Economic costs of terminal care for selected non-communicable diseases from a healthcare perspective: a review of mortality records from a tertiary hospital in Nigeria.

INTRODUCTION: WHO revealed that morbidity and mortality from non-communicable diseases (NCDs) are on the increase and NCDs accounted for approximately 29% of all deaths in Nigeria in 2016. This study was conducted to estimate the economic cost of selected NCDs-lung cancer, liver cancer and liver cirrhosis. These diseases are known to be associated with key modifiable health risk behaviours (smoking and alcohol use), which are prevalent in Nigeria and often commence during the adolescent years. METHODS: Data were obtained between 2016 and 2017, from mortality records of patients managed for the selected diseases in the University College Hospital, a major referral centre in Nigeria. Information on costs of treatment, clinic visits, admission and transportation was obtained. Average costs of terminal in-patient care and transportation costs (in 2020 prices) were computed per patient. Costs were converted to the US dollar equivalent using the current official rate of US$1: ₦360.50. RESULTS: Twenty-two (out of 90 cases recorded) could be retrieved and all the patients had been diagnosed in the terminal stages of the disease. The average direct costs were ₦510 152.62 (US$1415.13) for an average of 49.2 days of terminal care for lung cancer; ₦308 950.27 (US$857.00) and ₦238 121.83 (US$660.53) for an average of 16.6 and 21.7 days of terminal care for patients managed for liver cancer and liver cirrhosis, respectively. CONCLUSION: The economic costs of each of the diseases were very high. Findings emphasise the need for aggressive efforts to promote primary prevention, improve early diagnosis and provide affordable treatment in view of the fact that the monthly minimum wage is less than US$85.00 and treatment costs are borne out-of-pocket by the generality of the population in Nigeria.

Association of the ABO blood group with SARS-CoV-2 infection in a community with low infection rate.

BACKGROUND AND OBJECTIVES: Reports on the association of the ABO phenotypes with infection by the SARS-CoV-2 virus have mostly come from countries with high infection rates. This study examined the possible association between SARS-CoV-2 infection and the ABO phenotype in Black Africa. MATERIALS AND METHODS: This report is from a single centre where both asymptomatic and symptomatic patients were quarantined. At the time of this report, Oyo State, Nigeria had carried out 15 733 tests of which 3119 were positive for the virus with 1952 recoveries and 37 deaths. The ABO distribution of patients was compared with that of a blood donor population. RESULTS: Of the 302 participants, 297 (98%) had their blood group determined, asymptomatic and symptomatic individuals were 123 (40·7%) and 179 (59·3%) respectively. Blood group O was significantly less represented among the patients (P < 0·01) while blood groups B and AB were significantly more represented (P < 0·01, P = 0·03 respectively). Patients with anti-B (groups A and O) were significantly less represented than those without anti-B (B and/or AB): B and AB (P < 0·001), B (P = 0·002), AB (P = 0·01). There was no difference in the blood group distribution of symptomatic and asymptomatic patients (χ2 (3, N = 302) = 2·29; P = 0·51), but symptomatic patients with anti-A (groups B and O) were more represented than asymptomatic patients with anti-A (χ2 4·89; P = 0·03). CONCLUSION: The higher prevalence of blood group O and more potent beta haemolysins (anti-B antibodies) are likely reasons for the lower infectivity by the SARS-CoV-2 virus and severity of COVID-19 disease in the community.

Operative stabilization of open long bone fractures: A tropical tertiary hospital experience.

BACKGROUND: Operative treatment of open fractures in our environment is fraught with problems of availability of theater space, appropriate hardware, and instrumentation such that high complication rates may be expected. MATERIALS AND METHODS: We evaluated all open long bone fractures operatively stabilized at our center to determine the outcome of the various treatment modalities as well as the determinant factors. RESULT: A total of 160 patients with 171 fractures treated between December 1995 and December 2008 were studied. There were twice as many males; mean age was 35.0 years. About half were open tibia fractures. Gustilo IIIa and IIIb fractures each accounted for 56 cases (45.2%). Fifty-three percent were stabilized within the first week of injury. Interval between injury and operative fixation averaged 11.1 days. Anderson-Hutchin's technique was employed in 27 cases (21.8%), external fixation in 21 (16.9%), plate osteosynthesis in 50 (40.3%), and intramedullary nail 15 cases (12.1%). Mean time to union was 24.7 weeks. Fifty-two complications occurred in 50 fractures (40.3%) with joint stiffness and chronic osteomyelitis each accounting for a quarter of the complications. Union was delayed in grade IIIb open fractures and those fractures treated with external fixation. CONCLUSION: A significant proportion of open long bone fractures we operatively treated were severe. Severe open fractures (type IIIb) with concomitant stabilization using external fixation delayed fracture union. While we recommend intramedullary devices for open fractures, in our setting where locking nails are not readily available, external fixation remains the safest choice of skeletal stabilization particularly when contamination is high.

Changing pattern of pediatric maxillofacial injuries at the Accident and Emergency Department of the University Teaching Hospital, Ibadan--a four-year experience.

INTRODUCTION: Maxillofacial injuries are common among polytraumatized patients, and in Nigeria, the incidence seems to be on the increase. This probably is related to the drive of industrialization and the increase in the number of road traffic accidents. Delays in attending to severe maxillofacial injuries can be grave because of concomitant injuries that can be life threatening. METHODS: This is a prospective review of maxillofacial injuries in patients less than or equal to 16 years of age who were seen at the Accident and Emergency Department between October 2002 and December 2006. In all the patients, the accident and emergency physicians carried out initial resuscitation, and thereafter, they were referred to the maxillofacial unit on call. RESULTS: A total of 611 patients with maxillofacial injuries were seen during the study period and of this, 134 (22%) were less than or equal to 16 years old. The male:female ratio was 1.1:1.0. Road traffic accident (RTA) was the most common etiological factor in 73 (54.5%) cases, while gunshot injuries accounted for 6 (4.4%) cases. Soft tissue lacerations were the most common maxillofacial injuries occurring in 90 (55.9%) cases; mandibular fractures were the most common bony injury in 17 (13.4%). CONCLUSIONS: The upsurge in maxillofacial gunshot injuries in the pediatric age group is alarming and this may be a reflection of the global changes (westernization and drug-related offenses like armed robberies) and the harsh economic conditions in this community.

Unintentional injury outcomes secondary to pedestrian traffic crashes: a descriptive analysis from a major medical center.

INTRODUCTION: An environment in which traffic regulations are not strictly enforced often is characterized by carnage from motor vehicular crashes resulting in severe injuries with unacceptably high mortality. The descriptive demographics and injury characteristics of pedestrian road crash victims presenting to a tertiary medical center in southwestern Nigeria are presented in order to provide baseline epidemiology as a first step in determining areas of potential mitigation for care of unintentional injuries. METHODS: Consecutive pedestrian road traffic crash patients treated in the Accident and Emergency Department of a tertiary hospital were prospectively reviewed from March 2007 to February 2008 to determine baseline demographics and clinical outcomes. RESULTS: A total of 184 patients with a mean value of the ages of 31.4 years were studied; 27% of the patients were <11 years of age. The male to female ratio was 1.6:1. Fifty-four percent of the victims were struck by automobiles and 29% were struck by motorcycles. Sixty-five percent were struck while crossing common thoroughfares. Head injury was sustained in 61% of patients. The mortality rate was 31.0% (n = 57). The clinical course leading to death showed 22.8% of the patients who died initially experienced hemorrhagic shock, 17.5% suffered a severe head injury, and 17.5% suffered aspiration. Autopsy confirmed brainstem herniation in 28.1% of the patients who died. The average interval between injury and death was 5.5 +/-13.6 days (range: 0-77 days). In this setting, three out of every ten patients experiencing pedestrian vehicular trauma will die before leaving the hospital. The elderly are most at risk, with two-thirds of victims dying from injuries sustained. CONCLUSIONS: This raises serious questions about the prehospital- and hospital-based emergency services for vehicular road crash victims in this environment, and confirms the World Health Organization findings that Africa has the highest rate overall for unintentional injury deaths. A system-wide program must be put in place that addresses proven prevention measures across all sectors of the community.

Extraosseous osteosarcoma in Ibadan: case series over a 20-year period.

Extraosseous osteosarcoma (EOO) is a rare form of sarcoma. There have been few reports of cases and outcome from an African population.Out of 112 cases of sarcomas seen at the UCH, Ibadan between 1986-2005, 5 were EOO. All presented late on account of initial excision without histology and outcomes were poor. EOO occurs in the black population of Sub-Saharan Africa. The outlook for these patients is still bleak.

On-site physicians at a major sporting event in Nigeria.

INTRODUCTION: Although the need for on-site physicians at mass gatherings has been investigated in developed countries, it has not been studied in a developing country, where resources are limited, paramedical services are unavailable, and transportation and other facilities are inadequate. HYPOTHESIS: The presence of on-site physicians would result in the effective management and prehospital care of casualties at mass gatherings or major sporting events in a developing country. METHODS: A retrospective review of the planning procedures and medical records of the 19th Nigerian University games was conducted. Data from demographic profiles of visitors presenting to the on-site, secondary, and tertiary medical centers and the treatments used were extracted from log-books and processed and interpreted. RESULTS: The Games hosted 6000 accredited athletes and officials, and an estimated 80,000 spectators. Medical coverage was provided by 54 doctors and other healthcare staff at on-site, secondary, and tertiary medical centers. No trained paramedics were available. A total of 494 visits were made to the medical centers (medical usage rate of 2.1/1000, patient presentation rate of 0.08). Forty-six percent of the visitors were evaluated by a physician on-site. Ninety percent of the visits were managed on-site, while 5% and 3% were referred to secondary and tertiary medical centers, respectively. CONCLUSION: The presence of on-site physicians at a major sporting event resulted in the majority of injuries and complaints being effectively treated on-scene. This reduced the number of hospital referrals and saved time and money for treatment.

Osteophytes--an alternative source of chondrocytes for transplantation?

OBJECTIVE: The aim of this research was to evaluate the possibility of using osteophyte-derived chondrocytes for autologous chondrocyte implantation by comparing the behaviour of these chondrocytes with that of normal articular cartilage-derived chondrocytes in monolayer culture. MATERIALS AND METHODS: The scrapings from the cartilage mantle of osteophytes harvested during routine total knee replacement for osteoarthritis were enzymatically digested and grown in monolayer culture. Articular cartilage scrapings obtained from visually normal area of the femoral condyle (usually from the posterior cuts) were also enzymatically digested as for the cartilage from the osteophytes. The behaviours of these two sets of chondrocytes were evaluated in monolayer culture, by their gross appearance, matrix protein elaborated and collagen types with the articular cartilage-derived chondrocytes acting as controls. RESULTS: Osteophyte-derived chondrocytes confluenced earlier than normal articular cartilage-derived chondrocytes. The osteophyte-derived chondrocytes elaborated cartilaginous matrix as evidenced by positive staining for Toluidine blue and the cells were immunoreactive positive for collagen types I, II and III. CONCLUSION: Osteophyte-derived chondrocytes are similar to normal articular cartilage-derived chondrocytes in monolayer culture. Since osteophytes are expendable tissues and often found in association with full thickness articular cartilage defects, they may provide an alternative source of chondrocytes for transplantation in cases where autologous chondrocyte transplantation (implantation) is embarked upon.

Oncogene expression in the peri-articular osteophytes.

OBJECTIVE: The aim of this study was to ascertain the proliferative and probably reparative potentials of the periarticular osteophytes by evaluating the sites of expression of c-myc, c-jun and c-fos oncogenes in this neoplastic repair tissue. MATERIALS AND METHODS: Sections of osteophytes were obtained from knees of patients undergoing total knee arthroplasty for osteoarthritis. Decalcified sections of osteophytes were stained for c-myc and c-jun oncogenes using the avidin HRP technique. Sections of breast carcinoma were used as positive controls. Undecalcified or frozen sections of osteophytes were stained for c-fos oncogene using the avidin alkaline phosphatase technique. Sections of the human skin were used as positive control. For both techniques, sections of normal articular cartilage were used as negative controls. RESULTS: The chondrocytes of the entire cartilage mantle of the peri-articular osteophyte had positive staining for c-myc oncogene but no staining for c-jun oncogene. The basal chondrocytes of the deep layer of the cartilage mantle of the peri-articular osteophyte had positive staining for c-fos oncogene. The normal articular cartilage sections had no staining for any of the oncogenes evaluated. CONCLUSION: The expression of c-myc oncogene in the osteophytic chondrocytes suggests that these cells are actively proliferating. However, c-fos expression in the basal chondrocytes implies that these cells are capable of transformation. This result confirms the proliferative ability of the peri-articular osteophytes and this may suggest that this osteochondral repair tissue, which is apparently wrongly sited, may be a source of tissue for osteochondral grafting for full thickness articular cartilage defects.

Biochemical observations in Blount's disease (infantile tibia vara).

Blount's disease or congenital tibia vara is a clinical entity characterized by tibia bowing, tibia torsion, and beaking of the medial tibia metaphysis on plain radiograph. In our environment, burnt-out rickets patients with biochemical and radiological diagnosis of rickets who after treatment still have residual bone changes despite normal bone biochemistry) can also present with similar clinical and radiological features as Blount's disease. However, certain biochemical variations, including antioxidants, may serve as a basis for differentiation between these two disorders. The serum levels of calcium, inorganic phosphate, zinc, copper, and alkaline phosphatase in 15 patients (10 females and five males) aged between two- and five years (mean 3.8 +/- 1.1 (SD)) with clinical and radiological features of Blount's disease were determined. The mean weight of the patients with Blount's disease was 14.0 +/- 2.4 kg (range: 11.5-16.3 kg). Fifteen subjects (nine females and six males) matched for age and sex without clinical features of any metabolic bone and/or nutritional diseases who were attending the surgical outpatient clinic served as control subjects. The serum concentrations of inorganic phosphate and calcium, though lower in patients with Blount's disease compared with controls, did not reach statistical significance. Alkaline phosphatase activity was increased in the serum of all patients with Blount's disease. In addition, there was an observed significant reduction in serum concentration of zinc (P < 0.03) compared to the control subjects. As for calcium level, the concentration of serum copper in Blount's patients was reduced, but this was not statistically significant. These biochemical observations, especially those of the antioxidant micronuent zinc, may serve as a basis for the differentiaion of the sometimes clinically inseparable disorders of Blount's and rckets and may aid in early differential diagnosis, appropriate treatment as well as prevention of complications.

The choice of arthroplasty for secondary osteoarthritis of the hip joint following avascular necrosis of the femoral head in sicklers.

Secondary osteoarthritis of the hip joint often complicates avascular necrosis of the femoral head in young adults suffering from sickle cell anemia. These patients, particularly in our environment, are usually reluctant to use walking aids like crutches to alleviate the pain since they believe that these devices are temporary measures. They often demand long-term solutions which border on surgery. The surgical procedures carried out in these patients range from osteotomies to arthroplasties. With the advent of various forms of hip implants, osteotomies are not as popular in modern-day orthopedic practice. In this series, we treated five patients with secondary osteoarthritis in six hip joints (bilateral in one patient) using cementless bipolar arthroplasty with good outcome. This implant is available and affordable in Nigeria, and the use of a cementless implant obviates damage to the acetabulum and may make revision surgeries less hazardous both for the surgeon and the patient.