Mitral Valve Segmentation and Tracking from Transthoracic Echocardiography Using Deep Learning.

OBJECTIVE: Valvular heart diseases (VHDs) pose a significant public health burden, and deciding the best treatment strategy necessitates accurate assessment of heart valve function. Transthoracic echocardiography (TTE) is the key modality to evaluate VHDs, but the lack of standardized quantitative measurements leads to subjective and time-consuming assessments. We aimed to use deep learning to automate the extraction of mitral valve (MV) leaflets and annular hinge points from echocardiograms of the MV, improving standardization and reducing workload in quantitative assessment of MV disease. METHODS: We annotated the MV leaflets and annulus points in 2931 images from 127 patients. We propose an approach for segmenting the annotated features using Attention UNet with deep supervision and weight scheduling of the attention coefficients to enforce saliency surrounding the MV. The derived segmentation masks were used to extract quantitative biomarkers for specific MV leaflet scallops throughout the heart cycle. RESULTS: Evaluation performance was summarized using a Dice score of 0.63 ± 0.14, annulus error of 3.64 ± 2.53 and leaflet angle error of 8.7 ± 8.3°. Leveraging Attention UNet with deep supervision robustness of clinically relevant metrics was improved compared with UNet, reducing standard deviations by 2.7° (angle error) and 0.73 mm (annulus error). We correctly identified cases of MV prolapse, cases of stenosis and healthy references from a clinical material using the derived biomarkers. CONCLUSION: Robust deep learning segmentation and tracking of MV morphology and motion is possible by leveraging attention gates and deep supervision, and holds promise for enhancing VHD diagnosis and treatment monitoring.

The importance of concomitant mitral regurgitation for estimates of mitral valve area by pressure half time in patients with chronic rheumatic heart disease.

AIMS: Aim was to study how concomitant mitral regurgitation (MR) assessed by qualitative and quantitative methods influence mitral valve area (MVA) calculations by the pressure half time method (MVAPHT) compared to reference MVA (planimetry) in patients with rheumatic heart disease. METHODS AND RESULTS: In 72 patients with chronic rheumatic heart disease, MVAPHT was calculated as 220 divided by the pressure half time of the mitral early inflow Doppler spectrum. Direct measurement by planimetry was used as reference MVA and was mean (SD) 0.99 (0.69-1.99) cm2. Concomitant MR was present in 82%. MR severity was assessed qualitatively in all, semi-quantitatively by measuring the vena contracta width in 58 (81%), and quantitatively by calculation of the regurgitant volume in 28 (39%). MVA was significantly underestimated by MVAPHT, with increasing MR. In regression analyses MVAPHT underestimated MVA by 0.19 cm2 per higher grade of MR severity in qualitative assessment, and by 0.12-0.13 cm2 per mm larger vena contracta width and 10 ml larger regurgitant volume, respectively. The presented associations were more evident when i) MR severity was quantified compared to qualitative assessment and ii) reference measurements were made by three-dimensional transoesophageal recordings compared to transthoracic recordings. CONCLUSION: MVAPHT underestimated mitral valve area compared to planimetry in patients with MS and concomitant MR. This study highlights the importance of taking the MR severity into account when evaluating MVA based on the PHT method. Direct measurements should be included in clinical decision making.

Primary Tracheobronchial Amyloidosis Presenting with an Upper Airway Obstruction.

This is a case of localized primary tracheobronchial amyloidosis in a patient who presented with upper airway obstruction. Tracheobronchial amyloidosis is a type of localized bronchopulmonary amyloidosis that is frequently overlooked. It involves the deposition of amyloid protein on the tracheal and bronchial tissue, leading to progressive tracheal stenosis and airway obstruction that can be seen on imaging as a tracheal mass. Because of its significant diagnostic difficulty and therapeutic conundrum, it ought to be considered in the differential diagnosis of upper airway symptoms with an unknown etiology.

Short-term outcome after open-heart surgery for severe chronic rheumatic heart disease in a low-income country, with comparison with an historical control group: an observational study.

OBJECTIVES: Rheumatic heart disease (RHD) is a major burden in low-income and middle-income countries (LMICs). Cardiac surgery is the only curative treatment. Little is known about patients with severe chronic RHD operated in LMICs, and challenges regarding postoperative follow-up are an important issue. At Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia, we aimed to evaluate the course and 12-month outcome of patients with severe chronic RHD who received open-heart surgery, as compared with the natural course of controls waiting for surgery and undergoing only medical treatment. METHODS: Clinical data and outcome measures were registered in 46 patients operated during five missions from March 2016 to November 2019, and compared with the first-year course in a cohort of 49 controls from the same hospital's waiting list for surgery. Adverse events were death or complications such as stroke, other thromboembolic events, bleeding, hospitalisation for heart failure and infectious endocarditis. RESULTS: Survival at 12 months was 89% and survival free from complications was 80% in the surgical group. Despite undergoing open-heart surgery, with its inherent risks, outcome measures of the surgical group were non-inferior to the natural course of the control group in the first year after inclusion on the waiting list (p≥0.45). All except six surgical patients were in New York Heart Association class I after 12 months and 84% had resumed working. CONCLUSIONS: Cardiac surgery for severe chronic RHD is feasible in LMICs if the service is structured and planned. Rates of survival and survival free from complications were similar to those of controls at 12 months. Functional level and resumption of work were high in the surgical group. Whether the patients who underwent cardiac surgery will have better long-term prognosis, in line with what is known in high-income countries, needs to be evaluated in future studies.

Translation of the Amsterdam Preoperative Anxiety and Information Score (APAIS) into the Amharic Version and Its Validation for Evaluation of Preoperative Anxiety.

BACKGROUND: Peri-operative anxiety is a vague, unpleasant feeling, the source of which is often nonspecific and unknown to the individual. It affects all aspects of anesthesia. Although the magnitude and consequences of preoperative anxiety are well documented in the developed world, there are limited studies conducted in Ethiopia. The primary aim of this study is to produce the Amharic version of APAIS and evaluate its validity in assessing the prevalence of preoperative anxiety in surgical patients. METHODS: A cross-cultural adaptation process using a forward/backward translation of the APAIS scale was performed. The Amharic version was then tested in 365 sampled elective adult surgical patients scheduled for surgery at Tikur Anbessa specialized Hospital. The validity of the translated version was also checked by evaluating its psychometric properties of internal validity and acceptability. RESULT: The results showed that the reliability of the APAIS-Amharic was high (Cronbach's alpha of 0.87) and the data collected was a good fit (RMSEA of 0.04). In addition, the questionnaire was well-accepted 100% with no missing values for each dimension of the APAIS. The mean APAIS scores for total anxiety and desire for information were 11.6 and 6.0 respectively and 58.9% of the study participants had anxiety and those patients, who had some form of formal education, came from urban areas, had previous anesthesia experience and complications and who had average or high information requirement was more likely to be anxious. CONCLUSION: APAIS-Amharic is a reliable and acceptable tool for measuring patients' preoperative anxiety and their need for information. It can be used routinely as a screening instrument at pre-anesthesia clinics to assess patients' level of anxiety.

Clinico-Pathological Findings and Spatial Distributions of Esophageal Cancer in Arsi Zone, Oromia, Central Ethiopia.

PURPOSE: Arsi Zone is one of the esophageal cancer endemic areas and is reported to have a high incidence of esophageal cancer in Ethiopia. This study assessed clinicopathological patterns and spatial distributions of esophageal cancer in Arsi Zone, Oromia, Central Ethiopia. METHODS: A cross-sectional study design was carried out by abstracting data of 403 patients treated from January 2015 to January 2019. Data were collected by using a structured data collection form and Geographical Positioning System software. The collected data were summarized in the form of tables, figures, means, and standard deviations. Statistical data analysis was done using SPSS software version 21.0 while geospatial analysis was conducted using the Arc-GIS 10.1 software. RESULTS: The disease was prominent among individuals aged 50 to 59 years. The mean age of females and males was 52.2 (SD±10.41) and 56.94 (SD ±12.27) years respectively. The vast majority (98.3%) of cases had squamous cell carcinoma. Dysphagia with weight loss accounted for 87.6% of the presenting symptoms. A large proportion (42.9%) of patients had a tumor located at the lower thorax. The majority (62%) of patients were from the eastern and north-eastern parts of the Arsi zone. CONCLUSION: Dysphagia with weight loss was the major symptom during the first visit. Squamous cell carcinoma was the predominant histopathological type. Eastern and the northeastern parts of the Zone are the most affected regions. Future studies should focus on the determinants of esophageal cancer and precise areas with high incidences by using the population and/or facility-based cancer registry systems.

Dietary and Environmental Determinants of Oesophageal Cancer in Arsi Zone, Oromia, Central Ethiopia: A Case-Control Study.

PURPOSE: Oesophageal cancer is ranked 5th of all types of malignancies in Ethiopia and highly prevalent in the Arsi Zone. However, no study was conducted to elucidate the dietary and environmental determinants of oesophageal cancer in the Arsi Zone. METHODS: A matched case-control study was conducted from June 1, 2019, to June 30, 2020. A total of 104 cases and 208 controls were interviewed. Data were collected using food frequency questionnaires (structured questionnaires). Binary and multiple logistic regression analyses were conducted to check the association between independent and dependent variables. Adjusted odds ratios and the corresponding 95% confidence intervals were estimated for the strength of association. Statistical significance was declared at a P-value of <0.05. RESULTS: In multivariable logistic regression, drinking very hot coffee (AOR=5.1,[95% CI: (1.95, 13.71), drinking large volume of coffee (AOR=4.9, [95% CI: (2.03, 12.17), very hot porridge (AOR= 3.1,[95% CI: (1.38,7.03) and eating porridge fast (AOR=7.0, [95% CI: (2.48, 20.14), low intake of dairy products (AOR=6.0, [95% CI: (2.29, 15.95), cooking food in sleeping room (AOR=3.7, [95% CI: (1.22, 11.39), exposure to x-ray (AOR=9.4,[95% CI: (3.94, 22.82), nonalcohol homemade drinks (AOR=5.4,[95% CI: (1.97, 15.14), use of chemical containers (AOR=3.4, [95% CI: (1.48, 8.23) were determinants of oesophageal cancer. CONCLUSION: Coffee temperature, coffee drinking volume, porridge consumption temperature, porridge consumption speed, dairy products intake patterns, food cooking place, x-ray exposure, nonalcohol homemade drink, and use of chemical containers were independent determinants of the increased risk of oesophageal cancer in the study community.

How do caregivers of children with congenital heart diseases access and navigate the healthcare system in Ethiopia?

BACKGROUND: Surgery can correct congenital heart defects, but disease management in low- and middle-income countries can be challenging and complex due to a lack of referral system, financial resources, human resources, and infrastructure for surgical and post-operative care. This study investigates the experiences of caregivers of children with CHD accessing the health care system and pediatric cardiac surgery. METHODS: A qualitative study was conducted at a teaching hospital in Ethiopia. We conducted semi-structured interviews with 13 caregivers of 10 patients with CHD who underwent cardiac surgery. We additionally conducted chart reviews for triangulation and verification. Interviews were conducted in Amharic and then translated into English. Data were analyzed according to the principles of interpretive thematic analysis, informed by the candidacy framework. RESULTS: The following four observations emerged from the interviews: (a) most patients were diagnosed with CHD at birth if they were born at a health care facility, but for those born at home, CHD was discovered much later (b) many patients experienced misdiagnoses before seeking care at a large hospital, (c) after diagnosis, patients were waiting for the surgery for more than a year, (d) caregivers felt anxious and optimistic once they were able to schedule the surgical date. During the care-seeking journey, caregivers encountered financial constraints, struggled in a fragmented delivery system, and experienced poor service quality. CONCLUSIONS: Delayed access to care was largely due to the lack of early CHD recognition and financial hardships, related to the inefficient and disorganized health care system. Fee waivers were available to assist low-income children in gaining access to health services or medications, but application information was not readily available. Indirect costs like long-distance travel contributed to this challenge. Overall, improvements must be made for district-level screening and the health care workforce.

Evaluation of COVID-19 related knowledge and preparedness in health professionals at selected health facilities in a resource-limited setting in Addis Ababa, Ethiopia.

BACKGROUND: The World Health Organization has declared that infection with SARS-CoV-2 is a pandemic. Experiences with SARS in 2003 and SARS-CoV-2 have shown that health professionals are at higher risk of contracting COVID-19. Hence, it has been recommended that aperiodic wide-scale assessment of the knowledge and preparedness of health professionals regarding the current COVID-19 pandemic is critical. OBJECTIVES: This study aimed to assess the knowledge and preparedness of health professionals regarding COVID-19 among selected hospitals in Addis Ababa, Ethiopia. METHODS: A facility-based cross-sectional study was conducted from the last week of March to early April, 2020. Government (n = 6) and private hospitals (n = 4) were included. The front-line participants with high exposure were proportionally recruited from their departments. The collected data from a self-administered questionnaire were entered using EpiData and analyzed in SPSS software. Both descriptive statistics and inferential statistics (chi-square tests) are presented. RESULTS: A total of 1334 health professionals participated in the study. The majority (675, 50.7%) of the participants were female. Of the total, 532 (39.9%) subjects were nurses/midwives, followed by doctors (397, 29.8%) and pharmacists (193, 14.5%). Of these, one-third had received formal training on COVID-19. The mean knowledge score of participants was 16.45 (±4.4). Regarding knowledge about COVID-19, 783 (58.7%), 354 (26.5%), and 196 (14.7%) participants had moderate, good, and poor knowledge, respectively. Lower scores were seen in younger age groups, females, and non-physicians. Two-thirds (63.2%) of the subjects responded that they had been updated by their hospital on COVID-19. Of the total, 1020 (76.5%) participants responded that television, radio, and newspapers were their primary sources of information. Established hospital preparedness measures were confirmed by 43-57% of participants. CONCLUSION: The current study revealed that health professionals in Addis Ababa, Ethiopia, already know important facts but had moderate overall knowledge about the COVID-19 pandemic. There were unmet needs in younger age groups, non-physicians, and females. Half of the respondents mentioning inadequate preparedness of their hospitals point to the need for more global solidarity, especially concerning the shortage of consumables and lack of equipment.

COVID-19 and the public response: Knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia.

BACKGROUND: The COVID-19 pandemic is impacting the global community in many ways. Combating the COVID-19 pandemic requires a coordinated effort through engaging public and service providers in preventive measures. The government of Ethiopia had already announced prevention guidelines for the public. However, there is a scarcity of evidence-based data on the public knowledge, attitude, and practice (KAP) and response of the service providers regarding COVID-19. OBJECTIVE: This study aimed to assess the public KAP and service providers' preparedness towards the pandemic in Addis Ababa, Ethiopia. METHODS: A community-based cross-sectional study was conducted in Addis Ababa, Ethiopia, from late March to the first week of April 2020. Participants were conveniently sampled from 10 different city sites. Data collection was performed using a self-administered questionnaire and observational assessment using a checklist. All statistical analysis was performed using SPSS version Descriptive statistics, correlation coefficient and chi-square tests were performed. RESULT: A total of 839 public participants and 420 service providers enrolled in the study. The mean age was 30.30 (range = 18-72) years. The majority of the respondents (58.6%) had moderate knowledge about COVID-19, whereas 37.2% had good knowledge. Moreover, 60.7% and 59.8% of the participants had a positive attitude towards preventive measures and good practice to mitigate the pandemic, respectively. There was a moderate positive correlation between knowledge and attitude, whereas the correlations between knowledge and practice and attitude and practice were weak. With regard to service providers' preparedness, 70% have made hand-washing facilities available. A large majority of the respondents (84.4%) were using government-owned media followed by social media (46.0%) as a main source of information. CONCLUSION: The public in Addis Ababa had moderate knowledge, an optimistic attitude and descent practice. The information flow from government and social media seemed successful seeing the majority of the respondents identifying preventive measures, signs and symptoms and transmission route of SARS-CoV-2. Knowledge and attitude was not associated with practice, thus, additional innovative strategies for practice changes are needed. Two thirds of the service provider made available hand washing facilities which seems a first positive step. However, periodic evaluation of the public KAP and assessment of service providers' preparedness is mandatory to combat the pandemic effectively.

Risk Factors that Affect Morbidity and Mortality in Patients with Perforated Peptic Ulcer Diseases in a Teaching Hospital.

BACKGROUND: This study was done to identify risk factors that affect the morbidity and mortality of patients operated for a perforated peptic ulcer in a resource-limited setting. METHODS: A two years (January 1, 2016 -December 30, 2018) retrospective cross-sectional study was done on patients admitted and operated for PPU at Yekatit 12 Hospital, Addis Ababa, Ethiopia. RESULTS: A total of 93 patients were operated. The median age affected was 29 years (Range 15-75 years). Male to female ratio was 7.5:1. Chewing chat, smoking and alcohol use were seen in 22 (23.6%), 35(37.6%), and 34(36.5%), cases respectively. Only 23.6% gave previous history of dyspepsia. The median duration of illness was 48hours and the duodenal to gastric ulcer perforation ratio was 6.5:1. In majority of the cases (63.3%) the perforation diameter was =10mm (63.3%). Cellan-Jones repair of the perforations was done in 92.5% of cases. A total of 47 complications were seen in 25 cases. The total complications and mortality rates were 25(26.8%) and 6(6.5%) respectively. The most common postoperative complication was pneumonia (13.97%) followed by superficial surgical site infection (10.8%). Mortality rate was highest among patients >50yrs [AOR (95%CI) =2.4(230)]. Delayed presentation of >24 hours [AOR (95%CI) =4.3(1.4-13.5)] and a SBP =90mmhg [AOR (95%CI) =4.8(1-24)] were found to be significantly related with higher complication rate. CONCLUSIONS: Patients who presented early and immediate corrective measures were instituted had better outcomes while those seen late developed unfavorable out-come with significantly higher complications. Therefore, early detection and treatment of PPU is essential.

Factors associated with perioperative mortality in children and adolescents operated for tetralogy of Fallot: A sub-Saharan experience.

BACKGROUND: Patients with tetralogy of Fallot are now surviving to adulthood with timely surgical intervention. However, many patients in low-income countries have no access to surgical intervention. This paper reports the surgical access and perioperative mortality in a sub-Saharan center that was mainly dependent on visiting teams. METHODS: We reviewed records of patients operated from January 2009 to December 2014. We examined perioperative outcomes, primarily focusing on factors associated with perioperative mortality. RESULTS: During this period, 62 patients underwent surgery. Fifty-seven (91.9%) underwent primary repair, while 5 (6.5%) underwent palliative shunt surgery. Of the five patients with shunt surgery, four ultimately underwent total repair. Eight (12.9%) patients died during the perioperative period. Factors associated with perioperative mortality include repeated preoperative phlebotomy procedures (P < .001), repeated runs and long cardiopulmonary bypass time (P < .001), and aortic cross-clamp time (P < .001), narrow pulmonary artery (PA) valve annulus diameter (P = .022), narrow distal main PA diameter (P = .039), narrow left branch PA diameter (P = .049), and narrow right PA diameter (P = .039). Of these factors, cardiopulmonary bypass time/aortic cross-clamp time and pulmonary valve annulus diameter less than three SD were independently associated with perioperative mortality. CONCLUSION: In this series of consecutive patients operated by a variety of humanitarian surgical teams, cardiopulmonary bypass time/aortic cross-clamp time, and pulmonary valve annulus diameter less than three SD were independently associated with perioperative mortality risk. As some of these factors are modifiable, we suggest that they should be considered during patient selection and at the time of surgical intervention.

Pattern of Vascular Diseases at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Vascular diseases are evolving fast in sub-Saharan Africa, but its management is challenged by lack of expertise and infrastructure. In the light of the prevailing challenge, this study was done to see the pattern of vascular disease and its treatment in a tertiary referral hospital. METHODS: A prospective cross-sectional study was done over a period of one year (February 9, 2016 to February 8, 2017) at Tikur Anbessa specialized hospital (TASH) at Addis Ababa, Ethiopia. RESULTS: A total of 386 patients were seen at the surgical OPD. Of these, 78(20.2%) were admitted and operate on. The male to female ratio was 1.3:1. The mean age affected was 39 +/- 10 (Range 12-91 years). On the other hand, 132 (34.2%) patients came with PAD. Of them, 46(34.8%) presented with either frank Gangrene or pre-gangrene stage. The rest 86(65.1%) had claudication pain. The other diseases seen are Varicose Vein, 100(25.9%), Carotid body tumors, 60(15.4%), Aneurysmal diseases, 36(9.1%), Vascular malformations, 34(8.7%), and Vascular injuries, 22(5.6%). During the study period, 28(35.9%) PAD, 22(28.2%) trauma patients, 8(10.2%) Chemodectomas, 8(10.2%) aneurysms, 6(7.7%) hemangiomas, 4(5.1%) varicose vein and 2(2.6%) AV fistula patients were operated. CONCLUSION: The pattern of vascular disease in Ethiopia is becoming a challenge. The gap created due to limited vascular surgeons, poor infrastructure and absent supply chain system has significantly compromised the number and type of operated-on patients. These challenges result in preventable morbidity and mortality.

Bronchiectasis: Experience of Surgical Management at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Bronchiectasis is one of the major health problems in Ethiopia. We analyzed the outcome of surgery done for bronchiectasis in a resource-limited setup. METHODS: A retrospective cross-sectional analysis of 22 patients who underwent surgery for bronchiectasis in Tikur Anbessa specialized hospital (TASH) during the period 2012 - 2017 were done. RESULTS: There were 13(59%) female and 9(41%) male patients with a mean age of 34.1 +/-16.9 years. The mean duration of symptoms was 2.2 years. Blood streak sputum, 13(59%), dyspnea, 9(49.9%), fetid sputum, 8(36.4%), dry cough, 6(27.3%), chest pain, 6(27.3%) and massive hemoptysis 3(13.6%) were the main presenting symptoms. In 20(91%) of the patients, previous history of TB treatment was identified. Recurrent childhood infection, 1(4.5%), and tumor obstruction, 1(4.5%), were also seen. Bronchiectasis was left sided in 12(54.5%), right-sided in 7(31.8%) and bilateral in 3(13.6%) patients. The disease affected multiple lung lobes in 9(40.9%), left lower lobe in 6(27.3%) and left upper lobe in 3(13.6%) cases. Indications for surgery were the failure of medical management in 10(45.5%), destroyed lung in 9(40.9%), and massive hemoptysis in 3(13.6%) cases. The procedures performed were lobectomy in 14(63.6%) and pneumonectomy in 8(36.4%) cases. Postoperative complications occurred in 5(22.7%) patients with one (4.5%) death. On the other hand, 77.3% of operated patients had significant improvement compared to their preoperative symptoms. CONCLUSIONS: In a resource-limited setup like TASH, localized bronchiectasis can be treated surgically with an acceptable result. Proper selection and preparation with complete resection of the involved segments are needed for maximum control of symptoms and better outcomes.

Pattern of vascular diseases at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND: Vascular diseases are evolving fast in sub-Saharan Africa, but its management is challenged by lack of expertise and infrastructure. In the light of the prevailing challenge, this study was done to see the pattern of vascular disease and its treatment in a tertiary referral hospital. METHODS: A prospective cross-sectional study was done over a period of one year (February 9, 2016 to February 8, 2017) at Tikur Anbessa specialized hospital (TASH) at Addis Ababa, Ethiopia. RESULTS: A total of 386 patients were seen at the surgical OPD. Of these, 78(20.2%) were admitted and operate on. The male to female ratio was 1.3:1. The mean age affected was 39 +/- 10 (Range 12-91 years). On the other hand, 132 (34.2%) patients came with PAD. Of them, 46(34.8%) presented with either frank Gangrene or pre-gangrene stage. The rest 86(65.1%) had claudication pain. The other diseases seen are Varicose Vein, 100(25.9%), Carotid body tumors, 60(15.4%), Aneurysmal diseases, 36(9.1%), Vascular malformations, 34(8.7%), and Vascular injuries, 22(5.6%). During the study period, 28(35.9%) PAD, 22(28.2%) trauma patients, 8(10.2%) Chemodectomas, 8(10.2%) aneurysms, 6(7.7%) hemangiomas, 4(5.1%) varicose vein and 2(2.6%) AV fistula patients were operated. CONCLUSION: The pattern of vascular disease in Ethiopia is becoming a challenge. The gap created due to limited vascular surgeons, poor infrastructure and absent supply chain system has significantly compromised the number and type of operated-on patients. These challenges result in preventable morbidity and mortality

Humanitarian Cardiology and Cardiac Surgery in Sub-Saharan Africa: Can We Reshape the Model?

BACKGROUND: In recent decades, humanitarian cardiology and cardiac surgery have shifted toward sending short-term surgical and catheter missions to treat patients. Although this model has been shown to be effective in bringing cardiovascular care to the patients' environment, its effectiveness in creating sustainable service is questioned. This study reports the barriers to contribution of missions to effective skill transfer and possible improvements needed in the future, from the perspective of both the local and overseas teams. METHODS: We reviewed the mission-based activities in the Children's Heart Fund Cardiac Center in the past six years. We distributed questionnaires to the local surgeons and the lead surgeons of the overseas teams. RESULTS: Twenty-six missions visited the center 57 times. There were 371 operating days and 605 surgical procedures. Of the procedures performed, 498 were open-heart surgeries. Of the operations, 360 were congenital cases and 204 were rheumatic. Six local surgeons and 18 overseas surgeons responded. Both groups agree the current model of collaboration is not optimal for effective skill transfer. The local surgeons suggested deeper involvement of the universities, governmental institutions, defined training goals and time frame, and communication among the overseas teams themselves as remedies in the future. Majority of the overseas surgeons agree that networking and regular communication among the missions themselves are needed. Some reflected that it would be convenient if the local surgeons are trained by one or two frequently visiting surgeons in their early years and later exposed to multiple teams if needed. CONCLUSION: The current model of collaboration has brought cardiac care to patients having cardiac diseases. However, the model appears to be suboptimal for skill transfer. The model needs to be reshaped to achieve this complex goal.

Outcome in Children Operated for Membranous Subaortic Stenosis: Membrane Resection Plus Aggressive Septal Myectomy Versus Membrane Resection Alone.

BACKGROUND: The optimal surgical procedure for treatment of fibromembranous subaortic stenosis has been a subject of debate. We report our experience with patients treated for membranous subaortic stenosis using membrane resection alone and membrane resection plus aggressive septal myectomy. METHODS: Patients followed in the pediatric cardiology clinic of a university hospital, who had undergone surgery for subaortic stenosis between 2002 and 2013 were reviewed. Recurrence of subaortic membrane, residual left ventricular outflow gradient, and aortic valve function were analyzed. RESULTS: Forty-six patients underwent surgery for subaortic membrane. Of these, 19 had membrane resection plus aggressive septal myectomy, while 27 had membrane resection alone. Mean age at surgery for the membrane resection group was 7.7 ± 3.9 years and 10.9 ± 3.6 years for the membrane resection plus aggressive myectomy group. Preoperative subaortic gradient for the membrane resection group was 75.5 ± 26.7 mm Hg and 103.2 ± 39.7 mm Hg for the membrane resection plus aggressive myectomy group. The mean follow-up left ventricular outflow tract gradient was 42.3 ± 31.3 mm Hg in the membrane resection group, while it was 11.6 ± 6.3 mm Hg in the aggressive septal myectomy group. Nine patients from the membrane resection group had significant regrowth of the subaortic membrane during the follow-up period, while none of the aggressive septal myectomy group had detectable membrane on echocardiography. Seven of the nine patients with recurrence of the subaortic membrane underwent subsequent membrane resection plus aggressive septal myectomy. Intraoperative finding in all these redo cases was recurrence (growth) of a subaortic membrane. CONCLUSION: Aggressive septal myectomy offers less chance of recurrence, freedom from reoperation, and an improved aortic valve function. This is especially important in sub-Saharan settings where a chance of getting a second surgery is unpredictable.

Patterns of mediastinal tumors operated at the Tikur Anbessa Hospital, Addis Ababa, Ethiopia over a six years period.

BACKGROUND: The mediastinum is the space that lies between the two pleural cavities containing many vital structures in it. When tumors or cysts arise in the mediastinum they can be either asymptomatic or present as space occupying lesions causing symptoms and signs by their effect on the neighboring organs. Though mediastinal tumors are routinely treated at the study center, there are no studies in Ethiopia concerning the patterns, and modes of treatments of Mediastinal space occupying lesions. OBJECTIVE: To review all the primary mediastinal tumors and cysts operated upon at the Tikur Anbessa Teaching Hospital, Addis Ababa University over a six year period, from August 2005-2011. METHODOLOGY: Clinical retrospective review. RESULTS: In the six years, 73 patients were operated, 49 (67.1%) were males, the and male to female ratio being 2.04:1. The mean age of patients was 35.9 +/- 10.5 years (range 14 to 74). Forty-five (61.6%) had lesions of the anterior mediastinum, 23 (31.5%) in the posterior mediastinum and 5 (6.8%) in the middle. The commonest anterior mediastinal tumors were thymic origin (24/45), and thymic lesions were found more common in females (17:7 ratio). From the 23 patients with posterior mediastinal tumors, 18 had benign neurogenic tumors (4 of which were dumbbell tumors). Chest pain and shortness of breath (dyspnea) were the two most common symptoms in 31 (42.4%) of the patients. Twenty three patients (31.5%) were asymptomatic, and all had benign lesions. None of the malignant lesions were asymptomatic. Eleven (15%) patients; eight with anterior and three with posterior mediastinal masses, had undergone pre-operative tissue diagnosis procedure by image guided FNAC. Fifty-nine (80.8%) patients were operated with intent of therapeutic surgical procedures. There were 28 (38.5%) midline sternotomies, 40 (54.7%) thoracotomies, four underwent a left sided mediastinotomies and one mediastinoscopy performed. The rate of malignancy in this study was 24 (32.8%), of which 19 (79.1%) were in the anterior compartment. A total of 13 (17.8%) patients had complications in the hospital and four (5.4%) of the patients died CONCLUSION: Primary mediastinal tumors are not so rare in the setting. We would also like to recommend further large scale prospective studies which also included long-term outcome so that we can further understand the situation in the country.

Extended resection for advanced rectal cancer in Ethiopian context, a case report.

Complete resection is the most important prognostic factor in surgery for rectal cancer. In locally advanced rectal cancer, radical margins are sometimes difficult to obtain because of the close relationship to or growth in adjacent organs/structures. Such type of advanced tumors may require ebloc resection of the rectum, bladder, and/or internal genital organs (prostate/seminal vesicles or uterus, ovaries and/or vagina). Here, we present a case of advanced rectal cancer in a 45-year-old male patient who was successfully operated on by extended resection of rectum, bladder, and left ureter with urinary bladder reconstruction made using ileal conduit. Discussion of the case and literature review was also made.

Pattern of acute abdomen and variables associated with adverse outcome in a rural primary hospital setting.

OBJECTIVE: To analyze the clinical presentation, causes, outcomes of surgical intervention (as measured by postoperative morbidity and mortality), and variables associated with adverse outcomes of patients with surgically important acute abdominal pain. DESIGN: A cross sectional hospital based longitudinal case series analysis. SETTING: Glen C Olsen Memorial Primary General Hospital. Butajira, Ethiopia. SUBJECT: All patients admitted and operated for acute abdominal pain over a period of two years. (Oct. 10, 2004 -Nov. 20, 2006) OUTCOME MEASURES: Being referred from other centers, duration of symptoms, types of symptoms and physical findings, relevant investigations, diagnosis and procedure done, hospital stay, mortality, morbidity, and variables associated with adverse out comes. RESULTS: A total of 143 patients were operated and of them 55.2% were referred from other health care facilities. Male to female ratio was 2.5:1 and mean age of presentation was 26.6 +/- 16.6 years. Patients presented after an average of 88.4 +/- 87.9 hours of symptom onset. Intestinal obstruction 50 (34.9%), acute appendicitis 35 (24.5%), Intussusceptions 23 (16.1%) and bowel perforation 16 (11.2%) were the leading causes of admission. Clinical variables found to have statistical significant association (P < 0.05) with adverse outcomes were referred patients, those with abdominal distension, absolute constipation, deranged vital signs, abdominal mass, guarding, positive vaginal/rectal examination and/or leukocytosis. The average hospital stay was 8.74 +/- 4.66 days and 28.7% of patients develop one or more of acute complications. Forty two (29.4%) patients presented with deranged vital signs from either septic or hypovolemic shock and of them 7 (4.9%) died with subsequent multiple organ failure. CONCLUSION: Patients who presented early and immediate corrective measures were instituted had better outcome while those seen late developed unfavorable out-come with significantly higher complications. Therefore early detection and treatment of acute abdomen is essential.