Incidence and risk factors for colorectal cancer in Africa: a systematic review and meta-analysis.

INTRODUCTION: Colorectal cancer (CRC) is the second leading cause of cancer-related death worldwide. There is a significant burden of mortality from colorectal cancer in Africa. Due to the heterogeneity of dietary and lifestyle practices throughout Africa, our work sought to define risk factors for the development of CRC in the African continent. METHODS: We systematically searched PubMed, Embase, Global Health, CINAHL, Cochrane CENTRAL, and African Index Medicus for studies written in English, examining the incidence and risk factors of CRC in Africa. A systematic analysis was done to compare different risk factors in constituent studies. A meta-analysis random effects model was fitted to estimate the pooled incidence of CRC. RESULTS: Of 2471 studies screened, 26 were included for the quantitative analysis; 20 in the incidence analysis, and six in the risk factor analysis. The overall ASIR per 100,000 person-years of CRC for males and females was 7.51 and 6.22, respectively. The highest incidence rates were observed between 2012 and 2021. Risk factors for CRC in Africa include tobacco smoking, and consumption of red meat, butter, and alcohol. Protective factors included, regular consumption of fruits and regular physical activity. CONCLUSION: The incidence of CRC in Africa is higher than that suggested by previous studies. Our study shows that nonmodifiable and modifiable factors contribute to CRC in Africa. High-quality studies conducted on generalizable populations that examine risk factors in a comprehensive fashion are required to inform primary and secondary prevention initiatives for CRC in Africa.

Systematic review of cholangiocarcinoma in Africa: epidemiology, management, and clinical outcomes.

BACKGROUND: The prevalence, management, and clinical outcomes of cholangiocarcinoma in Africa are unknown. The aim is to conduct a comprehensive systematic review on the epidemiology, management, and outcomes of cholangiocarcinoma in Africa. METHODS: We searched PubMed, EMBASE, Web of Science and CINHAL from inception up to November 2019 for studies on cholangiocarcinoma in Africa. The results reported follow PRISMA guidelines. Quality of studies and risk of bias were adapted from a standard quality assessment tool. Descriptive data were expressed as numbers with proportions and Chi-squared test was used to compare proportions. P values < 0.05 were considered significant. RESULTS: A total of 201 citations were identified from the four databases. After excluding duplicates, 133 full texts were reviewed for eligibility, and 11 studies were included. The 11 studies are reported from 4 countries only: 8 are from North Africa (Egypt 6 and Tunisia 2), and 3 in Sub-Saharan Africa (2 in South Africa, 1 in Nigeria). Ten studies reported management and outcomes, while one study reported epidemiology and risk factors. Median age for cholangiocarcinoma ranged between 52 and 61 years. Despite the proportion with cholangiocarcinoma being higher among males than females in Egypt, this gender disparity could not be demonstrated in other African countries. Chemotherapy is mainly used for palliative care. Surgical interventions are curative and prevent cancer progression. Statistical analyses were performed with Stata 15.1. CONCLUSION: The known global major risk factors such as primary sclerosing cholangitis, Clonorchis sinensis and Opisthorchis viverrini infestation are rare. Chemotherapy treatment was mainly used for palliative treatment and was reported in three studies. Surgical intervention was described in at least 6 studies as a curative modality of treatment. Diagnostic capabilities such as radiographic imaging and endoscopic are lacking across the continent which most likely plays a role in accurate diagnosis.

Factors associated with hepatitis B and C among adults in Buea, Cameroon: A community-based cross-sectional study.

INTRODUCTION: Viral hepatitis is a major cause of death in Africa. A paucity of community-based studies on the determinants of viral hepatitis in Africa impedes efforts to appropriately target prevention, screening, and treatment interventions. We assessed factors associated with hepatitis B virus (HBV) and hepatitis C virus (HCV) in a semi-urban health district in Cameroon. METHODS: We conducted a community-based, cross-sectional study from 28 February to 15 May 2021 in the Buea Health District in Buea, Cameroon. We recruited a sample of consenting individuals aged over 15 years old. Participants were surveyed for factors associated with HBV/HCV and were screened for HBV surface antigen (HBsAg) and HCV antibody using rapid point-of-care tests. We performed univariable and multivariable logistic regression analyses to identify factors associated with HBsAg and HCV seropositivity. RESULTS: We screened 1144 participants (66% female) with a median age of 30 years (IQR: 23-44). HBsAg prevalence was 5.7% (95%CI: 4.5-7.2%) and HCV seropositivity was 1.9% (95%CI: 1.3-2.9%). Three people (0.3%) were seropositive for both HBsAg and HCV antibody. Male sex (adjusted OR [aOR] = 2.31; 95%CI: 1.28-4.18) and a history of traditional operation or scarification (aOR = 2.87; 95%CI: 1.67-4.92) were associated with HBsAg. None of the assessed factors was significantly associated with HCV antibody. CONCLUSION: Men and participants with a history of traditional operation and scarification had higher odds of HBsAg. We did not observe any associations with HCV seropositivity. Prevention and screening efforts among adults in this setting should prioritize men and those with a history of traditional operation and scarification.

How Would You Manage This Patient With Nonvariceal Upper Gastrointestinal Bleeding? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Nonvariceal upper gastrointestinal bleeding is common, morbid, and potentially fatal. Cornerstones of inpatient management include fluid resuscitation; blood transfusion; endoscopy; and initiation of proton-pump inhibitor therapy, which continues in an individualized manner based on risk factors for recurrent bleeding in the outpatient setting. The International Consensus Group released guidelines on the management of nonvariceal upper gastrointestinal bleeding in 2019. These guidelines provide a helpful, evidence-based roadmap for management of gastrointestinal bleeding but leave certain management details to the discretion of the treating physician. Here, 2 gastroenterologists consider the care of a patient with nonvariceal upper gastrointestinal bleeding from a peptic ulcer, specifically debating approaches to blood transfusion and endoscopy timing in the hospital, as well as the recommended duration of proton-pump inhibitor therapy after discharge.

Continuing Medical Education Questions: July 2021.

Article Title: Spontaneous internal pancreatic fistulae complicating acute pancreatitis.

Endoscopic management and clinical outcomes of obstructive jaundice.

BACKGROUND: This study aimed at evaluating the endoscopic management and clinical outcomes in patients with obstructive jaundice undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) within a newly established apprenticeship teaching model at an academic centre in a resource-limited setting. MATERIALS AND METHODS: We employed an apprenticeship-style model of ERCP training with graded responsibility, multidisciplinary group feedback and short-interval repetition. We collected sociodemographic and clinicopathologic data on consecutive patients who underwent ERCP from March 2018 to February 2020. RESULTS: A total of 177 patients were referred, of which 146 patients had an ERCP performed for obstructive jaundice and 31 excluded during the study period. The median age was 55 years, age range from 8 to 83 years. The most common referral diagnosis was pancreatic head cancer 56/146 (38.1%), followed by choledocholithiasis 29/146 (19.7%), cholangiocarcinoma 22/146 (15.0%) and gall bladder cancer 11/146 (7.5%). In all, 102 patients had a malignant indication for ERCP. The cannulation rate was 92%. The most common site for malignant biliary obstruction was proximal bile stricture in 31/102 (30.4%), followed by distal bile strictures in 30/102 (28.4%), periampullary cancer 20/102 (19.6%) and mid bile duct stricture in 9/102 (8.8%). The common benign obstructive etiology includes choledocholithiasis in 33/44 (75%) and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0%) patients had choledochal cyst. Overall complications were post-ERCP pancreatitis (8/146 patients), cholangitis (3/146 patients), stent migration and post-sphincterotomy bleeding (one patient each). Peri-procedural mortality was 5/146 (3.4%). CONCLUSION: ERCP is an effective and safe method of treatment of patients with benign and malignant biliary obstruction. The low morbidity and mortality and its immediate therapeutic benefits, together with the short duration of hospitalization, indicate that this procedure is an important asset in the management of such patients.

The Clinical Implications of Fatty Pancreas: A Concise Review.

Fatty pancreas is a newly recognized condition which is poorly investigated until today as compared to nonalcoholic fatty liver disease. It is characterized by pancreatic fat accumulation and subsequent development of pancreatic and metabolic complications. Association of fatty pancreas have been described with type 2 diabetes mellitus, acute and chronic pancreatitis and even pancreatic carcinoma. In this review article, we provide an update on clinical implications, pathogenesis, diagnosis, treatment and outcomes.

ASA Classification Pre-Endoscopic Procedures: A Retrospective Analysis on the Accuracy of Gastroenterologists.

OBJECTIVES: Before an endoscopic procedure, an evaluation to assess the risk of sedation is performed by the gastroenterologist. To risk stratify based on medical problems, the American Society of Anesthesiologists (ASA) classification scores are used routinely in the preprocedure evaluation. The objective of our study was to evaluate among physicians the ASA score accuracy pre-endoscopic procedures. METHODS: At a single tertiary-care center an institutional review board-approved retrospective study was performed. Upper endoscopies performed from May 2012 through August 2013 were reviewed; data were collected and recorded. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement (≤0.20 is poor agreement, 0.21-0.40 is fair, 0.41-0.60 is moderate, 0.61-0.80 is good, and 0.81-1.00 is very good). RESULTS: The mean ASA scores by the gastroenterologist compared with the anesthesiologist were 2.28 ± 0.56 and 2.78 ± 0.60, respectively, with only fair agreement (weighted kappa index 0.223, 95% confidence interval [CI] 0.113-0.333; 48% agreement). The mean ASA scores for gastroenterologists compared with other gastroenterologists were 2.26 ± 0.5 and 2.26 ± 0.44, respectively, with poor agreement (weighted kappa index 0.200, 95% CI 0.108-0.389; 68% agreement). Agreement on ASA scores was only moderate between the gastroenterologist and himself or herself (weighted kappa index 0.464, 95% CI 0.183-0.745; 75% agreement). CONCLUSIONS: Gastroenterologists performing preprocedure assessments of ASA scores have fair agreement with anesthesiologists, poor agreement with other gastroenterologists, and only moderate agreement with themselves. Given this level of inaccuracy, it appears that the ASA score pre-endoscopy is of limited significance.

Pancreatic Cancer Survival Outcomes at a Tertiary Medical Center Based on Sex and Geographic Location.

OBJECTIVES: To describe the survival outcomes of patients with histologically proven primary pancreatic cancer based on geographic location and sex. METHODS: We conducted a retrospective review of medical records from 2009 through 2013 of patients with pancreatic cancer using International Classification of Diseases, Ninth Revision code 157.9 and International Statistical Classification of Diseases, 10th Revision code C 25.9. The variables extracted included demographics, date of diagnosis, mode of diagnosis, duration, treatment methods, family history, history of chronic pancreatitis, and diabetes mellitus. ZIP codes were used to identify the geographic location of each subject, and rural urban commuting area codes were used to further classify the areas as metropolitan, micropolitan, small town, and rural. Population sizes were classified as metropolitan >50,000, micropolitan 10,000 to 49,999, small town 2500 to 9999, and rural <2500. Descriptive analysis and Kaplan-Meier survival for survival outcomes were performed with statistical significance identified as P < 0.05. RESULTS: A total of 400 medical charts were extracted for review, 301 of which belonged to patients with primary pancreatic cancer. Of the 301 cases, we identified 175 men (58%), 125 women (41%), and 1 missing sex data. There were 280 whites (95%), 8 African Americans (2%), 2 Asian Americans (0.64%), 1 Hispanic American (0.34%) and 1 Native American (0.34%), with a mean age of 63.2 ± 12.6 years. Based on geography, there were 34%, 27%, 20%, and 19% in rural areas, metropolitans, small towns, and micropolitans, respectively. No statistically significant difference was noted in sex on survival outcomes (P = 0.85) or geography (P = 0.62). Additional analysis revealed no statistical significant difference between sexes when stratifying by location (P = 0.96). CONCLUSIONS: There is no difference in survival outcomes of patients with primary pancreatic cancer based on sex or geographic location. Our survival outcomes differ from the national survival outcomes, which reveal that mortality in men is higher than it is in women.

Airway assessment of patients undergoing endoscopic procedures.

OBJECTIVES: In advance of endoscopic procedures, an evaluation to assess the risk of sedation is performed by the gastroenterologist. Based on regulations, gastroenterologists are required to perform an airway assessment. At this time, data supporting this regulation are limited; therefore, we evaluated airway assessment accuracy by gastroenterologists before endoscopic procedures. METHODS: A retrospective, single tertiary care center study was performed from May 2012 through August 2013. Patients who underwent an endoscopy or colonoscopy performed at the University of Missouri-Columbia with documented Mallampati scores were included in the analysis. Three primary cohorts of patients were included in our study: gastroenterologist versus anesthesiologist, gastroenterologist versus other gastroenterologists, and gastroenterologists versus themselves. Data were collected and recorded for patient age, body mass index, and Mallampati score. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement. RESULTS: For gastroenterologists versus anesthesiologists and versus other gastroenterologists, the agreement on Mallampati scores was poor (weighted kappa index 0.103, 95% confidence interval [CI] -0.0126 to 0.219; percentage of agreement 42% and 0.120, 95% CI -0.0211 to 0.260; percentage of agreement 46%, respectively). For gastroenterologists versus themselves for the same patient, the agreement on Mallampati scores was only moderate (weighted kappa index 0.420, 95% CI 0.119-0.722; percentage of agreement 65%). CONCLUSIONS: Gastroenterologists performing a preprocedure assessment using Mallampati scores have poor agreement with anesthesiologists and colleagues and only moderate agreement with themselves.

Costs of Community-Based Viral Hepatitis Screening in Cameroon Using Point-of-Care Technologies.

This cost analysis of a community-based viral hepatitis screening program in Cameroon found an investment of $3.52 per person screened, $50.63 per new diagnosis of hepatitis B, $159.45 per new diagnosis of hepatitis C, and $47.97 per new diagnosis of either hepatitis B or C.

Knowledge and approach towards Helicobacter pylori diagnosis and management among primary care physicians in Cameroon: a cross-sectional study.

BACKGROUND: Low- and middle-income countries have a high prevalence of Helicobacter pylori infection (HPI). In Cameroon, the majority of HPIs are diagnosed and treated by primary care physicians (PCPs). We sought to assess the knowledge and practices of PCPs in the diagnosis and management of HPI in Cameroon. METHODS: A hospital-based cross-sectional study was carried out in four randomly selected regions of Cameroon from November 2021 to June 2022. In each of the selected regions, PCPs were recruited by non-probability convenience sampling and interviewed using a pre-structured questionnaire. Chi-squared, Fisher's exact and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to examine associations between knowledge and practice, with the model adjusted by age of the PCP, geographic region, number of patients and years in practice. Analysis was performed in SAS version 9.4 (SAS Institute, Cary, NC, USA). RESULTS: A total of 382 PCPs were included in the analysis. The majority (60.0%) were males between the ages of 20-29 y (64.1%). Most PCPs (80.9%) reported that HPI is the cause of gastroesophageal reflux disease and 41.8% reported that HPI is the main cause of dyspeptic symptoms. The dominant diagnostic tests used for HPI were serology (52.8%) and stool antigen (30.9%). The most frequently used first-line therapies were amoxicillin (AMX), clarithromycin (CLA), metronidazole (MNZ) and proton pump inhibitor (PPI) concomitant therapy (32.2%), AMX-CLA-PPI triple therapy (18.6%) and AMX-MNZ-PPI triple therapy (13.1%). Half of the practitioners (48.6%) treat HPI empirically, without positive H. pylori testing. About half of the PCPs (48%) do not request laboratory confirmation of H. pylori eradication following treatment. CONCLUSIONS: There is inadequate knowledge and significant differences in the clinical approach towards HPI among PCPs in Cameroon. We recommend more teaching programs and continuous medical education on HPI.

Assessment of the knowledge, attitudes and perceived quality of education about antimicrobial use and resistance of medical students in Zambia, Southern Africa.

Introduction: Antimicrobial resistance (AMR) is a major global health threat, particularity in lower-middle-income countries (LMICs) where antibiotics are readily available, leading to antibiotic misuse. Educational interventions are lacking in Zambia. Our study assessed antimicrobial use and resistance knowledge, attitude and perceived quality of education relating to AMR in Zambian medical schools. Methods: A cross-sectional anonymous survey of students at six accredited medical schools in Zambia using a self-administered questionnaire was administered, using Qualtrics. Chi-squared, Fisher exact test, Pearson correlation test and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to examine associations between knowledge and antibiotic use, beliefs and behaviours. Analysis was performed in SAS version 9.4. Results: One hundred and eighty responses from six medical schools were included in the final analysis. Fifty-six percent of students rated their overall education on antibiotic use as useful or very useful. Ninety-one percent thought that antibiotics are overused, and 88% thought resistance was a problem in Zambia. Only 47% felt adequately trained on antibiotic prescribing, and 43% felt confident in choosing the correct antibiotic for specific infections. Only 2% felt prepared interpreting antibiograms, 3% were trained to de-escalate to narrow-spectrum antibiotics, 6% knew how to transition from IV antibiotics to oral antibiotics, 12% knew of dosing and duration, and 14% understood the spectrum of activity of antibiotics. Forty-seven percent of respondents think hand hygiene is unimportant. Conclusions: Medical students in Zambia expressed a good level of knowledge, but low levels of training and confidence regarding antimicrobial prescribing practices and resistance. Our study highlights training gaps and possible areas of intervention in the medical school curriculum.

Antimicrobial resistance from a One Health perspective in Zambia: a systematic review.

BACKGROUND: Antimicrobial resistance (AMR) is widely acknowledged as a global health problem, yet its extent is not well evaluated, especially in low-middle income countries. It is challenging to promote policies without focusing on healthcare systems at a local level, therefore a baseline assessment of the AMR occurrence is a priority. This study aimed to look at published papers relating to the availability of AMR data in Zambia as a means of establishing an overview of the situation, to help inform future decisions. METHODS: PubMed, Cochrane Libraries, Medical Journal of Zambia and African Journals Online databases were searched from inception to April 2021 for articles published in English in accordance with the PRISMA guidelines. Retrieval and screening of article was done using a structured search protocol with strict inclusion/exclusion criteria. RESULTS: A total of 716 articles were retrieved, of which 25 articles met inclusion criteria for final analysis. AMR data was not available for six of the ten provinces of Zambia. Twenty-one different isolates from the human health, animal health and environmental health sectors were tested against 36 antimicrobial agents, across 13 classes of antibiotics. All the studies showed a degree of resistance to more than one class of antimicrobials. Majority of the studies focused on antibiotics, with only three studies (12%) highlighting antiretroviral resistance. Antitubercular drugs were addressed in only five studies (20%). No studies focused on antifungals. The most common organisms tested, across all three sectors, were Staphylococcus aureus, with a diverse range of resistance patterns found; followed by Escherichia coli with a high resistance rate found to cephalosporins (24-100%) and fluoroquinolones (20-100%). CONCLUSIONS: This review highlights three important findings. Firstly, AMR is understudied in Zambia. Secondly, the level of resistance to commonly prescribed antibiotics is significant across the human, animal, and environmental sectors. Thirdly, this review suggests that improved standardization of antimicrobial susceptibility testing in Zambia could help to better delineate AMR patterns, allow comparisons across different locations and tracking of AMR evolution over time.

Gamification as an educational tool to address antimicrobial resistance: a systematic review.

Background: Antimicrobial resistance (AMR) poses a serious threat to global healthcare, and inadequate education has been identified as a major challenge by the WHO. The human , animal and agricultural sectors contribute to the emergence of AMR. Gamification has emerged as an innovative tool to improve knowledge and change behaviours. Our study provides an overview of the literature on existing games in prescribers' education across the One Health sectors, with a particular focus on the impact of gamification on learning. Methods: Using the PRISMA guidelines, we searched Cochrane, PubMed, Scopus and Google Scholar for articles related to gamification for future prescribers of antimicrobials from inception until 28 March 2023. Retrieval and screening of articles was done using a structured search protocol with strict inclusion/exclusion criteria. Results: A total of 120 articles were retrieved, of which 6 articles met the inclusion criteria for final analysis. High-income countries had the most studies, with one global study incorporating low- to middle-income countries. All games were evaluated in the human sector. Board and card games, featuring scoring and point systems, were the most prevalent game types. Most games focused on improving knowledge and prescribing behaviours of medical students, with bacteria or antibiotics as the only content. All studies highlighted the significant potential of gamification in mitigating AMR, promoting antimicrobial stewardship, and improving retention of information compared with conventional lectures. Conclusions: Our review found an absence of studies in the animal and environmental sectors, disproportionately focused on medical students with questionable sample size, inadequate assessment of game content and effectiveness, and opportunities for game developers.

Systematic review and meta-analysis of esophageal cancer in Africa: Epidemiology, risk factors, management and outcomes.

BACKGROUND: Esophageal cancer (EC) is associated with a poor prognosis, particularly so in Africa where an alarmingly high mortality to incidence ratio prevails for this disease. AIM: To provide further understanding of EC in the context of the unique cultural and genetic diversity, and socio-economic challenges faced on the African continent. METHODS: We performed a systematic review of studies from Africa to obtain data on epidemiology, risk factors, management and outcomes of EC. A non-systematic review was used to obtain incidence data from the International Agency for Research on Cancer, and the Cancer in Sub-Saharan reports. We searched EMBASE, PubMed, Web of Science, and Cochrane Central from inception to March 2019 and reviewed the list of articles retrieved. Random effects meta-analyses were used to assess heterogeneity between studies and to obtain odds ratio (OR) of the associations between EC and risk factors; and incidence rate ratios for EC between sexes with their respective 95% confidence intervals (CI). RESULTS: The incidence of EC is higher in males than females, except in North Africa where it is similar for both sexes. The highest age-standardized rate is from Malawi (30.3 and 19.4 cases/year/100000 population for males and females, respectively) followed by Kenya (28.7 cases/year/100000 population for both sexes). The incidence of EC rises sharply after the age of 40 years and reaches a peak at 75 years old. Meta-analysis shows a strong association with tobacco (OR 3.15, 95%CI: 2.83-3.50). There was significant heterogeneity between studies on alcohol consumption (OR 2.28, 95%CI: 1.94-2.65) and on low socioeconomic status (OR 139, 95%CI: 1.25-1.54) as risk factors, but these could also contribute to increasing the incidence of EC. The best treatment outcomes were with esophagectomy with survival rates of 76.6% at 3 years, and chemo-radiotherapy with an overall combined survival time of 267.50 d. CONCLUSION: Africa has high incidence and mortality rates of EC, with preventable and non-modifiable risk factors. Men in this setting are at increased risk due to their higher prevalence of tobacco and alcohol consumption. Management requires a multidisciplinary approach, and survival is significantly improved in the setting of esophagectomy and chemoradiation therapy.

Lumen apposing metal stents for pancreatic fluid collections: Recognition and management of complications.

For patients recovering from acute pancreatitis, the development of a pancreatic fluid collection (PFC) predicts a more complex course of recovery, and introduces difficult management decisions with regard to when, whether, and how the collection should be drained. Most PFCs resolve spontaneously and drainage is indicated only in pseudocysts and walled-off pancreatic necrosis when the collections are causing symptoms and/or local complications such as biliary obstruction. Historical approaches to PFC drainage have included surgical (open or laparoscopic cystgastrostomy or pancreatic debridement), and the placement of percutaneous drains. Endoscopic drainage techniques have emerged in the last several years as the preferred approach for most patients, when local expertise is available. Lumen-apposing metal stents (LAMS) have recently been developed as a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections, and less commonly, for other indications, such as gallbladder drainage. Physicians considering LAMS placement must be aware of the complications most commonly associated with LAMS including bleeding, migration, buried stent, stent occlusion, and perforation. Because of the patient complexity associated with severe pancreatitis, management of pancreatic fluid collections can be a complex and multidisciplinary endeavor. Successful and safe use of LAMS for patients with pancreatic fluid collections requires that the endoscopist have a full understanding of the potential complications of LAMS techniques, including how to recognize and manage expected complications.