The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications.

BACKGROUND: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. METHODS: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. RESULTS: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. CONCLUSIONS: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. CLINICAL TRIAL REGISTRATION: NCT03044899.

Population-based prevalence of abnormal cervical cytology findings and local risk factors in Ibadan, Nigeria: implications for cervical cancer control programs and human papilloma virus immunization.

OBJECTIVE: To investigate the prevalence of abnormal cervical cytological findings and local risk factors in Ibadan, Nigeria. STUDY DESIGN: All women aged ≥15 years in each household in Idikan, Ibadan, were invited to participate in a population-based study. Structured questionnaires were administered to all consenting women. Conventional cervical Papanicolaou smears obtained from sexually active women were classified using the 2001 Bethesda system. The diagnoses were correlated with sociodemographic data and risk factors. RESULTS: Of 2,870 women aged ≥15 years estimated to live in Idikan, 1,204 sexually active women consented to pelvic examination and cervical smears. Results were available for 1,104 women (mean age: 39.8 years). Mean ages at menarche, first sexual intercourse and first pregnancy were 16.1, 20.3 and 20.7 years, respectively. Cytological results were categorized into atypical squamous cells of undetermined significance and atypical glandular cells 22 (1.99%); low-grade 43 (3.89%) and high-grade squamous intraepithelial lesions (HSIL) 17 (1.54%); invasive cancer 2 (0.18%) and normal 593 (53.8%) and reactive changes 427 (38.7%). The prevalence of epithelial abnormalities is 7.6%. Significant host-related factors in those with HSIL and invasive cancer included older age (mean 56.2 years), high parity and gravidity, lack of formal education and being divorced (p < 0.05). CONCLUSIONS: This study provides prevalence data and local risk factors for abnormal cervical cytology in a Nigerian population, which will be useful for planning future cervical cancer control programs.

Towards the quantification of perioperative cardiovascular risk in the African context: A sub-analysis of the South African Surgical Outcomes Study and the African Surgical Outcomes Study.

BACKGROUND: The burden of cardiovascular disease in patients requiring non-cardiac surgery in Africa is not known. These patients are at increased risk for postoperative cardiovascular complications. OBJECTIVES: In this sub-study, to use data on comorbidities and surgical outcomes from two large observational studies, the South African Surgical Outcomes Study (SASOS) and the African Surgical Outcomes Study (ASOS), to investigate the prevalence of cardiovascular disease in elective surgical patients and the risk of postoperative cardiovascular complications in this population. METHODS: SASOS and ASOS were both prospective, observational cohort studies that collected data over 1 week in each participating centre. The primary outcome was in-hospital postoperative complications, which included prespecified and defined cardiovascular complications. We defined the cardiovascular disease burden of patients aged ≥45 years presenting for surgery (main objective), determined the relative risk of developing postoperative cardiovascular complications (secondary objective) and assessed the utility of the Revised Cardiac Risk Index (RCRI) for preoperative cardiovascular risk stratification of elective, non-cardiac surgical patients in Africa (third objective). RESULTS: The primary outcome analysis of 3 045 patients showed that patients with major cardiac complications were significantly older, with a higher prevalence of hypertension, coronary artery disease or congestive cardiac failure, and had undergone major surgery. In-hospital mortality for the cohort was 1.2%. CONCLUSIONS: The substantial burden of cardiovascular disease in patients presenting for non-cardiac surgery in Africa is shown in the principal findings of this study. The RCRI has moderate discrimination for major cardiac complications and major adverse cardiac events in African patients undergoing non-cardiac surgery.

Knowledge of Cervical Cancer and Cervical Cancer Screening Methods Among Female Secondary School Students in Ibadan, Nigeria.

Cervical cancer is the most common cancer of the female genital tract worldwide and a leading cause of cancer-related deaths. For many years, the cervical Papanicolaou smear or Pap Test has been the standard method for cervical cancer screening. Screening with a Pap test has been shown to reduce the cervical cancer incidence by 60-90% and mortality by up to 90%, especially when more than 70% of those at risk accessed the test. The objective of the current study was to ascertain the level of knowledge of screening for cervical cancer among female secondary school pupils, since they were or would soon be at risk of the disease. This cross-sectional descriptive study recruited 361 female secondary school students from three different schools in Ibadan. Data was obtained over a period of five months, using a structured self-administered questionnaire, and analysed using the Statistical Package for Social Sciences (SPSS) version 22. Of the 361 respondents aged 10 to 21, 78.7% had heard about cervical cancer but only 11% had good knowledge about it. Nearly 85% of the respondents had never heard about cervical cancer screening methods. Pupils attending private schools were more likely to have a better knowledge of cervical cancer screening methods than those attending public schools (p < 0.001). Majority of the secondary school students were not equipped with sufficient knowledge about cervical cancer, its causation and the screening methods to prevent it. Such information ought to be included in the curricula of secondary schools.

Trends in The Patterns of Cancers in Nigerian Women Over Five Decades.

Cancers are major contributors to mortality among women in developing countries, with patterns changing over time. This study was done to ascertain the changes in trends and patterns of breast, cervical and ovarian cancers in women over two periods of one decade each, thirty-five years apart. Data on breast, cervical and ovarian cancers in Nigerian women over the two ten-year periods were obtained from the Ibadan Cancer Registry, using a well-structured proforma with extraction of information such as age, cancer sites and year of presentation. The extracted data were analyzed and related to information provided by the International Agency for Research on Cancer (IARC). There were about 400 cases of breast, cervical and ovarian cancers from 1960 to 1969 with cervical cancer having the highest relative frequency, while about 3000 cases of these cancers were reported from 2004 to 2013, with breast cancer having the highest ratio frequency. The age group with the highest frequencies for the three cancer types from 2004 to 2013 was 40 - 49 years, while it was 60 - 69 years from 1960 to 1969. Mean ages at presentation were 48.96 ± 13.32, 54.40 ± 13.41 and 44.42 ± 16.99 years for breast, cervical and ovarian cancers respectively. Breast and cervical cancers are the two commonest cancers in Nigerian women over the five-decade period, with breast cancer overtaking cervical cancer as the most frequently diagnosed. The number of cancer cases recorded increased seven-fold and the peak age group at diagnosis of breast cancer dropped by about twenty years over the period.

Abdominal pregnancy at the University College Hospital, Ibadan: a ten-year review.

Fourteen cases of abdominal pregnancy managed at the University College Hospital, Ibadan, Nigeria, over a ten-year period (January 1994 to December 2003) were reviewed. The incidence ratio of abdominal pregnancy was one in 654 deliveries. It accounted for 4.3% of ectopic pregnancies. Age range was 20 to 43 years; 63.4% of the patients were unemployed and 50% were nullipara. Pre-operative diagnosis was possible only in half of the cases. Only two patients with advanced pregnancies and live fetuses (14.3%) were allowed to have conservative management while the others had immediate laparotomy. Live birth rate was 7.1%, but overall fetal survival rate was 0%. Fetal malformations were common, with talipes equinovarus and jaw abnormalities occurring in 49.2% and 14.3% respectively. Twelve patients (85.7%) who had complete removal of the placenta, though lost more blood, had better outcome than those with placenta left in-situ. The case fatality rate was 7.1%.

Cervico-vaginal foetal fibronectin: a predictor of cervical response at pre-induction cervical ripening.

CONTEXT: Not all pregnant women with an "unripe" cervix can be successfully ripened by the cervical ripening agents; therefore tests with predictive information are justified. OBJECTIVES: To examine the effect of the presence of foetal fibronectin (FFN) in the cervico-vaginal secretions on pre-induction cervical ripening with either intravaginal Misoprostol or transcervical Foley catheter. METHODOLOGY: Twenty (20) patients managed at a tertiary health institution in South-western Nigeria between March and May 2003 were randomised for cervical ripening by either intravaginal Misoprostol or Transcervical Foley catheters. Cervico-vaginal secretions were assessed for presence of FFN with Foetal Fibronectin Enzyme Immunoassay Kit (Adeza Corp.) prior to commencement of cervical ripening. MAIN OUTCOME MEASURES: FFN status, Pre-ripening and Pre-induction modified Bishop scores and duration of cervical ripening. RESULTS: Ten of the fifteen patients with positive membrane immunoassay for FFN achieved ripened cervix (modified Bishop score > or = 6) within 6 - 12 hours of exposure to the agents of cervical ripening. In the FFN negative group, only 2 of the five patients achieved ripe cervix within the >12 - 18 hours period, the rest being in the >18 - 24 hours period. CONCLUSION: Foetal fibronectin test may offer useful predictive information prior to institution of processes of cervical ripening in patients with unfavourable cervices.

Total ovulating period: any contribution to ovarian carcinogenesis?

The etiology of ovarian cancer has many postulates including that of incessant ovulation. Women of high parity especially those that breastfeed in addition are supposed to be protected. Ovarian cancer patients in the developing world are of higher parity than their Caucasian counterparts. Our study compared the length of reproductive career (LRC), the physiological ovulation free period (PFP) and the total ovulating period (TOP) amongst histologically proven ovarian cancer patients and age - matched controls. This is a questionnaire survey of 21 ovarian cancer patients managed by us between 1st December 1998 and 31st July 2002 and 42 gynaecological patients not known to have ovarian cancer. The mean age among the patients was 45.7+16.9 years while among the controls it was 45.4 +/- 16.1 years. The mean parity of the patients was 3.6 +/- 2.2 compared to 3.4 +/- 2.9 in the controls. The patients had a mean LRC of 23.8 +/- 11.2 years while in the controls it was 25.7+10.8 years. The mean PFP of the patients was 7.4 +/- 5.6 years and for the controls 7.1 +/- 6.5 years. The patients had a mean TOP of 15.8 +/- 8.8 years while this was 18.6 +/- 8.1 years for the controls. None of these differences was statistically significant. Our study revealed no statistically significant differences in the total ovulating periods between ovarian cancer patients and age-matched controls. Further studies will be necessary.

Comparison of changes in pre-induction cervical factors' scores following ripening with transcervical foley catheter and intravaginal misoprostol.

The study compares the changes in the cervical factors in pre-induction cervical ripening with both transcervical Foley catheter and Intravaginal Misoprostol. This was a randomised prospective study of pregnant women, with singleton gestations who presented for antenatal care and delivery at a tertiary health institution in the South-western Nigeria between 1st March 2003 and 31st March 2004. One hundred and two (102) patients received 50microg intravaginal Misoprostol and Ninety-six (96) received size 16F Transcervical Foley catheters. Both groups were similar at the baseline. Misoprostol group showed greater improvement in the final cervical length score, with 38.4% and 58.6% scoring 2 and 3 respectively, in contrast with the Foley catheter group where 77.7% had final score of 1, with only 16% scoring 2 and none scored 3 (P = 0.00). Ninety-one percent of the patients in the misoprostol group achieved the maximum cervical consistency score of 2, contrasting with the 31.9% in the Foley Catheter group (P = 0.00). 64.9% of the patients in the Foley catheter group did not achieve appreciable change in cervical consistency. Our findings indicate that intravaginal misoprostol was more effective in improving the scores of cervical length and consistency, while transcervical Foley catheter was better at improving the cervical os dilatation score at pre-induction cervical ripening. The clinical implication is that, patients for pre-induction cervical ripening can be selected for either of these ripening agents based on which cervical factors require improvement in scores

Mobilization for cervical cancer screening: lessons from a poor-urban Yoruba community in Nigeria.

Cervical cancer is a major public health problem worldwide and it remains one of the commonest malignancies in Nigeria. Screening remains the most effective tool for the detection of pre-invasive stages of cervical cancer, giving the opportunity for prompt and effective treatment before the emergence of invasive disease. In Nigeria, as in most developing countries, the concept of screening for cancer and its pre-emptive treatment is underdeveloped. The fact that the facilities and logistics for cervical cancer screening are generally located in the hospital setting, a place where one goes when ill, according to local beliefs, makes acceptance more difficult. That Nigeria urgently needs to set up or develop cervical screening programmes that will reach women outside the hospital setting in a culturally acceptable milieu is not in doubt. A community cervical screening survey for the prevalence of cervical intraepithelial neoplasia and HPV infection was initiated in Idikan, a poor-urban inner core area of Ibadan. The challenges and experiences encountered in the execution of the project which could serve as useful knowledge to those undertaking similar exercises, requiring mass mobilization for cancer screening of an uninformed group, are highlighted. Our experience in the course of this study is important as it brought out the probable influences of community dynamics and social organization in illness decisions and prescriptions for health operative in this particular population group. Cervical cancer screening programmes should therefore make provisions to accommodate the occasional outcomes as we had encountered. In addition, screening programmes in developing societies would require sensitive designs that should address the cultural attitudes, personal conflicts, expectations of treatment and overall context of preventive care.

The psychosocial burden of caring for some Nigerian women with breast cancer and cervical cancer.

In Nigeria, the rising incidence of cancer and the paucity of institutional facilities and specialist man-power implies that the burden of care rests largely on relatives. We assessed the severity of indices of psycho-social and economic burden among relatives of women with breast and cervical cancer; and its relationship with patients' psychosocial distress. Using a burden questionnaire, relatives of 73 women with cancer (41 cervical and 32 breast, mean age of caregivers 35.6 years) were interviewed, in out-patient clinics. While the caregivers admitted high frequency of all indices of 'objective' burden, emotional ties at home and social relationships in the neighbourhood seemed intact, indicating tolerance and lack of social stigma. The financial burden was more problematic than the effect of caring on family routines; and these two factors significantly predicted global rating of burden. The severity of patient's worries and psychopathological symptoms were not significantly correlated with care-giver global rating of burden. The tolerance shown by this group of relatives implies that they have strong potentials for playing useful roles in community care of patients.

Cytologic detection of urinary bladder involvement in cervical cancer.

One-hundred and four patients with advanced carcinoma of the cervix had their urine specimens collected, at the time of cystoscopy, for cytologic detection of the presence of malignant cells. Forty-eight (46%) of the patients had evidence of bladder mucosal involvement at cystoscopy. The overall sensitivity of urine cytology in detecting bladder mucosal involvement was 56%, with a specificity of 93%. The predictive value for a positive result was 87% and the accuracy of the test was 76%. The findings indicate that urine cytology is a useful test for detecting bladder mucosal involvement in cervical cancer where cystoscopy is not available.

Pregnancy in hemoglobin sickle cell patients at the University College Hospital, Ibadan.

A retrospective review of pregnancy outcome in hemoglobin (Hbsc) patients managed at the University College Hospital, Ibadan over a 5-year period (1984-1988) was carried out. The main antenatal complications included anemia (51.2%), bacterial infection (22.0%), bone pain crisis (7.3%) and preeclampsia (2.4%). Intrapartum complications included anemia (29.2%), bone pain crisis (12.2%) and pseudotoxemia (4.9%). The maternal and perinatal mortality rate were 48 and 195 per 1000, respectively. The duration of labor and operative delivery rate were not different from the general population.

Effect of saline and glucose infusions of oxytocin on neonatal bilirubin levels.

OBJECTIVE: To ascertain the effect of isotonic saline and glucose infusions of oxytocin on neonatal bilirubin levels. METHOD: Eighty-two parturient Nigerian women requiring oxytocin infusion in labor were randomized into two groups receiving 0.9% saline or 5% glucose, respectively. A group of 82 women not requiring oxytocin were recruited for comparison. All had sodium and bilirubin estimations in cord plasma and neonatal bilirubin assay on Day 3. RESULT: Analysis of variance revealed higher mean cord and neonatal bilirubin levels in the glucose group compared with the other two (P < 0.05). Significant inverse correlation was observed between cord plasma sodium and neonatal bilirubin levels in all groups. Hyperbilirubinemia occurred in 55% of babies in the glucose group compared with 21% and 22% in the saline and control groups, respectively (P < 0.001). CONCLUSION: The use of isotonic saline rather than 5% glucose solution as vehicle for oxytocin infusion in labor appears to be associated with lower neonatal bilirubin levels.

Duration of human singleton pregnancies in Ibadan, Nigeria.

Analysis of gestation length in an obstetric population of indigenous African women revealed a mean pregnancy duration of 274.8 days, which is similar to values recorded in women of African descent elsewhere, but about 1 week less than what generally has been reported in women of European ancestry and Japanese women. Factors associated with lower pregnancy duration among these women include increasing maternal age and gravidity, and the birth of a male infant. It is concluded that mean pregnancy duration in Nigerian women is shorter than the 280 days normally used in obstetric calculations. The consistent finding of a shorter length of gestation in these and other black women suggests earlier maturity of the fetoplacental unit. Earlier institution of antepartum fetal monitoring in women of African descent, particularly women > 30 years old and those with high parity, may reduce the risks of fetal morbidity and mortality attributable to postmaturity in their offspring.

Effects of using either saline or glucose as a vehicle for infusion in labour.

Seventy pregnant Nigerian women requiring oxytocin for the induction or augmentation of labour were randomized into two groups, one administered 5% glucose, and the other 0.9% saline as vehicle for oxytocin. Another group of seventy women who did not receive intravenous fluids in labour were included for comparison. Sodium ion concentration in maternal antepartum and postpartum plasma as well as umbilical cord plasma samples were estimated in all the patients. There was a statistically significant fall in the maternal postpartum plasma sodium concentration relative to the ante-partum values only in patients receiving 9% glucose solution (P less than 0.001). There was also a significant correlation between the sodium levels in maternal postpartum and cord plasma samples, suggesting that these changes were transmitted to the fetus transplacentally. The use of normal saline as a vehicle for oxytocin administration in parturient women can prevent the hyponatraemia associated with the use of 5% glucose for this purpose.

Management of cervical intraepithelial neoplasia where colposcopy is not available.

A study was carried out to determine the effectiveness of the various methods used for treating patients with cervical intraepithelial neoplasia (CIN) detected by the cervicovaginal smear screening programme at the University College Hospital, Ibadan, Nigeria, over a period of five years. During the period, 3 004 patients were screened, of whom 292 (9.7 pc) had smears suggestive of CIN. There were no facilities for colposcopic evaluation of the patients. The patients were treated by cryotherapy, electrocautery, conization of the cervix and hysterectomy. Persistence rates of CIN after cryotherapy and electrocautery were 30.3pc and 31.2pc respectively. There was no evidence of persistent CIN in patients treated with conization or hysterectomy. It is suggested that in the absence of colposcopic guidance, conization or hysterectomy should be used to treat CIN rather than blind application of locally destructive methods like cryotherapy and electrocautery, particularly the higher grades of CIN.

Ultrasonography as an adjunct to hydrotubation in the management of female infertility.

Thirty one female patients who were being investigated for infertility had hydrotubation with ultrasound monitoring (sonosalpingography) in addition to the standard tubal patency tests of hysterosalpingography (HSG) and dye test at laparoscopy. Compared to the standard tests, sonosalpingography (SSG) had a sensitivity of 90 to 100 pc and a specificity of 95 pc in detecting bilateral tubal occlusion. In the detection of side-specific patency of the tubes, SSG had a sensitivity of 94 pc and 89 pc when compared with HSG and laparoscopy respectively. The corresponding specificity values were 83 pc and 85 pc. Hydrotubation enhanced the ability of ultrasonography to detect such uterine abnormalities as uterine synechae, intrauterine septa and submucous fibroids. It was concluded that sonosalpingography is a sensitive and relatively safe screening method for assessing tubal patency in infertile women. It also provides valuable information about the uterine wall and uterine cavity.

Awareness of cervical cancer, Papanicolaou's smear and its utilisation among female undergraduates in Ibadan.

A survey was conducted among 421 undergraduates of the University of Ibadan using self-administered questionnaires probing into their risk factors for neoplastic cervical lesions, awareness of cervical cancer, Papanicolaou's smear and its utilisation. The percentage of sexually active respondents was 81.5%. Sexual exposure before the age of 20 years occurred in 51.7%. The mean age at sexual debut was 18.8 years while the modal age was 18 years. Fifty seven per cent had multiple sexual partners, but only 38.1% used condoms. Seventy one per cent were aware of cervical cancer, while only 33.5% were aware of Papanicolaou's smear. Awareness was found to be more among medical students and the married ones. On the other hand, only 8.3% of them had ever done a Papanicolaou's smear. There is a need to increase awareness and incorporate cervical screening into the pre-existing university health services. Also, logistic barriers to cervical screening need to be removed.

Invasive cervical carcinoma in two sisters.

The occurrence of pre-invasive cervical carcinoma among siblings and in mother-daughter pairs has been reported previously in Europe. Invasive cervical cancer diagnosed in two Nigerian sisters within a period of three months is reported. It is suggested that sisters and daughters of patients with cervical cancer may be at a higher risk of developing the lesion because of similar socio-economic and cultural backgrounds and should therefore have regular cervical screening.