West Africa Journal of Medicine

CASE REPORT: Skull Base Chordoma: A Case Presentation and Review of Literature

M. O. Udoh — 2021-02-26

Chordomas are rare, aggressive, bone cancers with notochordal differentiation, a marked predilection for the axial skeleton, and higher incidence in males. Approximately 30% of chordomas occur at the skull base where they make up 0.1-0.2% of all intracranial neoplasms, and 6-16% of skull base neoplasms. Skull base chordomas typically occur between 20 and 40 years of age. We report a case of skull base chordoma in a 35 year old man, who presented with a 10 year history of symptoms, and died before treatment could be instituted. Late presentation and delay in treatment are contributing factors in the demise of this patient. The need for a high index of suspicion, early imaging and prompt referral in patients with symptoms attributable to an intracranial tumor is emphasized.

CASE REPORT: COVID-19 and Mycobacterium Tuberculosis Coinfection: A Case Report

A. A. Agada — 2021-02-26

COVID-19 is a global pandemic, with attendant high morbidity and mortality. There is no previous documentation of its coinfection with Mycobacterium tuberculosis; the single most common cause of death from an infectious disease. Management and survival from this "cruel duel" in a low resource country will be daunting. We report the case of a middle-aged man who survived and the lessons learned from a COVID-19 treatment centre in the north-central of Nigeria. The patient presented with symptoms and clinical features of COVID-19 and Mycobacterium tuberculosis was confirmed with laboratory investigation. The patient commenced anti-tuberculous medications, received nutritional support and other supportive treatment for COVID-19 infection. He was discharged home to continue follow up at the medical outpatient and the DOTS clinic. Early recognition and prompt treatment are critical for a favourable clinical outcome.

CASE REPORT: Hyper-Immunoglobulin E Syndrome and Squamous Cell Carcinoma of the Lower Lip: A Case Report

A. O. Akinboro — 2021-02-26

Hyperimmunoglobulin E syndrome is a Primary Immuno-deficiency Syndrome (PIDS) characterized by high serum immunoglobulin E, eczema rash and recurrent sinopulmonary and skin infections. In this report, we present a case of squamous cell carcinoma of the lower lip in a young patient with Hyper IgE syndrome. The patient had initially developed a chronic non-healing ulcer and a biopsy done revealed a squamous cell carcinoma. Immunodeficiency has been recognized as an essential risk factor for cancer through immune dysregulation and defective immunosurveillance.

ORIGINAL: Arterial Oxygen Saturation and other Clinical Predictors of Survival in Patients with Covid-19: A Review of Cases in a Tertiary Care Hospital in Nigeria.

S. A. Ayinbuomwan — 2021-02-26

Background: We assessed clinical parameters in patients confirmed to have COVID-19 in relation to arterial hypoxaemia and survival.

Methodology: This was a retrospective chart review of patients who were confirmed positive for SARS-CoV-2 virus by Real Time-Polymerase Chain Reaction (RT-PCR) testing. Data extracted from patients' case files included patient demographics, presenting symptoms, provisional diagnoses, and outcomes of hospitalisation. Descriptive variables were summarized; proportions were compared using Chi-square tests, and independent predictors of mortality were assessed using multivariate regression analysis. A p-value of < 0.05 was considered as statistically significant.

Results: There were a total of 61 patients with positive RT-PCR testing: mean age ± SD (minimum - maximum) was 53.0 ± 18.5 (5 months - 90) years. Persons aged 60 years and above were the largest group (n=24, 39.3%). More than half were male (n=35, 57.4%); about 43% had one morbidity; 41.0% had at least two co-morbidities. The mean (SD) arterial oxygen saturation (SpO2) was 86.9% ± 16.7. Patients who were clinically dyspnoeic at presentation, and who had co-morbidities were significantly more hypoxaemic (p = 0.026 and 0.04, respectively). Significantly more patients who had normal oxygen saturation at presentation survived (p = 0.006). None of these variables was an independent predictor of mortality, however.

Conclusion: Arterial hypoxaemia was significantly associated with dyspnoea and underlying disease, and normal oxygen saturation at presentation was significantly associated with survival. Hospital managers and clinicians may thus prioritize routine pulse oximetry, supplemental oxygen therapy and management of co-morbidities in the COVID-19 fight.

ORIGINAL: Determinants of Outcome among Under-Five Children Hospitalized with Pneumonia at a Tertiary Health Facility in South-West Nigeria.

A. O. Odeyemi — 2021-02-26

Background: Pneumonia contributes largely to mortality among children particularly in developing countries. In 2018, about 15% of all deaths in children aged less than 5 years were attributed to pneumonia globally. This study aimed to identify factors at presentation that determine mortality among children less than 5 years of age hospitalized with pneumonia.

Methods: This was a prospective observational study conducted at the Children emergency unit of Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria. Subjects were consecutive children aged between 1-60 months with clinical and radiological pneumonia. Treatment outcome and determinants of mortality were studied.

Results: A total of 129 subjects were studied with a male to female ratio of 1.5: 1. Thirteen subjects died, giving a case fatality rate of 10.1%. Mortality was associated with age <24 months (p= 0.001), severe wasting (p< 0.001), temperature >38.30C (p= 0.001), grunting (p< 0.001), central cyanosis (p < 0.001), hypoxaemia (p < 0.001), loss of consciousness (p = 0.007), severe anaemia (p < 0.001), and leucopaenia (p = 0.001). Among the significant variables, temperature >38.30C [adjusted odds ratio (OR) 34.241, 95% confidence interval (CI) 2.496 - 469.815], grunting (OR 19.444, 95% CI 1.744 - 216.725), central cyanosis (OR 43.984, 95% CI 2.001- 966.729), hypoxaemia (OR 41.883, 95% CI 1.918 - 914.495) and severe anaemia (OR 48.201, 95% CI 3.351 - 693.432) were the independent determinants of mortality.

Conclusion: Children hospitalized for pneumonia with temperature >38.30C, grunting, cyanosis, hypoxaemia, and severe anaemia are more likely to die. Hence, they must be treated intensively.

ORIGINAL: Self-Perceived Halitosis in La, a Suburb of Accra, Ghana

D. Tormeti — 2021-02-26

Background: Many individuals, irrespective of their age, sex and social status suffer from halitosis. There is very little evidence, however, of the disease burden in Ghana. The aim of this study was to determine the prevalence and associated factors of self-perceived halitosis in La, a suburb in Accra.

Methods: This was a cross-sectional study conducted among adults in La. The main outcome variable was self-perceived halitosis. Other variables collected included the socio-demographic characteristics (age, sex, occupation category, education), previous visit to a dentist, and previous/current consumption of alcohol. Background characteristics for all respondents were described, and summaries for variables reported. Cross-tabulations were done to explore the factors related to self-perceived halitosis.

Results: A total of 324 participants were involved in the study. This consisted of 165 males (51%) and 159 females (49%). The mean age of the entire population was 41.2±14.9 years. The prevalence of self-perceived halitosis among the study population was 18%, while halitosis was found to be significantly distributed among persons with bleeding gums (p=0.007) and those who poorly rated their oral hygiene (p<0.001).

Conclusion: Halitosis is a source of concern to a considerable number of inhabitants of La. Education in this regard is therefore essential in promoting awareness and better oral health practices.

ORIGINAL: Sensorineural Hearing Loss among Hypertensives

O. R. Quadri — 2021-02-26

Background: The effect of hypertension on the vascular system leads to Target Organ Damage (TOD). The cochlea is one of the target organs affected by hypertension, giving rise to Sensorineural Hearing Loss (SNHL).

Objective: To determine the prevalence and pattern of Sensorineural Hearing Loss (SNHL) among hypertensives.

Design: Case-Control Study.

Setting: Tertiary hospital.

Subjects: Two hundred and twenty six hypertensives, aged 21 to 60 years and a corresponding number of age and sex matched control.

Methodology: Eligible participants were prospectively evaluated. Their blood pressures were verified, hearing thresholds assessed through Pure Tone Audiometry, Pure Tone Average were calculated and the types and degree of hearing loss were confirmed. Data was analyzed using SPSS 21 and statistical significance was set at p-value 0.05.

Results: Each group had 127 (56.19% ) females and 99 ( 43.81 % ) males. The difference in the mean age between the cases (40.02 ± 0.70years) and the controls (37.42 ± 0.47years) was not statistically significant (p = 0.542).The difference in the mean Pure Tone Average in dBHL between the cases (15.53± 6.95) and the controls (13.98 ± 4.35) was significant (p = 0.005) with a 12.83% prevalence of SNHL among the hypertensives against 1.77% in the controls. Majority (96.6 %) of them demonstrated bilateral, symmetrical, mild SNHL with 51.7% of them being above 50 years. The odds ratio in this study was 8.17 (p = 0.0001).

Conclusion: This study demonstrated a SNHL prevalence of 12.83% with a mild, bilateral, symmetrical pattern among hypertensives; increasing with advanced age and an eight-fold risk of occurrence.

ORIGINAL: Clinico-pathological Profile of Head and Neck Tumours with Intracranial Extension

M. O. Udoh — 2021-02-26

Background: Intracranial extensions of Head and Neck region tumours are a result of direct spread, into the brain and meninges, of tumours arising in the pharynx, paranasal sinuses, orbit, middle ear, scalp, skull and neck tissues. Presenting features may resemble those of an intracranial mass, or the contiguous structure of origin, or both. Delayed diagnosis is not uncommon when patients are not able to afford diagnostic imaging or when the possibility of an intracranial extension is not readily considered in the evaluation of patients with head and neck lesions.

Aim: To highlight the important histologic entities in the head and neck region presenting as intracranial mass lesions.

Methods: This was a retrospective database study of tumours in the head and neck region with extension into the cranial cavity.

Results: We present 13 patients with intracranial extension of tumours from contiguous structures. There were 7 males and 6 females. Age ranged from 16 to 80 years. Mean age of the patients was 48.92 ± 19.13 years. Specific histologic entities included: nasopharyngeal carcinoma, olfactory neuroblastoma, squamous cell carcinoma, rhabdomyosarcoma and adenoid cystic carcinoma, amongst others CONCLUSION: Early and accurate diagnosis requires a raised awareness of tumours in the head and neck region; their likelihood to invade the cranial cavity; and a familiarity with the likely presentation. Multidisciplinary approach is needed when clinical and radiological features are suggestive of mass lesions breaching the skull and invading the brain from adjacent structures. Confirmation of clinical suspicion by histology is essential.

ORIGINAL: Profiles of Tuberculosis Patients: A Single-Center Experience in a Semi-Urban Tuberculosis Center in Southeast Nigeria

C. U. Ufoaroh — 2021-02-26

Background and objectives: Tuberculosis infection (TB) is a global healthcare problem. In Sub-Saharan African countries TB-HIV co-infection is an evil duo. This study sought to evaluate TB characterization and mortality rate in TB subjects in a semi-urban tuberculosis center in Southeast Nigeria.

Methodology: This was a retrospective study of 241 TB patients between September 2014 and August 2017. Data on clinical profiles, demography, anthropometry, occupation, HIV status, treatment, treatment outcome, and loss to treatment were retrieved and compared within subgroups.

Results: The male subjects were 97(40.2%) and female 144(59.8%). TB rate was low at extremes of age. Traders (38.2%) and artisans (17.4%) have high TB rate, with male preponderance, p=0.039. TB cure rate was 11.2%, death rate 17.4%, treatment completion 29.5%, loss to follow-up12.5%. TB-HIV co-morbidity rate was 42.3% and was high among traders, artisans, dependents, drivers, as well as civil servants, p=0.039 and specifically higher in females, p = 0.039. Low TB cure rate (25.0%) and high TB mortality rate (66.7%) occurred with TB-HIV co-infection, p=0.003.

Conclusion: TB infection declined at extremes of age, and was high among traders and artisans. TB-HIV co-infection rate was high overall, associated with low TB cure rate and high mortality rate in this study.

ORIGINAL: Caring for Children with Congenital Heart Diseases:Economic Burden of Pre-Surgical Management on Nigerian Families

C. O. Duru — 2021-02-26

Background and objectives: Managing children with Congenital Heart Disease (CHD) attracts enormous cost especially in resource-poor settings like Nigeria. This study sought to determine the healthcare costs of pre-surgical management of CHD and describe its catastrophic effects on households.

Methods: Using a semi-structured interviewer-administered questionnaire, caregivers of children with CHD were interviewed. Family income, type of CHD, co-morbidity, healthcare payment mechanism and healthcare cost were explored over 3 months prior to the study. Healthcare costs were then averaged to obtain monthly estimates. Catastrophic health expenditure (CHE) was defined as healthcare spending above 10% family monthly income. Factors associated with increased healthcare spending in CHD management were explored using the Kruskal Wallis test of significance.

Results: Of the 108 parents interviewed, 81.0% paid for healthcare using out-of-pocket payment mechanism. The median direct monthly medical and non-medical costs were N==3,625 (range: N==200 - N==59,350) [$10.07; range:$0.56-$164.86] and N==420 (range: N==150 -N ==11,000) [$1.17; range $0.42-$30.56] respectively. Hospitalisation and transportation accounted for majority of the direct medical and non-medical costs, respectively. About 36.1% of families suffered financial catastrophe. Catastrophic overshoot and mean positive overshoot were 5.6% and 30.8% above the 10% income threshold, respectively. The healthcare spending was significantly higher in families of children with CHD complicated with heart failure (p=0.001) and pulmonary hypertension (p=0.038) and those who suffered financial catastrophe (p=0.001). Health insurance did not significantly reduce healthcare spending among the insured(p=0.630).

Conclusion: The economic burden of pre-surgical management of children with CHD is high in Nigeria. Appropriate interventions governmental and non-governmental organisations are needed to cushion the burden of healthcare costs on affected families.

ORIGINAL: Rate, Indications and Outcome of Blood Transfusion in Neonates at Federal Teaching Hospital, Gombe, Nigeria

I. Jalo — 2021-02-26

Background: Blood transfusion is a lifesaving procedure with varying indications. Neonates, especially the extremely preterm are among the most frequent recipients of blood products. The indications could be from anaemia of prematurity or pathological causes such as haemolysis from ABO or rhesus incompatibility, neonatal sepsis and acute haemorrhage, among others.

Objective: To determine the rate, indications and outcome of blood transfusion in neonates at Federal Teaching Hospital Gombe, Nigeria.

Methodology: The study was retrospective and included 96 neonates who received blood transfusion at the SCBU of Federal Teaching Hospital Gombe from January, 2015 to December, 2019. Data was extracted from patients' medical records and analysed using IBM SPSS statistics version 24.

Results: The prevalence of blood transfusion was 3.5% with top up blood transfusion being the most frequent, 63 (65.6%), form. Half of the patients, 48(50%), received fresh whole blood while 45 (46.9%) received packed red cells, other types of blood products accounted for 3.1%. The most common indication for exchange blood transfusion was severe hyperbilirubinaemia followed by severe anaemia. Similarly, severe anaemia and acute haemorrhage were the main indications for top-up transfusion. Seventy-four (77.1%) patients who received transfusion were discharged while 22 (22.9%) died. Blood transfusion was significantly related to the place of delivery and admitting unit.

Conclusion: The rate of blood transfusion was low, severe hyperbilirubinaemia and severe anaemia were the main indications for blood transfusion in this study. Mortality among transfused neonates was high.

ORIGINAL: A Doctor's Experience from Covid-19

T. Ibekwe — 2021-02-26

Background: COVID-19 infection can present with a range of clinical manifestations including asymptomatic, mild, moderate, severe and critical illnesses. However, it is uncommon for a single patient to pass through all the 4-phases of the infection.

Objectives: To present my experience with COVID-19 as first responder having , passed through all the phases of the COVID-19 infections while on admission at the Isolation/Treatment centre.

Methods: Experience RESULTS: I was managed with Remdesivir, Meropenem, Dexamethasone and Clexane. In the course of the illness, I developed some severe complications including COVID-19 pneumonia and suspected adrenal gland failure. The absence of known predisposing and underlining factors in this case made it unconventional COVID-19 presentation.

Conclusion: We conclude that the presentation with the four stages of COVID-19 including suspected adrenal gland failure is a rare phenomenon. There is need for more research into this case.

ORIGINAL: Comprehensive Idiopathic Clubfoot Treatment based on the Ponseti Method: The FMC, Umuahia Experience

P. I. Amaraegbulam — 2021-02-26

Background: Clubfoot is a common foot deformity worldwide. The gold standard of treatment is the Ponseti regimen, a nonoperative method comprised of manipulation, casting, percutaneous Achilles tenotomy and bracing. There has been no report on the presentation of clubfoot and Ponseti regimen from our centre.

Objectives: This study reports the pattern of the presentation of patients with idiopathic clubfoot, the factors that affected presentation to the hospital for care and the outcomes of their treatment at the Federal Medical Center, Umuahia during a 21-month period.

Methods: This is a prospective, descriptive analytical study, recruiting patients presenting consecutively with idiopathic Clubfoot at the Federal Medical Center, Umuahia during a 21-month period and treated with the standard Ponseti method. Pirani score was used for assessment and monitoring. The data were recorded and analyzed using the IBM SPSS version 20.

Results: There were 114 patients presenting with 189 feet were seen during this period. 69 of the patients were males while 45 were females. The age range at presentation was 0-16 years, with a mean of 2.3 years. 75 patients had bilateral clubfeet and 39 were unilateral, affecting 23 right and 16 left. 47 patients had previous care including the traditional bonesetting before they came to FMC, Umuahia. 55 cases have had tenotomies and 87 patients are currently on braces. There have been 9 early relapses.

Conclusion: Ponseti treatment has a good outcome in the treatment of clubfoot in children. Ignorance and poverty were major factors that hindered parents from presenting their children for Clubfoot care early. Education and free care would change this tide.

ORIGINAL: Indications for Removal of Orthopaedic Implants in a Nigerian Tertiary Hospital: A Review of 128 Cases

D. D. Mue — 2021-02-26

Background: With expanding indications for operative fracture treatment, removal of orthopaedic implants has become a frequent elective orthopaedic procedure in developing countries. The clinical indications for implant removal are not well established and there are no specific indications despite the morbidity associated with implant removal operations.

Objective: To determine the frequency, indications and complications of removal of orthopaedic implants with a view to guiding implant removal protocol among surgeons.

Materials and methods: Retrospective data was obtained over a 5-year-period in NKST Rehabilitation Hospital, Mkar, Nigeria. One hundred and twenty-eight patients aged 4-88 years met the criteria for inclusion. Patients were followed up for at least 1 year and all complications recorded. Data was analysed using SPSS version 21.

Results: A total of 128 patients were studied. There were 84(55%) males and 44(45%) were females. The mean age was 40.0±15.5 years. The commonest indication for implant removal was infected implant in 29(22.6%) patients, followed by patient's demand 22(17.2%). Femoral plate was the commonest [29(22.6%)] implant removed, followed by tibia plate [20(15.6%)] and humeral shaft plate [7(5.5%)]. The mean duration of hospital stay was 21.7±24.1 days. Twenty-five (19.5%) patients had post-operative complications.

Conclusion: The commonest indication for implant removal was infected implant followed by patients demand. Femoral plate was the commonest implant removed. Post-operative complications included fractures, bleeding, nerve injuries and infection. Findings from this study suggest that implant removal operation may be associated with substantial morbidity. Therefore, not all orthopaedic implants require removal. Strict implant removal policy is advocated to guide the surgeon.

EDITORIAL: Challenges of Congenital Heart Disease and the Impact of Covid-19 on Health Workers.

G. E. Erhabor — 2021-02-26

It gives me great pleasure to present the February 2021 edition of the West African Journal of Medicine. The articles in this edition, as usual, cuts across numerous fields in Medicine and Surgery making it a compelling read. It also reflects the versatility of our contributors.

I am especially delighted to introduce the editorial on ‘The Challenges of Managing Congenital Heart Diseases in Africa’ by a passionate and astute Paediatric Cardiologist, who has made significant contributions to the advancement of paediatric paediatric cardiac services on the African continent - Professor Samuel Omkhodion.

Morbidity and mortality from congenital heart diseases remains unacceptably high in Africa. While most congenital heart diseases (CHD) are amenable to intervention in developed countries, needless deaths from CHD remain unabated in developing nations. Paediatric cardiovascular healthcare services are capital intensive and require the availability of modern diagnostics facilities, interventional procedures, definitive surgical solutions and matching intensive postoperative care. This editorial is very enlightening and reveals the peculiarities involved in managing congenital heart diseases in resource constrained environments like ours. The article which the editorial focused on, is quite timely and brings to fore the enormous financial burden associated with congenital heart diseases. The study describes the catastrophic effects of the cost of pre-surgical management of CHD on typical Nigerian families.

The challenges of the previous year have been rolled over into this new year and the battle with COVID-19 virus is far from over. The corona virus pandemic is still ravaging, with increased virulence as new strains of the virus are being discovered. The discovery of the UK strain of the COVID-19 virus has made the battle fiercer with increased rate of infectivity, severe infections and increased mortality. Other variants have also emerged including the South African variant and the Brazilian variant making the control of this disease more challenging.¹ The fact remains that mutations may not be susceptible to antibodies induced by currently available vaccines and might not respond to available therapies.²

Health workers globally continue to face the full brunt of this pandemic as they work at the frontline, managing patients infected with this deadly virus. The increasing number of health care workers getting infected with the virus gives cause for concern. Many healthcare workers have succumbed to the virus all over the world. A systematic analysis of health workforce infectivity and care fatality rates shows that Europe had the highest number of infections and deaths with the lowest case fatality rate while the Eastern Mediterranean region had the highest case fatality rate.³Reports from the United States of America and Mexico revealed that health workers represent ‘one in every seventh case’ of COVID-19 infections. As at mid-last year, data from 37 countries in the Pan American region showed that over 570,000 healthcare workers were infected with the virus and 2,500 died from Covid-19 in North and South America. ^4,5

Africa and India have reported a relatively lower number of infections and deaths.³ However, this is increasing in view of the second wave of the pandemic. Report from the World Health Organization’s Regional Office for Africa showed over 10,000 infections among healthcare workers in Africa, mid-last year. This is only the tip of the iceberg as cases are grossly under reported and there is paucity of data in sub-Saharan Africa. Just two months ago, within a period of a week Nigeria lost 20 doctors to COVID- 19. Recently, some hospitals have lost very senior colleagues. This calls for an increase in preventive and mitigation measures.

Most COVID-19 cases and deaths reported among the health work force were found in the 50–59 age range, while the group aged over 70 years had the highest case fatality rate.³ This is a reflection of the general trend of the disease among the populace. In this edition, a 51-year-old Nigerian frontline health care worker details his terrifying personal experience with the COVID- 19 infection. He experienced all the four phases of the infection. This brings closer home the dire consequences of infectivity with COVID-19 among health care workers. Nigeria is one of the countries with the highest number of health care workers infected by the corona virus in Africa. African countries are currently facing a crisis in the health sector with the exodus of health workers to Western countries resulting in shortage of man-power. Losing healthcare workers to COVID-19 will further compound the current precarious situation.

The government of African nations need to be more proactive in guarantying the safety of health care workers by ensuring increased testing, provision of personal protective equipment, safe working environment for health care workers, provision of prophylactic medications and the establishment of more treatment centers to cater for the increasing number of persons infected by the virus.

There is the need for strict enforcement of the COVID -19 guidelines. Isolation centers should be well equipped and maintained. Risk assessment and stratification should be done. Considerations should be made for the elderly, those with co-morbid conditions and the immunosuppressed amongst the health work force who may be at higher risk of being infected with the COVID-19. Elderly health care workers may be assigned to less risky settings such as telemedicine or administrative positions to reduce exposure. Routine testing and vaccination of health care workers for COVID-19 should be done.

We, as health care practitioners, endure considerable psychological and physical stress in caring for patients. Hence, we cannot afford to be careless. We must protect ourselves, colleagues, patients and families. It is time we all must take heed to the call ‘Physician heal thyself.’ As long as there is still one person infected with COVID-19, we cannot drop our guards.

We commend the efforts of the global health workforce in combating this pandemic and applaud the commitment of researchers who have continued to pursue laudable research in the face of such dire circumstances. We encourage you to keep sending your manuscripts for review and subsequent publication in this highly educative journal. Together, we can survive this pandemic and come out stronger.

REFERENCES

https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant.html. Accessed 16/02/2021

https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/a-new-strain-of-coronavirus-what-you-should-know. Accessed 16/02/2021

Bandyopadhyay S, Baticulon RE, Kadhum M, et al. Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review. BMJ Global Health 2020;5:e003097. doi:10.1136/ bmjgh-2020-003097

Erdema H., Lucey D.R. Healthcare worker infections and deaths due to COVID-19: A survey from 37 nations and a call for WHO to post national data on their website. International Journal of Infectious Diseases Volume 102, January 01, 2021; 239-241

https://www.paho.org/en/news/2-9-2020-covid-19-has-infected-some-570000-health-workers-and-killed-2500-americas-paho. Accessed 16/02/2021

https://www.afro.who.int/news/over-10-000-health-workers-africa-infected-covid-19

EDITORIAL: The Challenges of Managing Congenital Heart Diseases in Africa.

S. I. Omokhodion — 2021-02-26

Most African countries, especially those in sub-Saharan Africa frequently have an annual budgetary allocation to the entire healthcare sector below the WHO recommended minimum of 6%. Paediatric cardiovascular healthcare services which include the ready availability of modern diagnostics facilities, interventional procedures as well as definitive surgical solutions with extra-corporeal circulatory support and matching postoperative intensive care are capital intensive and are generally not on the healthcare priority lists of such resource-challenged countries. This is in the face of other competing health needs.

The global incidence of congenital heart diseases (CHD) is about 9 per 1000 live births. Without appropriate medical and surgical interventions, about one-third of these children (those with the most complex malformations) do not attain the age of one year before succumbing to the complications. It is known that among congenital anomalies, malformations affecting the cardiovascular system have the greatest effect on infant mortality. Congenital Heart disease is also a major contributor to childhood morbidity in developing countries. There are now almost no CHD that are not amenable to some form definitive solutions in centres where there are appropriate facilities and personnel. On the other hand, in resource challenged settings many of these preventable deaths continue unabated.

The authors of the article in this edition titled ‘Caring for children with congenital heart diseases: Economic burden of pre-surgical treatment on Nigerian families’ have brought into sharp focus the catastrophic health expenditure imposed on families who had to care for such children before they had access to definitive solutions.

This naturally begs the question, which way forward Africa? Africa has a history of outstanding performance in the field of cardiovascular surgery. Professor C.O. Easmon’s team successfully performed closure of an atrial septal defect in Accra Ghana in 1964. The world’s first human to human heart transplant led by the surgeon Christiaan Barnard was performed in Africa at the Groote Schuur Hospital in Cape Town on December 3, 1967. A surgical team from the UK led by Professor Magdi Yacoub in 1974 performed the first open heart surgery in Nigeria at the University of Nigeria Teaching Hospital (UNTH) in Enugu. The same Surgeon had earlier pioneered open heart surgical procedures in Egypt before moving on to establish the now famous Harefield hospital UK. He later became a National icon in the field, became a British citizen and was Knighted by the Queen in recognition of his many landmark undertakings in cardiac surgery. Professor Edmond Bertrand similarly led the first open heart surgery in Cote d’Ivoire in 1978. A successful pulmonary valvotomy under cardiopulmonary bypass was recorded at the University College Hospital, Ibadan by a wholly indigenous team led by Professor Adebonojo in September 1979. A further four successful open-heart procedures were carried out by the same team over the following year. But he first successful open-heart surgery in the world had taken place on July 9, 1893 in Chicago, U.S.A. and was undertaken by Dr. Daniel Hale Williams. Although we were far behind in Africa we have not shown the same accelerated progress in the field of cardiovascular surgery as we have seen more recently in other areas such as information technology. A pertinent question is, where did we go wrong?

Using Nigeria as a case study, we may find some answers and pointers to the way forward. In 1981, there was a military coup, and the economy took a nose-dive for the worse. The national currency, the Naira which previously had exchanged for 1.8 dollars suffered progressive devaluation. Consequently, imported medical equipment became quite expensive. This was compounded by dwindling government subvention to healthcare establishments and Government was no longer able to fund open-heart procedures. Patients were required to pay the full cost of their treatment which was clearly an impossible demand. This brought cardiac by-pass surgery to a halt. About the same time, highly skilled manpower could not withstand the underutilization of their skills and so began the exodus to greener pastures which became known as ‘brain drain’. Many years would pass before a good number of specialist cardiovascular healthcare personnel in the diaspora would organize into viable groups, link up with home groups to organize medical missions. One such mission was undertaken to Ibadan in 2006, and just surmounting the odds to get equipment setup, ensure uninterrupted power supply, appropriate oxygen delivery outlets and a viable postoperative intensive care proved to be a daunting undertaking on that first occasion. They could only manage two cases, a VSD and an ASD repair in 8 days with a 14-member team. There were ethical issues over the more than 80 families that turned up for screening only to have their hopes dashed when the team left. Thereafter, Ibadan linked up with Israeli, Indian, Ghanaian, and Italian groups that provided subsidized treatment for children with CHD. In about 10 years, 469 children were successfully treated with 7 surgically related mortalities and 2 non[1]surgically related mortalities.

We have taken advantage of the relationships developed with these groups to take up 28 training opportunities in the relevant disciplines as part of the human capital development component of our fresh capacity building efforts in Chennai, India and Accra, Ghana. We have had some requisite hardware acquisition through donor[1]efforts. We have also had donor assisted infrastructural development towards setting up a centre for Cardio-vascular diseases as well as a Cardio-vascular diseases research institute. These latter outcomes will provide training opportunities to meet local and regional needs as well as translational research to develop appropriate technology that will aid cost reduction and more affordable procedures. Interventional techniques that are less human capital intensive are evolving already in this regard. Hospital Management is supporting these efforts and further aid from the diaspora is being channelled to boost these efforts with a view to making the services more affordable. Finally, as the article in this edition has suggested, the national health insurance scheme could also lend support by including the definitive treatment of at least some of the more common forms of CHD on the list of coverage of the scheme. While these measures may not address all the problems, they do represent a good starting place in the management of CHDs in Africa.

REFERENCES

Omokhodion S.I. Meeting the Challenges of Pediatric Cardiovascular Healthcare in a Developing economy: the Ibadan experience. Archives of Ibadan Medicine; Child Health I Edition. 2006; 8: 26–31.
Cohen AJ, Tamir A, Houri S., Abegaz B, Gilad E, Omokhodion S, Zabeeda D, Khazin V, Ciubotaru A, Schachner Arie. Save a Child’s Heart: We can, and we should. Ann Thorac Surg. 2001; 71: 462–468.
Adebo OA. History of open-heart surgery at the University College Hospital, Ibadan. Nig J Cardiol. 2005; 2: 6–9.

Brief Communication: The Transgender Phenomenon and its Effect on the Practice of Anatomic Pathology: A Futuristic Perspective

C. A. Okolo — 2021-02-26

Introduction of the 'Transgender Phenomenon' "Dave King and Richard Ekins are the leading world sociologists in the field of transgender research. They have put together a brilliant synthesis of history, case studies, ideas and positions as they have emerged over the past thirty years, and bring together a rich and grounded account of this field, providing a state of the art of critical concepts and ideas in this field further during the twenty first century."¹ Based on two decades of fieldwork, life history work, qualitative analysis, archival work and contact with several thousand cross-dressers and sex-changers around the world, these researchers have distinguished a number of contemporary Transgendering 'stories'. 'The assignment of an individual as being of the male or female sex is most often based on the phenotypic appearance of the external genitalia at birth, which is largely determined by the chromosomal type (most commonly 46,XX or 46,XY). Gender identity, however, is an individual's perceived or experienced gender, which may or may not be the same as one's sex assigned at birth. The concept of gender identity includes gradations of masculinity to femininity and maleness to femaleness, as well as identification of some individuals as having nonbinary gender, which means being essentially neither male nor female, or a combination of both. Gender nonconformity is behavioral variation in gender expression (e.g., clothing, mannerisms, accessories, and hairstyles) from cultural and societal norms expected for that gender. Sexual orientation is defined as the physical and emotional attraction of an individual to same-sex people (lesbian or gay; homosexual), both same-sex and opposite-sex people (bisexual), or opposite-sex people (heterosexual).² Transgender is an all-inclusive term that may include all individuals whose gender identity or expression does not align with their assigned birth sex and/or those whose gender identity is outside of the binary male/female classification'.².

ERRATUM: WAJM 2021; 38(1): Page Sonographic Diagnosis of Metastatic Cervical Lymph Nodes in Primary Orofacial Malignancies: Role of the Radiologist's Experience

U. A. Okeke — 2021-02-26

Background: There is uncertainty surrounding the choice of a better imaging modality to detect metastases in cervical lymph nodes. The aim of this study is to examine the role of Ultrasound in the diagnosis of metastatic cervical lymph nodes in orofacial malignancies in a resource limited environment and the effect of the radiologist's experience in interpretation of the results.

Methods: Sixty patients with various histologically diagnosed orofacial malignancies and clinical evidence of cervical lymph nodes metastases were examined with ultrasound by a consultant and a trainee radiologist. Affected lymph nodes were subsequently biopsied and examined histologically. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were calculated. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 19 (SPSS Inc., Chicago, IL, USA) and Microsoft Excel 2010 (Microsoft, Redmond, WA, USA). Test of statistical significance was set at 0.05.

Results: Ultrasonography examination by the consultant radiologist recorded a sensitivity of 80.0%, specificity of 57.1%, PPV of 77.5%, NPV of 60.0%, accuracy of 71.7% and a P value of 0.004. The trainee radiologist recorded a sensitivity of 69.2%, specificity 38.1%, PPV of 67.5%, NPV of 40.0%, accuracy of 58.3% and a P value of 0.566.

Conclusion: Ultrasonography is useful in the diagnosis of metastatic cervical lymph nodes in orofacial malignancies and the interpretation and reliability of the results depend on the experience of the radiologist. Examination of patients should therefore be done and interpreted by an experienced radiologist.