Solid locked intramedullary nailing for expeditious return of bone-setting-induced abnormal fracture union victims to work in South-western Nigeria

Background: Wage earning in low- and middle-income countries (LMICs) is predominantly through physical labour. Consequently, limb-related disabilities caused by abnormal fracture unions (AFUs) preclude gainful employment and perpetuate the cycle of poverty. Many AFUs result from traditional bone-setting (TBS), a pervasive treatment for long bone fractures in LMICs. The objective of this study was to accentuate the expediency of solid locked intramedullary nail in the early restoration of victims of traditional TBS-induced abnormal fracture unions (AFUs) to their pre-injury functioning, including work.

Methods: One hundred AFUs in 98 patients treated with a solid locked intramedullary nail in our center over a period of 7 years were prospectively studied.

Results: We found the mean age to be 47.97 years. Males constituted 63.9% of the patients’ population. Atrophic non-union accounted for 54.1% of the AFUs. The mean fracture-surgery interval was 21.30 months. By the 12th post-operative week, more than 75% of the fractures had achieved knee flexion/shoulder abduction beyond 900, were able to squat and smile (or do shoulder abduction-external rotation), and were able to bear weight fully.

Conclusion: The study demonstrated the expediency of solid locked nail in salvaging TBS-induced abnormal fracture unions in a way that permitted early return to pre-injury daily activities and work, thereby reducing fracture-associated poverty.

Vision impairment and self-reported anxiety and depression in older adults in Nigeria: evidence from a cross-sectional survey in Kogi State

Background
More than 2 billion people are thought to be living with some form of vision impairment worldwide. Yet relatively little is known about the wider impacts of vision loss on individual health and well-being, particularly in low- and middle-income countries (LMICs). This study estimated the associations between all-cause vision impairment and self-reported symptoms of anxiety and depression among older adults in Kogi State, Nigeria.

Methods
Individual eyes were examined according to the standard Rapid Assessment of Avoidable Blindness methodology, and anxiety and depression were assessed using the Washington Group Short Set on Functioning–Enhanced. The associations were estimated using multivariable logistic regression models, adding two- and three-way interaction terms to test whether these differed for gender subgroups and with age.

Results
Overall, symptoms of either anxiety or depression, or both, were worse among people with severe visual impairment or blindness compared with those with no impairment (OR=2.72, 95% CI 1.86 to 3.99). Higher levels of anxiety and/or depression were observed among men with severe visual impairment and blindness compared with women, and this gender gap appeared to widen as people got older.

Conclusions
These findings suggest a substantial mental health burden among people with vision impairment in LMICs, particularly older men, underscoring the importance of targeted policies and programmes addressing the preventable causes of vision impairment and blindness.

Impact of the COVID-19 Pandemic on Pediatric Surgical Volume in Four Low- and Middle-Income Country Hospitals: Insights from an Interrupted Time Series Analysis

Background
The impact of the COVID-19 pandemic on surgical care delivery in low- and middle-income countries (LMIC) has been challenging to assess due to a lack of data. This study examines the impact of COVID-19 on pediatric surgical volumes at four LMIC hospitals.

Methods
Retrospective and prospective pediatric surgical data collected at hospitals in Burkina Faso, Ecuador, Nigeria, and Zambia were reviewed from January 2019 to April 2021. Changes in surgical volume were assessed using interrupted time series analysis.

Results
6078 total operations were assessed. Before the pandemic, overall surgical volume increased by 21 cases/month (95% CI 14 to 28, p < 0.001). From March to April 2020, the total surgical volume dropped by 32%, or 110 cases (95% CI − 196 to − 24, p = 0.014). Patients during the pandemic were younger (2.7 vs. 3.3 years, p < 0.001) and healthier (ASA I 69% vs. 66%, p = 0.003). Additionally, they experienced lower rates of post-operative sepsis (0.3% vs 1.5%, p < 0.001), surgical site infections (1.3% vs 5.8%, p < 0.001), and mortality (1.6% vs 3.1%, p < 0.001).

Conclusions
During the COVID-19 pandemic, children’s surgery in LMIC saw a sharp decline in total surgical volume by a third in the month following March 2020, followed by a slow recovery afterward. Patients were healthier with better post-operative outcomes during the pandemic, implying a widening disparity gap in surgical access and exacerbating challenges in addressing the large unmet burden of pediatric surgical disease in LMICs with a need for immediate mitigation strategies.

Burden and outcome of neonatal surgical conditions in Nigeria: A countrywide multicenter cohort study

Background: Despite a decreasing global neonatal mortality, the rate in sub-Saharan Africa is still high. The contribution and the burden of surgical illness to this high mortality rate have not been fully ascertained. This study is performed to determine the overall and disease-specific mortality and morbidity rates following neonatal surgeries; and the pre, intra, and post-operative factors affecting these outcomes.

Methods: This was a prospective observational cohort study; a country-wide, multi-center observational study of neonatal surgeries in 17 tertiary hospitals in Nigeria. The participants were 304 neonates that had surgery within 28 days of life. The primary outcome measure was 30-day postoperative mortality and the secondary outcome measure was 30-day postoperative complication rates.

Results: There were 200 (65.8%) boys and 104 (34.2%) girls, aged 1-28 days (mean of 12.1 ± 10.1 days) and 99(31.6%) were preterm. Sepsis was the most frequent major postoperative complication occurring in 97(32%) neonates. Others were surgical site infection (88, 29.2%) and malnutrition (76, 25.2%). Mortality occurred in 81 (26.6%) neonates. Case-specific mortalities were: gastroschisis (14, 58.3%), esophageal atresia (13, 56.5%) and intestinal atresia (25, 37.2%). Complications significantly correlated with 30-day mortality (p <0.05). The major risk predictors of mortality were apnea (OR=10.8), severe malnutrition (OR =6.9), sepsis (OR =7. I), deep surgical site infection (OR=3.5), and re-operation (OR=2.9).

Conclusion: Neonatal surgical mortality is high at 26.2%. Significant mortality risk factors include prematurity, apnea, malnutrition, and sepsis.

Supporting strategic health purchasing: a case study of annual health budgets from general tax revenue and social health insurance in Abia state, Nigeria

Background
Tracking general trends in strategic purchasing of health financing mechanisms will highlight where country demands may exist for technical support and where progress in being made that offer opportunities for regional learning. Health services in Abia State, Nigeria are funded from general tax-revenues (GTR), and a new state social health insurance scheme (SSHIS) is proposed to overcome the failings of the GTR and expand coverage of services. This study examined purchasing functions within the GTR and the proposed SSHIS to determine if the failings in GTR have been overcome, identify factors that shape health purchasing at sub-national levels, and provide lessons for other states in Nigeria pursuing a similar intervention.

Methods
Data was collected through document review and key informant interviews. Government documents were retrieved electronically from the websites of different organizations. Hard copies of paper-only files were retrieved from relevant government agencies and departments. Interviews were conducted with seven key personnel of the State Ministry of Health and State Health Insurance Agency. Thematic analysis of data was based on a strategic health purchasing progress tracking framework which delves into the governance arrangements and information architecture needed for purchasing to work well; and the core purchasing decisions of what to buy; who to buy from; and how to buy.

Results
There are differences in the purchasing arrangements of the two schemes. Purchaser-provider split does not exist for the GTR, unlike in the proposed SSHIS. There are no data systems for monitoring provider performance in the GTR-funded system, unlike in the SSHIS. Whereas GTR is based on a historical budgeting system, the SSHIS proposes to use a defined benefit package, which ensures value-for-money, as the basis for resource allocation. The GTR lacks private sector engagement, provider accreditation and contracting arrangements while the SSHIS will accredit and engage private providers through selective contracting. Likewise, provider payment is not linked to performance or adherence to established standards in the GTR, whereas provider payment will be linked to performance in the SSHIS.

Conclusions
The State Social Health Insurance has been designed to overcome many of the limitations of the budgetary allocation to health. This study provides insights into the enabling and constraining factors that can be used to develop interventions intended to strengthen the strategic health purchasing in the study area, and lessons for the other Nigeria states with similar characteristics and approaches.

Spectrum of paediatric surgical cases in a private mission teaching hospital in Nigeria

Introduction: Establishing the nature of conditions requiring surgery among children in a particular location may be crucial for policy formulation and implementation as regards paediatric surgery. Objective: This study aimed to describe the pattern and outcome of paediatric surgical cases operated upon in a newly established paediatric surgical unit in Nigeria. Subjects and Methods: This was a cross-sectional study of all subjects that were operated upon by the paediatric surgery unit over a 28-month period. Data obtained included age, sex, diagnosis, timing of surgery, post-treatment complications and outcome. Diagnoses were categorised based on the International Classification of Diseases 11th revision for morbidity and mortality statistics. Data analysis was done using Stata version 12. Results: A total of 377 procedures were performed on 336 patients with a male-to-female ratio of 2.1:1. The median age at surgery was 36 months. Disorders of the digestive system (184, 48.8%) and developmental anomalies (119, 31.6%) accounted for majority of the cases, with inguinal hernias and hydrocoeles accounting for 17.0% of all cases. Thirty-six per cent of the procedures were emergent ones, and the overall complication rate was 23.6% (89/377). The unplanned re-operation rate was 7.4% (25/336) and mortality rate was 5.1% (17/336). Typhoid ileal perforation was responsible for 4 (23.5%) of the deaths. Conclusion: Congenital anomalies and surgical infections represent a major surgical burden among children in our sub-region of Nigeria. There is, therefore, the need for focused research on these conditions and the integration of children surgery into public health programmes for children in sub-Saharan Africa.

Cancer pain control in a Nigerian oncology clinic: treating the disease and not the patient

Introduction: inadequate pain control negatively impacts the quality of life of patients with cancer while potentially affecting the outcome. Proper pain evaluation and management are therefore considered an important treatment goal. This study assessed the prevalence of pain, the prescribing patterns, and the efficacy of pain control measures in cancer patients at the Radiation Oncology Unit of the Lagos University Teaching Hospital, Lagos.
Methods: this was a longitudinal study design recruiting adults attending outpatient clinics. Participants were assessed at initial contact and again following six weeks using the Universal Pain Assessment Tool developed by the UCLA Department of Anaesthesiology.
Results: among the patients reviewed, 34.0% (118 of 347) were at the clinic, referred for initial assessment following primary diagnosis. All respondents had solid tumours; the most common was breast cancer. The prevalence of pain at initial assessment was 85.9% (298 of 347), with over half of respondents, 74.5% (222 of 347) characterising their pain as moderate to severe. Over a quarter, 28.9% (100 of 347) of patients were not asked about their pain by attending physicians, and none of the patients had a pain assessment tool used during evaluation. In 14.4% (43 of 298) of patients, no intervention was received despite the presence of pain. At six weeks review, 31.5% (94 of 298) of patients had obtained no pain relief despite instituted measures.
Conclusion: under-treatment of cancer pain remains a significant weak link in cancer care in (Low-to-middle-income country) LMICs like Nigeria, with a significant contributor being physician under-evaluation and under-treatment of pain. To ensure pain eradication, the treatment process must begin with a thorough evaluation of the patient’s pain, an explicit pain control goal and regular reevaluation

Assessment of proton-pump inhibitor use at a tertiary teaching hospital in Nigeria

Background:
Proton-pump inhibitor (PPI) is a widely used medication class globally. Because of its good safety profile, there is a huge likelihood of inappropriate use.

Objectives:
To determine the prevalence of PPI use and indications, describe its pattern of usage, and identify factors associated with inappropriate prescriptions at a federal tertiary teaching hospital in Maiduguri, Nigeria.

Methods:
PPI prescriptions were retrospectively assessed in the General Outpatients’ Department (GOPD) and Gastroenterology Unit (GITU) of a teaching hospital. Relevant data for the study were extracted from the patients’ medical records. Chi-square or Fisher’s exact tests where appropriate were used to identify factors associated with inappropriate PPI prescriptions. A p < 0.05 was considered to be significant.

Results:
PPIs were prescribed to 73.3% (220/300) of patients, while inappropriate prescriptions were noted in 91.4% (201/220) of these patients. Epigastric pain (49.5%) was the most common PPI indication, while omeprazole was the highest prescribed (53.4%). Nearly all inpatients (98.2%), those with epigastric pain (95.7%), and patients who were prescribed intravenous PPIs had more inappropriate PPI prescriptions compared to others.

Conclusion:
This study revealed a high prevalence of PPI use and inappropriate prescriptions at the study hospital. As a result, these findings highlight the importance PPI-based stewardship program at the study hospital.

Experiences of women seeking care for abortion complications in health facilities: Secondary analysis of the WHO Multi-Country Survey on Abortion in 11 African countries

Objective
Despite evidence of acute and long-term consequences of suboptimal experiences of care, standardized measurements across countries remain limited, particularly for postabortion care. We aimed to determine the proportion of women reporting negative experiences of care for abortion complications, identify risk factors, and assess the potential association with complication severity.

Methods
Data were sourced from the WHO Multi-Country Survey on Abortion for women who received facility-based care for abortion complications in 11 African countries. We measured women’s experiences of care with eight questions from an audio computer-assisted self-interview related to respect, communication, and support. Multivariable generalized estimating equations were used for analysis.

Results
There were 2918 women in the study sample and 1821 (62%) reported at least one negative experience of postabortion care. Participants who were aged under 30 years, single, of low socioeconomic status, and economically dependent had higher odds of negative experiences. Living in West or Central Africa, rather than East Africa, was also associated with reportedly worse care. The influence of complication severity on experience of care appeared significant, such that women with moderate and severe complications had 12% and 40% higher odds of reporting negative experiences, respectively.

Conclusion
There were widespread reports of negative experiences of care among women receiving treatment for abortion complications in health facilities. Our findings contribute to the scant understanding of the risk factors for negative experiences of postabortion care and highlight the need to address harmful provider biases and behaviors, alleviate health system constraints, and empower women in demanding better care.

Surgical Capacity in Rural Southeast Nigeria: Barriers and New Opportunities

Background: Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive.

Objective: The aim was to document the state of surgical care at district hospitals in southeast Nigeria.

Methods: We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the “Lancet Commission on Global Surgery” initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing.

Findings: Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10–22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer.

Conclusion: Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as w