The iBreastExam versus clinical breast examination for breast evaluation in high risk and symptomatic Nigerian women: a prospective study

BACKGROUND

The iBreastExam electronically palpates the breast to identify possible abnormalities. We assessed the iBreastExam performance compared with clinical breast examination for breast lesion detection in high risk and symptomatic Nigerian women.

METHODS

This prospective study was done at the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) in Nigeria. Participants were Nigerian women aged 40 years or older who were symptomatic and presented with breast cancer symptoms or those at high risk with a first-degree relative who had a history of breast cancer. Participants underwent four breast examinations: clinical breast examination (by an experienced surgeon), the iBreastExam (performed by recent nursing school graduates, who finished nursing school within the previous year), ultrasound, and mammography. Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the iBreastExam and clinical breast examination for detecting any breast lesion and suspicious breast lesions were calculated, using mammography and ultrasound as the reference standard.

FINDINGS

Between June 19 and Dec 5, 2019, 424 Nigerian women were enrolled (151 [36%] at high risk of breast cancer and 273 [64%] symptomatic women). The median age of participants was 46 years (IQR 42-52). 419 (99%) women had a breast imaging-reporting and data system (BI-RADS) assessment and were included in the analysis. For any breast finding, the iBreastExam showed significantly better sensitivity than clinical breast examination (63%, 95% CI 57-69 vs 31%, 25-37; p<0·0001), and clinical breast examination showed significantly better specificity (94%, 90-97 vs 59%, 52-66; p<0·0001). For suspicious breast findings, the iBreastExam showed similar sensitivity to clinical breast examination (86%, 95% CI 70-95 vs 83%, 67-94; p=0·65), and clinical breast examination showed significantly better specificity (50%, 45-55 vs 86%, 83-90; p<0·0001). The iBreastExam and clinical breast examination showed similar NPVs for any breast finding (56%, 49-63 vs 52%, 46-57; p=0·080) and suspicious findings (98%, 94-99 vs 98%, 96-99; p=0·42), whereas the PPV was significantly higher for clinical breast examination in any breast finding (87%, 77-93 vs 66%, 59-72; p<0·0001) and suspicious findings (37%, 26-48 vs 14%, 10-19; p=0·0020). Of 15 biopsy-confirmed cancers, clinical breast examination and the iBreastExam detected an ipsilateral breast abnormality in 13 (87%) women and missed the same two cancers (both <2 cm).

INTERPRETATION

The iBreastExam by nurses showed a high sensitivity and NPV, but lower specificity than surgeon's clinical breast examination for identifying suspicious breast lesions. In locations with few experienced practitioners, the iBreastExam might provide a high sensitivity breast evaluation tool. Further research into improved specificity with device updates and cost feasibility in low-resource settings is warranted.

FUNDING

Prevent Cancer Foundation Global Community Grant Award with additional support from the P30 Cancer Center Support Grant (P30 CA008748).

Molecular and phenotypic profiling of colorectal cancer patients in West Africa reveals biological insights

Understanding the molecular and phenotypic profile of colorectal cancer (CRC) in West Africa is vital to addressing the regions rising burden of disease. Tissue from unselected Nigerian patients was analyzed with a multigene, next-generation sequencing assay. The rate of microsatellite instability is significantly higher among Nigerian CRC patients (28.1%) than patients from The Cancer Genome Atlas (TCGA, 14.2%) and Memorial Sloan Kettering Cancer Center (MSKCC, 8.5%, P < 0.001). In microsatellite-stable cases, tumors from Nigerian patients are less likely to have APC mutations (39.1% vs. 76.0% MSKCC P < 0.001) and WNT pathway alterations (47.8% vs. 81.9% MSKCC, P < 0.001); whereas RAS pathway alteration is more prevalent (76.1% vs. 59.6%, P = 0.03). Nigerian CRC patients are also younger and more likely to present with rectal disease (50.8% vs. 33.7% MSKCC, P < 0.001). The findings suggest a unique biology of CRC in Nigeria, which emphasizes the need for regional data to guide diagnostic and treatment approaches for patients in West Africa.

Understanding the molecular and phenotypic profile of colorectal cancer (CRC) in West Africa is important for early detection and treatment. Here, the authors use a multigene next-generation sequencing panel to identify genomic differences in Nigerian CRCs compared to those from TCGA and MSKCC cohorts.

High-burden Cancers in Middle-income Countries: A Review of Prevention and Early Detection Strategies Targeting At-risk Populations

Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system-related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

Opportunities for Improvement in the Administration of Neoadjuvant Chemotherapy for T4 Breast Cancer: A Comparison of the U.S. and Nigeria

BACKGROUND

Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions.

MATERIALS AND METHODS

Cross-sectional retrospective analysis included all patients with non-metastatic T4 BCa treated from 2010 to 2016 at Memorial Sloan Kettering Cancer Center (New York, New York) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated.

RESULTS

Three hundred and eight patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. Fifty-six out of ninety-three (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt. Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative versus 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five-year survival was significantly shorter in Nigeria versus the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5-year survival (67% vs. 72%) and 5-year recurrence-free survival (48% vs. 61%) did not significantly differ between countries.

CONCLUSION

Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria.

IMPLICATIONS FOR PRACTICE

This cross-sectional retrospective analysis of patients with T4 breast cancer in Nigeria and the U.S. found a significant difference in pathologic complete response to neoadjuvant chemotherapy (5% Nigeria vs. 27% U.S.). Five-year survival was shorter in Nigeria, but in patients receiving multimodality treatment, including neoadjuvant chemotherapy and surgery with curative intent, 5-year overall and recurrence-free survival did not differ between countries. Capacity-building efforts in Nigeria should focus on access to pathology services to direct systemic therapy and promoting receipt of complete chemotherapy to improve outcomes.

Multistakeholder Needs Assessment to Inform the Development of an mHealth-Based Ultrasound-Guided Breast Biopsy Training Program in Nigeria

PURPOSE

The incidence of breast cancer is rising in Nigeria, and one major barrier to care is the lack of affordable and appropriate breast cancer diagnosis by ultrasound (US)-guided biopsy. The prohibitive cost of US devices limits their availability in low- and middle-income countries. The emergence of mobile health (mHealth) imaging devices may offer an acceptable low-cost alternative. The purpose of this research was to perform a comprehensive needs assessment to understand knowledge, use, training needs, and attitudes as regards image-guided biopsy in Nigeria to inform the development of an mHealth-based US-guided biopsy training program.

METHODS

A multistakeholder needs assessment was conducted at the Sixth Annual African Research Group for Oncology Symposium. Voluntary anonymous surveys were administered to all attendees. A subset of attendees (ie, surgeons, radiologists, pathologists, and nurses) participated in six focus groups. Survey items and interview guides were developed collaboratively with local and international input.

RESULTS

Surveys focusing on use, training needs, and attitudes regarding US-guided biopsies were completed with a 55% response rate (n = 54 of 98) among participants from 22 hospitals across Nigeria. Respondents expressed dissatisfaction with the way breast biopsies were currently performed at their hospitals and high interest in having their institution participate in a US-guided biopsy training program. Focus group participants (n = 37) identified challenges to performing US-guided procedures, including equipment functionality and cost, staff training, and access to consumables. Groups brainstormed the design of an mHealth US-guided biopsy training program, preferring a train-the-trainer format combining in-person teaching with independent modules.

CONCLUSION

A multidisciplinary needs assessment of local stakeholders identified a need for and acceptability of an mHealth-based US-guided biopsy training program in Nigeria.

Variations of renal vascular anatomy in a nigerian population: A computerized tomography studys

Background

A broad spectrum of renal vascular variations has been reported by anatomists and radiologists. The prevalence of these variations is extremely divergent in different populations. Therefore, radiologists and surgeons in different climes must be knowledgeable about the type and prevalence of the variants in their area of practice to avoid diagnostic pitfalls and for optimization of surgical techniques.

Objective

The objective of this study is to describe the types and prevalence of renal vascular variations among patients undergoing contrast-enhanced computerized tomography (CECT) of the abdomen in a Nigerian population, as well as provide a concise review of literature on the embryological basis and clinical significance of the identified variations.

Materials and Methods

This study was a retrospective review of 200 CECT of the abdomen to identify variations of arterial (accessory, early branching, and precaval) and venous (multiple, retroaortic, and circumaortic) anatomy of the kidneys.

Results

We studied 200 patients, 102 (51%) females and 98 (49%) males. Age range is 18-90 years (mean = 53.08 ± 17.01). Prevalence of any renal vascular variations was 50%, arterial variations were 37%, and venous variations were 13%. Variations were significantly more common in males, P = 0.000075. The most common arterial variant was the accessory renal artery (23%) seen in 10% (right) and 13.0% (left); early branching was seen in 4.0% (right) and 0.5% (left) as well as precaval right renal artery seen in 4.5%. Venous variants were late confluence 3.0% (right) and 2.5% (left); multiple veins was seen in 2.5% (right) and 2.5% (left) as well as retroaortic left renal vein seen in 2.0%. The inferior polar accessory artery was the most prevalent accessory artery. Early arterial bifurcation was significantly more common on the right (P = 0.016) while other vascular variants showed no statistically significant association with laterality.

Conclusion

Variation of renal vascular anatomy is a frequent finding among Nigerians. Radiologists and surgeons must be aware of these variants for optimization of surgical techniques.

Sphenoid Sinus Pneumatization, Septation, and the Internal Carotid Artery: A Computed Tomography Study

Background:

The air spaces of the nasal cavity and the sphenoid sinus (SS) constitute a convenient corridor to access lesions of the skull base using the endoscopic endonasal transsphenoidal approach (EETA). Safe EETA depends on the SS and skull base anatomy of the patient. Individual variations exist in the degree and pattern of SS pneumatization. This study aims to examine the variations in SS pneumatization, the inter-sphenoid septum (ISS), and their relationship with the internal carotid artery (ICA) among adult Nigerians.

Materials and Methods:

We reviewed computerized tomography (CT) images of 320 adult patients that had imaging for various indications. This excluded those with traumatic, inflammatory, or neoplastic process that may alter anatomical landmarks. The images were evaluated for the types of SS pneumatization, number and insertion of ISS, and the protrusion of ICA into the sinus cavity.

Results:

Prevalence of SS pneumatization types: 1.9% conchal, 1.2% presellar, 56.6% sellar, and 40.2% postsellar. The lateral extension of SS occurred into the pterygoid in 138 patients (45.1%), greater wing 112 (35%), lesser wing 37 (11.6%), the full lateral type was seen in 97 (30.3%) patients. One ISS occurred in 150 (46.9%) patients, 162 (50.6%) had multiple, and 8 (2.5%) had none. ISS insertion into ICA bony covering occurred in 101 (31.6%) patients, whereas protrusion of ICA into SS cavity occurred in 110 (34.4%) patients.

Conclusion:

Variations of the SS, ISS, and ICA anatomy are present among native Africans. Detailed imaging evaluation of each patient is considered for EETA is mandatory.

Missed Distal Tracheal Foreign Body in Consecutive Bronchoscopies in a 6-year-old Boy

It is unusual but not uncommon for foreign bodies to be missed at bronchoscopy. This case report highlights the importance of the clinical history in the diagnosis of aspirated foreign bodies and the usefulness of chest imaging modalities. A 6-year-old boy presented with recurrent breathlessness and cough of 2 months. He was said to have aspirated the base cap of a pen at about the time symptoms started. He had two sessions of rigid bronchoscopy and a session of flexible bronchoscopy at three different hospitals. He had an initial rigid bronchoscopy which failed to show the foreign body (FB). A chest computerized tomographic scan demonstrated the FB, which was retrieved at combined flexible/rigid bronchoscopy. Although rigid bronchoscopy is the gold standard for managing airway foreign bodies, there remains a false negative rate for this procedure and where necessary, appropriate imaging may compliment rigid bronchoscopy, especially where there is some confusion.

African histoplasmosis - masquerading as a malignant bone tumour

A 23-year-old immunocompetent woman presented with a two-month history of fungating left shoulder and left elbow swellings associated with fever, weight loss and anaemia. X-rays showed lytic destruction of the lateral third of the left clavicle and distal half of the left humerus. Histology of biopsy specimen confirmed African histoplasmosis. The lesion resolved following treatment with ketoconazole.

Colorectal cancer patient outcomes in Nigeria: Results from the African Colorectal Cancer Group

729

Background: Colorectal cancer (CRC) is a growing problem in sub-Saharan Africa. There are, however, limited data describing the demographics, risk factors, presentation, treatments, and outcome of patients with CRC there. We established the African Colorectal Cancer Group (ARGO) to prospectively capture data and tissue from patients with CRC in Nigeria. This is vital to guide screening and treatment trials. Methods: The Consortium consists of 5 hospitals in Nigeria and MSKCC (USA). We have been prospectively collecting data since 2013. Tissue and blood samples were obtained. Ultrasounds and CT scans were provided by an NCI grant. Overall survival from date of diagnosis was estimated using Kaplan-Meier methods. Results: 152 patients have been accrued. The majority was male (56.8%), the median BMI was 22, the majority were non-smokers (89.1%) and non-drinkers (73.5%). Many patients had symptoms, as 65.8% of patients presented with obstruction or bleeding, 52.1% of patients had pellet like stool, and 88.4% had weight loss. 33.3% saw a traditional healer prior to presentation. The common locations of the primary tumor were rectum (52%) and right colon (23%). 8 patients (6.4%) had CEA > 30 ng/mL. The majority of patients presented with advanced disease. 43 (32.3%) patients had T3 tumors; 87 patients (66.9%) had T4 tumors. AJCC stage was II (n = 12, 9.3%), III (n = 34, 26.4%), and IV (n = 83, 64.3%). 97 patients (66%) had surgery. The most common operations were right hemicolectomy (23.1%) and diverting colostomy (22.4%). 110 patients (88.7%) had chemotherapy recommended; only 71 patients (61.2%) received chemotherapy. The reasons for not receiving chemotherapy included patient finances (n = 19) and mortality (n = 12). The commonly utilized chemotherapies were FOLFOX (n = 24) and XELOX (n = 15). 62 patients died with a median follow-up among survivors of 4.4 months. Overall 12-month survival from date of diagnosis (N = 138), was 48.4% (95% confidence interval 38.9-60.1). Conclusions: The majority of patients that present to hospitals in Nigeria with CRC are stage IV. The mortality rate is high. These data serve as a baseline to judge current screening trials. Identifying high-risk patients for screening is vital to improve outcomes.

Radiation dose and radiation protection principle awareness: a survey among Nigerian paediatricians

AIMS AND OBJECTIVES

This study is aimed at determining the knowledge of Paediatricians in Nigeria about the basic principle of radiation protection ALARA (As Low As Reasonably Achievable) and their knowledge of the radiation doses that children receive during some common radiological procedures.

MATERIALS AND METHODS

Two hundred and fifty questionnaires were circulated among paediatricians at the 2012 annual Paediatricians' Association of Nigeria Conference. The questionnaires contain 10 questions designed to asses the pediatricians' general knowledge on : ionising radiation and the risks, doses children receive during some common radiological procedures and awareness of the radiation protection principle, ALARA ( As Low As Reasonably Achievable).

RESULTS

Of the 162 Paediatricians that participated, 69% named at least one non medical source of ionising radiation, 54.9% would not recommend CXR to screen an apparently healthy child for tuberculosis and 87% believe that children are at greater risk of adverse effects of ionising radiation. For dose estimation, 51.9% and 51.2% of the paediatricians underestimated doses received during Cranial and abdominal computerised tomography respectively while 13.6% and 37% respectively erroneously believed that abdominal ultrasound and brain magnetic resonance imaging utilise ionising radiation. 13.6% gave the correct meaning of the Acronym ALARA.

CONCLUSIONS

The Paediatricians' knowledge about the basic principle of radiation protection ALARA and the doses that children receive during some common radiological procedures is poor. There is need to ensure adequate training on radiation hazards and protection at all levels of medical education.

Relationship of ultrasonographically determined kidney volume with measured GFR, calculated creatinine clearance and other parameters in chronic kidney disease (CKD)

INTRODUCTION

Kidney length has traditionally been used as a predictor of chronic kidney disease (CKD); however, kidney volume (KV) rather than length has been emphasized by researchers as a true predictor of kidney size in states of good health and disease. Since KV can be assumed to be a predictor of kidney mass or remaining surviving nephrons in CKD patients, we theorized that the KV should reflect the functional capacity of the kidneys, i.e. the glomerular filtration rate (GFR).

METHODOLOGY

Forty CKD patients were recruited and investigated. Measured GFR was determined by calculating the average of endogenous creatinine clearance (mCrCl) and urea clearance (mUrCl) while predicted GFR was determined using Cockcroft and Gault, Hull and Modification of Diet in Renal Disease (MDRD) equations. KV was assessed ultrasonographically using the formulae of Dinkel et al. and Solvig et al. for ellipsoid organ. The relationship between the KV and GFR was assessed using Spearman's correlation coefficient while Bland and Altman tests were used to assess intraobserver variation and agreement between measured and predicted GFR.

RESULTS

The results showed a weak but positive correlation between KV and various indices of GFR, best with measured CrCl (correlation coefficient ranged between 0.408 and 0.503; P < 0.05), and which was not improved after normalization for body surface area (BSA). We also found a significant correlation between the measured CrCl and various values of estimated CrCl.

CONCLUSION

Ultrasonographically determined KV was found to correlate with GFR and hence can be used to predict it in established CKD, particularly in resource-poor settings.

Rickets of prematurity- a case report

OBJECTIVE

This case report seeks to create awareness of the aetiology of rickets of prematurity among very low birth weight infants in Nigeria

METHODS AND RESULT

This is a case report of an 800 gramme premature male neonate delivered by caesarean section at 28 weeks gestation following severe maternal pre-eclampsia. The infant was hospitalised for sixty days and fed exclusively on his mother's breast milk for seven months. He had two episodes of sepsis and was transfused twice while on admission. He was on Abidec drops, which contained 400 IU/0.6 ml of vitamin D from the age of two weeks. He defaulted from the follow up clinic at postnatal age of 16 weeks only to reappear at 30 weeks postnatal age with overt clinical, biochemical and radiologic signs of rickets. He responded well to calcium and phosphate supplementation.

CONCLUSION

This case highlights the role of mineral deficiency in the aetiology of rickets of prematurity in very low birth weight infants fed with their mothers' breast milk.

Complete recovery of renal allograft function after sixty days of delay following living related transplantation

Delayed graft function (DGF), a term employed when a newly transplanted organ does not function efficiently is commonly observed following cadaveric renal transplantation but is very rare after living related transplants. We present a 31-year-old female recipient of a related donor kidney (mother) who had DGF following trans-plantation due to acute tubular necrosis, probably caused by partial allograft arterial thrombosis, which recovered function after 60 days. Appropriate use of allograft biopsy should be encouraged even in resource-limited settings lest the allograft be assumed to have failed irreversibly.

Burkitt's lymphoma of the head and neck region in a Nigerian tertiary hospital

BACKGROUND

Burkitt's lymphoma is endemic in Nigeria; it forms about 39% of all childhood cancers. In recent times more of these cases are being seen presenting first to the Ear Nose and Throat clinic.

OBJECTIVE

This study is designed to look at the pattern of presentation of head and Neck Burkitt's lymphoma at a Nigerian Tertiary hospital and to evaluate current treatment modality.

DESIGN

It is a retrospective study of all confirmed Burkitt's lymphoma of the head and neck region seen at the Obafemi Awolowo University Teaching Hospital Ile Ife (OAUTHC) between 1986 and 2002.

PATIENTS AND METHODS

The medical records of all the patients with the histopathologically confirmed Burkitt's lymphoma over a 17-year period (1986-2002) were evaluated. The proportion of the tumor affecting the Head and neck region were noted. The data extracted were entered into a questionnaire and analysis of data was done using the SPSS 10.0 software.

RESULTS

A total of 196 cases of Burkitt's lymphoma were seen over the period out of which 140 (71.4%) were in the head and neck region. There was a male preponderance with the incidence of 72% and 28% in females. The peak age incidence was found to be within the first decade of life. The most common sites that were affected are; the jaw (65.9%), nasal and paranasal sinuses (12.2). Majority of the patients presented with advanced disease. Combination Chemotherapy comprising Cyclophosphamide, Oncovin, Methotrexate and Prednisolone (COMP) was the mainstay of management. The treatment outcome was only favorable in 36.6%. Default rate was (11.7%) while the mortality rate was (12.6%). Relapse\recurrence was found in (5.1%) of cases. Frank drug resistance was found in (2.6%). Blindness was found to be a major morbidity associated with this disease. Septicemia and severe anemia were found to be the major causes of mortality. Some complications of treatment were noted.

DISCUSSION

The importance of the findings in this work was discussed in line with the existing literature.

CONCLUSION

Head and neck remain the mostly affected parts in Burkitt's lymphoma in this environment. Presentation with advanced disease is the bane. This partly explains high morbidity and mortality in affected children.

Chronic hepatitis in Nigerian patients: a study of 70 biopsy-proven cases

BACKGROUND

Liver cirrhosis and hepatocellular carcinoma are known sequelae of chronic hepatitis. Early diagnosis and treatment of chronic hepatitis could delay or even abort progression to terminal liver disease.

STUDY DESIGN

Prospective study of 70 consecutive patients with features of early liver disease or discovered with HBsAg (or anti-HCV) during pre-employment and/ or pre-donation screening at Ile-Ife, Nigeria. All the patients had liver biopsy and the histology evaluated with the Knodell Histological Activity Index.

RESULT

Fifty-three patients had symptomatic disease (M: F ratio, 1.5:1) while 17 were asymptomatic (M: F ratio, 3:1). The mean ages were 49.04 (SD+/-16.78) and 29.82 (SD+/-6.13) for the symptomatic and the asymptomatic patients respectively (P< 0.005). Major symptoms were right upper abdominal pain (68%), weight loss (51%) and fatigue (41.5%). Alcohol consumption was significantly related to symptomatic chronic hepatitis (P< 0.01). Over 50 % of patients with asymptomatic chronic hepatitis had abnormal liver scan and liver function tests. All the asymptomatic cases and 77.4 % of the symptomatic group had HBsAg while only 1 patient (symptomatic) was anti-HCV positive. On liver histology, all the patients with asymptomatic chronic hepatitis had a Knodell score of< or = 8 and none had fibrosis. Over half of the symptomatic patients had a Knodell score of > or = 9 (56.6%) and stage 2 or 3 fibrosis (51 %).

CONCLUSION

Asymptomatic chronic hepatitis patients tend to be younger and of the male sex. Symptomatic chronic hepatitis may signal the onset of significant fibrosis and alcohol abuse may accelerate this process. Serum ALT and liver scan are useful initial screening tests for asymptomatic patients with hepatitis B or C viral markers.

Kidney transplantation in a developing economy: challenges and initial report of three cases at Ile Ife

BACKGROUND

Kidney transplantation (KT) is globally adjudged the best alternative treatment for end stage renal disease (ESRD) in preference to life-long dialysis. This form of therapy was hitherto unavailable in Nigeria until our hospital and a private hospital embarked on a KT programme despite our depressed economy, and inadequate facilities. We present the initial report of KT performed in our hospital and the challenges of KT in our developing society.

CASE REPORTS

Three patients with ESRD had living related KT between June 2002 and April 2003. The first patient died with functioning graft six and a half months post transplantation from complications of Diabetes mellitus and sepsis, while the remaining two still enjoy a good quality of life 35 months post transplantation. There were problems with procurement and monitoring of immunosuppressive drugs in the three patients. This report also illustrates the common causes of ESRD in Nigeria and some of the complications of KT. To our knowledge, these are the first reported cases of KT in Nigeria.

CONCLUSION

Kidney transplantation is cost effective and offers a good quality of life for ESRD patients. Poverty, inadequate facilities and lack of donors are major problems facing KT in our society. Although KT requires high technical and material resources, with proper training, commitment and adequate funding, it is feasible, safe and cheaper on a long term basis for the management of patients with ESRD in a developing economy like ours. There is a need for government funding of KT programmes in developing countries.

Successful separation of two pairs of conjoined twins in Ile Ife, Nigeria: case reports

Conjoined twins are rare phenomena occurring in one in 1 in 50,000 live births. Successful surgical separation of conjoined twins is a major undertaking requiring careful planning by a multidisciplinary team. Reports of seperation of joined twins in developing countries like Nigeria are rare. Ten cases of conjoined twins were separated between 1936 and January 2003 (including the authors two new cases). There were five omphalopagus, two pygopagus, two heterpagus and one ishiopagus twins. Three underwent emergency separation with 83.3% mortality while seven underwent elective seperation with 64.3% survival. The overall mortality rate was 50%. Despite the absence of advanced technological resource selected group of conjoined twins can be successfully separated in a developing country like Nigeria. An improvement in facilities and availability of trained personnel in likely to be associated with improved outcome.

Pulmonary alveolar microlithiasis--a case report

Pulmonary alveolar microlithiasis (PAM) is a rare disease of unknown aetiology. It is characterized by the presence of calcific concretions (calcospherites) inside the alveoli. We present a case of a 22 year old sickle cell anaemia patient with an incidental finding of PAM. This report is to highlight the fact that though rare, PAM is not entirely unheard of in this environment and should be kept in mind as a cause of diffuse opacities of the lungs.

Exudative retinal detachment occurring in a patient with pyogenic liver abscess

This is a report of a rare case of bilateral exudative retinal detachment occurring in a young Nigerian male with pyogenic liver abscess. Detailed ocular and clinical examination with biochemical, haematological and microbiological studies of the blood and liver aspirate were done. Ocular and abdominal scan plus surgical drainage of abscess were also done. The main features were febrile illness with hepatomegaly and sudden loss of eyesight. Visual acuity was light perception in both eyes. The cardiovascular and renal systems were normal. Ocular scan showed bilateral bullous retinal detachment while abdominal ultrasound revealed multiple liver abscess cavities. HIV and HBsAg tests were negative. Pyogenic liver abscess should be regarded as possible cause of exudative retinal detachment and has a potential blinding complication.

Primary hepatocellular carcinoma in Ile-Ife, Nigeria: a prospective study of 154 cases

Primary hepatocellular carcinoma is a tumour with a dismal prognosis. In recent times, however, great advances have been made in its management. This 13-year prospective study done at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, was an attempt to appraise the outlook of the disease in Nigeria at the turn of the 21st century. Primary hepatocellular carcinoma affected mainly middle-aged Nigerians (peak age-group = 40-59 years), predominantly males (M:F = 2:1) and, in a sizeable proportion (78%), it co-existed with cirrhosis. Significant risk factors found were scarification marks (87%), anicteric hepatitis (71.3%), abuse of medicinal herbs and analgesics (68.6%) and injection from quack doctors (51%). Blood test for HBsAg was positive in 61% of patients. The mean duration of symptoms. before diagnosis was 12.64 weeks (SD 13.77) while, on the average, patients died within 14.0 weeks (SD 13.0) of illness, usually of liver failure (67.7%). Only symptomatic treatment could be offered in 148 patients (96.1%) while chemotherapy was merely attempted in 5 (3.25%). Majority of the patients (59.8%) were either discharged against medical advice or lost to follow-up. This study shows that Nigerian patients presenting with primary hepatocellular carcinoma already have advanced disease and this makes treatment and survival hopeless. Universal immunisation with HB vaccine should be implemented in Nigeria without further delay and health education should be directed against socio-cultural practices which are aetiological risk factors for primary hepatocellular carcinoma.