Hereditary Susceptibility for Triple Negative Breast Cancer Associated With Western Sub-Saharan African Ancestry: Results From an International Surgical Breast Cancer Collaborative.

OBJECTIVE: To investigate subtype-specific risk of germline alleles associated with triple negative breast cancer (TNBC) in African ancestry populations. BACKGROUND: Breast cancer (BC) mortality is higher in African American (AA) compared to White American (WA) women; this disparity is partly explained by 2-fold higher TNBC incidence. METHODS: We used a surgically maintained biospecimen cohort of 2884 BC cases. Subsets of the total (760 AA; 962 WA; 910 West African/Ghanaian; 252 East African/Ethiopian) were analyzed for genotypes of candidate alleles. A subset of 417 healthy controls were also genotyped, to measure associations with overall BC risk and TNBC. RESULTS: TNBC frequency was highest in Ghanaian and AA cases (49% and 44% respectively; P < 0.0001) and lowest in Ethiopian and WA cases (17% and 24% respectively; P < 0.0001). TNBC cases had higher West African ancestry than non-TNBC (P < 0.0001). Frequency of the Duffy-null allele (rs2814778; an African ancestral variant adopted under selective pressure as protection against malaria) was associated with TNBC-specific risk (P < 0.0001), quantified West African Ancestry (P < 0.0001) and was more common in AA, Ghanaians, and TNBC cases. Additionally, rs4849887 was significantly associated with overall BC risk, and both rs2363956 and rs13000023 were associated with TNBC-specific risk, although none as strongly as the Duffy-null variant. CONCLUSIONS: West African ancestry is strongly correlated with TNBC status, as well as germline variants related to BC risk. The Duffy-null allele was associated with TNBC risk in our cohort.

Comparative Analysis of Breast Cancer Phenotypes in African American, White American, and West Versus East African patients: Correlation Between African Ancestry and Triple-Negative Breast Cancer.

INTRODUCTION: Triple-negative breast cancer (TNBC) is more common among African American (AA) and western sub-Saharan African breast cancer (BC) patients compared with White/Caucasian Americans (WA) and Europeans. Little is known about TNBC in east Africa. METHODS: Invasive BC diagnosed 1998-2014 were evaluated: WA and AA patients from the Henry Ford Health System in Detroit, Michigan; Ghanaian/west Africans from the Komfo Anokye Teaching Hospital in Kumasi, Ghana; and Ethiopian/east Africans from the St. Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia. Histopathology and immunohistochemistry for estrogen receptor (ER), progesterone receptor (PR), and HER2/neu expression was performed in Michigan on formalin-fixed, paraffin-embedded samples from all cases. RESULTS: A total of 234 Ghanaian (mean age 49 years), 94 Ethiopian (mean age 43 years), 272 AA (mean age 60 years), and 321 WA (mean age 62 years; p = 0.001) patients were compared. ER-negative and TNBC were more common among Ghanaian and AA compared with WA and Ethiopian cases (frequency ER-negativity 71.1 and 37.1 % vs. 19.8 and 28.6 % respectively, p < 0.0001; frequency TNBC 53.2 and 29.8 % vs. 15.5 and 15.0 %, respectively, p < 0.0001). Among patients younger than 50 years, prevalence of TNBC remained highest among Ghanaians (50.8 %) and AA (34.3 %) compared with WA and Ethiopians (approximately 16 % in each; p = 0.0002). CONCLUSIONS: This study confirms an association between TNBC and West African ancestry; TNBC frequency among AA patients is intermediate between WA and Ghanaian/West Africans consistent with genetic admixture following the west Africa-based trans-Atlantic slave trade. TNBC frequency was low among Ethiopians/East Africans; this may reflect less shared ancestry between AA and Ethiopians.

HYDATID CYST DISEASE IN THE LEFT LATERAL NECK: AN UNCOMMON PRESENTATION.

Cysts commonly occurring in the neck include thyroglossal cyst and dermoid cysts in the midline, cystic thyroid nodules, branchial cysts and cystic Hygroma in the lateral neck. Hydatid cyst disease is commonly seen in the right lobe of the liver, the lung and rarely in other parts of the body. In general, cysts in the neck are not common in the second decade of life. In this article, we present a case of hydatid cyst presenting as left lateral cystic mass in an Ethiopian boy. The diagnostic difficulty, the need for diagnostic suspicion and consideration of hydatid cyst in the differential diagnosis and the management options are discussed.

REFERRAL OF EMERGENCY SURGICAL PATIENTS IN A TERTIARY HOSPITAL, ADDIS ABABA, ETHIOPIA.

Introduction: Referral is part of patient care when done appropriately. Common reasons for referral include seeking expert advice, technical examination and/or intervention, care beyond the facility's capacity. Objectives: Determine the rate, reason for and type of cases referred among patients seen at surgical Emergency Room of SPHMMC during May to July 2015. Patients and Methods: Cross sectional study was done at St. Paul's Hospital Millennium Medical College Emergency Room, including all surgical patients seen in three months period. Data was collected from the individual patient's medical records, records of the ER and the liaison office and Interns morning reporting book. Data was analyzed with SPSS version 20. Results: Total of 2,492 patients were seen. The mean number of patients seen per day was 27.7 with a range from 13 to 51. Trauma made 70% (1746) of all cases seen. Cases that needed admission made 30.1% (755), but only 49.5 % (374) of them were admitted. The overall referral rate was 15.3%. The referral rate in patients who needed admission was 50.5 % (381). Trauma made 77.4% (295) of the referrals, mainly orthopedic, 54.6% (161) and neuro-traumas, 38% (112). Among non trauma cases acute abdominal conditions tops, 75% (56). Lack of inpatient beds was the main reason for referral 65.6% (250). Specialist care need was the reason for referral in 34.5% (131) of cases. Among patients referred only 14.4% (55) left the hospital at the time of referrals. Four percent (13) of the kept patients died in the ER waiting for referrals. Conclusions: The rate of referral from St. Paul's Hospital Millennium Medical College Emergency Room is high. It is higher in trauma cases, specifically orthopedic and neuro-traumas. Main reason for referrals was lack of bed. The capacity of the hospital and other hospitals in AA in absorbing traumas, specifically orthopedic and neurotraumas need to be evaluated and necessary policy adjustments should be implemented. Further study at each hospital and the whole city gives better picture of referrals among hospitals in Addis Ababa.

Surgical residents' perceptions of the operating theatre educational environment at St. Paul's Hospital Millennium Medical College: A cross-sectional survey.

Background: The educational environment refers to the "climate" that influences all aspects of learning in an educational context and the experience in the operating room is particularly crucial in surgical residents learning. Hence, this study aimed to assess surgical residents' perceptions of the operating theatre educational environment and associated factors in the surgical department at St. Paul's Hospital. Methods: This cross-sectional study was conducted in March 2022 among surgical residents at St. Paul's Hospital Millennium Medical College to assess their perceptions of the operating room educational environment using the OREEM questionnaire. Descriptive statistics (mean, median, SD) were used to summarize demographic data and OREEM scores. The student t-test and one-way analysis of variance (ANOVA) testing followed by posthoc tests were used for comparison of quantitative data, with p-values < 0.05 considered significant. Results: Of the participants, 103 (79.8%) were male and 26 (20.2%) were female with a mean age of 28 years. The overall mean score was 69% with subscale scores for teaching and training at 47.9/65.0 (73.7%), learning opportunities at 34.5/55.0 (62.7%), the atmosphere at 28.9/40.00 (72.4%) and workload/supervision/ support at 27.5/40.0 (68.7%). Male and female residents differed significantly in perceptions of "atmosphere" (t127 = 3.35, p < 0.001) and in junior versus senior residents' perceptions of the "learning opportunities" and "atmosphere" at p-values of 0.023 and 0.028 respectively. However, age, marital status, and specific surgical training programs did not have a significant effect on the scores. Conclusion: Overall, residents had positive perceptions of their training and teaching, learning opportunities, the atmosphere in the operation theatre, and the supervision they received in the operation theatre. The operating room's "teaching and training" component received the highest score, while the operating room's "learning opportunities" component received the lowest. This indicates the importance of establishing a positive learning environment with sufficient "hands-on" experience, especially during emergencies. In addition, preoperative planning, case discussions, and feedback after the surgery should be routine.

Reduction of In-Hospital Preoperative Waiting Time of Elective Surgeries in the Amidst of COVID-19 Pandemic: Experience from Ethiopia.

Background: The higher demand for surgical services during the advancement of the COVID-19 pandemic has resulted from the need for a pre-admission negative result, the need for extra resources, and a shortage of skilled expertise. This quality improvement project aimed to reduce the in-hospital preoperative waiting time of elective cases to less than 24 hours. Methods: The study was conducted in a tertiary care center. Following the collection of baseline data, we formed a multidisciplinary team to analyze the root causes and intervention ideas of delay using fishbone and driver diagrams, respectively. We prioritize key drivers and implemented several low-cost interventions using Plan-Do-Study-Act (PDSA) model. We monitored the average in-hospital preoperative waiting time of patients. Results: Overall, in-hospital preoperative waiting time for elective cases has been reduced from a baseline of 4.89 days to 1.32 days on average by the end of 10 months of initiating the project. Similarly, monthly elective case cancellation rate due to COVID-19-related reason has been reduced from baseline 62.5% of the total cancellation to 0%. Due to this, the average monthly inpatient bed utilization has increased from 2.21 patients per month during pre-COVID-19 period to 5.9 patients per month in each bed of the surgical ward by the end of the project. Conclusion: The implementation of a quality improvement project can optimize operation theatre efficiency, inpatient bed utilization, and reduce the surgical backlog. Meticulous and rigorous effort has to be laid down to do root cause analysis, generate feasible change ideas, and continuous follow-up, and testing of multiple PDSA cycles is required to impact an improvement and sustain it in the long run. The emergence of COVID-19 pandemic could be used as an opportunity to reduce the length of stay in the hospital.

Clinical Profile and Outcome of Patients Operated on for Renal Cell Carcinoma: Experience from a Tertiary Care Center in a Developing Country.

Purpose: With nearly 500,000 new cases and over 150,000 deaths worldwide in 2020, renal cancers remain a significant component of the global burden of cancer. The aim of this study is to describe the clinical presentation, peri-operative condition and short-term outcome of patients operated with the primary diagnosis of renal cell carcinoma (RCC) at a large tertiary care referral center. Patients and Methods: A retrospective institution-based study was done. The study population consisted of all patients who were operated for a primary diagnosis of renal cell carcinoma from January 1st, 2015, to December 31st, 2020, at the Urology Unit of St Paul's Hospital Millennium Medical College. Results: The final cohort consisted of 107 patients (mean (standard deviation) age 49 (±14) years, 48% male, 46% residence in Addis Ababa). The most common presenting complaint was flank pain (65%), followed by hematuria (34%) and abdominal mass (6%). One patient had the classic triad of RCC. The median (IQR) duration of illness was 9(7-11) months. Fourteen (13%) patients were asymptomatic and diagnosed incidentally. Over half (57%) of the cohort were clinical TNM stage II, with the remaining 17%, 18% and 8% being stage I, III and IV, respectively. Nearly all patients (94%) underwent open radical nephrectomy with a transabdominal approach. Most patients (61%) had no Clavien-Dindo grade complications, and a minority (11%) experienced post-operative complications (7% postoperative bleeding, 6% hospital acquired pneumonia, 3% surgical site infection). The median (IQR) length of stay was 6 (5-7.6) days. Nearly all patients (94%) were discharged and improved. Conclusion: In this retrospective study, we have shown that patients operated for RCC are a low-risk cohort with few comorbidities, have a relatively short symptomatic course and good discharge outcome. Further prospective studies are needed to show the long-term outcome and factors associated with such outcomes in this patient population.

African Ancestry-Associated Gene Expression Profiles in Triple-Negative Breast Cancer Underlie Altered Tumor Biology and Clinical Outcome in Women of African Descent.

Women of sub-Saharan African descent have disproportionately higher incidence of triple-negative breast cancer (TNBC) and TNBC-specific mortality across all populations. Population studies show racial differences in TNBC biology, including higher prevalence of basal-like and quadruple-negative subtypes in African Americans (AA). However, previous investigations relied on self-reported race (SRR) of primarily U.S. populations. Due to heterogeneous genetic admixture and biological consequences of social determinants, the true association of African ancestry with TNBC biology is unclear. To address this, we conducted RNA sequencing on an international cohort of AAs, as well as West and East Africans with TNBC. Using comprehensive genetic ancestry estimation in this African-enriched cohort, we found expression of 613 genes associated with African ancestry and 2,000+ associated with regional African ancestry. A subset of African-associated genes also showed differences in normal breast tissue. Pathway enrichment and deconvolution of tumor cellular composition revealed that tumor-associated immunologic profiles are distinct in patients of African descent. SIGNIFICANCE: Our comprehensive ancestry quantification process revealed that ancestry-associated gene expression profiles in TNBC include population-level distinctions in immunologic landscapes. These differences may explain some differences in race-group clinical outcomes. This study shows the first definitive link between African ancestry and the TNBC immunologic landscape, from an African-enriched international multiethnic cohort. See related commentary by Hamilton et al., p. 2496. This article is highlighted in the In This Issue feature, p. 2483.

Investigation of triple-negative breast cancer risk alleles in an International African-enriched cohort.

Large-scale efforts to identify breast cancer (BC) risk alleles have historically taken place among women of European ancestry. Recently, there are new efforts to verify if these alleles increase risk in African American (AA) women as well. We investigated the effect of previously reported AA breast cancer and triple-negative breast cancer (TNBC) risk alleles in our African-enriched International Center for the Study of Breast Cancer Subtypes (ICSBCS) cohort. Using case-control, case-series and race-nested approaches, we report that the Duffy-null allele (rs2814778) is associated with TNBC risk (OR = 3.814, p = 0.001), specifically among AA individuals, after adjusting for self-indicated race and west African ancestry (OR = 3.368, p = 0.007). We have also validated the protective effect of the minor allele of the ANKLE1 missense variant rs2363956 among AA for TNBC (OR = 0.420, p = 0.005). Our results suggest that an ancestry-specific Duffy-null allele and differential prevalence of a polymorphic gene variant of ANKLE1 may play a role in TNBC breast cancer outcomes. These findings present opportunities for therapeutic potential and future studies to address race-specific differences in TNBC risk and disease outcome.

Patterns of Surgically Treated Thyroid Disease: A Two Years Review at St. Paul Hospital Millennium medical Collage, Addis Ababa, Ethiopia.

BACKGROUND: Thyroid disease is a common disorder of the endocrine system worldwide. It is a common problem in developing countries, including Ethiopia. The aim of this study was to determine the burden and the pattern of thyroid disease in St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. METHODS: A retrospective review of patients' medical records over a two-year period, January 2013-december 2014, was done. OR log books, and individual patient medical records was used for the review. Data was analyzed with SPSS version 20. RESULTS: A total of 2201 general surgical operations were done in a two-year period. Of these, 250(11%) were for thyroid surgery. Records of 222(88.8%) patients were found and used for analysis. Females accounted for 91.4% with F: M ratio of 10.7:1. The common mode of presentations were anterior neck swelling (91.4%) and toxic (29.7%) and pressure symptoms(19.4%). The common physical findings identified were multi nodular goiter (57.2%), diffuse goiter (23.9%) and solitary nodule (5.8%). FNAC showed that Nodular colloid goiter was common diagnosis (68.5%). Neoplasms accounted for 15.9% of the diagnosis; of this follicular neoplasm make (54%) and papillary cancer (20%). Functionally, hyperthyroid goiter 28.8% and euthyroid goiters (64 %). Transient hypocalcaemia (3.2%) and hoarseness of voice (1.8%) were the commonest complications. There was no postoperative mortality. CONCLUSION: Hyperthyroidism and neoplasms make significant proportions of the patients. Follicular neoplasm is the commonest tumor. Morbidity and mortality rates are comparable to the literature.

Indications and Outcome of Patients who had Re-Laparotomy: Two Years' Experience from a Teaching Hospital in a Developing Nation.

BACKGROUND: Complications from abdominal surgery may necessitate a second or more surgeries, re-laparotomy. It is associated with significant morbidity and mortality. Data on relaparotomy from the developing nations is limited. This study aims to assess the indications and outcome of patients who had relaparotomy. METHODS: A retrospective review of medical records of all patients who underwent Re-laparotomy at St. Paul's Hospital Millennium Medical College from January 2016 to December 2017 was done. RESULT: Of 2146 laparotomies, 6.9% (149) needed re-laparotomy and 129 patients were analyzed. Most (123,95.3%) had on-demand re-laparotomy. Patients operated on emergency made 70.5% (91) of the cases making the ratio of emergency to elective surgery 2.4:1. The three most common surgeries that needed re-laparotomy were, Perforated appendicitis (35,27.1%), bowel obstructions (28,21.7%) , and trauma (20,13.4%). The most common indications for relaparotomy were intra-abdominal abscess (57,44.23%), wound dehiscence (17,13.2%) and anastomotic leak (15 ,11.6%). Surgical site infection (128,100%) and malnutrition (58,45%) were the leading complications. The overall mortality rate was 12.8 % (19). There was no statically significant difference in mortality rate between on-demand and planned re-laparotomy (P=0.388), urgency of the primary surgery (P=0.891) and the number of relaparotomy (p=0.629). Re-laparotomy for anastomotic leak (p=0.001) and patients above fifty years of age (P=0.015) had significant associations with mortality. CONCLUSION: Intra-abdominal abscess collection, wound dehiscence and anastomotic leak were the most common indications of re-laparotomies. Age above fifty years and anastomotic leaks were significantly associated with mortality.

Ileosigmoid Knotting: Analysis of Patients Clinical Profiles and Determinants of Outcomes.

INTRODUCTION: Ileosigmoid knotting (ISK) is an uncommon form of bowel obstruction due to wrapping of the ileum or sigmoid colon around the base of the other. It is associated with poor prognosis. Data on ISK are scarce in our country. The aim of this study was to assess clinical profiles, management, and outcome of patients operated for ISK. Methodology. A retrospective analysis of all patients operated for ISK at St. Paul's hospital millennium medical college (SPHMMC) from February 2014 to January 2020 was performed. RESULTS: A total of 28 patients (M: F = 3 : 1) were studied. The mean age was 41.7 years (SD ± 19.5) and ranged from 18 to 80 years. The mean duration of illness was 1.6 days (SD ± 1.1). Abdominal pain and vomiting were seen in all patients followed by abdominal distention (24, 85.7%) and failure to pass feces or flatus (23, 82.1%). Preoperative diagnosis was correct in 6 (21.4%) patients. Almost all patients (26, 92.8%) had gangrenous bowel. The commonest procedure performed was resection of the gangrenous segments with primary ileoileal anastomosis and sigmoid end colostomy (16, 57.1%). Complications were seen in 11 (39.3%) patients and the commonest being surgical site infection (SSI) (7, 25%). Death occurred in 6 (21.4%) patients, and it was significantly (p=0.020) associated with intraoperative shock (systolic blood pressure (SBP) < 90 mmHg). CONCLUSION: ISK lacks specific clinical features and imposes a significant rate of bowel strangulation, which deserves high index of suspicion and urgent laparotomy. The choice of surgical procedure should be determined by intraoperative bowel status and patients' general condition.

Female Breast Cancer Patients, Mastectomy-Related Quality of Life: Experience from Ethiopia.

BACKGROUND: Mastectomy is the most common form of treatment for a developing-nation woman diagnosed with breast cancer. This can have huge effect on a women's quality of life. OBJECTIVE: To assess mastectomy-related quality of life in female breast cancer patients. MATERIALS AND METHODS: A facility-based cross-sectional descriptive study was conducted from February 1st to July 30th, 2018. A pretested structured data collection format was used to interview patients. The European Organization for Research and Treatment for Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) and Breast Cancer-Specific (EORTC QLQ-BR23) were used to evaluate quality of life, functional capacity, and symptom scales. Data was analyzed with SPSS version 23. RESULTS: The mean age of the 86 patients was 43.2 years (SD ± 11.4) and ranged from 25 to 70 years. 54.7% (47) of patient's mastectomy was done on the right side. Based on EORTC QLQ-C30 global health status/QOL scale, the mean score was 48.3. On the evaluation of EORTC QLQ-BR23, future perspective about their health was low with a mean of 40.3 and their sexual functioning and enjoyment were significantly affected with mean scores of 85.3 and 71.2, respectively. Symptom scales were low with mean from 19.1 to 24.5. Majority (49, 57%) of respondents do not want to have breast reconstruction after mastectomy. CONCLUSION: Our breast cancer patients who underwent mastectomy performed poor in terms of quality of life as compared to international findings which demands attention in incorporating psychosocial aspects in the treatment plan.

Giant Appendicolithiasis Presenting with Chronic Abdominal Pain and Mass: A Case Report.

BACKGROUND: Appendicitis is the most common cause of acute abdomen. The diagnosis of appendicitis can be easy when it presents with the classical symptoms or is very challenging when present with atypical presentation. Around 20-30% of patients operated on for appendicitis have appendicolithiasis. Appendicolithiasis are usually small in size, and are called giant when more than 2cm in size. CASE DETAIL: A 36 years old man was referred from a district hospital with a diagnosis of cecal cancer. His complaints were right lower quadrant (RLQ) abdominal mass of 03 months and pain of 18 months duration. Colonoscopy was normal but abdominal CT showed a RLQ mass with a dense radio-opaque shadow at its center. CONCLUSIONS: Giant appendicolith is a rare condition. A high index of suspicion and careful review of imaging findings is the key in early diagnosis and improved patient outcomes.

Huge thyroglossal duct cyst at the supra-sternal notch.

Thyroglossal duct cysts (TGDC) are the most common congenital cysts in the neck. TGDC typically present as a midline swelling anywhere between the foramen cecum and the isthmus of the thyroid gland. Majority occurs just below the hyoid bone and those descending below the thyrohyoid membrane are rare. TGDC are usually less than 3 cm in diameter while big cysts are uncommon. We present a 19 years old female patient who presented with giant (12 cm diameter) supra-sternal notch cyst which was diagnosed as TGDC only after histopathology. The rarity of such huge TGDC in such uncommon site, which was misdiagnosed as a retention cyst (Mucocele) made us report this case.

Colorectal Anastomosis Leak: Rate , Risk Factors and Outcome in a Tertiary Teaching Hospital, Addis Ababa Ethiopia, a Five Year Retrospective Study.

BACKGROUND: Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of perioperative risk factors for colorectal anastomosis leak helps to identify patients requiring increased postoperative surveillance. METHODS: Institution based retrospective study was done to determine colorectal anastomosis leak rate and risk factors associated with it at a teaching hospital in Addis Ababa Ethiopia. Patients operated from January 2013 to December 2017 G.C were included. Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events on postoperative anastomotic leakage. RESULTS: Inclusion criteria were met by 221 patients. Mean age of patients was 46.44(SD=19.1) with range of 1 to 85 years. Male accounted to 166 (74.8%) of the patients. Anastomotic leakage occurred in 12 (5.2%) of the patients. Mean time to diagnosis was 9.55 days (95% CI, 7.2-11.8) after surgery. Univariate analyses showed high preoperative level of creatinine, ASA score III and IV, emergency operation, operative time more than three hours, and malignant diseases were associated with colorectal anastomosis leak. Multivariate logistic regression model failed to show an association. Colorectal anastomosis leak increased the inpatient mortality rate by 50%. Median length of hospitalization in colorectal anastomosis leak group was 27.5 days, versus 7 days in patients without leak. CONCLUSION: Colorectal anastomosis leak remains common problem after colorectal surgery resulting significant post-operative mortality and morbidity.

Schistosomal Peritonitis Presenting as Acute Abdomen: A Case Report.

BACKGROUND: Schistosomiasis is a trematode infestation causing a chronic granulomatous disease in various organs. Both S. mansoni & S. haematobium are endemic in Ethiopia. Most infected individuals are asymptomatic. Ectopic schistosomiasis can affect the lungs, genitalia, CNS, skin, peritoneum, Lymph nodes & other organs. Schistosomiasis as a cause of acute abdomen is seldom reported. CASE DETAIL: A 51 years-old male Ethiopian farmer presented with a two weeks history of abdominal pain with recent onset bilious vomiting and abdominal distention. Emergency laparotomy done & the finding was multiple tiny whitish nodule over the peritoneum & small bowel with multiple mesenteric lymphadenopathy. The diagnosis was confirmed with histopathology study. CONCLUSIONS: Schistosomal peritonitis is a very uncommon form of schistosomiasis. Physicians should be aware of such atypical presentation in patients from endemic areas of schistosomiasis. And biopsy should be considered in unsettled forms of peritonitis during laparotomy. The pathogenesis is not well known which warrants further study.

Appendiculo-ileal knot presenting at the third trimester of pregnancy.

Though appendicitis is the most common cause of acute abdomen, the vermiform appendix as a cause of small bowel obstruction is a rarity. The inflamed appendix can cause obstruction by making a knot around the small bowel. There are only few case reports on Appendico-ileal knotting (AIK). We have not found any report on AIK causing small bowel obstruction during pregnancy. The diagnosis of acute abdomen in pregnancy is difficult due to the accompanying anatomic and physiologic changes. Because obstruction due to AIK present like any other cause of obstruction diagnosing the condition pre-operatively is uncommon. Here, we report 30 years old Gravida 9, Para 8 women who presented with cardinal symptoms of small bowel obstruction at term and found to have AIK intra-operatively. The challenge of difficulty in making the diagnosis and management options are discussed.

Laparotomy for Abdominal Injury Indication & Outcome of patients at a Teaching Hospital in Addis Ababa, Ethiopia.

BACKGROUND: Abdominal injury is among the major causes of trauma admissions. The aim was to determine etiology, commonly injured organs, indication and outcome of patients with abdominal injuries requiring laparotomy. METHODS: A retrospective study of all adult patients who underwent laparotomy for abdominal injury at St. Paul's Hospital Millennium Medical College was conducted from January 2014 to December 2016. The factors associated with outcome were identified with bivariate and multivariate logistic regressions. RESULTS: Laparotomy for abdominal injury was performed for 145 patients. Of these, 129 (89%) case records were retrieved. The male to female ratio was 6.2:1. The mean age was 29 years, and most of them were unemployed. Penetrating trauma was the commonest injury, stab (46, 35.7%) and Road Traffic Accidents (RTA) (27, 20.9%) being the leading causes. Extra-abdominal injuries were seen in 33.3% (46) of the cases. Hollow organs were commonly injured than solid organs. Small intestine (35, 43.8%) and Spleen (17, 34.7%) were the leading injured organs in penetrating and blunt respectively. The main procedure performed was repair of hollow and solid organ laceration/perforation (70,54.3%). The negative laparotomy rate was 4.6% (6). Complications were seen in 23(17.8%) patients, the commonest being irreversible shock (7,30.4%). The mortality rate was 8.5 % (11), and it was significantly associated with blunt abdominal injury (AOR=7.25; 95% CI 1.09-48.37; p=0.041) and systolic blood pressure<90mmHg (AOR=8.66; 95% CI 1.1-68.41; p=0.041). CONCLUSION: Stab and RTA were the commonest indications of laparotomy. The mortality was significantly associated with blunt abdominal injury and hypotension (SBP<90mmHg).

Types of Cancers Diagnosed and the Preference of Families of Adult Patients with Cancer about Disclosing Diagnosis to the Patients.

BACKGROUND: Cancer has become one of the top causes of death in developing nations killing more people than the common infectious diseases do. For several reasons, disclosing cancer diagnosis to the patient is a challenging job for physicians and family members. MATERIALS AND METHODS: A cross-sectional study was done to determine the common cancer diagnosis and the preference about disclosing cancer diagnosis to the patients among attendants of adult cancer patients seen at the regular surgical OPD of St. Paul's Hospital Millennium Medical college (SPHMMC) in June 1-31st 2015. Medical records of the patients and face-to-face interview with attendants were used to generate the data and analysis was done with SPSS version 19.0. RESULTS: A total 112(7.3%) patients were diagnosed to have cancer and 104 attendants (93%) were interviewed. The mean age of the patients was 48.2 years, Females made up 59% of the patients. The commonest cancer diagnosed was breast cancer. Male (62.7%) and children (36.1%) were the main attendants. Only 56.6% of the attendants agreed that patients should be the first to know diagnosis results. When possible, 84.3% preferred to hide diagnosis. Although 81.3% attendants did not like diagnosis disclosure to the patient, all of them wanted to know the diagnosis if they develop cancer. Nearly all, 98.8%, of the attendants preferred to hear the diagnosis from their doctors. CONCLUSIONS: Cancer is a relatively common diagnosis occurring at a younger age. The rate of cancer diagnosis disclosure acceptance and practice by attendants was low. Population-based and multicentre study with a larger sample size is recommended to define the condition better.