hospital.
Methods: All cases ORIF of fractures of the ankle at the University College Hospital (UCH), Ibadan
between March 2010 and December 2012 were recruited into the study. The indications for surgery,
techniques of fixation, time interval between injury and presentation as well as outcome measures
like time to union, complications and functional outcomes were evaluated.
Results: Seventy patients who had ORIF of ankle fractures were studied. Twenty-one (30%) were
open fractures while forty-nine (70%) were closed. Sixty (85.7%) patients presented within the first
week of injury, 4 (5.7%) after 4 weeks, 4 (5.7%) after 6 weeks and 2 (2.9%) after 52 weeks. Time to
union averaged 12.6±4.1weeks. Complications included wound infection 14.3%, wound dehiscence
with exposed implants 2.9%, malunion 8.6% and non union 5.7%. Good to excellent functional
outcomes were achieved in 77.1% of the patients.
Conclusion: ORIF is a viable option in the treatment of ankle fractures.
Introduction
Ankle fractures are some of the most common injuries managed by orthopaedic surgeons. Common
causes of ankle fractures include trauma which ranges from motor vehicular crashes, motorcycle and
pedestrian traffic injuries, sports injuries to falls and assaults. Many ankle fractures are simple and their
management is straight forward leading to successful outcomes. Some fractures, however, are unstable,
thus posing significant problems and questions about how best to manage them to achieve an optimal
outcome1. Anatomical reduction and satisfactory fixation usually leads to a rapid return of function2.
Several studies have also indicated that internal fixation of displaced fractures of the ankle gives better
results compared to non-operative treatment3,4,5. Fractures of the ankle are heterogeneous and hence
the decision to operate is usually individualized4,5. We have employed the AO methods of fracture
fixation in our centre in the last 18 years.
The objectives of this study were to evaluate the results of operative treatment of ankle fractures and the
functional outcomes.
Patients and Methods
A prospective study of all patients with ankle fractures who had open reduction and internal fixation of
fractures of the ankle in our hospital between March 2010 and December 2012 was carried out. A
questionnaire was completed for each patient presenting with ankle fracture to the emergency and the
surgical outpatient departments. Patients presenting acutely were initially assessed and resuscitated
based on the ATLS® protocol. Patients with Gustillo and Anderson type IIIb fractures were excluded
from the study. Other patients with open fractures had initial wound debridement before operative
fixation. Data collated included age, sex, type and patterns of fractures, time interval between injury
and presentation in the hospital, indications for surgery, techniques of fixation, outcome measures like
time to union, functional outcomes and complications. Functional outcome measurement was
determined using the Olerud and Molander scoring system.6
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Results
Seventy patients who had ORIF for ankle fractures were recruited. Twenty-one (30%) were open
fractures while forty-nine (70%) were closed fractures. The ankle fractures consisted of 9 (12.9%)
Weber type A, 25 (35.7%) Weber type B and 36 (51.4%) Weber type C fractures. The mean age of
presentation is 44.5± 2.8 years (peak age 40-49 years, range 17-80 years) with a male: female ratio of
1.3:1. This is shown in Figure 1.
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Table 1.Time Interval before Presentation, Types of Ankle Fractures, Complications and Functional
Outcomes.
Variable
Time interval
1 week
4 weeks
6 weeks
52 weeks
Total
Complications
Wound infection
Type of
fracture
0-30
31-60
61-90
Closed
I
II
IIIa
Closed
Closed
Closed
0(0.0)
2(50.0)
0(0.0)
0(0.0)
2(50.0)
0(0.0)
0(0.0)
4
4 (33.3)
0 (0.0)
2 (16.7)
0 (0.0)
2 (16.7)
2 (16.7)
2 (16.7)
12
8 (66.7)
4 (33.3)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
12
91-100
27 (64.3)
4 (9.5)
5 (11.9)
4 (9.5)
0 (0.0)
2 (4.8)
0 (0.0)
42
Closed
I
II
IIIa
2 (50.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
2 (25.0)
0 (0.0)
0 (0.0)
0 (0.0)
2 (25.0)
0 (0.0)
2 (50.0)
0 (0.0)
0 (0.0)
2 (33.3)
Wound dehiscence
0 (0.0)
0 (0.0)
0 (0.0)
2 (33.3)
Malunion
0 (0.0)
0 (0.0)
4 (50.0)
2 (33.3)
Non union
0 (0.0)
2 (100.0)
0 (0.0)
0 (0.0)
Total
4
2
8
6
0-30= Poor outcome, 31-60=Fair outcome, 61-90=Good outcome, 91-100=Excellent outcome.
Total
39
10
7
4
4
4
2
70
2
2
2
4
2
6
2
20
Figure 3. Postoperative Radiograph of a Patient Who Had ORIF for Ankle Fractures
Twenty patients (28.6%) had been involved in motor vehicular crashes. Motorcycle injuries accounted
for 16 (22.9%) and falls for 22 (31.4%) of the cases. There were 8 (11.4%) pedestrian road traffic
injuries and 2 (2.9%) patients each were involved in assaults and bull fights respectively. The average
follow-up period was 18 ± 1.3 weeks. Methods of open reduction and internal fixation of ankle
fractures is shown in figure 2 and a postoperative x-ray in figure 3. Time to union averaged
12.6±4.1weeks. (Range 6-20 weeks) Complication rate was 31.4%; wound infection in 14.3% (wound
infection rate in closed fractures is 2.9% and 11.4% in open fractures) wound dehiscence with exposed
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implants in 2.9%, mal-union with unstable ankle joint in 8.6% and non union in 5.7%. The functional
outcomes using the Olerud and Molander6 scoring of symptoms after ankle fracture is shown in Table 1.
Discussion
Open reduction and internal fixation is the foremost treatment employed for displaced ankle fractures5,7.
Results are generally favourable with the majority of patients having a good functional outcome3,7.
Proponents of open reduction and internal fixation suggest that restoration of the normal anatomy will
reduce the risk of subsequent osteoarthritis due to incongruency of the joint. Michelson et al8, however,
have shown by using computerized tomography that the apparent displacement and external rotation of
the distal fragments are actually due to internal rotation of the proximal part of the fibula.
Operative treatment for ankle fractures restores sufficient stability to allow full mobility at the ankle
joint. Options of treatment include plate and screws or malleolar screws for the lateral malleolar
fractures and tension band wiring or malleolar screws for the medial malleolar fractures depending on
fracture configuration or bone stock. In the older patient, there are concerns about poor fixation, poor
bone quality and impaired wound healing which makes some authors believe that open reduction and
internal fixation carries an unacceptable risk especially in women5,9. There is however, paucity of data
on management of ankle fractures in our environment. Makwana et al3, 9 compared 22 cases of ORIF
and 21 cases of conservatively treated patients with ankle fractures and found that ORIF treatment
yielded a significantly higher functional outcome score and a significantly better range of movement of
the ankle.
Ponzer et al10 demonstrated satisfactory outcomes in 76%-83% of operatively treated type- B malleolar
injuries. Although we did not compare the outcome of patients treated conservatively versus
operatively, we were able to achieve 77.1% of good or excellent outcomes in our patients. This is
presented in table 1. Miller11 reported infections in 2.2% of 1841 patients after foot and ankle surgery
while Butterworth et al12 in a similar study found 3.1%. Our wound infection rate of 14.3% was rather
high. This may be attributed to the inclusion of open fractures in our series which was responsible for a
wound infection rate of 11.4%. Antibiotic coverage is usually based on the severity of the soft tissue
injury and the grade of the open fracture although this does not completely obviate the risk of infectious
complications13. The risk of infection after internal fixation of open or closed fractures can be decreased
by the use of antimicrobial prophylaxis / therapy and proper surgical technique that includes proper soft
tissue handling during placement of the implant14. Infection following foot and ankle surgery or trauma
can range from commonly occurring superficial cellulitis to less common deep soft tissue or bone
infections that can have disastrous consequences.
Infection is the most important factor in the development of non-union, loss of function and other
complications after foot and ankle trauma and its prevention is essential to obtaining bony union and
soft tissue coverage which ensures a functional plantigrade foot15. Patients who had wound infection in
this study had more frequent wound dressing until healing while those with exposed implants were
managed in-conjunction with plastic surgeons until wounds were healed and subsequently discharged
from the hospital. Those with malunion and unstable ankle joints had their hardwares removed and
arthrodesis of the ankle joint while those with non-union either had a repeat operative fixation with
bone grafting or arthrodesis of the ankle joints.
Conclusion
Open reduction and internal fixation is a viable option in the treatment of ankle fractures in this
environment in view of the high success rates. Early presentation, appropriate patient selection and
good surgical techniques are required to achieve adequate post-operative functional outcome in these
patients.
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References
1. Anderson S, Li X, Franklin P, Wixted J. Ankle fractures in the elderly: Initial and Long-term
outcomes. Foot Ankle Int 2008; 29(12): 1184-88.
2. Burwell HN, Charnley AD. The treatment of displaced fractures at the ankle by rigid internal
fixation and early joint movement. J Bone Joint Surg Br 1965; 47-B: 634-60.
3. Makwana N, Bhowal B, Harper W, Hui A. Conservative versus operative treatment for
displaced ankle fractures in patients over 55 years of age. J Bone Joint Surg Br 2001; 83: 52529.
4. Michelson J. Fractures about the ankle. J Bone Joint Surg Am 1995; 77: 142-52.
5. Beauchamp CG, Clay NR, Thexton PW. Displaced ankle fractures in patients 50 years of age. J
Bone Joint Surg Br 1983; 65: 329-32.
6. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch
Orthop Trauma Surg 1984; 103: 190-94.
7. Egol K, Tejwani C, Walsh M, Capla E, Koval K. Predictors of short-term functional outcome
following ankle fractures surgery. J Bone Joint Surg Am 2006; 88: 974-79.
8. Michelson J, Magid D, Ney D, Fishman E. Examination of the pathologic anatomy of ankle
fractures. J Trauma 1992; 32:65-70.
9. Ahmad Hafiz Z, Nazri M, Azril M, Kassim N, Nordin N etal. Ankle fractures: The operative
outcome. Malaysian orthopaedic journal 2011; 5(1): 40-43.
10. Ponzer S, Nsell H, Bergman B, Trnkvist H. Functional Outcome and Quality of Life in Patients
with Type B Ankle Fractures: A Two-Year Follow-up Study. J OrthopTrauma 1999; 13(5):
363-68.
11. Miller W. Postoperative wound Infection in Foot and Ankle Surgery. Foot Ankle 1983; 4: 10224.
12. Butterworth P, Gilheany F, Tinley P. Postoperative infection rates in foot and ankle surgery: a
clinical audit of Australian podiatric surgeons, January to December 2007. Australian Health
Review 2010; 34: 180-85.
13. Flynn J, Rodriguez-del Rio F, Piza P. Closed Ankle Fractures in the Diabetic Patient. Foot
Ankle Int 2000; 21: 311-19.
14. Worlock P, Slack R, Harvey L, Mawhinney R. The prevention of infection in open fractures:
An experimental study of the effect of fracture stability. Injury 1994; 25: 31-38.
15. Donley B, Philbin T, Tomford J, Sferra J. Foot and Ankle Infections after Surgery. Clin Orthop
Relat Res 2001; 391: 162-70.
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Hand Tumours in Lagos, Nigeria: A Clinicopathologic Study
B.O. Mofikoya 1 , C.C. Anunobi2, A.O. Ugburo1.
1
Burns, Plastic Surgery and Hand Rehabilitation unit, Department, College of Medicine, University of
Lagos. PMB 12003 , Lagos Nigeria.
2
Department of Anatomic and Molecular Pathology , College of Medicine University of Lagos PMB
12003, Lagos Nigeria
Correspondence to: Dr. B.O. Mofikoya, Email: bmofikoya @yahoo.com
Background: Hand tumours occur infrequently and are commonly benign, however when malignant
they could be life threatening. This study was aimed at determining the prevalence, demographics,
the clinical presentations and treatment outcome of hand tumours among patients attending the
hand service of the Lagos University Teaching Hospital.
Methods: We studied the clinical and pathological records of a 124 consecutive hand tumours that
presented at hand clinic of the Lagos University Teaching Hospital(LUTH) between June 2003 and
June 2013 .
Results: A total of 124 patients were seen of which 98 had excision biopsies . The male to female sex
ratio was 1: 1.3. The mean age at presentation was 32.7 years sd ± 8.44 years. An overwhelming
majority (94.9%) had their procedures done under local/regional anaesthesia. Two patients died and
three of the tumours recurred during the follow up period. The commonest histopathological
diagnoses included ganglion cyst, giant cell tumor of the tendon sheath and pyogenic granuloma
constituting 23.8%. 15.7% and 6.7% of the cases seen respectively.
Conclusion: Hand tumours in Lagos tend to affect young adults with a slight female preponderance.
Majority of the tumours were benign. Primary hand malignancy was uncommon and mortality was
low. Nearly all (97%) of the surgically treated patients returned to their premorbid occupation.
Key words: Hand tumours, biopsy, soft tissue.
Introduction
Hand tumours are commonly encountered entities by many clinicians. Some have estimated that they
make up about 16% of all soft tissue tumours in the body and 6% of all bony tumours1,2 . Majority of
the tumours in the hand are benign .In our setting majority seek medical advice on account of aesthetic
concerns, though when large, functional considerations become significant. The initial behaviour of
many malignant lesions may be similar to that of a benign one and when missed consequences may be
fatal .All tissues that make up the hand can be involved in the neoplastic process and occasionally
diagnostic and therapeutic approach to certain lesions require unique considerations . In spite of their
frequency there are relatively few reports concerning tumours of the hand in literature particularly from
Africa. In this report we review our series of hand tumours seen in our centre highlighting the
demographics of the lesions, discussions of the pathologies seen as well as treatment outcome.
Patients and Methods
A comprehensive review of the clinical and anatomic pathology records of all patients seen at the Hand
rehabilitation clinic of the Lagos University Teaching Hospital Idi Araba, Lagos between January
2002 and December 2012 was done. All patients who presented with tumours of the hand were included
in the study. Patients basic biodata such as name, age, sex, site of lesion , duration of symptoms were
noted . All patients had baseline Full blood counts as well as Radiological evaluation of the area. A pre
operative incisional biopsy was done where required.
All patients had enbloc excision of the lesion carried out under digital, intravenous regional or general
anaesthesia as required. All specimens were evaluated by standard histopathological techniques. Few
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patients required adjuvant chemoradiation. All patients were followed up for 12 months. The results
are presented.
Results
One hundred and twenty four patients were seen at the Clinic over the study period with 50 males and
64 females (M:F, 1:1.3) . The age ranged between 5 to 80 years with a mean of 32.7 years sd ± 8.44
years. There were 66 and 58 right and left handed lesions respectively. Ninety eight patients had
surgical excision biopsy of their lesions . Ten of the cases were malignant. Eight of the patients had no
definitive histopathological diagnosis and could not afford immunohistochemical analysis for further
evaluation. Three patients had a spontaneous resolution of their lumps (Two patients with diagnoses of
dorsal wrist ganglia and one with pyogenic granuloma).
All procedures except five were carried out under digital or intravenous regional block. Three patients
(two with fibrosarcoma and one with epitheloid sarcoma) developed recurrence during the study, two of
which necessitated a below elbow amputation. Two patients died of pulmonary metastases (one
recurrent fibrosarcoma and one epitheloid sarcoma ). All patients with benign tumours returned to their
premorbid occupation .In the malignant group a patient with a diagnosis of neurofibrosarcoma who had
a radial hemi-amputation in his dominant hand had to change jobs.
Table 1. Distribution of the Histopathological Diagnoses
Histopathological diagnosis
Ganglion cyst
Giant cell tumour of tendon sheath
Pyogenic Granuloma
Sarcoma
Glomus
Neurofibroma
Lipoma
Enchondroma
Dermatofibroma
Squamous cell carcinoma
No pathological diagnosis
Not operated
Total
Number
29
19
12
8
9
3
3
3
2
2
8
26
124
Percentage
23.8
15.3
9.7
6.4
7.3
2.4
2.4
2.4
1.6
1.6
6.4
18.5
100
Discussion
The clinical importance of hand tumours is underscored by the wide varieties of pathologies that can
present in this appendage. Many series estimate that they make up about 15% of all soft tissue tumors1.
In our work tumours involving the hand make up 13.9% of all hand cases seen. The ten malignant ones
made up 8% of all the hand tumours seen.
Ganglion cysts
These represent the most frequent of all hand tumours in all reported studies3. This was further
confirmed by our study where the 29 ganglia cysts seen constituted 35% of the cases operated . They
tend to be benign, can be painful at extremes of motion and have a female preponderance4 which is
similar to our series that showed male: female ratio of 1:1.3. Of all the lesions seen in our study, four
(19.3%) were volar while the remaining were dorsal which is in keeping with other reports3. They may
be dorsal, wrist and distal metaphalangeal joint or volar (retinacular and metacarpophalangeal joint).
Though their exact aetiology is unknown , numerous theories have been put forward. At present most
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workers believe they represent cysts from the modified synovial or mesenchymal cells at the synovial –
capsular interface in response to repetitive minor regional trauma3.
The common dorsal wrist ganglion has been shown to have an attachment to the scapholunate ligament
in nearly all cases5. Microscopically the lesion usually consists of single or multiloculated cysts with
their wall made of sheets of collagen fibres and completely devoid of synovial or epithelial lining, the
fluid contained is clear jelly like and contains high levels of mucopolysaccharides6. Though there are
continuing reports of non operative methods of treating the Ganglion in the hand, many of these
experiences have been difficult to reproduce and recurrence rates have remained disappointingly high7.
Enbloc excision in a bloodless field with meticulous dissection of the pedicle along with a cuff of dorsal
wrist capsule is currently recommended by most workers7,8 . In our series all operated patients were
females. Three patients who opted for non operative treatment (aspiration and sclerosant injection) had
an unsatisfactory outcome.
Giant cell tumour of the tendon sheath
This was the second commonest tumour seen in our series and similar to what has been reported by
other workers 9,10. Its other synonyms are pigmented villonodular tenosynovitis, fibrous histiocytoma of
the synovium, tenosynovial giant cell tumour, localized nodular synovitis, benign synovioma and
fibrous xanthoma of the synovium. The recurrence rates have been shown to be as high as 45% in some
series 11,12. In our series all tumours occurred around the fingers(figure1). The tumour is typically
yellowish, well circumscribed, lobulated exophytic masses attached to the tendon sheath(figure 2).
Some workers have classified it based on the degree of encapsulation, extent of growth (palmar, dorsal
or circumferential) as well as the involvement of neurovascular structures13. Histologically, the lesion is
said to be characterized by synovial cell hyperplasia , multinucleated giant cells , large amounts of
histiocytes , haemosiderin laden macrophages as well as numerous collagen strands (figure3). This
peculiar lesion has been classified as intra articular localized, intra articular diffused type, extra articular
diffuse and the rare malignant variety14. Though bony compression may be noted no frank erosion is
usually observed.
Histological diagnosis of giant cell tumour is rarely difficult but the evaluation of certain atypical
features can be problematic. The presence of mitotic features occasionally leads to a mistaken diagnosis
of a malignant lesion. Although it may indicate an actively growing lesion that is likely to recur, but
there is no evidence to suggest that such lesions metastasise15. The diagnosis is usually suspected
clinically, Ultrasound usually demonstrates a solid homogenous hypoechoic mass and can provide
information about surrounding structures16. Magnetic resonance imaging has been shown to be the most
useful preoperative investigative tool as it depicts both the internal architecture of the tumour, its
vascularity, tumour extension s as well as location of digital vessels in circumferential lesions17. We
have not found these investigations cost effective for most patients in our practice. Standard complete
surgical excision was done in all our patients. We do not administer post operative radiotherapy as
reported by some workers18. All our patients were followed up for a period of 3 to 5 years with no
recurrence in eighteen cases.
Pyogenic Granuloma
This was the third commonest tumour in this study accounting for 9.7%. The most common areas of
involvement by this tumour are the head and neck, followed by the extremities. Since bleeding is a very
common feature, the patient generally covers it with an adhesive. Therefore, some authors have called
this “the band-aid sign ‘’19 .This is also known as lobular capillary haemangioma . The basic lesion is a
lobular haemangioma set in a fibromyxoid matrix. Each lobule of the haemangioma is made up of a
larger vessel with muscular wall and surrounded by smaller capillaries. Pyogenic granuloma is a
misnomer, as it is neither infectious nor granulomatous in origin. This common tumour has no exact
aetiology but commonly associated with a recent history of trauma and infection. It is said to arise due
to an imbalance between positive and negative angiogenic stimuli following injury20. Others believe it
represents an abnormal reaction to a foreign body. It bleeds easily following minor trauma. There is a
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pregnancy associated variety seen in 2% of women occurring commonly in the oral cavity21. Though
some22 have recommended curettage and silver nitrate application to the base we have preferred a wide
excision and had one recurrence among our 12 cases. Other treatment modalities described, include
curettage, electrodessication, pulse dye laser, cryotherapy, and topical imiquimod 5% cream23
Sarcoma
Soft tissue sarcoma involving the hand are uncommon and make up 8% of the hand tumours
surgically treated 24.The eight patients seen in this study included 5 with fibrosarcoma ,one each with
epitheloid sarcoma , glomangiosarcoma and a neurofibrosarcoma .The absence of sarcoma s of bony
origin from our series may reflect the general rarity of primary bone sarcomas in the hand . There is a
wide range of subtypes with different disease pattern, recurrence, metastasis and response to treatment.
They commonly present as painless masses.
Figure 1. A typical Giant cell tumour of the
tendon sheath.
Figure 2. Intraoperative view of a yellowish
lobulated lesion.
Figure3. Giant cell tumour cell tendon Sheath
(H & E, X20). A circumscribed moderately
cellular tumour composed of sheets of round,
polygonal and multinucleated giant cells
In our series three occurred in the web spaces and the rest arose from the hand. No patient with bony
erosion was seen and all had an incisional biopsy. Only four patients had definitive surgery (two had
wide excision and skin grafting, one fifth ray amputation for epitheliod sarcoma and a radial hemiamputation for sarcomatous transformation of a neurofibroma).The predominance of fibrosarcoma in
this study is at variance with some workers24.25 who reported epitheloid sarcoma as the commonest
soft tissue sarcoma occurring in the hand with others including synovial sarcoma rhabdomyoarcoma,
malignant fibrous histocytoma, and leiomyosarcoma . While literature has proposed that deep
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location, high grade and a diameter of >5cm are associated with distant metastasis, studies on
sarcomas of the hand have revealed a higher prevalence of local recurrence and metastatic disease
compared to other sites26. Only four of our eight patients consented to any form of ablative surgery.
While studies have shown that margin negative resections combined with radiation therapy reduces
the recurrence rate of high grade soft tissue sarcomas of the hand resulting in comparable survival
rates to amputations27-29 . Our 25% mortality rate at one year in eight patients is inadequate to draw
valid conclusions.
Glomus tumours
Glomus tumours are rare benign tumours that occur in the hand . They make up 1 to 5% of all hand
tumours . It arises from a glomus body which is from a neuromyoarterial apparatus described by
Masson in 192430. The tumour is yellowish in the African and consists of afferent arteriole and
vascular channels lined by normal endothelial cells surrounded by solid proliferation of round and
cuboidal cells. It accounted for 9.2% of all surgically treated patients in our series. One lesion was
periungal, the rest occurred in various parts of the digits .Clinically distinguished by the Love and
Hildreth‘s tests 31,32. They were all completely excised under digital block, with complete resolution
of the symptoms and no recurrence at two years.
Neurofibroma
Neurofibromas along with schwannomas make up the commonest hand tumours of neural origin
seen. Neurofibromas may assume one of three growth patterns: localized, diffuse, or plexiform.
Diffuse and plexiform forms have a close association with neurofibromatosis 1
(NF 1). The
localized variety is seen most commonly as superficial solitary tumour. All lesions seen were solitary
lesions. Histologically tend to show a more disordered cellular pathology but in most characteristic
form the neurofibroma contains interlacing bundles of elongated cells with wavy dark staining nuclei.
There may be a solitary variety of nerve sheath myxoma called paccinian neurofibroma. While
complete excision in our patients was curative, neurofibromas associated with Von Recklinghausen’s
disease have a distinct higher likelihood of malignancy.The remaining lesions such as
dermatofibroma, enchondroma and lipoma each made up less than 5 % of all the tumours seen.
This study demonstrated a wide variety of lesions presenting as tumours of the hand. Hand tumours in
Lagos tend to affect young adults with a slight female preponderance. Majority of the tumours were
benign and nearly all patients returned to work after treatment.
References
1. Garcia J, Bianchi S. Diagnostic imaging of tumors of the hand and wrist. Eur Radiol 2001; 11:
1470–1482.
2. Kransdorf MJ, Meis JM. From the archives of the AFIP: extraskeletal osseous and
cartilaginous tumors of the extremities. Radiographics 1993; 13: 853–884.
3. Angelides AC. Ganglions of the hand and wrist. In: Green DP, ed. Operative hand surgery. 3rd
ed. New York: Churchill Livingstone, 1993:2171-2183.
4. Barnes WE, Larson RD, Posch JL. Review of ganglia of the hand and wrist with analysis of
surgical treatment. Plast Reconstr Surg 1964; 34: 570-578.
5. Angelides AC, Wallace PF. The dorsal ganglion of the wrist:its pathogenesis, gross and
microscopic anatomy, and surgical treatment. J Hand Surg 1976;1:228-235.
6. Soren A. Pathogenesis and treatment of ganglion. Clin Orthop 1966;48:173-179.
7. Wright TW, Cooney WP, Ilstrup DM. Anterior wrist ganglion.J Hand Surg [Am] 1994;
19A:954-958.
8. Clay NR, Clement DA. The treatment of dorsal wrist ganglia by radical excision. J Hand Surg
[Br] 1988;13B: 187-191.
9. Monaghan H, Salter DM, Al-Nafussi A. Giant cell tumor of tendon sheath (localised nodular
tenosynovitis): clinicopathological features of 71 cases. J Clin Path 2001; 54:404-7.
85
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Journal of Surgery. November/December 2013 Vol. 18 (3
ISSN 2073
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10. Martin RC 2nd, Osborne DL, Edwards MJ, Wrightson W, McMasters KM. Giant cell tumor
of tendon sheath, tenosynovial giant cell tumor, and pigmented villonodular synovitis:
defining the presentation, surgical therapy and recurrence. Oncol Rep 2000; 7:413-419.
11. Reilly KE, Stern PJ, Dale JA. Recurrent giant cell tumors of the tendon sheath. J Hand Surg
[Am] 1999; 24:1298-302.
12. Uriburu IJ, Levy VD. Intraosseous growth of giant cell tumors of the tendon sheath
(localized nodular tenosynovitis) of the digits: report of 15 cases. J Hand Surg [Am] 1998;
23:732-736.
13. Monahagm H, Salter DM , Al-Nafussi A. Giant cell tumour of tendon sheath (localized
nodular tenosynovitis): clinicopathological features of 71 cases J Clin Pathol 2001;54:404–
407.
14. Lucas DR. Tenosynovial Giant Cell Tumor Case Report and Review Lab Med. 2012;
136:901–906;
15. Enzinger and Weiss’s Soft Tissue Tumours. Eds Sharon W. Weiss and John R. Goldlum. 4th
Edition, 2001. Mosby. 1038-1047
16. Middleton WD , Patel V, Teefey SA, Boyer M. Giant Cell Tumors of the Tendon Sheath:
Analysis of Sonographic. American Journal of Roentgenology. 2004;183: 337-339
17. Beuckeleer L, De Schepper A , Belder F, Von Goethem J, et al. Magnetic resonance imaging
of Localized Giant cell tumor of the tendon sheath(MRI of localized GCTTS). European
Radiology (7). 1997:198-201
18. Prakash P. Kotwal, Vikas Gupta, Rajesh Malhotra. Giant-cell tumour of the tendon sheath Is
radiotherapy indicated to prevent recurrence ? J Bone Joint Surg [Br] 2000; 82-B: 571-3.
19. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granu-loma (lobular capillary hemangioma): A
clinico-pathological study of 178 cases. Pediatr Dermatol. 1991; 8:267–276.
20. Catherine Godfraind, Monica L Calicchio and Harry Kozakewich Pyogenic granuloma, an
impaired wound healing process, linked to vascular growth driven by FLT4 and the nitric
oxide pathway Modern Pathology 2013 26, 247-255
21. Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of
hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. Jul 1996;
41(7):467-470.
22. Quitkin HM, Rosenwasser MP, Strauch RJ. The efficacy of silver nitrate cauterization for
pyogenic granuloma of the hand. J Hand Surg Am. May 2003; 28(3):435-438.
23. Sud AR, Tan ST. Pyogenic granuloma–treatment by shave-excision and/or pulsed-dye laser.
J Plast Reconstr Aesthet Surg. 2010;63: 1364–1368.
24. Bryan RS, Soule EH, Dobyns JH, et al. Primary epithelioid sarcoma of the hand and
forearm. J Bone Joint Surg 1974;56A:458–465.
25. SG Talbot, BJ Mehrara, JJ Disa, AK Wong, A Pusic, PG Cordeiro, EA Athanasian Soft
Tissue Reconstruction of the Hand Following Sarcoma Resection Plast Reconstr Surg 121:
534-543, 2008
26. Brien EW, Terek RM, Geer RJ, et al. Treatment of soft-tissue sarcomas of the hand. J Bone
Joint Surg [Am] 1995;77:564–571.
27. Talbert ML, Zagars GK, Sherman NE, et al. Conservative surgery and radiation therapy for
soft tissue sarcomas of the wrist, hand, ankle, and foot. Cancer 1990; 66:2482-2491
28. McPhee M, McGrath BE, Zhang P, et al. Soft tissue sarcoma of the hand. J Hand Surg [Am]
1999; 24:1001–1007.
29. Bray PW, Bell RS, Bowen CV, et al. Limb salvage surgery and adjuvant radiotherapy for
soft tissue sarcomas of the forearm and hand. J Hand Surg [Am] 1997; 22:495–503.
30. Sorene ED, Goodwin DR. Magnetic resonance imaging of a tiny glomus tumour of the
fingertip: a case report. Scand J Plast Reconstr Surg Hand Surg. 2001; 35:429–431.
31. Dahlin LB, Besjakov J, Veress B. A glomus tumour: classic signs without magnetic
resonance imaging finding. Scand J Plast Reconstr Surg Hand Surg. 2005; 39:123–125.
32. Bhaskaranand K, Navadgi BC. Glomus tumour of the hand. J Hand Surg 2002;27B:229 –
231.
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A Uterine Stone: A Case Report
T. Negussie, P. Kidane
Department of Surgery, School of Medicine, CHS, Addis Ababa University
Correspondence to: Philipos Kidane, E-mail: philiposkidane@gmail.com
Human uterine stone formation is an exceedingly rare condition and to our knowledge only two
previous case reports has been published on uterine stones. Uterine calcification occurs in many
animal species related to the formation of a protective shell for the developing embryo1 and human
endometrial calcification has been rarely associated with some benign and malignant conditions in
the form of Psammoma bodies. We present here a rare case of uterine stone in an 8 year old female
child.
Case report
An 8 year old female child was admitted to our hospital for colostomy closure. The child initially
presented at the age of 2 years with perianal region necrotizing fasciitis (following intramuscular
antibiotic injection for diarrheal illness) with sphincter damage and debridement of wound and
sigmoid loop colostomy was done and at the age of 4 years anal sphincter reconstruction and
colostomy closure attempted but the faecal incontinence persisted along with urinary incontinence and
currently admitted with significantly improve anal sphincter tone and mild stress incontinence for
colostomy reversal.
The physical examination showed a patent anal canal with good anal tone but tight or frozen pelvis.
Plain abdominal x-ray and Barium enema through colostomy showed patent and good calibre distal
bowel with radiopaque shadow in the pelvis (Figure 1 A and B). She was explored and the finding
was a big hard mass inside the uterus (Figure 2) which was opened over the fundus and an 8 x 5 cm
stone identified in the endometrial cavity which was crashed in pieces and removed (Figure 3). The
endometrial cavity was found to be normal, with no fistula to the bladder and the vaginal cavity was
also normal as was the other pelvic viscera. The child was subsequently discharged on her 8thpostoperative day improved. The stone removed was sent for chemical analysis which revealed a
composition of calcium and carbonate (calcite).
A
B
Figure 1. Plain abdominal x-ray(A) and distal colostogram(B) showing radio-opaque
in the pelvis(arrow)
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Figure 2. Stone (arrow) inside the open uterus
Figure 3.The removed Crashed Stone
Discussion
Calcification and hence stone formation in the human endometrium is an extremely rare phenomenon
except when it occurs in the developing embryo and foetus. After extensive literature search using
pubmed and the Ptolemy library, there have been only two cases of uterine stones reported in a 73 and
46 year old women 2, 3. Calcium deposition has also been found to occur in intrauterine contraceptive
devices. Calcification has been reported in Asherman`s syndrome4, in papillary adenocarcinoma5,6 and
in degenerated leiomyomata. Two old gynaecology text books mentioned uterine stones consisting of
phosphate and carbonate with the explanation of pedunculated fibroids rarely getting twisted,
strangulated, necrosed, calcified and fall into the endometrial cavity7,8. In animal species, such as
hens, calcification occurs in the formation of a protective egg shell that will permit ongoing
respiration for the developing offspring. Human urinary tract stones are mainly composed of calcium
oxalate and phosphate and also magnesium ammonium phosphate and sometimes urate, cystine and
xanthine but stones composed of calcium carbonate or calcite are unheard of in humans but do occur
in herbivores.
In summary, we have presented a very rare case of uterine stone composed of calcium carbonate,
rarely found in human urinary tract, but common in other animals.
References
1. Taylor TG. How an eggshell is made. Sci Am 1970; 222:89-95
2. Am J SurgPathol. 1990; 14 (11):1071-5. Uterine Lithiasis. Alpert LC, Haufrect EJ, Schawrtz
MR.
3. Hadda FS. Uterine Calculi (womb Stones). Annu Rep Orient Hosp 1963;16:1205-7.
4. Untawale VG, Gabriel JB, Chauhan PM, Calcific endometritis. Am J ObstetGynecol 1982;
144:482-3.
5. Factor SM. Papillary adenocarcinoma of the endometrium with psammoma bodies. Arch
Pathol 1974; 98; 201-5.
6. Hameed K, Morgan DA. Papillary adenocarcinoma of endometrium with psammoma bodies.
Cancer 1972; 29:1326-35.
7. Hirst BC. A text-book of diseases of women. Philadelphia: WB Saunders, 1903:330.
8. Lynch FW. Chapter 12. In: Davis CH, ed. Gynecology and obstetrics, vol 2, Hagerstown: WF
Prior, 1939:11.
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The Prevalence of HIV Infection among Pregnant Women at Kabutare District Hospital Rwanda
R. Kabera 1,L. King 2
1
Family Physician, KabutareDistrict Hospital
2
Family and Community Medicine Department, University of Rwanda
Correspondence to: René Kabera Email: renekabera@yahoo.fr
Background:Kabutare Hospital is a District Hospital in Rwanda. The HIV infection has been a
threat to mothers and their babies since many years in Rwanda, where the prevalence countrywide is
estimated at 3% (DHS 2010) and 4.7% among pregnant women (UNAIDS2009). We conducted a
study to know the sero-prevalence of HIV infection among pregnant women who delivered at
Kabutare District Hospital .The objectives were to determine the prevalence of HIV infection among
pregnant women in Kabutare Hospital and to compare the prevalence of HIV infection in Kabutare
Hospital with the prevalence at the National level.
Methods:A retrospective, descriptive study conducted from July 2012 to December 2012.The study
concerned 1258 pregnant women who delivered in the Kabutare District Hospital. From the Hospital
records the data were extracted and analyzed by SPSS.20 software.
Results:A total of 1258 pregnant women attended and delivered at Kabutare Hospital between July
2012 and December2012.The vaginal deliveries were 680 (54.1%) and the women who delivered by
Caesarean section were 578 (49.1%), the rate of deliveries per day is 7 with a mean number of
pregnancy estimated at 2.14.Themajority of pregnant women is situated in age group of 21-35 years
(78 %).The monthly attendance is within a range of 171 women and 246 women (December and
August respectively). A total of 613 (48.7%) of women were primigravida. The foetal presentation
which was dominant is the cephalic presentation with 97.1% (1226 pregnant women). The
prevalence of HIV infection was 2.9 % (36 women)
Among HIV infected women, the age group of >35 years old pregnant women was more affected by
the HIV infection with a percentage of 4.2%.Among HIV infected women 50% had a vaginal delivery
and 50% undergone a cesarean section .The women who had two or more pregnancies were infected
by the HIV infection with a percent of 3.8 (24 pregnant women).
Conclusion:The sero-prevalence of HIV infection among pregnant women in Kabutare Hospital is
slightly below to the sero-prevalence at the national level. But persistent vigilance is needed to
prevent the Mother to Child transmission.
Keywords: pregnant women, Kabutare Hospital, HIV sero-prevalence.
Introduction
The HIV infection has been a threat to mothers and their babies since many years in Rwanda, where the
prevalence countrywide is estimated at 3% (DHS 2010) and 4.7% among pregnant women (UNAIDS
2009). During the pregnancy, the HIV infection has a double impact both on mother and the newborn
with the risks of worsening the current mother immunodepressed state due to pregnancy and to the
infection. During antenatal care visits the HIV is a mandatory test at the level of Health Centre and in
the Hospital for a good follow up and a decrease in prevention of mother to child.
Patients and Methods
In Kabutare District Hospital, We conducted a retrospective, descriptive study for a period of 6 months
from July 2012 to December 2012. The data were found in Hospital records and were analyzed by
SPSS.20 software. The difference is statistically significant if p<0.05 for the Pearson test. The inclusion
criterion was all pregnant women who attended and delivered in our hospital. All pregnant women who
attended our Hospital and didn’t deliver at our Hospital were excluded from our study.
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Results
As shown in Table 1, in our study we had 3 age groups: 10 to 20 years; 21 to 35 years and above 35
years with 148, 986 and 124 pregnant women respectively. The pregnant women who had more than
one pregnancy were almost the same as primigravida (51.3 % vs 48.7%). The majority of women had a
vaginal delivery (54.1%) and 45.9% delivered by Caesarean section. About foetal presentation, the
cephalic presentation was by far the most frequent with 97.1%, the breech presentation came next with
2.1% and the transverse is the least represented with 0.5%. The HIV prevalence is 2.9%.
Table1. Socio-physiological Characteristics
Frequency
148
986
124
613
270
Percent
11.8
78.4
9.9
48.7
21.5
Pregnancy
10-20 years
21-35 years
>35 years
G1
G2
Delivery
G3-G11
Vaginal
C-section
375
680
578
29.8
54.1
45.9
Cephalic
1226
97.5
Breech
Transverse
HIV negative
HIV positive
Total
26
6
1222
36
1258
2.1
0.5
97.1
2.9
100
Age group
Foetal
presentation
HIV test
Table 2.Descriptive data
Age
Pregnancy
N
1258
1258
Minimum
15
1
Maximum
50
11
Mean
27.24
2.14
Std. Deviation
5.989
1.546
The age range was 15 years to 50 years; the mean age was 27 years. The range of pregnancy was from 1
pregnancy to 11 pregnancies the mean was 2 pregnancies. As shown in Table 2. As shown in Table 3,
the prevalence of HIV infection is 1.95% in primigravida and 3.72 % in women who had more than one
pregnancy. The prevalence of HIV infection was 3.11% in women who delivered by caesarean section,
and 2.64% in women who had vaginal delivery. The age group which was more affected by the HIV
infection was the group of > 35 years women with the prevalence of 4.2%, the age group of 10-20 years
had a 2.70 % HIV infection rate. The HIV infection rate among pregnant women aged between 21 and
35 years was 2.8 %.
As shown in table 4, a total 339 (55.3 %) pregnant women with 1st pregnancy had a vaginal delivery
and 274 (44.7 %) women delivered by caesarean section. About 52.6% Multigravida had a vaginal
delivery and 47.4 %delivered by caesarean section.
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The age group of 10-20 years had more vaginal deliveries with a percentage of 59.4% and the age
group of >35 years had less vaginal deliveries with 50.4%.
Table 3.HIV Sero-prevalence
Pregnancy
Delivery
Age group
G1
G2
G3-G11
Vaginal
C-section
10- 20
years
21-35
years
>35 years
HIV Negative
601
264
357
662
560
HIV Positive
12(1.95%)
6(2.22%)
18(5.04%)
18(2.64%)
18(3.11%)
P-value
0.023
144
4(2.7%)
0.712
959
119
27(2.8%)
5(4.2%)
0.62
Table 4: Delivery
G1
G2
G3-G11
10-20 yrs
21-35 yrs
> 35 yrs
July
August
September
October
November
Delivery
Vaginal No. (%)
339 (55.3)
138(51.1)
203(54.1)
88(59.4)
529(53.6)
63(50.4)
111(48.9)
134(54.4)
126(63.3)
108(51.9)
116(56.0)
C-section No. (%)
274(44.7)
132(48.9)
172(45.9)
60(40.6)
457(46.4)
61(49.6)
116(51.1)
112(45.6)
73(36.7)
100(48.1)
91(44)
December
85(49.7)
86(50.3)
Foetal presentation
Cephalic
Breech
Transverse
680(55.4)
0(0)
0(0)
546(44.6)
26(100)
6(100)
HIV test
HIV negative
662(54.1)
560(45.9)
0.74
HIV positive
Total
18(50)
680
18(50)
578
1258
Pregnancy
Age
Month
91
p-value
0.5
0.3
0.045
0.0001
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Discussion
The objective of our study was to determine the prevalence of HIV infection in pregnant women in
Kabutare Hospital. The Prevalence of 2.9% is below to the national prevalence of HIV Infection among
pregnant women.
In Nigeria, Okeudofound a prevalence of 6.9 % .The survey was conducted at Imo State University
Teaching Hospital, Orlu, Imo State from May 2005 to April 2010 The rate is higher than the one in our
study.9
Ratnam12 in a study done over a period of 3 years in Canada found a HIV prevalence of 1 per 1147
pregnant women. Stringer17 in Zambia found a HIV infection rate of 7.7% in pregnant women in
Lusaka between July 2002 and December 2006. The HIV infection rate found in our study was almost
similar to the 2% found by YahyaMalima22 in Manyara and Singida in North Tanzania.
Conclusion
The sero-prevalence of HIV infection among pregnant women in Kabutare Hospital is slightly below to
the sero-prevalence at the national level. But permanent vigilance is needed to prevent the Mother to
Child transmission.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
92
John TJ, Bhushan N, Babu PG, Seshadri L, Balasubramanium N, Jasper P. Prevalence of HIV
infection in pregnant women in Vellore region. Indian J. Med. Res. 1993 Nov;97:227–30.
Kigadye RM, Klokke A, Nicoll A, Nyamuryekung’e KM, Borgdorff M, Barongo L, et al. Sentinel
surveillance for HIV-1 among pregnant women in a developing country: 3 years’ experience and
comparison with a population serosurvey. AIDS. 1993 Jun;7(6):849–55.
Leroy V, De Clercq A, Ladner J, Bogaerts J, Van de Perre P, Dabis F. Should screening of genital
infections be part of antenatal care in areas of high HIV prevalence? A prospective cohort study
from Kigali, Rwanda, 1992-1993.The Pregnancy and HIV (EGE) Group.Genitourin Med. 1995
Aug;71(4):207–11.
Maher D, Hoffman I. Prevalence of genital infections in medical inpatients in Blantyre, Malawi. J.
Infect. 1995 Jul;31(1):77–8.
Mahomed K, Kasule J, Makuyana D, Moyo S, Mbidzo M, Tswana S. Seroprevalence of HIV
infection amongst antenatal women in greater Harare, Zimbabwe. Cent Afr J Med. 1991
Oct;37(10):322–5.
Mbizvo MT, Mashu A, Chipato T, Makura E, Bopoto R, Fottrell PF. Trends in HIV-1 and HIV-2
prevalence and risk factors in pregnant women in Harare, Zimbabwe. Cent Afr J Med. 1996
Jan;42(1):14–21.
Meda N, Zoundi-Guigui MT, van de Perre P, Alary M, Ouangré A, Cartoux M, et al. HIV
infection among pregnant women in Bobo-Dioulasso, Burkina Faso: comparison of voluntary and
blinded seroprevalence estimates. Int J STD AIDS. 1999 Nov;10(11):738–40.
Okeke TC, Obi SN, Okezie OA, Ugwu EOV, Akogu SPO, Ocheni S, et al. Coinfection with
hepatitis B and C viruses among HIV positive pregnant women in Enugu south east, Nigeria.
Niger J Med. 2012 Mar;21(1):57–60.
Okeudo C, B U E, Ojiyi EC. Maternal HIV positive sero-prevalence at delivery at a tertiary
hospital in South-Eastern Nigeria. Niger J Med. 2010 Dec;19(4):471–4.
Okeudo C, Ezem BU, Ojiyi EC. Human immuno-deficiency virus antibody seroprevalence among
pregnant women at booking at a university teaching hospital in South-Eastern Nigeria. Niger J
Med. 2012 Jun;21(2):227–30.
Olajubu FA, Osinupebi OA, Deji-Agboola M, Jagun EO. Seroprevalence of HIV among blood
donors, antenatal women and other patients in a tertiary hospital in Nigeria. Braz J Infect Dis.
2009 Aug;13(4):280–3.
Ratnam S, Hogan K, Hankins C. Prevalence of HIV infection among pregnant women in
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13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
93
Newfoundland. CMAJ. 1996 Apr 1;154(7):1027–32.
Sagay AS, Kapiga SH, Imade GE, Sankale JL, Idoko J, Kanki P. HIV infection among pregnant
women in Nigeria. Int J Gynaecol Obstet. 2005 Jul;90(1):61–7.
Sangaré KA, Coulibaly IM, Ehouman A. [Seroprevalence of HIV among pregnant women in the
ten regions of the Ivory Coast]. Sante. 1998 Jun;8(3):193–8.
Sangaré L, Meda N, Lankoandé S, Van Dyck E, Cartoux M, Compaoré IP, et al. HIV infection
among pregnant women in Burkina Faso: a nationwide serosurvey. Int J STD AIDS. 1997
Oct;8(10):646–51.
Siriwasin W, Shaffer N, Roongpisuthipong A, Bhiraleus P, Chinayon P, Wasi C, et al. HIV
prevalence, risk, and partner serodiscordance among pregnant women in Bangkok. Bangkok
Collaborative Perinatal HIV Transmission Study Group.JAMA. 1998 Jul 1;280(1):49–54.
Stringer EM, Chintu NT, Levy JW, Sinkala M, Chi BH, Muyanga J, et al. Declining HIV
prevalence among young pregnant women in Lusaka, Zambia. Bull. World Health Organ. 2008
Sep;86(9):697–702.
Taha TE, Dallabetta GA, Hoover DR, Chiphangwi JD, Mtimavalye LA, Liomba GN, et al. Trends
of HIV-1 and sexually transmitted diseases among pregnant and postpartum women in urban
Malawi. AIDS. 1998 Jan 22;12(2):197–203.
Ukey PM, Akulwar SL, Powar RM. Seroprevalence of human immunodeficiency virus infection
in pregnancy in a tertiary care hospital. Indian J Med Sci. 2005 Sep;59(9):382–7.
Utulu SN, Lawoyin TO. Epidemiological features of HIV infection among pregnant women in
Makurdi, Benue State, Nigeria. J Biosoc Sci. 2007 May;39(3):397–408.
Wilkinson D, AbdoolKarim SS, Williams B, Gouws E. High HIV incidence and prevalence
among young women in rural South Africa: developing a cohort for intervention trials. J. Acquir.
Immune Defic.Syndr. 2000 Apr 15;23(5):405–9.
Yahya-Malima KI, Olsen BE, Matee MI, Fylkesnes K. The silent HIV epidemic among pregnant
women within rural Northern Tanzania.BMC Public Health. 2006;6:109.
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The Umbilical Artery Resistive Index and the Cerebro-Placental Ratio as a Predictor of
Adverse Foetal Outcome in Patients with Hypertensive Disorders of Pregnancy during
Third Trimester.
L.P. Parmar1, G.N. Mwango1, M.N. Wambugu1, J.O. Ong’ech2
1
Dept of diagnostic imaging and radiation medicine ,University of Nairobi,
Obstetrics and Gynaecology, Kenyatta National Hospital – Nairobi, Kenya
Correspondence to: L.P. Parmar , Email: linal.parmar@gmail.com
2
Department of
Background: Hypertensive disorders of pregnancy causes adverse effects both the maternal and
faetal circulations. These circulations can be assessed safely and non-invasively by Doppler
`ultrasound using arterial Doppler indices of umbilical artery alone or combining the umbilical
artery with the middle cerebral artery thus attaining the cerebroplacental ratio (ratio of the middle
cerebral artery resistive index over that of the umbilical artery). The main objective of this study was
to compare the Umbilical Artery Resistive index alone and the cerebroplacental ratio as a predictor
of adverse fetal outcome in patients with hypertensive disorders of pregnancy in third trimester.
Methods: A prospective cohort study was carried out at the Kenyatta National Hospital (KNH) over a
period of nine months. Gravid patients at least 32 weeks gestations by dates were recruited from
labor ward. Consecutive sampling method was used. The Umbilical Artery Resistive Index was
obtained and the cerebroplacental ratio was also calculated from the Umbilical Artery Resistive
Index and Middle Cerebral Artery Resistive index.
Results: A total of 160 patients were recruited into the study. Among neonates of mothers with
pregnancy induced hypertension with Umbilical Artery Resistive Index ≤ median (0.64), a fetal birth
score < 7 was 0.5 (95% CI 0.3, 0.8; p <0.001) times more likely than a score > 7 and 6.6 (Odds Ratio
6.6; 95% CI 2.5, 17.3; p <0.001) times more likely relative to hypertensive mothers with Umbilical
Artery Resistive Index > median (0.64). Combining Umbilical Artery Resistive Index and Middle
Cerebral Artery Resistive Index (cerebroplacental ratio) improves the prognostic odds ratio from 6.6
to 82. The Umbilical Artery Resistive Index (≤/> median) had 80% (95% CI 63%, 90%) sensitivity,
62.3% (95% CI 54%, 70%) specificity, 33% positive predictive value, and 93.1% negative predictive
value for neonatal adaption after birth as seen from the foetal birth score. Among infants of mothers
with hypertensive disorder during pregnancy with Umbilical Artery Resistive Index ≤ median (0.64),
low birth weight (<10th percentile of expected weight at gestation week) was 0.5 (95% CI 1.9, 7.3)
times more likely than normal weight and 9.5 (Odds Ratio 9.5; 95% CI 3.1, 29.2; p<0.001) times
more likely relative to infants of hypertensive mothers with Umbilical Artery Resistive Index >
median (0.64). Combining Umbilical Artery Resistive Index and Middle Cerebral Artery Resistive
Index (cerebroplacental ratio) does not improve the prognostic odds ratio. The Odds Ratio drops
from 9.5 to5.6. This implies the Umbilical Artery Resistive Index is a better predictor of low birth
weight. The Umbilical Artery Resistive Index (≤/> median) had 85.2% (95% CI 67.5%, 94%)
sensitivity, 62.4% (95% CI 54%, 70%) specificity, 31.5% positive predictive value, and 95.4% negative
predictive value for abnormal birth weight.
Conclusion
• The Cerebroplacental ratio is a better predictor of faetal birth score < 7 as compared to
Umbilical Artery Resistive Index.
• The Umbilical Artery Resistive Index is a better predictor of low birth weight as opposed to
cerebroplacental ratio.
• Both cerebroplacental ratio and Umbilical Artery Resistive Index can be used in combination
to get the best results on faetal birth score and foetal weight.
Introduction
Hypertensive disorders of pregnancy (HDP) include pre-eclampsia/eclampsia (PE), chronic
hypertension, gestational hypertension and chronic hypertension with superimposed pre-eclampsia (1).
The Umbilical Artery Resistive Index (UA-RI) is only reflective of placental vascular resistance. The
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cerebroplacental ratio is reflective of placental vascular resistance via Umbilical Artery Resistive Index
and systemic resistance via Middle Cerebral Artery Resistive Index. A comparison of the Middle
Cerebral Artery and Umbilical Artery Resistive Index gives the cerebroplacental ratio (CPR). A ratio
>1.0 indicates preferential flow to vital structures like brain, heart and adrenal glands and is therefore
considered normal while a cerebroplacental ratio <1.0 is indicative of high resistance in utero-placental
circulation and is considered abnormal. This study was aimed at comparing the cerebroplacental ratio to
Umbilical Artery Resistive Index as a predictor of adverse foetal outcome in patients with hypertensive
disorders of pregnancy at or more than 32 weeks.
Patients and Methods
This was a prospective cohort study carried out in a tertiary hospital setting of Kenyatta National
Hospital in Nairobi. A cohort of women (160) with hypertensive disorders of pregnancy at least 32
weeks by gestation was recruited over the 9 month period after obtaining informed consent.
Recruitment took place from the labour ward over a period of 24 hours a day by the principal
investigator or research assistant.
After obtaining informed consent from the patient or next of kin, a structured questionnaire was filled
out by the principal investigator or research assistant. Blood pressure and urinalysis results recorded.
An obstetric ultrasound scan was carried out on request by the clinician and coded for foetal
presentation, placental position, foetal heart rate, and approximate ultrasonographic age, BPPS, UA-RI
and MCA-RI. The ultrasound machines used were real time machines, the Phillips HD11 and GE Logic
7. The transducer frequency was 3.5 – 5.0 MHz, the Doppler sample volume was 2 mm and the wall
filter was 50–100 Hz. The examination was performed with the mother in a semi-recumbent position
during relative foetal inactivity and apnoea. This is because the end diastolic flow (EDF) decreases with
decreasing foetal heart rate and foetal breathing movements increase variability in the Doppler
measurements.
The Umbilical Artery was sampled at the middle of a free loop of umbilical cord. It could also be
assessed at the level of the foetal bladder. For Middle Cerebral Artery, a transverse image of the foetal
head was obtained at the level of the sphenoid bones. Colour Flow imaging was used to display the
circle of Willis. The MCA in the near field was isolated about 1 cm distal to its origin from the internal
carotid artery. By using the optimal spectral trace from each artery, the Resistive Index was calculated
from the mean of a minimum of five consecutive waveforms on a frozen image. A series of three
readings were taken for each artery to avoid errors. The cerebral/placental ratio was calculated from the
MCA -RI and UA-RI. The study outcome variables were:
1. The 5 minute APGAR score-5 min (< 7 or ≥ 7)
2. Birth weight – (<10th percentile of the expected weight for gestation was considered as
low birth weight)
Results
Among neonates of mothers with hypertensive disorder during pregnancy with UARI ≤ median (0.64),
an APGAR score < 7 was 0.5 (95% CI 0.3, 0.8; p<0.001) times more likely than a score > 7 and 6.6
(OR 6.6; 95% CI 2.5, 17.3; p<0.001) times more likely relative to hypertensive mothers with UARI >
median (0.64). Combining UA-R.I and MCA-R.I (cerebroplacental ratio) improves the prognostic odds
ratio from 6.6 to 82. Implying CPR is a better predictor of APGAR score < 7] The UARI (≤/> median)
had 80% (95% CI 63%, 90%) sensitivity, 62.3% (95% CI 54%, 70%) specificity, 33% positive
predictive value, and 93.1% negative predictive value for neonatal adaption after birth.
Among infants of mothers with hypertensive disorder during pregnancy with UARI ≤ median (0.64),
low birth weight (<10th percentile of expected weight at gestation week) was 0.5 (95% CI 1.9, 7.3)
times more likely than normal weight and 9.5 (OR 9.5; 95% CI 3.1, 29.2; p<0.001) times more likely
relative to infants of hypertensive mothers with UARI > median (0.64). Combining UA-R.I and MCAR.I does not improve the prognostic odds ratio. The prognostic Odds Ratio (OR) however drops from
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9.5 to5.6. This implies that the UA-R.I is a better predictor of low birth weight. The UA-R.I (≤/>
median) had 85.2% (95% CI 67.5%, 94%) sensitivity, 62.4% (95% CI 54%, 70%) specificity, 31.5%
positive predictive value, and 95.4% negative predictive value for abnormal birth weight.
Table 1 : Logistic regression for the correlates of Infant’s APGAR (5 minutes) Score among mothers with
hypertensive disorder during the index pregnancy
Infant’s APGAR score
Prognostic Odds Ratio
Characteristics
APGAR score
Odds
Unadjusted
p-value
Adjusted
p-value
(< 7)/n
(95% CI)
OR (95% CI)
OR (95% CI)
Cerebral/Placental Ratio
28/47 (59.6%)
1.47 (0.8, 2.6)
82 (18, 372)
< 0.001
66 (13, 340)
< 0.001
• < 1.0
2/113 (1.8%)
0.018 (0.005, 0.07)
ref
ref
• ≥ 1.0
UARI
• ≤ median (0.64)
• > median (0.64)
24/73 (32.9%)
6/87 (6.9)
0.5 (0.3, 0.8)
0.07 (0.03, 0.2)
6.6 (2.5, 17.3)
ref
< 0.001
Table 2. Logistic regression for the correlates of Infant’s birth weight among mothers with hypertensive disorder
during the index pregnancy
Infant’s birth weight
Prognostic Odds Ratio
Characteristics
% Low birth
Odds
Unadjusted
p-value
Adjusted
p-value
weight
(95% CI)
OR (95% CI)
OR (95% CI)
Cerebral/Placental Ratio
37/47 (78.7%)
3.7 (1.9, 7.3)
5.6 (2.5, 12.4)
< 0.001
4.7 (2, 11.1)
< 0.001
• < 1.0
45/113
(39.8%)
0.66
(0.45,
0.96)
ref
ref
• ≥ 1.0
UARI
• ≤ median (0.64)
• > median (0.64)
23/73 (31.5%)
4/87 (4.6%)
0.5 (0.3, 0.75)
0.05 (0.02, 0.13)
9.5 (3.1, 29.2)
ref
<0.001
Discussion
In this study that studied a total of 160 patients with hypertensive disorders in pregnancy, the aim was
to compare the prediction value on the adverse foetal outcome of the Umbilical Artery Resistive Index
versus the cerebroplacental ratio. Combining Umbilical Artery Resistive index and Middle Cerebral
Artery Resistive Index (cerebroplacental ratio) improves the prognostic odds ratio from 6.6 to 82. This
Implies the cerebroplacental ratio is a better predictor of foetal birth (APGAR) score < 7]. This is in
contradiction to the study by Lakhkar which found the umbilical S/D ratio as a sensitive indicator and
the Middle Cerebral Artery P.I as a specific indicator2. It is also in contradiction to a study by Fong
Katherine which found the Umbilical P.I to be a better predictor of adverse foetal outcome3. This could
be explained by the differences in sample size which was 58 in Lakhkar et al and 293 in Fong Katherine
et al though randomized control trials may be needed to confirm this. It could also be due to the other
studies using P.I which is a measurement of variability of blood velocity in a vessel equal to the
difference between PSV and EDV divided by the mean velocity during one cardiac cycle. It is a more
accurate indicator of vascular resistance as it continues to show change even with no diastolic flow as
compared to R.I that was used in this study which is a measure of resistance of an organ to perfusion. It
is measured by subtracting end- diastolic velocity (EDV) from peak systolic velocity (PSV) and
dividing that by peak- systolic velocity and with vascular compliance, RI is dependent on resistance of
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the vessel and it therefore increases with increase in vascular resistance. It approaches one when the
diastolic velocity reaches zero.
This finding was in keeping with Gramellini et al4 which showed the diagnostic accuracy for the
cerebral-umbilical ratio was 90%, compared with 78.8% for the middle cerebral artery and 83.3% for
the umbilical artery. Combining the Umbilical Artery Resistive Index and Middle Cerebral Artery
Resistive Index (cerebroplacental ratio) does not improve the prognostic odds ratio for low birth weight
which dropped from 9.5 to5.6. This implies that the Umbilical Artery Resistive Index is a better
5
predictor of low birth weight. This was in keeping with Khanduri Sachin et al found that the Umbilical
Artery Resistive Index was more sensitive at 75% for intrauterine growth restriction resulting in low
birth weight.
Conclusion
1. The Cerebroplacental ratio is a better predictor than Umbilical Artery Resistive Index of low foetal
birth (APGAR) score (less than 7) thus the cerebroplacental ratio should be used to determine
degree of intrauterine foetal distress.
2. The Umbilical Artery Resistive Index is a better predictor than cerebroplacental ratio of low birth
weight. Thus the Umbilical Artery Resistive Index should be used to determine intrauterine growth
restriction as an indicator of low birth weight
3. Both the cerebroplacental ratio and the Umbilical Artery Resistive Index should be used in
combination as one is a better predictor of foetal birth (APGAR) score <7 while the other is a better
predictor of low birth weight.
References
1. Reynolds Courtney, Mabie William C and Saibai Bah M, Alan DeCherney and Lauren
Nathan (Editors) Hypertensive Disorders in Pregnancy. Currents Obstetric and
Gynecologic Diagnosis and Treatment. Tenth edition-2004- Chapter 19 pages 338-353.
2. Lakhkar BN, Rajagopal KV and Gourisankar PT. Doppler Prediction of Adverse Perinatal
Outcome in PIH and IUGR. Indian Journal of Radiological Imaging2006 16:1:109-116
www.ijri.org
3. Fong Katherine W,Arne Ohlsson,Mary E Hannah, Sorina, John Kingdom, Howard Cohen,
Marylou Ryan, Rory Windrim, Gary Foster and Kofi Amankwah
Prediction of Perinatal Outcome in Fetuses suspected to have Intrauterine Growth
Restriction:Doppler US study of Fetal Cerebral, renal and Umbilical Arteries
December 1999 Radiology, 213, 681-689. (Published by Radiological Society of North
America
4. Gramellini D, Folli MC, Raboni S, Vadora E,Merialdi A. Cerebral-Umbilical Doppler Ratio
as a predictor of Adverse Perinatal outcome. The American College of Obstetricians
and Gynecologists. March 1992-volume 79-Issue 3
5. Khanduri Sachin, Umesh C Parashari, Shazia Bashir, Samarjit Bhadury, Anurag Bansal
Comparison of Diagnostic Efficacy of Umbilical Artery and Middle Cerebral Artery
waveform with Color Doppler Study for detection of Intrauterine Growth Restriction. The
Journal of Obstetrics and Gynecology of India. 2013; 63(4): 249-255
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Ileosigmoid Knotting in Pregnancy: A case Report Seen in Uganda.
D. Mutiibwa1, G. Tumusiime2
1
Department of surgery, Mbarara University of Science and Technology (MUST)
2
Lecturer, School of Biomedical Sciences Makerere University College of Health Sciences.
Correspondence to: Dr David Mutiibwa, Email: mutiibwadavid@yahoo.com
Ileo-sigmoid knotting (ISK) refers to the intertwining of the ileum and the sigmoid colon.
The incidence of ISK is not known but generally occurs in areas with high incidence of
sigmoid volvulus such as Africa, Asia, Middle East, and South America. ISK is more
common in adult males, particularly the old. ISK in pregnancy is not common but if it
occurs, early surgical intervention is necessary to avert its associated morbidity and
mortality. Normal pregnancy complaints may cloud the clinical picture of ISK and efforts to
avoid radiological investigations may contribute to diagnostic delay. We report a case of a
pregnant mother in her second trimester who was admitted at Mbarara Regional Referral
Hospital with features of intestinal obstruction and exploratory laparotomy revealed ISK
with gangrenous bowel. After surgery, she recovered very well, carried her pregnancy to
term and delivered normally.
Introduction
Ileo-sigmoid Knotting (ISK) refers to the wrapping of the ileum around the sigmoid colon and its
mesentery or vice versa. This often causes a double loop obstruction. The incidence of ISK is not
known but it generally occurs in areas with a high incidence of sigmoid volvulus like Africa, Asia,
Middle East and south America1. Ileo-sigmoid knotting in pregnancy is not common2 but if it occurs,
early surgical intervention is necessary to avert its associated morbidity and mortality. In their study,
Atamanalp2, reviewed the clinical outcomes of 3 pregnant patients with ISK and compared the
characteristics of these pregnant women with 16 nonpregnant women. The three pregnant patients
accounted for 4.2% of 72 total ISK patients and 15.8% of 19 female ISK patients. He confirmed that
ISK in pregnancy is a rare occurrence. It is generally seen in multiparous women and in the 3rd
trimester.
In this review, we report a case of ileo-sigmoid Knotting (ISK) in pregnancy we encountered at
Mbarara Regional Referral Hospital in Western Uganda.
Case report
ML, 37yrs old G5P4+O at 14 WOA, was admitted on Gynaecology ward in October 2011 at
Mbarara Regional Referral Hospital (MRRH) with a two days history of colicky abdominal
pain associated with abdominal distension, vomiting and constipation but no history of fever,
dysuria or PV bleeding. On examination she was ill-looking, afebrile, mild pallor, BP=
106/74mmHg, PR=146bpm, RR=19bpm, SaO2 = 94%, Wt= 51kg, girth= 79cm, Ht= 162cm.
The abdomen was grossly distended, with tenderness, guarding, rebound tenderness and
reduced bowel sounds. Per rectal examination was unremarkable. Other systems were
unremarkable. A diagnosis of intestinal obstruction was made and surgeons were consulted.
We reviewed the patient and noted the above examination findings. We came up with a
diagnosis of compound volvulus.
Some of the investigations that had already been done included: Blood slide for malaria
parasites and it was negative; Hb=14.2g/dl; Electrolytes (Na+=122mmol/L, K+=4.1mmol/L)
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and obstetric ultrasound that confirmed that she was 14 weeks pregnant. The patient was
resuscitated with IV fluids and exploratory laparotomy was done. At laparotomy, we found a
bulky uterus and the terminal ileum was wrapped around the sigmoid colon which was
suggestive of type 1 ileosigmoid knotting with gangrenous bowel. About 50cm of the terminal
ileum and 25cm of the sigmoid colon were resected and end-to-side ileotransverse anastomosis
together with end sigmoid colostomy was done. She was managed postoperatively with IV
fluids, antibiotics, analgesia and blood transfusion (3 units).
Obstetric ultrasound done on the 2nd post-op day revealed a single viable intrauterine foetus.
She was discharged on the 9th post-operative day and the pregnancy was carried to term. She
delivered normally a baby girl, 2.7kg at MRRH. She came for colostomy closure seven months
after delivery and her baby was in good health.
Figure 1. Patient's colostomy site seven
months after delivery
Figure 2. Mother and her baby seven
months postpartum
Discussion
In ISK, bowel loops involving the ileum and sigmoid colon are intertwined together causing
bowel obstruction. This leads to strangulation and thrombosis of vessels which results in
ischaemia and gangrene. Bacterial translocation to the peritoneal cavity causes peritonitis.
Endotoxins are released into circulation leading to shock1.
Some of the predisposing factors to ISK include: hyper-mobile bowel with elongated
mesentery and a narrow base; relaxed abdominal wall may predispose to bowel torsion;
consumption of high bulk diet in the presence of empty small bowel; adhesions; internal
hernias; malrotation of the gut; and Meckel’s diverticulum1, 5. In this patient, the relaxed
abdominal wall due to the high parity may have been a predisposing factor. ISK can be
categorised into 3 types. In type 1, the ileum revolves around the sigmoid colon. In type II, the
sigmoid revolves around the ileum while in type III, the ileocaecal segment revolves around
the sigmoid colon. However, in some cases of ISK, it may be impossible to determine the
revolved segment and this is referred to as the undetermined type1, 5.
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Normal pregnancy complaints may obscure the clinical picture of ISK and efforts to avoid
radiological investigations may contribute to diagnostic delay. Symptoms include: colicky
abdominal pain; abdominal distension; constipation; and vomiting. Clinical signs include:
asymmetrical abdominal distension; visible peristalsis and increased or reduced bowel sounds.
If the gut is gangrenous, there may be tenderness, guarding, rebound tenderness and melanotic
stools per rectum2,4. The presentation of our patient was in line with the above mentioned
features.
Specific investigations for ISK include: plain erect abdominal radiograph which may show
dilated sigmoid colon with multiple small intestinal air-fluid levels; Barium or water soluble
contrast enemas may show obstruction in the lumen of the sigmoid but they are contraindicated
in patients with peritonitis, bowel perforation and gangrene; Abdominal CT may show twisted
and dilated sigmoid with whirled sigmoid mesentery as well as twisted and dilated small gut;
Flexible sigmoidoscopy may show spiral sphincter-like twist of the mucosa but it does not give
any information about the small bowel1. However, these investigations were not done in our
patient since she had obvious features of acute abdomen that would warrant exploratory
laparotomy. Furthermore, some of these radiological investigations were avoided because they
are risky in pregnancy. Besides, we did not have a functioning CT or endoscopic facilities in
place.
Management of patients with ISK involves adequate fluid resuscitation and correction of
electrolyte derangements, placement of a nasogastric tube, nil per os, and intravenous broad
spectrum antibiotics. During emergency laparotomy, untwisting the knot is difficult and there
is risk of bowel perforation. Thus en bloc resection of the gangrenous bowel is recommended.
Entero-enterostomy and primary anastomosis of the sigmoid or colostomy may be performed 1,
2, 3, 5
. In our patient, we resected the gangrenous terminal ileum and sigmoid colon; and then
performed ileotransverse anastomosis plus Hartmann’s procedure. In non-gangrenous cases,
one may carefully untwist the knot and perform a volvulus preventing procedure (such as
mesopexy or mesoplasty) or do resection and primary anastomosis1, 2, 3, 5.
References
1. S. Selcuk Atamanalp. Ileosigmoid knotting. The Eurasian journal of medicine 2009;
41:116-119
2. Atamanalp S. Selcuk. Ileosigmoid knotting in pregnancy. Turkish Journal of Medical
Sciences 2012; 42(4): P553
3. T.R. Okello, D.M. Ogwang, P. Kisa et al. Sigmoid volvulus and ileosigmoid knotting at
St Mary’s Hospital Lacor in Gulu, Uganda. East and Central African Journal of
Surgery 2009; 14 (2): 58-64
4. Raveenthiran V. The ileosigmoid knot: new observations and changing trends. Diseases
of the colon and rectum 2001; 44 (8): 1196–200.
5. Norman O. Machado. Ileosigmoid Knot, a case report and literature review of 280
cases. Ann Saudi Med 2009; 29(5): 402-406
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