Cost effectiveness analysis of duration of nonoperative management for adhesive bowel obstruction in a developing country

Background Adhesive bowel obstruction (ABO) costs billions of dollars in developed countries. Cost is unknown in developing countries. This depends on the type of management and duration of hospital stay. Nonoperative management (NOM) of uncomplicated obstruction is safe for up to 10 days. While it remains cost effective, the most efficient duration of nonoperative management must retain its advantages over operative management. AimTo describe cost effectiveness of various durations of nonoperative management of adhesive obstruction in a developing country. MethodOver 2 year period, Patients who had uncomplicated adhesive obstruction were observed on trial of nonoperative management. Length of hospital stay and success rate were combined as surrogates for Cost effectiveness analysis of 2 to 5 days and ≥7 days nonoperative management. Results41 patients (24(58.5%) females) were eligible. Mean age 38.4 ± 14.7 (range 18-80) years. 31 (75.6%) were first time admissions. The most common previous abdominal operations were for appendix and obstetrics and gynecologic pathologies. Median duration of nonoperative management (dNOM) was 4 days, median LOS was 9 days. Nonoperative management was successful in 53.7% (22 patients). Total estimated direct hospital cost of 41 adhesive bowel obstructions was $133,279. Total personnel charges were$112,142. Mean operative and nonoperative management was $4,914 and$1,814 respectively (p <0.0001). Most of successful nonoperative management was within 5 days. 4 days nonoperative management had the highest cost utility.Conclusion From this study, without indications for immediate surgical intervention, 4 days nonoperative management is the most cost effective course, after which surgical intervention may be considered if there is no improvement.

Universality of prisoners’ right and appraisal of the level of conformity in Nigeria

This paper examines the concept of human right as well as the universality in the application of the concept to the prisoners’ welfare in most countries of the world. To determine the level of conformity of this concept in Nigeria, the paper discusses the post-conviction problems prisoners face in Nigeria as against what is obtainable in some other countries of the globe. In the final analysis, the paper posits that, due to unrealistic nature of prisoner’s right enforcement in Nigeria, the situation is an aberration to the best global practices. To check the situation, the paper made some practical recommendations that could make the issue of prisoner rights conform to that which is obtainable in most civilised countries of the world.Keywords: Prisoners’ Right, Conformity, Aberration, Universality of Human Right

Level of awareness and knowledge of breast cancer in Nigeria. A systematic review

Background: Despite reports of improved awareness of breast cancer entity and seemingly upbeat levels of other awareness subthemes in Nigeria, patients continue to present late when treatment is least rewarding. This paradoxical trend of both rising awareness and late presentation coupled with reports suggesting other competing drivers of late presentation question the “theory of poor awareness” as the foremost driver of late presentations. By aggregating available data, we aimed to assess what still constitutes poor breast cancer awareness in Nigeria in order to suggest how to allocate resources to reverse the paradoxMethod: Studies conducted on Nigerian populace from 2000 to date were reviewed systematically. Search was made in PROSPERO, PubMed/MEDLINE, AJOL, Cochrane library, GOOGLE, ResearchGate and ACADEMIA. Primary outcome was level of awareness about breast cancer entity.Result: Fifty-one eligible (48 descriptive surveys, 3 interventional ones) studies were reviewed. They included 19,598 respondents (98.5% females; 43% rural dwellers). 17,086(87.2%) were laypersons in various walks of life; 2,512(12.8%) were healthcare professionals. There were high levels of awareness of breast cancer entity, BSE, knowledge of fatality and benefit of early detection (weighted percentages 80.6%, 60.1%, 73.2% and 73.9% respectively). Weighted percentages of knowledge of symptoms/signs was 45.1%. Weighted percentages of sense of susceptibility and performance of BSE were low-26.8% and 22.9% respectively. Generally, rate of performance of screening did not vary with changes in the level of awareness/knowledge of concepts.Conclusion: In general, low awareness of breast cancer may not be the direct and foremost driver of persistent late presentation in Nigeria.Keywords: Breast cancer, awareness, knowledge, Systematic review, Nigeri

Goitre-related factors for predicting difficult intubation in patients scheduled for thyroidectomy in a resource-challenged health institution in north central Nigeria

Background: Airway management problems may arise when intubating patients with goitre scheduled for thyroidectomy. Goitres are not uncommon in sub-Saharan Africa, thyroidectomy being the main treatment. The aim of this study was to determine incidences of difficult intubation (DI), failed intubation (FI) and predictors of DI using a modified intubation difficulty score (IDS).Methods: One hundred and twenty-five consenting patients with goitre scheduled for thyroidectomy were recruited. Goitrerelated factors (GRF) of duration of illness, diagnosis, neck circumference, tracheal deviation and narrowing and retrosternal extension were recorded as well as Mallampati classification and BMI. At intubation, modified IDS was determined for each patient. Patients with modified IDS ≤ 5 were categorized as easy intubation group (E), and those with modified IDS >5 were categorized as difficult intubation group (D). The GRF of all patients in group D were compared with matched patients in group E.Results: Incidence of DI was 13.6% with 2 (1.6%) cases of failed intubation. Comparing groups D and E, duration of illness was 4.28 ± 3.78 years in group D versus 7.44 ± 7.63 years group E, p = 0.1353. Neck circumference was 41.42 ±5.30 cm in group D versus 37.43±2.68 cm in group E, p = 0.0200. Tracheal deviation, narrowing and retrosternal extension, and surgical diagnosis were not significantly different among both groups.Conclusion: Incidence of DI was 13.6% and that of FI was 1.6%. Neck circumference was found to be a predictor of difficult intubation in goitre patients scheduled for thyroidectomy using the modified IDS.Keywords: Goitre, thyroidectomy, difficult intubation, predictive factors, modified intubation difficulty scor

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Relationship between tumour size and response to neoadjuvant chemotherapy among breast cancer patients in a tertiary center in Nigeria

Background Tumour biology, physiologic features such as growth fraction and physical features such as size may influence response of breast cancer to neoadjuvant chemotherapy. Molecular biology is an established basis for predicting response and selecting neoadjuvant chemotherapy. Whether physical characteristics such as size should influence chemotherapy regimen is inconclusive and has not been adequately studied in developing countries. Aim To determine the relationship between breast tumour size and response to neoadjuvant chemotherapy and hence define the role of tumour size during selection of neoadjuvant chemotherapy regimen for locally advanced breast cancer. Method: Records of women managed at the University of Ilorin Teaching Hospital, Ilorin Nigeria, with neoadjuvant chemotherapy (NAC) for locally advanced breast cancer were reviewed between January 2013 and June 2015. Data was analyzed as 2 subgroups; primary tumour ≥100 mm as group 1 and primary tumour ≥100mm as group 2. Primary outcome was 50% reduction in tumour size. Comparison was by chi-square test of independence at p value 0.05. Results 57 records were reviewed (group1=24, group2=33). Majority (37( 65%)) were premenopausal. Mean age was 47.9 ± 13.1 (range 28-85). NAC was either taxane or anthracycline based regimen. Median chemotherapy dose was 4 (range 2-6). Widest diameter of tumours was 30mm to 180mm (mean 96 ±3.8mm, median 100mm). Mean tumour diameter for groups 1 and 2 was 7.2 ±1.6mm and 12.2± 2.9mm respectively. 50% reduction in tumour size was 45.8% and 6.0% for groups 1 and 2 respectively (p=0.0001) Conclusion There was relationship between breast tumour size and response to neoadjuvant chemotherapy at a cut-off of 10mm. Well-designed prospective studies are required to confirm this relationship

Health-Seeking Behavior and Barriers to Care in Patients With Rectal Bleeding in Nigeria

Purpose: Colorectal cancer (CRC) incidence rates are steadily increasing in Nigeria. Organized screening is still largely unused because of financial and logistical barriers; most CRCs are detected by symptoms. One symptom of CRC is rectal bleeding. This study sought to determine health-seeking behavior and barriers to care in patients with rectal bleeding in Nigeria. This study also surveyed physicians to determine major breakdowns in access to care. Methods: The recruitment process for this study involved patients referred for colonoscopy because of rectal bleeding as well as response to a media advertisement for a free colonoscopy. Physicians were recruited at the African Research Group for Oncology meeting. Patient responses were scored on the basis of knowledge of rectal bleeding. The physician questionnaire was supporting information and mainly descriptive in nature. Results: A total of 82 patients and 45 physicians participated in this study. Less than 40% of patients knew that rectal bleeding could be caused by cancer. Major barriers to care were resolution of the symptom (42%), no consideration of the bleeding as problematic (40%), and financial constraint (22%). Education was strongly correlated with knowledge of rectal bleeding and health-seeking behavior. Although physicians regularly saw patients with rectal bleeding, most of them provided a differential diagnosis of hemorrhoids and few referred patients for colonoscopy. Conclusion: General awareness about the signs of colorectal cancer is lacking. This demonstrates the strong need for patient education programs about this issue. Physicians should also receive additional training on differentiation of a potential cancer diagnosis from something more benign, such as hemorrhoids

That dyspepsia in the young could be cancer

Malignant tumour of the stomach is not common in young adults. When it does occur, it is associated with a high morbidity and mortality. The objective of this report is to document our experience with three cases of gastric adenocarcinoma in young adult Nigerians seen over a period of 18 months in our centre