Planar 99m Tc-PSMA Imaging of Prostate Cancer in a Low-Resource Setting: A Series Report.

Objective Technetium-99m labeled prostate-specific membrane antigen (PSMA) single-photon emission computed tomography/computed tomography (SPECT/CT) is a suitable alternative to prostate-specific membrane antigen-positron emission tomography (PSMA-PET) imaging. However, the availability of SPECT/CT in many developing countries is limited. Materials and Methods To evaluate the utility of planar 99m Tc-PSMA in the absence of SPECT/CT, we compared planar 99m Tc-PSMA and routine bone scan imaging in low-, intermediate-, and high-risk prostate cancer in five patients with histologically confirmed prostate cancer who had both scans within a period of less than 4 days. The mean age of patients was 66.8 ± 5.24, and the median prostate-specific antigen level was 175 ng/mL (range: 0-778 ng/mL). Results Planar 99m Tc-PSMA scan provided no additional benefit over bone scans in the low-risk prostate cancer cases. In the cases with intermediate-risk prostate cancers, planar 99m Tc-PSMA indicated complete and partial response to treatment in oligometastatic and widespread metastatic disease, respectively. In one patient with high-risk prostate cancer, planar 99m Tc-PSMA detected additional skeletal lesions that were not seen on bone scan. Conclusion In the absence of SPECT/CT, planar 99m Tc-PSMA was useful for confirming extent of disease in treated intermediate- and high-risk prostate cancer. It showed little value in low-risk prostate cancer, especially when bone scan is normal. It was particularly useful for treatment response assessment in oligometastatic disease, and its utility should be further explored.

EXPERIENCE WITH MANAGING CHILDHOOD URETHROCUTANEOUS FISTULA AT IBADAN.

BACKGROUND: Urethrocutaneous fistula could be a distressing condition to the child and parents alike. Its management could be challenging and requires adequate expertise. AIM: To review the characteristics and aetiology of urethrocutaneous fistula managed in our division over a ten-year period. METHODOLOGY: All children with urethrocutaneous fistulae from July 2006 to June 2015 were subject of this review. The demography, aetiology, type of fistula, operation performed and the outcome were retrieved from the division operation book and case notes of the patients. The data was analyzed using SPSS Inc. version 20 and odd ratio. RESULTS: Thirty-five children were managed over a period of ten tears. The age ranged from 6 months to 13 years with a mean of 4±1.9years. Seventy one percent of urethrocutaneous fistulae resulted from complication of childhood male circumcision procedures performed in private hospitals and by nurses. One child (3%) had isolated perineal urethrocutaneous fistula while 26% complicated hypospadias repair at these locations: glandular in 1% case, subcoronal in 3% cases, penile in 2% cases, and penoscrotal in 3% cases. Ten (29%) children with abnormal haemoglobin AC was noted in 3 (9%) patients and haemoglobin AS in 7 (20%) patients. The odd ratio between abnormal haemoglobin and normal haemoglobin was 3.8. The surgical repair of post-circumcision urethrocutaneous fistulae and post-hypospadias had a recurrent fistulae in 4 (16%) and 3 (33%) respectively. Majority of the fistulae were repaired by simple closure in 80% post-circumcision and in 44% post-hypospadias repair. in the more difficult cases, penile degloving with urethral mobilization was done in 16% post-circumcision fistula and 22% post-hypospadias fistula with no recurrence. CONCLUSION: in this study, post-circumcision urethrocutaneous fistula was the commonest cause of childhood urethrocutaneous fistula, the severe ones could require penile degloving to achieve repair without tension; recurrence was a major complication.

Essential professional duties for the sub-Saharan medical/dental graduate: An Association of Medical Schools of Africa initiative.

BACKGROUND - Globally, human resources for health are being optimized to address the increasing health burden and concomitant increased demands on health professionals. These demands are even more exacting in Sub-SaharanAfrica considering the shortage of health care workers, especially physicians. The noteworthy efforts at deploying task-shifting to address this situation not-withstanding, the situation also signals the need to re-define the objectives of medical instruction to ensure effective and contemporary medical practice in a mostly physician-led health workforce across the sub-continent. In this regard, medical and dental graduates must be educated to perform certain minimum essential professional duties competently. Essential Professional Duties are locally relevant professional activities of international standard that represent identifiable outcomes against which the effectiveness of physicians in a specific community can be measured to ensure social accountability. PROCEDURE AND PRODUCT - The Association of Medical Schools of Africa has developed the 'Essential Professional Duties for sub-Saharan medical and dental graduates' to ensure these physicians provide safe and effective contemporary medical/dental practice on the sub-continent. The duties have been grouped into those required for basic patient care, basic administrative skills, basic emergency care, communication, inter-professional relationships, self-directed learning and social responsibilities. Their relevance and suitability have been evaluated prior to their adoption by the Association. CONCLUSION; These Essential Physician Duties have been developed to serve as targets for health professionals training instruments and thus give direction to health system strategies. It is hoped that they will be adopted by medical and dental schools across sub-,. Saharan Africa.

Frequency and Pattern of Lower Urinary Tract Symptoms in a screened population of Men above 40 Years in Ibadan, Southwestern Nigeria.

BACKGROUND: The epidemiology of lower urinary tract symptoms in adult men in Nigeria is presently not well known. AIM: To evaluate a screened population of men for lower urinary tract symptoms and their impact on the participants' quality of life. METHODS: A cohort study was conducted among men aged 40 years and older from 3 selected centres in Ibadan, Southwestern Nigeria. The presence of lower urinary tract symptoms and their impact was determined using the International Prostate Symptom Score (IPSS) administered via standardized questionnaires. RESULTS: Six hundred and fifty-five men participated in the study. The median age was 56 years with a range of 40 - 92 years. Eight percent (8%) of respondents were asymptomatic, whilst 66%, 20% and 6% had mild, moderate and severe symptoms respectively. Nocturia was the most common symptom and the second most troublesome. Overall storage (irritative) symptoms occurred with the similar frequency to voiding (obstructive) symptoms (91% v 92%), but voiding symptoms were more likely to be severe and thus more troublesome (p = <0.000.1). The severity of the individual symptoms as well as the overall score also increased significantly with age [p = 0.001]. There was a high correlation between IPSS and Quality of Life (QoL) scores (correlation coefficient 'r' = 0.75 [p = <0.0001]. Despite this, 72% of QoL respondents were satisfied with their quality of life. CONCLUSION: The frequency of non-troublesome lower urinary tract symptoms was high in adult men in this cohort of men in Southwestern Nigeria and that severity was age-related. In addition, whilst storage and voiding symptoms occurred with similar frequency, voiding symptoms were the more severe and troublesome.

HISTOPATHOLOGIC PATTERN OF BLADDER CANCERS IN IBADAN SOUTHWEST NIGERIA: AN UPDATE.

BACKGROUND: A study from the University College Hospital, Ibadan, Southwest, Nigeria on bladder cancers had described an increase in the frequency of urothelial carcinoma compared to the earlier reported preponderance of squamous-cell carcinoma. AIM: To provide an update on the histopathologic pattern of bladder cancers in our community and to explore its implications for future health system policies. METHODS: The records of the Ibadan Cancer Registry from January 1997 to December 2014 were reviewed and the data analyzed for the histologic subtypes of bladder cancers diagnosed in the hospital. RESULTS: Two hundred and sixteen bladder tumours were recorded during this period with a male to female ratio of 3.2:1. Complete information was available in 195 cases of which 181 (96.8%) were bladder carcinomas whilst 14 were sarcomas. Of the bladder carcinomas, 68.5%, 19.9% and 11.6% were urothelial carcinomas, squamous cell carcinomas, and adenocarcinomas (AC) respectively. Urothelial carcinoma was more common in all age groups and its peak age of occurrence was in the 51-60 year age group. The peak age for squamous cell carcinoma was in the 41-50 year age group. Mean and median age of occurrence was significantly lower in females in the urothelial and squamous cell carcinomas, but lowest in squamous cell carcinoma [P = < 0.0001]. CONCLUSION: This population study has confirmed urothelial carcinoma as the predominant histotype of bladder cancer in Ibadan, Southwest Nigeria currently and that both urothelial and squamous cell carcinomas occur earlier in women.

Knowledge and Perception of Nigerian Men 40 years and above Regarding Prostate Cancer.

BACKGROUND: Carcinoma of the prostate is now the most commonly diagnosed male cancer worldwide. However, knowledge and perception of Nigerian men about the disease has not been fully investigated. AIM: To determine the level of awareness about prostate cancer among men 40 years and older in Ibadan, Southwestern Nigeria. METHOD: Four focus group discussions were used to obtain information from 29 randomly- selected Nigerian men, aged 40 years and above, about their knowledge of the common causes of morbidity and mortality among men of their age group as well as prostatic diseases and their perceived causes. In-depth interviews were then conducted among 656 participants using questionnaires. RESULTS: Generally, the respondents and discussants were unaware of the prostate gland and its diseases; whilst relatively few knew about carcinoma of the prostate and most were ignorant of the symptoms of the disease. Among discussants and respondents who knew about the gland, most thought that benign and malignant prostatic diseases were long-term complications of promiscuity and sexually transmitted infections. All the participants were interested in receiving information about all aspects of carcinoma of the prostate. CONCLUSION: . These results indicate that a large proportion of adult Nigerian men are ignorant of the prostate gland and its diseases in general, and carcinoma of the prostate in particular. There is therefore the need for community awareness programs on prostatic diseases in our locality.

Torsion of the testis and factors that determine the choice of orchidectomy and unilateral orchidopexy.

AIMS AND OBJECTIVES: To determine the age group affected by testicular torsion and the relationship with orchidectomy and unilateral orchidopexy. To determine if seasonal variation affects the incidence of torsion of the testis. MATERIALS AND METHODS: Data of confirmed patients with testicular torsion from July 1998 to June 2010 were retrieved. They were divided into two, group I (age<21 years) and group II (age e"21 years). The indices analyzed were the relationship of age group, occupation on orchidectomy and unilateral orchidopexy and seasonal variation and torsion. Cases of acute epididymo-orchitis, torsion of appendix testis, and testicular tumor were excluded from the study. RESULTS: A total of 169 confirmed cases of testicular torsion were analysed.The estimated incidence was 12.1 cases per 100,000 populations. Their age range from 9 months to 45 years and mean age 23.8±7.6 (SD). 62.1% of torsion occurred at e" 21 years. One hundred and twenty patients (71%) had bilateral orchidopexy, 32 (18.9%) had orchidectomy and 17 (10.1%) had unilateral orchidopexy. In group II; unilateral orchidopexy was significant (p<0.03) and there was a correlation between the occupation and orchidectomy (p<0.02). There was no statistical correlation between total torsion and humidity (r=0.321, p=0.309), or ambient temperature (r=0.248, p=0.437). CONCLUSIONS: Testicular torsion was commoner in men age e" 21 years and more students lost their testes. Unilateral orchidopexy should be considered in some cases. There was no relationship between torsion, orchidectomy, ambient temperature and relative humidity. The need for rigorous pre-school and pre-employment health education is advocated.

Cutaneous metastasis from prostate cancer in a nigerian: a case report and literature review.

BACKGROUND: Prostate cancer is the most common male malignancy in Nigeria and most patients present with advanced and metastatic disease. Cutaneous metastasis from prostate cancer is rare worldwide and to our knowledge has not been previously reported in a native African. We hereby report a case in a 62-year-old Nigerian. CASE PRESENTATION AND MANAGEMENT: A 62-yr-old Nigeria man presented with 6 months history of lower urinary tract symptoms that culminated in urinary retention for which he was catheterized. He noticed multiple painless skin nodules about the same time on the neck and trunk. On examination, he had multiple cutaneous nodules on his neck, limbs and trunk. His prostate gland was enlarged, hard and irregular. Prostate biopsy revealed adenocarcinoma of the prostate. He had bilateral orchidectomy with progressive regression of the skin nodules. He had successful trial of voiding without a catheter 3 weeks after bilateral total orchidectomy. CONCLUSION: Cutaneous metastasis from prostate cancer is rare in native Africans despite the high incidence of the disease in this population. To our knowledge, this index case is the first report in a native African in the English literature.

Caudal block anesthesia for transrectal prostate biopsy.

OBJECTIVE: Transrectal prostate biopsy is a potentially painful procedure. Our service has significant experience with caudal anesthesia for perianal procedures. This study is aimed to determine the effectiveness of caudal anesthesia for transrectal prostate biopsy. PATIENTS AND METHODS: Seventy consecutive patients undergoing transrectal prostate biopsy were entered into the study. The patients were requested to complete a questionnaire structured to assess the pain felt during the procedure using the visual analog score (VAS). The effectiveness of the caudal anesthesia was determined by the anesthesia of the perineum and the laxity of the anal sphincter. Complications from the procedures were recorded. RESULTS: All the patients completed and returned the questionnaire. The average age of the respondents is 65.8 years. Among the 34 patients with caudal block, effective anesthesia was achieved in 28 patients and ineffective in six patients. However, the mean VAS for the pain from transrectal prostate biopsy was 1.49 +/- 1.93 SD (range 0-6.0) for the patients with effective caudal anesthesia and 8.02 +/- 1.79 SD (range 5.0-10.0) for patients with no caudal anesthesia. There was a reduced requirement for analgesics after prostate biopsy for patients with effective caudal anesthesia. Three patients (8.8%) had minor complications (transient dizziness) following the injection of the anesthetic into the caudal epidural space. CONCLUSION: Satisfactory analgesia for transrectal prostate biopsy can be achieved with the use of CA and it results in better cooperation of the patient during the procedure.

Early endoscopic realignment of traumatic anterior and posterior urethral disruptions under caudal anaesthesia - a 5-year review.

OBJECTIVE: We recently described early rigid retrograde endoscopic realignment of the disrupted urethra under caudal anaesthesia in the outpatient setting. This retrospective study was performed to evaluate our medium-term results. PATIENTS AND METHODS: A retrospective review of patients who had early rigid retrograde endoscopic realignment of traumatic urethral disruptions in our institution over a 5-year period was done and the relevant data extracted and analyzed. RESULTS: Fourteen acutely ruptured urethras (10 posterior and four anterior) were endoscopically realigned early in the study period. Nine (90%) of the posterior disruptions occurred at bulbo-membranous urethra (distal to the external sphincter mechanism). Thirteen of the ruptured urethras (93%) were successfully realigned (nine posterior and four anterior) and postoperative clean intermittent self-calibration (CIC) was instituted in 10 patients. The mean follow-up period was 36.6 months (range 18-54 months). The mean operating time and the median hospital stay were 22 min (range 8-68 min) and 3 days (range 1-10 days), respectively, and were shorter in patients with injuries of the anterior urethra than those with posterior urethral tears (p < or = 0.0001). Post-realignment, all 13 patients were potent and continent. Two patients required additional procedures (direct vision internal urethrotomy or urethral dilation) and one patient has remained on CIC i.e. a stricture rate of 21%. CONCLUSION: Early retrograde endoscopic realignment under caudal analgesia is suitable and cost-effective for patients with acute traumatic urethral disruptions and has good medium-term results. In addition, an early postoperative regimen of CIC significantly reduced stricture-formation in our series.

A variant epidermal growth factor receptor protein is similarly expressed in benign hyperplastic and carcinomatous prostatic tissues in black and white men.

BACKGROUND AND OBJECTIVE: Anti-epidermal growth factor receptor strategies are now established in cancer treatment We have recently described the presence of EGFRvIII (a variant EGFR) in prostatic tumours from UK white men and this is now a target for anti-prostate cancer treatments. However, there has been no report on the expression of this abnormal protein in black men. MATERIALS AND METHODS: We determined EGFRvIII expression in sections of normal, benign hyperplastic (BPH) and carcinomatous (CaP) prostatic archival tissues from Nigerian men and UK white men using streptavidin immunohistochemical techniques. The EGFRvIII immunoreactivity was scored visually using a semi-quantitative method and the results compared statistically. RESULTS: EGFRvIII expression increased with increasing malignancy in both study populations (CaP > BPH > Normal p, <0.0001). Furthermore, EGFRvIII expression was similar in both BPH and CaP tissues in black and white men (p, 0.86 and 0.31 respectively). CONCLUSION: These results demonstrate that EGFRvIII immunoreactivity in prostatic tumours in black men is similar to that in white men. Anti-cancer treatments directed at the EGFRvIII should be equally effective in men from both subpopulations.

Anti-PSA immunoreactivity in primary prostatic tissues from black African men.

Prostatic specific antigen (PSA) immunoreactivity is the most commonly used histological marker to identify epithelial cells of prostate origin. Unlike tissues from white men in which grade-related variability has been reported, the pattern of PSA immunoreactivity in prostatic tissues from black African men is presently unknown. This study was done to evaluate the pattern of PSA staining in sections of normal, benign hyperplastic and malignant prostatic glands from men from this sub-population. PSA immunostaining was done on 4-microm serial sections from archival specimens of benign prostatic hyperplasia (BPH) and carcinoma of the prostate (CaP) obtained from black African men using standard immunoperoxidase techniques. The intensity of PSA immunoreactivity of the glands was scored using a semi-quantitative method. PSA expression decreased with increasing de-differentiation of the tissue histotype with poorly differentiated tumours staining least. PSA immunoreactivity was strong in 100% of normal glands and 84% of BPH glands and moderate in the rest. In contrast, PSA immunopositivity was strong in 32% of CaP glands, moderate in 26%, weak in 34% and absent in 8%. Statistical comparison revealed that PSA expression was significantly higher in benign tissues (normal/ atrophic and BPH) than in CaP glands [p = < 0.0001]. Our findings show that PSA immunoreactivity is grade-related in prostatic tissues from black men and this has implications for clinical diagnosis and research. It also confirms the limitations of PSA-testing in diagnosing CaP, and indicates that newer immunohistochemical tests for malignant prostatic cells should be acquired by Sub-Saharan laboratories.

Preoperative analgesia in emergency surgical care in Ibadan.

Pain is the main complaint of patients presenting as surgical emergencies. However, preoperative analgesia has not been studied in developing countries. The adequacy of preoperative analgesia in 106 consecutive acute surgical cases admitted to the Accident and Emergency Department of The University College Hospital, Ibadan, was evaluated using the visual analogue scale and the verbal rating scale. In all, 58% of cases were trauma victims, and the male-to-female ratio was 2.5:1. Analgesia was not prescribed in 45.2% of the patients, 65% of whom were in severe pain. In addition, 81% who were given preoperative analgesia had 'moderate to severe' residual pain. The results showed that provision of preoperative analgesia is inadequate in emergency surgical cases in Ibadan.

International training in medical education--the FAIMER institute 2002 fellowship experience.

The concept of Medical Education as a specific discipline has advanced significantly. The Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, USA was formed in the year 2000 to disseminate the concept to medical schools worldwide. FAIMER Institutes are 2-year long fellowship programs that were developed in 2001 to teach education methods and leadership skills to middle and senior level academicians from medical institutions in the developing world. In addition, the Institute fellows also carry out a curriculum innovation project in their institutions, in the interim period between two U.S. based workshops. This paper describes the experience of the authors and their co-fellows who participated in the 2002 FAIMER Institute and highlights the main learning points of the course.

HIV/AIDS and the surgeon.

Human Immunodeficiency Virus and Acquired Immunodeficiency Disease (HIV/AIDS) are one of the most difficult challenges facing practicing surgeons worldwide. The challenge is more acute in sub-Saharan Africa as it currently has the highest prevalence of HIV infection in the world. Surgeons are at risk of occupationally acquired infection as a result of intimate contact with the blood and other body fluids of HIV patients requiring surgery. Patients also risk being infected by surgeons and other health care workers during surgical or dental procedures. The seropositive status of the majority of HIV positive patients may be unsuspected by the attending medical personnel who may not practice universal precautions against infection. The non-availability of relevant devices is however the most important factor militating against the use of universal precautions, especially in developing countries. There is therefore a need to increase the awareness about universal precautions and to provide the necessary devices to promote constant adherence to these procedures in order to reduce the risk of nosocomial HIV infection.

Study processes of first year clinical students of the College Of Medicine, University of Ibadan, Ibadan Nigeria.

Students adopt several learning approaches towards achieving the perceived goal of passing their prescribed examinations. This study was carried out to determine the study processes being used by medical students of the College of Medicine, University of Ibadan on arrival at the Faculty of Clinical Sciences. One hundred and sixty five first year clinical students were studied using the modified 'Biggs' Study Process Questionnaire. Additional questions to identify local factors that would contribute to the learning were also included. There were 143 respondents (87% of the study population). The predominant study pattern among the students was the deep approach (63%). The achieving and superficial approaches were used by 8% and 29% of the students respectively. Additional analysis showed that 68%, 31% and 1% had 'good', 'average' and poor learning capacities respectively. Self interest was the principal reason why the students chose medicine as a career. Most students (76%) preferred lectures to tutorials, and only 30% found out extra information about topics taught frequently. Thirty-nine percent of the study cohort saw their teachers as role models, and 76% intended to travel abroad after graduation. Majority of 1st year clinical students of the College of Medicine, University of Ibadan adopted a deep approach to learning and have a good capacity to learn. However, most do not employ self-directed learning strategies and do not see their teachers as role models. The majority intend to travel abroad upon graduation.

Chronic dehydration and symptomatic upper urinary tract stones in young adults in Ibadan, Nigeria.

INTRODUCTION: Upper urinary tract stones are relatively uncommon in Nigeria and they are most often seen in men in their 4th and 5th decades. There is however no recent report on this disease from our locality. This retrospective study was done to evaluate the pattern of presentation of upper tract urolithiasis in our institution. PATIENTS AND METHODS: We reviewed all cases of renal stones referred to a single Consultant in a Teaching Hospital in Southwestern Nigeria over a two year period. RESULTS: Twenty cases of renal calculi presented within the study period. All patients presented with sudden onset of loin or back pain, and the diagnosis was confirmed radiologically. The mean age of our patients was 27 years (age range 13-38 years), and the male to female ratio was 1.5: 1. Nineteen patients (95%) reported poor fluid intake (<1.5L/day), and 17/20 (85%) frequently total fasted totally (no water or food intake) for religious reasons. Serum calcium was normal in 15 of 16 patients (94%) and only marginally raised in the remaining patient. All patients were treated with a high fluid intake (3L/day) and analgesics, and 16 of the patients (80%) passed their stones spontaneously. The other four are currently pain free, one of whom is awaiting surgery. CONCLUSION: This (uncommon) occurrence of upper tract urolithiasis in young adults in Ibadan may be related to chronic dehydration exacerbated by religious fasting. Further studies are required to explore this relationship,