Epidemiology and Anatomic Distribution of Colorectal Cancer in South Africa

Background: Colorectal cancer (CRC) is the 5th most common cancer in subSaharan Africa (SSA) and the 3rd most common cancer in Southern Africa. CRC characteristics in SSA, including anatomic distribution, are not well described. Objective: To describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in South Africa. Design: This was a retrospective study of CRC using the South African National Cancer Registry from 2006-2011. Main Outcome Measures: Patient age, gender, racial/ethnic group, province, histology type, and tumour location. Results: 6146 patients were included in the analysis. Among patients with adenocarcinomas, the median age of presentation was 60 (interquartile range, 49-70) years. 1372 (25%) of patients were < 50 years and 2870 (52%) were male. There were 5498 (89%) cases of adenocarcinoma (AC). 1277 (26%) CRC-AC were right colonic lesions, 1214 (25%) were left colonic lesions, and 2404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR=1.29. p< 0.001) and from Limpopo province (OR=1.46, p=0.029) were more likely to have left colonic and rectal adenocarcinoma on multivariate analysis. Patients who were black (OR=1.67, p< 0.001), had right colonic lesions (OR=1.25, p=0.007), and were from Mpumalanga (OR=1.67, p=0.007), Limpopo (OR=1.60, p=0.002), or Northwest (OR=1.76, p=0.001), were significantly associated with early onset adenocarcinoma. Conclusion: CRC-AC in South Africa presents at an earlier age than in HICs, such as the US. Early-onset CRC is higher in black South Africans who live in Mpumalanga, Limpopo, and Northwest in comparison with other provinces. The majority of colorectal cancer were leftsided and rectal; thus screening flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics of CRC-AC in South Africa are needed.

Identifying the epidemiology of traumatic injury in Benghazi, Libya through the implementation of an electronic trauma registry

Traumatic injury is the leading cause of morbidity and mortality globally, and there is little data in the literature for low middle-income countries (LMIC), although it is slowly growing. Libya has been suffering from low resources that are further strained by an ongoing civil war. Benghazi Medical Centre (BMC) is the only operating trauma public hospital in the country’s eastern region and trauma is on the rise. Currently, there is no system in place to identify the trends of traumatic injuries nor any formal surveillance. The objective of this thesis is to describe the epidemiology of traumatic injuries and identify gaps in the trauma system.Methods: This is a prospective study conducted at BMC’s emergency room through the implementation of an electronic trauma registry, iTrauma application. Data collection occurred during January of 2017 over a 10-day trial period. Upon the traumatic patient’s arrival to the emergency department twenty-five data points were collected and entered into iTrauma. Data points included patient demographics, mechanism of injury and clinical outcomes. Results: A total of 231 patients were evaluated and included into the TR. Males were at higher risk for traumatic injury making up 68% of injured patients. The average age was 31 years old, however, the majority of were in the 0-10 and 31-40 age groups. Falls were the most common cause of injury at 31%, followed closely by motor vehicle collisions at 30%. None of the patients injured in a car collision wore a seatbelt, and half of motorbike collision patients dawned helmets. The most common type of injury was bone fractures at 13% and the most common anatomical region was extremity injuries. The vast majority of trauma patients arrived by private vehicle (57%), whereas 20% arrived by ambulance. In terms of clinical outcome, 36% of patients were either treated and discharged in the ER or discharged by the 2 weeks follow up. However, there was a mortality rate of at least 11%. Conclusion: Traumatic injuries lead to a high mortality rate and carry a large burden to the individual clinically and economically. The implementation of a simple TR was shown to be feasible and has a tremendous value in identifying the epidemiology of traumatic injury, most notably falls and motor vehicle collisions. Advocating for programs that address preventative measures can have remarkable benefits in reducing morbidity and mortality. Furthermore, continued support for TR can evolve with the institution and provide ongoing improvement to quality of car

Epidemiology of Surgical Amputations in Tamale Teaching Hospital, Ghana

The current study aimed to explore the details of surgical amputations in Tamale, Ghana. This was a retrospective descriptive study. We analyzed case files of 112 patients who underwent surgical amputations
between 2011 and 2017. Demographics, site of amputation, indication for amputation, and outcomes were
retrieved from case files. Descriptive statistics were used to report the means and frequencies. Associations
between variables were assessed using Chi-Square, ANOVA, and Student’s t-test. The mean age of the participants was 43.6±23.1 years (range 2 to 86). Most (64.3%) were males. Lower limb amputations accounted for most (78.6%) cases. Diabetic vasculopathy was the most prevalent indication (44.6%), followed by trauma (36.6%). The mean hospital stay was 30.1±22.4 days (range 5 to 120). Surgical site infection (17.9%) was the main complication. In our study setting, there is thus far limited capability for proper management of diabetes mellitus, which needs to be improved. There is also an urgent need for multidisciplinary foot care teams that will help patients receive comprehensive care to reduce complications from diabetes and other vasculopathies

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy

Background: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation’s unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). Summary: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Epidemiology of injured patients in rural Uganda: A prospective trauma registry’s first 1000 days

Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of injury in rural Uganda is limited. Hospital-based trauma registries are a critical tool in illustrating injury patterns and clinical outcomes. This study aims to characterize the traumatic injuries presenting to Soroti Regional Referral Hospital (SRRH) in order to identify opportunities for quality improvement and policy development. From October 2016 to July 2019, we prospectively captured data on injured patients using a locally designed, context-relevant trauma registry instrument. Information regarding patient demographics, injury characteristics, clinical information, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. A total of 4109 injured patients were treated during the study period. Median age was 26 years and 63% were male. Students (33%) and peasant farmers (31%) were the most affected occupations. Falls (36%) and road traffic injuries (RTIs, 35%) were the leading causes of injury. Nearly two-thirds of RTIs were motorcycle-related and only 16% involved a pedestrian. Over half (53%) of all patients had a fracture or a sprain. Suffering a burn or a head injury were significant predictors of mortality. The number of trauma patients enrolled in the study declined by five-fold when comparing the final six months and initial six months of the study. Implementation of a context-appropriate trauma registry in a resource-constrained setting is feasible. In rural Uganda, there is a significant need for injury prevention efforts to protect vulnerable populations such as children and women from trauma on roads and in the home. Orthopedic and neurosurgical care are important targets for the strengthening of health systems. The comprehensive data provided by a trauma registry will continue to inform such efforts and provide a way to monitor their progress moving forward.

Epidemiological trends in community acquired acute Kidney Injury in Pakistan: 25 years Experience from a Tertiary Care Renal Unit

Background: Epidemiological studies of community acquired acute kidney injury (AKI) are sparse especially from South Asia and none has published from Pakistan. Reported incidences from different countries vary with use of different criteria of defining AKI. There is also variation found in different class of income countries, hospital based versus community based AKI.

Methods: The current study was carried out in all adult AKI patients developing community acquired AKI and coming to a tertiary care renal institution from January 1990 to December 2014. This is a retrospective data collection from patient’s records and AKI was defined according to KDIGO guidelines. Trends among different groups which are classified in medical, obstetrical and surgical were observed and presented.

Results: In medical AKI there has been found a rise in toxic rhabdomyolysis, vivax malaria and dengue infection during later part of study. In obstetrical AKI observed continuous rise in numbers contributing to total AKI during these years. Surgical AKI included obstructed cases during initial ten years and only surgical trauma during later 15 years. Older age on presentation in medical AKI, and thrombocytopenia, deranged coagulation, deranged liver function, hyperkalemia, requirement of mechanical ventilation and multi organ failure in all groups remained predictors of higher mortality.

Conclusion: From Pakistan epidemiology for community acquired AKI has never been published on a large scale and this study would remain source of great information in this regard over coming years.

Patterns of neurosurgical conditions at a major government hospital in Cambodia

Background: Low- and middle-income countries (LMICs) have a growing and largely unaddressed neurosurgical burden. Cambodia has been an understudied country regarding the neurosurgical pathologies and case volume. Rapid infrastructure development with noncompliance of safety regulations has led to increased numbers of traumatic injuries. This study examines the neurosurgical caseload and pathologies of a single government institution implementing the first residency program in an effort to understand the neurosurgical needs of this population. Methods: This is a longitudinal descriptive study of all neurosurgical admissions at the Department of Neurosurgery at Preah Kossamak Hospital (PKH), a major government hospital, in Phnom Penh, Cambodia, between September 2013 and June 2018. Results: 5490 patients were admitted to PKH requiring neurosurgical evaluation and care. Most of these admissions were cranial injuries related to road traffic accidents primarily involving young men compared to women by approximately 4:1 ratio. Spinal pathologies were more evenly distributed in age and gender, with younger demographics more commonly presenting with traumatic injuries, while the older with degenerative conditions. Conclusions: Despite increased attention and efforts over the past decade, Cambodia’s neurosurgical burden mirrors that of other LMICs, with trauma affecting most patients either on the road or at the workplace. Currently, Cambodia has 34 neurosurgeons to address the growing burden of a country of 15 million with an increasing life expectancy of 69 years of age, stressing the importance of better public health policies and urgency for building capacity for safe and affordable neurosurgical care.

Increases in cholecystectomy for gallstone related disease in South Africa

tudies suggest that the rate gallstone disease in Africa is low. Previous studies suggested an increase in gallstone rates and cholecystectomies related to urbanization and the adoption of Western lifestyle habits. This study examined cholecystectomy rates for gallstone disease in South Africa (SA). An audit of cholecystectomies in SA was done by reviewing gallbladder specimens processed by the SA National Health Laboratory Service (NHLS) from 2004 and 2014. Urbanization rates were obtained from Statistics South Africa and BMI data from previously published studies. Fisher’s exact test, t test’s and Pearson’s R were used for comparisons; cholecystectomy rates were calculated per 100,000 population. 33,467 cholecystectomy specimens were analysed. There was a 92% absolute increase in cholecystectomies during the study period (Pearson r 0.94; p < 0.01) with the overall cholecystectomy rate increasing by 65% from 8.36 to 13.81 per 100,000 population. The data was divided into two equal periods and compared. During the second period there was a 28.8% increase in the number cholecystectomies and patients were significantly younger (46.9 vs 48.2 years; p ≤ 0.0001). The Northern Cape was the only province to show a decline in the cholecystectomy rate in this period and was also the only province to record a decline in urbanization. Population based studies in SA demonstrate increases in BMI and an association with increased urbanization. This nationwide African study demonstrates a sustained increase in cholecystectomies for gallstone disease. Increases in BMI and urbanization may be responsible for this trend.

A review of the epidemiology, post-neurosurgical closure complications and outcomes of neonates with open spina bifida

Background. Spina bifida (SB) is a neural tube defect (NTD) that has an increased risk of fatal and disabling effects if not repaired early, i.e. within the first 24 to 48 hours of life. Its diagnosis holds an increased burden for the patient and the caregiver owing to secondary complications. The effects of the disease are detrimental even with early repair, because of the long-term disabling nature of the disease.

Objective. This retrospective study aimed to assess the effects of demographics, immediate post-surgical complications and impact of time to surgical intervention on the outcome of neonates with open SB (OSB) admitted to the neonatal intensive care unit (NICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa (SA), between January 2011 and December 2015.

Methods. A retrospective chart review was conducted at the NICU of IALCH. All neonates diagnosed with SB were identified. The study period was from 1 January 2011 to 31 December 2015. Data were collected from the IALCH electronic database. All neonates with SB admitted to the IALCH NICU were included; any patient who presented beyond the neonatal period (i.e. >28 days) was excluded from the study. Data collected included maternal demographics. Additionally, neonatal history was reviewed and post surgery complications evaluated. Outpatient management post discharge was reviewed.

Results. One hundred and fifty neonates were included (58% male). The mean (standard deviation) maternal age was 26.7 (6.6) years. Only 10% had an antenatal diagnosis of OSB. Seventy-eight percent were born at term and 22% prematurely. The lumbar/sacral region was the most commonly affected. More males (14%) had thoraco/lumbar lesions than females (7.8%). Forty-eight percent presented before 3 days of life (early presentation). In the late-presentation group, there was an association with wound sepsis (p=0.003). Twenty-five percent were repaired between days 0 and 3 of life and 75% after 3 days. Postoperative complications in patients whose open SBs were repaired beyond 3 days of life were not statistically significant compared with those with early repair; all were p>0.05. There was a borderline association of prolonged hospitalisation with wound sepsis (p=0.07). Long-term outcomes showed that 68% had lower limb dysfunction, 18% urological complications, 14% limb deformity, and 11% hydrocephalus. A minority had psychomotor (7%) and developmental (15%) disorders. Ten percent required readmission secondary to shunt complications, and 7% died.

Conclusion. SB remains a significant disease burden that affects outcome and survival of neonates in SA. Lack of good antenatal care, which includes early ultrasound and timely referral to centres, are barriers to good outcomes. Long-term follow-up is also necessary to prevent morbidity.

Epidemiology of surgical valvular heart diseases in a north african tertiary referral hospital

Introduction
The etiology of valvular heart disease (VHD) has changed dramatically in the last five decades. In the western world, the significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of VHD induced the metamorphosis in the etiology of valvular disorders. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology.

Methods
A retrospective study involving the 246 last patients hospitalized in our department and proposed for valvular surgery from January 2012 to December 2017.

Results
The mean age was 57 years. One hundred twenty-one patients were male (49%). Before surgery mean LVEF is 60% ± 13. Ten percent of the patients were operated with (left ventricular dysfunction LVEF ≤ 40%). Arterial hypertension, diabetes mellitus and smoking are respectively present in 29, 7%, 21, 8% and 27, 7% of the patients. A history of rheumatic fever was present in 60, 8% of rheumatic valvular disease. The rheumatic etiology was the most important (50,5%). A preoperative coronary angiography was performed in 63,4% of the patients and coronary artery disease was associated to the valvular heart disease in 14,9%. Mitral valve replacement, aortic-valve replacement and double valve replacement were respectively performed in 38,7%, 35,4% and 18,7% of the cases. Bioprothesis were implanted in 5,29% of the cases. One eighth of the patients underwent coronary artery bypass graft in addition to the valvular surgery. In 16,8% of the cases it was a redo surgery.

Conclusion
Contemporary epidemiological data show a rise of the degenerative etiology and associated coronary artery disease. Surgery offers good results for patients with significant valvular heart disease. Valve replacement and repair are the main surgical options. Older patients and redo procedures are increasingly frequent.