Single center analysis of therapy and outcomes of hepatocellular carcinoma in Sub-Saharan Africa.

PURPOSE: To evaluate the characteristics and response to therapy for HCC in sub-Saharan Africa. PATIENTS AND METHODS: We retrospectively evaluated demographic, clinical and outcome variables of HCC in a referral clinic in Ethiopia from 2016 to 2018. Survival assessment was performed using the Mann-Whitney test. Associations between categorical variables was assessed using Pearson Chi-square test. RESULTS: We report 46 HCC cases with a median age of 54 years (IQR 45-62) and 50% female. Viral hepatitis was the most common underlying etiology, with 41% of subjects infected with hepatitis B virus (HBV) and 45% with hepatitis C. The median MELD was 12 (IQR 8-17), we found no association between survival and a MELD score 15, regardless of underlying disease (pr=0.61, p>0.05). 31% of individuals underwent supportive treatment with a median survival of 27 days (IQR 19-181), 18% used Sorafenib (median survival of 94 days, IQR 24-121), and trans-arterial chemoembolization (TACE) was utilized in 16% (median survival of 352 days, IQR 30-436). HBV cases were diagnosed younger (31% before the age of 40) and those on Tenofovir had a longer median survival than those off Tenofovir (121 vs 34 days). CONCLUSION: Our study found that antiviral treatment of HBV infection was associated with longer survival in HCC. Furthermore, Sorafenib seemed beneficial in patients that used this modality and NLR was a good prognostic factor.

Prevalence of human papillomavirus and Helicobacter pylori in esophageal and gastroesophageal junction cancer biopsies from a case-control study in Ethiopia.

BACKGROUND: Ethiopia lies in the high-risk corridor of esophageal squamous cell carcinoma in East Africa, where individuals with this malignancy often do not report established risk factors, suggesting unidentified etiologies. Here, we report the prevalence of mucosal human papillomavirus (HPV) and of Helicobacter pylori (H. pylori) detection in endoscopy-obtained esophageal and gastroesophageal junction biopsies and in oral cell specimens taken at the time of esophageal cancer diagnosis in a case-control study in Addis Ababa, Ethiopia. METHODS: DNA extraction was performed from fresh frozen tissue and oral cell pellets obtained with saline solution gargling subsequently fixed with ethanol. Mucosal HPV and H. pylori DNA was detected using highly sensitive assays that combine multiplex polymerase chain reaction and bead-based Luminex technology. The proportions of specimens testing positive were expressed as percentages, with binomial 95% confidence intervals. Agreement of results between tissue biopsy and oral cell specimens was estimated using the kappa statistic. Comparison of study participants' characteristics by test results was done using the Pearson chi-square test. RESULTS: HPV DNA was detected in 1 of 62 tumor specimens (2, 95% confidence interval (CI): 0-9%), corresponding to HPV16 type. HPV DNA was detected in the oral cavity of 7 cases (11, 95% CI: 5-22%) and 4 of 56 matched healthy controls (7, 95% CI: 2-17%), with multiple HPV types detected. Detection of H. pylori DNA was 55% (95% CI: 42-68%), and 20 of 34 H. pylori-positive specimens (59, 95% CI: 41-75%) were positive for the cagA gene. Agreement of detection rates between tissue and oral cells in cases was poor for HPV and for H. pylori. CONCLUSIONS: The prevalence of mucosal-type HPV was very low, whereas H. pylori was more commonly detected, with a high proportion testing positive for the pro-inflammatory gene cagA. These novel findings remain to be replicated in larger studies and with the addition of serological determinations to better understand their biological significance in the context of esophageal and gastroesophageal junction cancers.

Qat use and esophageal cancer in Ethiopia: A pilot case-control study.

BACKGROUND: Qat (Catha edulis) chewing is reported to induce lesions in the buccal mucosa, irritation of the esophagus, and esophageal reflux. Case series suggest a possible etiological role in oral and esophageal cancers. This pilot study aimed to generate preliminary estimates of the magnitude and direction of the association between qat use and esophageal cancer (EC) risk and to inform the logistics required to conduct a multi-center case-control study. METHODS: Between May 2012 and May 2013, 73 EC cases (including 12 gastro-esophageal junction cases) and 133 controls matched individually on sex, age, and residence were enrolled at two endoscopy clinics and a cancer treatment hospital in Addis Ababa. A face-to-face structured questionnaire was administered. Qat use was defined as ever having chewed qat once a week or more frequently for at least one year. Odds ratios were calculated using conditional logistic regression. RESULTS: Only 8% of cases resided in Addis Ababa. Qat use was more frequent in cases (36%) than in controls (26%). A 2-fold elevation in EC risk was observed in ever qat chewers compared with never users in unadjusted conditional logistic regression (OR = 2.12; 95% CI = 0.94, 4.74), an association that disappeared after adjusting for differences in tobacco use, consumption of alcohol and green vegetables, education level, and religion (OR = 0.95; 0.22, 4.22). Among never tobacco users, however, a non-significant increase in EC risk was suggested in ever qat users also after adjustment. Increases in EC risk were observed with ever tobacco use, alcohol consumption, low consumption of green vegetables, a salty diet, illiteracy, and among Muslims; the four latter associations were significant. CONCLUSIONS: This pilot study generated EC risk estimates in association with a habit practiced by millions of people and never before studied in a case-control design. Results must be interpreted cautiously in light of possible selection bias, with some demographics such as education level and religion differing between cases and controls. A large case-control study with enrolment of EC cases and carefully matched controls at health facilities from high-risk areas in the countryside, where the majority of cases occur, is needed to further investigate the association between qat use and EC.

Chronic viral hepatitis: policy, regulation, and strategies for its control and elimination in Ethiopia.

BACKGROUND: Hepatitis B and C are silent killers not yet recognized as major public health challenges in many developing countries with huge disease burden. In Ethiopia, Hepatitis B is endemic with an average prevalence of 10.8 %, and the prevalence of Hepatitis C is 2 %. The prevalence of both infections, however, is likely to be underreported due to the lack of diagnostic facilities and appropriate surveillance systems. Ethiopia is also among the many Sub-Sahara African countries lacking a coordinated and systematic national response to chronic viral hepatitis. The objective of this study is to examine the current level of response to viral Hepatitis B & C in Ethiopia with the aim to bring identified gaps to the attention of relevant stakeholders and policy makers. METHODS: This cross-sectional qualitative study was based on semi-structured in-depth interviews with 21 key informants from health facilities, health offices, pharmaceutical companies, regulatory bodies, professional association and blood bank units. Participants were selected purposively based on their role in the national hepatitis response. The investigators also reviewed available policy and strategy documents, standards of practice and surveys, and paid visits to pharmaceutical premises to check the availability of antiviral drugs. Thematic analysis was employed to make sense of the data. During the data analysis process, all the authors critically read the materials, and data was triangulated by source, interpreter view and thematic perspective to ensure accurate representation and comprehensiveness, and validation of the interviewees' responses. Once each investigator reviewed the data independently, the team reached a common understanding of the scope and contexts of the information attained. Data were subsequently reduced to key concepts, and case stories were taken with successive revisions. The key concepts were later coded into most basic meaningful categories. The World Health Organization (WHO) global hepatitis response framework was used to organize the analysis. RESULTS: Ethiopia is in the process of preparing strategic plan and guidelines for viral hepatitis. However, the country still lacks the required partnerships, and resource mobilization as a national health response is limited. Community awareness on the disease transmission and its sequel is poor. Viral hepatitis screening services are not widely available except for the occasional mandatory medical checkups for work or travel purposes. Healthcare providers often take no further action after diagnosing patients with viral hepatitis due to lack of treatment guidelines and strategic frameworks for screening, diagnosis, and treatment. Besides, drugs that are effective in the treatment of viral hepatitis are not available, mainly due to regulatory challenges. CONCLUSIONS: Viral hepatitis and its disease burden are getting little attention in Ethiopia and many low-income countries. The levels of technical guidance and financial support from the international community are low. To date, the response to the infections in Ethiopia is patchy. Thus, the country needs to formulate policy and strategies in the areas of disease surveillance, risk group identification and screening, use of the birth dose of hepatitis B vaccine, and care and treatment. Improving availability of data on viral hepatitis, access to low-cost generic drugs and developing and dissemination of treatment guidelines are also critical. Leveraging the successful Health Extension Program for a hepatitis response, and exploring ways to learn from and integrate into the HIV/AIDS program should also be considered.

Veno-occlusive liver disease: a case report.

A case of veno-occlusive liver disease (VOLD) in a 12-years old Ethiopian boy is described The salient clinical features and gross and microscopic examination of biopsy material are reviewed. Veno-occlusive disease which occurs in the West Indies, East and West Africa, and India is an acute, subacute or chronic condition that affects the central and sublobular hepatic veins. In the West Indies (1) it is related to the consumption of bush tea made from plants that contain toxic pyrrolizidine alkaloids, such as Crotalaria and Senecio (2). Hepatotoxic compounds in Crotalaria, Senecio, Heliotropium and other composite plants can also enter the diet through the contamination of cereals with weed seeds. For example 28 of 67 patients died with veno-occlusive disease in central India after consuming a local cereal, gondli contaminated with the seeds of Crotalaria (3). Heliotropium Popovii has been implicated in outbreaks in villages in northwestern Afghanistan, with high mortality (4). The primary pathological change of hepatic veno-occlusive disease is sub-endothelial edema followed by intimal growth of connective tissue, with narrowing and occlusion of the central and sub-lobular hepatic veins. Atrophy or necrosis of liver cells, with consequent fibrosis leads to gross changes similar to those seen in cardiac cirrhosis, portal hypertension results. The present report, the first of it kind in Ethiopia describes a case of veno-occlusive liver disease in a 12-year old Ethiopian boy.

Association of dyspepsia symptoms and Helicobacter pylori infections in private higher clinic, Addis Ababa, Ethiopia.

BACKGROUND: The discovery of Helicobacter pylori [H. pylori] by Marshall and Warren revealed that, this organism has been implicated as the main etiological agent in the development of acute and chronic active gastritis, peptic ulcer disease, gastric cancer and mucosa-associated lymphoid tissue [MALT] lymphoma in humans. Recent estimates suggest that 50% of the world's population is infected with this gastric bacterium. Dyspepsia is a complex set of symptoms, rather than an indication of a specific disease entity and many causes of dyspepsia exist including Helicobacter pylori infections. OBJECTIVE: This study was initiated to determine the association of dyspepsia symptoms and H. pylori infections. DESIGN: A Case control study was conducted to determine the association of dyspepsia symptoms and H. pylori infections using non-invasive tests [Helicobacter pylori stool antigen and Helicobacter pylori rapid antibody] at Noble Higher Clinic, Addis Ababa. Ethiopia, between April 2009 and June 2009. METHODS: A total of 238 informed and consented adult outpatients [n=119 dyspeptic patients and n=119 asymptomatic controls] were investigated for H. pylori infections by Helicobacter pylori stool antigen and Helicobacter pylori rapid antibody tests. RESULTS: The prevalence of H. pylori infection was found in 53% [63/119] dyspeptic patients and 39%[46/119] asymptomatic controls. odds ratio[OR: 1.785:95%, CI, 1.066 to 2.989]. In the asymptomatic controls, the prevalence of H. pylori infection was peak at the age group of 38-45 yrs [61%], followed by 54-61 yrs [60%]. In the dyspeptic patients, the peak prevalence of H. pylori infection was at the age group of 54-61 yrs [75%], followed by 30-37 yrs [72%]. CONCLUSION: There is a statistically significant difference between dyspeptic and non-dyspeptic participant by HpSA test. This demonstrates that H. pylori infection is associated with dyspepsia in this study, even if the causes of dyspepsia were not assessed by the study. Although, this 53 percent prevalence of H. pylori infection in dyspeptic patients seems lower than the previous hospital based studies, further study need to be conducted in the primary health care setup.

Pattern of upper gastrointestinal tumors at Tikur Anbessa Teaching Hospital in Addis Ababa, Ethiopia: a ten-year review.

BACKGROUND: Due to lack of public awareness and cancer surveillance, patients in developing countries usually present with advanced and terminal malignancies. The absence of early diagnostic facilities and standard chemotherapeutic and radiotherapy services in low-income countries further confound the problem in the care of such patients. Moreover, the prevalence of cancers (including upper GI malignancies) is unknown in Ethiopia due to lack of national cancer registry. OBJECTIVE: To assess the type and the pattern of upper GI tumors among the patients whose upper GI tract biopsies were seen at the Tikur Anbessa Hospital (TAH) during September 1, 1992 through August 31, 2002. METHODOLOGY: A ten-year retrospective analysis of upper gastrointestinal tract (UGIT) biopsy reports of adult patients was made at the Tikur Anbessa teaching Hospital. RESULTS: There were 608 UGIT biopsy specimens submitted to the pathology department of Addis Ababa University Medical Faculty, from different hospitals and clinics in the country for histological studies. There were 369 males (67.7%) and 239 (39.3%) females with a male to female ratio of 1.5:1. The mean age for males was 50 years while 48 years for females. Although most of biopsies were submitted from Addis Ababa and Shewa, esophageal squamous cell carcinoma and adenocarcinoma were apparently predominant among the patients from Arsi and Bale areas as compared to Addis Ababa and other regions. The mean duration of major presenting symptoms was 4-6 months both for esophageal and gastric cancers. In this study, upper GI endoscopy had a 90% correlation with the histological diagnosis. CONCLUSION: Esophageal cancers were observed to be relatively common among the patients from Arsi and Bale zones while gastric cancers were apparently predominant among patients referred from Addis Ababa. Upper GI endoscopic diagnosis was also noted to correlate well with the histological diagnosis.

Meningitis complicated with sinus venous thrombosis and intracranial hemorrhage in a patient who received bupivacaine spinal anesthesia.

We report a 26 year old male patient who developed meningitis with cerebral venous thrombosis and multiple intracranial hemorrhages following spinal anesthesia. He received 15 mg of bupivacaine at L3-L4 level for diagnostic arthroscopy of a right knee joint at the major operation theatre.