The burden of HPV associated cancers in two regions in Nigeria 2012-2014.

INTRODUCTION: HPV attributable cancers are the second most common infection-related cancers worldwide, with much higher burden in less developed regions. There are currently no country-specific estimates of the burden of these cancers in Nigeria just like many other low and middle income countries. METHODS: In this study, we quantified the proportion of the cancer burden in Nigeria that is attributable to HPV infection from 2012 to 2014 using HPV prevalence estimated from previous studies and data from two population based cancer registries (PBCR) in Nigeria. We considered cancer sites for which there is strong evidence of an association with HPV infection based on the International Agency for Research on Cancer (IARC) classification. We obtained age and sex-specific estimates of incident cancers and using the World Standard Population, we derived age standardized incidence (ASR) rates for each cancer type by categories of sex, and estimated the population attributable fractions (PAF). RESULTS: The two PBCR reported 4336 new cancer cases from 2012 to 2014. Of these, 1627 (37.5%) were in males and 2709 (62.5%) in females. Some 11% (488/4336) of these cancers were HPV associated; 2% (38/1627) in men and 17% (450/2709) in women. Of the HPV associated cancers, 7.8% occurred in men and 92.2% in women. The ASRs for HPV associated cancers was 33.5 per 100,000; 2.3 and 31.2 per 100,000 in men and women respectively. The proportion of all cancers attributable to HPV infection ranged from 10.2 to 10.4% (442-453 of 4336) while the proportion of HPV associated cancers attributable to HPV infection ranged from 90.6% to 92.8% (442-453 of the 488 cases). In men, 55.3% to 68.4% of HPV associated cancers were attributable to HPV infection compared to 93.6% to 94.8% in women. The combined ASR for HPV attributable cancers ranged from 31.0 to 31.7 per 100,000. This was 1.4 to 1.7 per 100,000 in men and 29.6 to 30.0 per 100,000 in women. In women, cervical cancer (n=392, ASR 28.3 per 100,000) was the commonest HPV attributable cancer, while anal cancer (n=21, ASR 1.2 per 100,000) was the commonest in men. CONCLUSIONS: HPV attributable cancers constitute a substantial cancer burden in Nigerian women, much less so in men. A significant proportion of cancers in Nigerian women would be prevented if strategies such as HPV DNA based screening and HPV vaccination are implemented.

The need for an integrated approach for chronic disease research and care in Africa.

With the changing distribution of infectious diseases, and an increase in the burden of non-communicable diseases, low- and middle-income countries, including those in Africa, will need to expand their health care capacities to effectively respond to these epidemiological transitions. The interrelated risk factors for chronic infectious and non-communicable diseases and the need for long-term disease management, argue for combined strategies to understand their underlying causes and to design strategies for effective prevention and long-term care. Through multidisciplinary research and implementation partnerships, we advocate an integrated approach for research and healthcare for chronic diseases in Africa.

Prevalent high-risk HPV infection and vaginal microbiota in Nigerian women.

In this study, we evaluated the association between high-risk human papillomavirus (hrHPV) and the vaginal microbiome. Participants were recruited in Nigeria between April and August 2012. Vaginal bacterial composition was characterized by deep sequencing of barcoded 16S rRNA gene fragments (V4) on Illumina MiSeq and HPV was identified using the Roche Linear Array® HPV genotyping test. We used exact logistic regression models to evaluate the association between community state types (CSTs) of vaginal microbiota and hrHPV infection, weighted UniFrac distances to compare the vaginal microbiota of individuals with prevalent hrHPV to those without prevalent hrHPV infection, and the Linear Discriminant Analysis effect size (LEfSe) algorithm to characterize bacteria associated with prevalent hrHPV infection. We observed four CSTs: CST IV-B with a low relative abundance of Lactobacillus spp. in 50% of participants; CST III (dominated by L. iners) in 39·2%; CST I (dominated by L. crispatus) in 7·9%; and CST VI (dominated by proteobacteria) in 2·9% of participants. LEfSe analysis suggested an association between prevalent hrHPV infection and a decreased abundance of Lactobacillus sp. with increased abundance of anaerobes particularly of the genera Prevotella and Leptotrichia in HIV-negative women (P < 0·05). These results are hypothesis generating and further studies are required.

Surgeon-patient information disclosure practices in southwestern Nigeria.

OBJECTIVE: This study examined the practice of information disclosure to patients by surgeons in Nigeria. SUBJECTS AND METHODS: A 55-item self-administered semi-structured questionnaire was sent to 150 surgeons in southwestern Nigeria in 2004-2005. The data obtained from the completed questionnaire were analyzed using descriptive statistics. RESULTS: Of the 150 surgeons, 102 completed the questionnaire, giving a response rate of 68.0%. Of these 102, 85 (85.3%) were men, 44 (43.1%) were consultants and 55 (54.0%) were senior and junior surgical trainees. Most were from surgical subspecialties and obstetrics and gynecology. A documented policy statement about information disclosure was not available in most hospitals. A third, i.e. 35 (34.3%), of the surgeons did not routinely engage patients in discussions about disease diagnosis, management and prognosis. Most, i.e. 73 (71.6%), would rather disclose worsening disease progression to the patient's spouse. Others would disclose such information to the patient's children, family members or clergy. This was presumably to shield the patient from psychological distress. Only 22 (21.6%) of them routinely disclose operative findings to patients or their families. Thirty (29.4%) of them had been involved in disclosing medical errors to their patients in the past while 63 (61.8%) respondents did not know if surgical errors with potentially negative consequences should be disclosed. CONCLUSION: Most of the surgeons in southwestern Nigeria did not routinely provide detailed information to patients about their illness and possible outcome of illness even in the presence of worsening disease progression and prognosis. When surgical errors with potential negative consequences occurred, the majority did not know if such errors should be disclosed.

Office based muscle biopsy using Vacora vacuum assisted biopsy system.

INTRODUCTION: Muscle biopsy is a minor surgical procedure that has been conducted over several decades in clinical practice. Over the years, the technique to implement this procedure has been modified to make it easier to perform and more tolerable for the patient. This study aimed to assess the feasibility of muscle biopsy as an office based procedure, by using a vacuum Assisted Biopsy System. METHOD: The procedure was successfully carried out on 57 individuals with/without diabetes, currently involved in the African American Diabetes Mellitus Study. One specimen was collected percutaneously from the vastus lateralis, under local anesthesia. A 16-gauge needle was used. RESULTS: Muscle biopsies were successfully carried out on all study participants. The study participants reported no complications after the procedure. CONCLUSION: The findings from our study show that muscle biopsy can be feasibly implemented as an office based procedure, involving minimal muscle invasion, less trauma, hospital stay time, and expenses.

An appraisal of the process of protocol review by an ethics review conmmittee in a tertiary institution in Ibadan.

It is a well established norm that biomedical research involving human participants must conform to acceptable scientific principles and international codes of research ethics. The University of Ibadan/University College Hospital Health Research Ethics Committee (UI/UCH HREC) is the body that plays an oversight role and performs the function of a third party independent review of research protocols submitted by staff and students of the two institutions. A 6-year (2002-2007) retrospective audit of the protocols submitted to the HREC was performed to determine the profile of the lead investigator, sources of funding for the research and the duration for review using a 25 item questionnaire. A total of 752 protocols were submitted, 618 protocols (82%) were approved while 38 protocols were not approved. The principal investigators were mainly postgraduate students (67.1%) while academic staff constituted 21.3%. The average time from submission to approval was approximately 21 weeks (95% CI: 20-23 weeks). The period from submission to approval is significantly affected by the number of revision required and the funding agent (p < 0.05); it took a shorter time to review internationally funded research.

Cancer in Africa: opportunities for collaborative research and training.

Cancer is a worldwide public health problem causing increasing morbidity and mortality, particularly in the developing world. Underlying trends are changing the pattern of cancer and this is also being influenced by the HIV/AIDS pandemic, particularly in Sub-Saharan Africa. Even though the pattern of cancer varies across Africa, there are identifiable trends. Breast and cervical cancers, and Kaposi sarcoma are the commonest cancers in women, while Kaposi sarcoma, liver and prostate cancers are the commonest in men. Cancer causes more morbidity and mortality in Africa compared to other parts of the world. Infections account for a disproportionate amount of cancers in Africa. The HIV epidemic is contributing to increased prevalence of many cancers particularly those associated with Herpes and Papilloma viruses. Tobacco use, another major carcinogen, is increasing, particularly among the young. Dietary factors, alcohol use, physical inactivity and environmental pollution are also important aetiological factors of cancer in Africa. In developing countries, poverty, limited government health budget and poor health care systems complicate cancer prevention, treatment and outcomes. Coordinated response by international agencies and NGOs is needed to help developing countries and several successful models exist. More action is also needed on ensuring safety and quality of chemotherapy and the price needs to be reduced. Responses advocated for cancer control in Africa include banning tobacco use, better regulation of alcohol sale, better environmental planning and immunization against cancer associated viruses. Training of health care workers to diagnose cancer and treat it effectively within limited budgets is needed. Research to develop these new treatments and others, particularly from natural products is urgently needed and this can be done safely within established health research ethics regulatory frameworks. Several opportunities for collaborative research and training include an update of the epidemiology of cancers in African females; the relationship between HIV and other carcinogenic viruses; biological factors making cancers in Africa more lethal; cheaper vaccines that will be more available and easier to store and hence can be included in the immunization programme in African countries and development of vaccines like the HPV against other uncommon serotypes of the virus.

Closed suction drainage versus closed simple drainage in the management of modified radical mastectomy wounds.

OBJECTIVE: To compare the outcomes of modified radical mastectomy wounds managed by closed wound drainage with suction and without suction. METHOD: A prospective randomised trial was conducted at the University College Hospital in Ibadan, and the University of Nigeria Teaching Hospital in Enugu. Fifty women who required modified radical mastectomy for breast cancer were randomised to have closed wound drainage with suction (26 patients) and closed wound drainage without suction (24 patients). RESULTS: There was no significant difference in the intraoperative and postoperative variables. Suction drainage drained less volume of fluid and stayed for a shorter time in the wound, but the differences were not significant. There was no difference in the length of hospital stay, time to stitch removal, and number of dressing changes. More haematomas and wound infections occurred in the simple drain group while more seromas occurred in the suction drain group, but these were not significant. The suction drain was more difficult to manage and the cost was 15 times higher than the simple drainage system. CONCLUSION: Closed simple drains are not inferior to suction drains in mastectomy wounds and, considering the cost saving and simplicity of postoperative care, they are preferable to suction drains.

Parity and breastfeeding are protective against breast cancer in Nigerian women.

As the relation between reproductive factors and breast cancer risk has not been systematically studied in indigenous women of sub-Saharan Africa, we examined this in a case-control study in Nigeria. In-person interviews were conducted using structured questionnaires to collect detailed reproductive history in 819 breast cancer cases and 569 community controls between 1998 and 2006. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI). Compared with women with menarcheal age<17 years, the adjusted OR for women with menarcheal age>or=17 years was 0.72 (95% CI: 0.54-0.95, P=0.02). Parity was negatively associated with risk (P-trend=0.02) but age at first live birth was not significant (P=0.16). Importantly, breast cancer risk decreased by 7% for every 12 months of breastfeeding (P-trend=0.005). It is worth noting that the distribution of reproductive risk factors changed significantly from early to late birth cohorts in the direction of increasing breast cancer incidence. Our findings also highlight the heterogeneity of breast cancer aetiology across populations, and indicate the need for further studies among indigenous sub-Saharan women.

West African Bioethics Training Program: Raison D'être.

There has been increase in the amount of research and services provided for diseases that are predominantly prevalent in developing countries. In addition, the amount of clinical trials conducted in developing countries for diseases in general and for those that contribute substantial proportions of the disease burden of the population has increased. Furthermore, interest in genomics and its potential for improving understanding of gene-environment-disease interactions and population history has drawn researchers to developing countries including Africa. These factors have highlighted the need for sound ethics training for researchers and members of ethics review committees. Increased training of bioethicists will enhance the contributions of developing countries bioethicists to the global research ethics discourse thereby enriching it. Such bioethicists will be able to drawn on their rich multicultural and multi-religious to inform discussions and issues. In this essay, I discuss the West African Bioethics Training, a United States National Institutes of Health supported training program for biomedical researchers and bioethicists in West Africa.

Spontaneous epigastric hernia causing gastric outlet obstruction: a case report.

Epigastric hernia, a rare form of ventral abdominal hernia, accounts for 0.4 - 1.5% of all abdominal wall hernias. It usually occurs in middle - aged individuals and is rarely large enough to admit more than a small amount of extra-peritoneal fat. In this case report, we present a 64 years old woman with 6 days history of sudden onset of painful epigastric swelling associated with acute gastric outlet obstruction. We did not find a previous report of a similar case in the medical literature.

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.

Ovarian cancer in Ibadan: characteristics and management.

Ovarian cancer has the highest case fatality rate among gynaecological cancers worldwide because of lack of effective screening methods and non-specific early warning symptoms with late presentation. A reinvigorated study is necessary in the developing countries because of a projected increase in its incidence. The decreasing fertility rate and increasing use of ovulation induction drugs are some of the reasons. The Ovarian Cancer Service of the Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria commenced the first longitudinal study of this malignancy from 1 December 1998 in order to establish a regional management and research centre. It is a questionnaire survey detailing the demography, clinical and staging laparotomy findings and histology of all confirmed cases. Twenty-one staging laparotomy and histologically confirmed ovarian cancer cases were managed from 1 December 1998 to 31 July 2002, about 1.5% of the 1387 gynaecological admissions. It is the third most common of the gynaecological cancers, representing 9.8% of the 214 cases. More than 60% of the patients were 50 years or younger. Only 19% were nulliparous, with 47.6% having had five or more deliveries. Only two patients (9.5%) had used the oral contraceptive pill, for a maximum period of 1 month. Only one patient (4.8%) had a positive family history of cancer. Abdominal swelling was the most common presenting symptom. Eighty-one per cent of the patients presented in Stages III and IV. Epithelial ovarian cancer constituted about 76.2% of the cases. Only 23.8% had adjuvant therapy, consisting of combination chemotherapy using cisplatin-based regimes. The case fatality rate 6 months after surgery was 76%. The ovarian cancer patients in this environment are younger and of higher parity than expected. The risk factors for this disease require further study.

Osteogenic sarcoma in the breast--case report of a diagnostic dilemma.

Breast cancer is the leading cancer in females worldwide, the vast majority being carcinomas, and only 0.2-0.3% being sarcomas. Of the mammary sarcomas, extra-osseous osteogenic sarcomas constitute a small heterogeneous group. This communication reports a case of primary extra-osseous osteogenic sarcoma occurring in the breast of a48-year-old female, and presents a literature review of this condition. A pre-requisite for the diagnosis of primary mammary osteogenic sarcoma is the exclusion of an osteogenic sarcoma arising from the underlying ribs or sternum. Like all other osteogenic sarcomas in general, these neoplasms are characterized by the direct formation of osteoid matrix by the tumour cells. Primary osteogenic sarcoma of the breast may arise from metaplastic sarcomatous transformation of neoplastic cells in a primary breast carcinoma, fibroadenoma, malignant phyllodes tumour, or may exceptionally represent a nonphyllodes sarcoma of the breast arising from the soft tissues of an otherwise normal or previously irradiated breast.

Fascia lata autograft for orbital floor reconstruction.

Enophthalmos and diplopia are two major complications that result from a downward displacement of the eyeball. A case in which a fascia lata autograft was used to prevent these complications is presented. When covered by a flap with rich blood supply, this autograft can be used as a good substitute for alloplastic materials.

Anterior abdominal wall reconstruction with fascia lata.

Anterior abdominal wall is a complex fasciomuscular structure, defects of which may arise as a result of infection, trauma, malignancy and herniation. Different techniques have been devised to repair these defects with varying result, availability and cost implications. In the communication, the use of fascia lata for repair of major anterior abdominal wall defect in five patients is reported. The result suggests that this is a useful technique that is associated with satisfactory outcome and minimal morbidity.

Breast cancer in Nigeria.

Breast cancer is now the commonest malignancy affecting women in Nigeria. It is likely to become an important public health issue in the next millennium. Recent years have witnessed an explosion in knowledge about the basic sciences of the disease, including the genetic basis and the pathology. These changes are leading to revisions in the management of the disease with a positive impact on prognosis. In this review, the recent developments in the various aspects of breast cancer are reviewed with reference to how they affect the disease in this environment.

Emergency non-obstetrics surgery during pregnancy.

Female constitute the majority of the population in Nigeria according to the 1991 census. Since most of these are young women in childbearing age, it is to be expected that the need for emergency, non-obstetric surgery will occasionally arise in them. This review article sets out a consideration of the anatomical and physiological factors that influence presentation, diagnosis therapy and outcome in these patients. The various common clinical scenarios are discussed and their outcome reviewed.