Implementing oncology clinical trials in Nigeria: a model for capacity building

Background: There is both higher mortality and morbidity from cancer in low and medium income countries (LMICs) compared with high income countries (HICs). Clinical trial activities and development of more effective and less toxic therapies have led to significant improvements in morbidity and mortality from cancer in HICs. Unfortunately, clinical trials remain low in LMICs due to poor infrastructure and paucity of experienced personnel to execute clinical trials. There is an urgent need to build local capacity for evidence-based treatment for cancer patients in LMICs.

Methods: We conducted a survey at facilities in four Teaching Hospitals in South West Nigeria using a checklist of information on various aspects of clinical trial activities. The gaps identified were addressed using resources sourced in partnership with investigators at HIC institutions.

Results: Deficits in infrastructure were in areas of patient care such as availability of oncology pharmacists, standard laboratories and diagnostic facilities, clinical equipment maintenance and regular calibrations, trained personnel for clinical trial activities, investigational products handling and disposals and lack of standard operating procedures for clinical activities. There were two GCP trained personnel, two study coordinators and one research pharmacist across the four sites. Interventions were instituted to address the observed deficits in all four sites which are now well positioned to undertake clinical trials in oncology. Training on all aspects of clinical trial was also provided.

Conclusions: Partnerships with institutions in HICs can successfully identify, address, and improve deficits in infrastructure for clinical trial in LMICs. The HICs should lead in providing funds, mentorship, and training for LMIC institutions to improve and expand clinical trials in LMIC countries.

Inverted flap technique with air tamponade and one day face down positioning for posttraumatic macular hole surgery in a young male patient in sub-Saharan Africa

Introduction: Surgery has been the mainstay of macular hole treatment since the first description of its success. Different techniques are, however, described. Our case report looks into the use of the inverted flap technique for managing patients with posttraumatic full thickness macular holes with a single day supervised face down positioning and air tamponade.

Case Report: A 32-year-old young man sustained blunt ocular trauma to his left eye while under training seven months prior to presentation with reduced central vision and metamorphopsia. On examination visual acuities were best corrected 6/6 in the right and 6/60 in the left, anterior segments were normal. Fundoscopy revealed flat retinae, and extensive linear chorioretina scars in the posterior pole suggestive of healed choroidal ruptures and a posttraumatic stage 4 full thickness macular hole (FTMH) in the left. The FTMH measured 877 μm on optical coherence tomography (OCT). The patient had a macular hole surgery using the inverted flap technique with one-day face down positioning and air tamponade. Significant hole closure was seen in the first postoperative week and by six weeks after surgery, the macular hole was fully closed and vision improved to 6/6 best corrected. The inverted flap technique with air tamponade and one day face down positioning can offer another option to retina surgeons treating complex macular holes. Early visual recovery and ability to undertake air travel immediately after surgery is an additional advantage.

Conclusion: Using the inverted flap technique for surgery provides surgeons with another option for repair of complex FTMHs, like those secondary to trauma that have been known to respond poorly to initial standard repair.

Cancellation of Elective Surgical Cases in a Nigerian Teaching Hospital: Frequency and Reasons

Background: Dwindling economic resources and reduced manpower in the health sector require efficient use of the available resources. Day of surgery cancellation has far reaching consequences on the patients and the theatre staff involved. Full use of the theatre space should be pursued by every theatre user.

Objective: The study aimed to report on the rates and causes of day of surgery cancellation of elective surgical cases in our hospital as a means towards proffering solutions.

Materials and methods: It was a retrospective study of all elective cases that were booked over a 15-month period from January 2016 to March 2017. Cancellation was said to have occurred when the planned surgery did not take place on the proposed day of surgery. Cancellations were categorized into patient-related, surgeon-related, hospital-related and anesthetist-related. Reasons for the cancellations were documented. Data were analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 22. Variables were compared using Chi-square tests. A value of P < 0.05 was considered statistically significant. Results: During the 15-month period, a total of 1296 elective surgeries were booked. Of this, 118 (9.1%) cases were cancelled. Patient-related factor was the most common reason (47.5%) followed by surgeon-related factor (28%). Lack of funds was the most common patient related-reason for cancellation. Majority of the cancelled cases were general surgical cases (36.4%) followed by orthopedics (25.4%) and urology (11%). Seventy percent of the cancelled cases were first and second on the elective list. Conclusion: The cancellation rate in this study is high. The reasons for these cancellations are preventable. To ensure effective use of the theatre, efforts should be made to tackle these reasons.

Association of Gynecological Endoscopy Surgeons of Nigeria (AGES) Advisory on Laparoscopic and Hysteroscopic Procedures During the COVID-19 Pandemic

Coronavirus 2, or SARS-CoV-2 disease (COVID-19) is a global public health concern. Although there is a paucity of evidence to advise on the best practice, we recommend postponement of elective gynecological endoscopic surgeries until the pandemic is contained. Emergency surgeries should preferably be done through open surgeries than laparoscopy or hysteroscopy approach. However, if or when laparoscopy or hysteroscopy is considered, health personnel in theatre must wear appropriate personal protective equipment (PPE) and all standard precautions should be observed to prevent COVID-19 infection. When COVID-19 is highly suspected or confirmed, the patient should be referred to centers equipped in taking care of such cases.

Non-endoscopic management of a giant ureterocele: a case report in resource poor African hospital

Ureterocele is a cystic dilatation of the distal sub mucosal part of the ureter. It is a congenital anomaly that may co-exist with other anomalies. It has an incidence 1 in 4000 live births. Patients present with symptoms at paediatric age or may remain asymptomatic till adulthood. Our 30 year old female patient was assessed for a giant orthotropic right ureterocele with obstructive uropathy, in a hospital that has no modern facilities for endoscopic treatment. She then had successful open surgical repair of the ureterocele with satisfactory outcome. Minimally invasive endoscopic treatment options remains the gold standard. Patients from poor resource regions can as well be treated successfully by open surgical repair like our index case presented.

Popliteal fossa reconstruction with medial genicular artery flap in a low resource setting: A report of two cases

Background: Popliteal fossa defects are common arising from several causes. Options of reconstruction around the knee could be limited by the cause of defect or interventions. Medial genicular artery flap is known in the books but not in popular use despite its obvious advantages of superior vascularity, adequate size, suppleness, and hidden donor site.

Aim: To promote the use of this flap due to its advantages and ease of use especially in resource poor settings.

Patients and methods: We report two patients from a low resource setting aged 23 and 20 years respectively. The first case was managed for avulsion wound of the popliteal fossa while the second had post burn knee contracture release. The resultant large popliteal fossa defects on both patients were seen on clinical examination. Both patients were offered popliteal fossa reconstruction for the popliteal fossa defects using medial genicular artery flap with good outcome.

Conclusion: The medial genicular artery flap is a veritable option of popliteal fossa reconstruction especially for defects that are located contiguous to the flap and when other regional flap options are not available. Flap survival is excellent and donor site is hidden

Lagos state ambulance service: a performance evaluation

Objectives: The mortality rate from road traffic accidents (RTAs) in Nigeria is almost double that of the USA. In Nigeria, the first emergency medical services (EMS) system was established in March 2001, The Lagos State Ambulance Service (LASAMBUS). The objectives of this study are to (1) determine the burden of RTAs in Lagos, (2) assess RTA call outcomes, and (3) analyze LASAMBUS’s response time and causes for delay.

Methodology: We reviewed completed LASAMBUS intervention forms spanning December 2017 to May 2018. We categorized the call outcomes into five groups: I. Addressed Crash, II. No Crash (False Call), III. Crash Already Addressed, IV. Did Not Respond, and V. Other. We further explored associations between the (1) causes for delay and outcomes and (2) response times and the outcomes.

Results: Overall, we analyzed 1352 intervention forms. We found that LASAMBUS did not address 53% of the RTA calls that they received. Of this, Outcome II. No Crash (False Call) accounted for 26% and Outcome III. Crash Already Addressed accounted for 22%. Self-reported causes for delay were recorded in 180 forms, representing 13.7% of the RTA burden. Traffic congestion accounted for 60% of this distribution.

Conclusion: LASAMBUS response rates are significantly lower than response rates in high-income countries such as the USA and lead to increased RTA mortality rates. Eliminating causes for delay will improve both LASAMBUS effectiveness and RTA victims’ health outcomes. Changing the public perception of LASAMBUS and standardizing LASAMBUS’ contact information will aid this as well.

Challenges and Outcome of Management of Gastroschisis at a Tertiary Institution in North-Eastern Nigeria

Introduction: Gastroschisis is a congenital anterior abdominal wall defect characterized by herniation of abdominal contents through a defect usually located to the right side of the umbilical cord. It occurs in about 1 in 2,000–4,000 live births and is slightly commoner in males. Management has remained challenging in the low and middle-income countries, with high mortality rates. This study highlights the clinical presentation, treatment, outcomes, and challenges in the management of gastroschisis at a tertiary healthcare center in a resource-limited setting.

Methods: This was a retrospective review of the records of all patients with gastroschisis managed over a period of 30 months (January 2016–June 2018). Data on patients’ demographics, age, birth weight, clinical presentation, method of gastroschisis reduction and closure, complications, and outcomes were collated. Statistical analysis was performed using SPSS version 20. A p < 0.05 was considered significant.

Results: Twenty-four patients with gastroschisis were managed. Of these, 18 patients had data available for analysis. There were 14 males, with a male-female ratio of 3.5:1. The median age at presentation was 11.0 h (range 1–36 h). Ten patients (55.6%) were delivered in a medical facility. One patient had type II jejunal atresia and transverse colonic atresia as associated anomalies. Improvised silos were applied by the bedside in 15 (83.3%) patients, while two patients (11.1%) had primary closure under general anesthesia. One patient died before definitive treatment could be done. Sterile urobags and female condoms were used for constructing improvised silos in 9 (60%) and 6 (40%) patients, respectively. Eight patients who had initial silo application had complete bowel reduction over a median time of 8.0 days (mean 10.0 ± 6.5days, range 2–23 days). Total parenteral nutrition was not available. The average time to commencement of feeding was 8.0 days ± 6.6 (median 6.0 days, range 2–22 days). Full feeding was achieved in five patients (two patients in the primary closure group and three from the silo group) over a mean time of 16.8 days ± 10.4 (median 14.0 days). Sepsis was the commonest complication. Four patients (22.2%) survived.

Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters

Background
Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system.

Methods
Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method.

Results
Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them.

Conclusion
This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.

Affording Unavoidable Emergency Surgical Care – The Lived Experiences and Payment Coping Strategies of Households in Ibadan Metropolis, Southwestern Nigeria

Background
Pre-payment and risk pooling schemes, central to the idea of universal health coverage, should protect households from catastrophic health expenditure and impoverishment; particularly when emergency care is required. Inadequate financial protection consequent on surgical emergencies occurs despite the existence of risk-pooling schemes. This study documented the experiences and coping strategies of slum and non-slum dwellers in a southwestern metropolis of Nigeria who had undergone emergency surgery.
Methods
In-depth interviews were conducted with 31 participants (13 slums dwellers, 18 non-slum dwellers) who had recently paid for emergency surgical care in Ibadan. Patients who had experienced catastrophic health expenditure from the use of emergency surgical care were identified and people who paid for the care were purposively selected for the interviews. Using an in-depth interview guide, information on the experiences and overall coping strategies during and after the hospitalization was collected. Data were analyzed inductively using the thematic approach.
Results
The mean age of the 31 participants (consisting of 7 men and 24 women) was 31 ± 5.6years. Apathy to savings limited the preparation for unplanned healthcare needs. Choice of hospital was determined by word of mouth, perceptions of good quality or prompt care and availability of staff. Social networks were relied on widely as a coping mechanism before and during the admission. Patients that were unable to pay experienced poor and humiliating treatment (in severe cases, incarceration). Inability to afford care was exacerbated by double billing and extraneous charges. It was opined that health care should be more affordable for all and that the current National Health Insurance Scheme, that was operating sub-optimally, should be strengthened appropriately for all to benefit.
Conclusion
The study highlights households’ poor attitude to health-related savings and pre-payment into a social solidarity fund to cover the costs of emergency surgical care. It also highlights the factors influencing costs of emergency surgical care and the role of social networks in mitigating the high costs of care. Improving financial protection from emergency surgical care would entail promoting a positive attitude to health-related savings, social solidarity and extending the benefits of social health insurance.