Gerald Dafe Forae

An audit of paediatric mortality patterns in a Nigerian teaching hospital

Background: The 4th millennium development goals (2002) reported that sub-Saharan Africa countries including Nigeria have a persistently high childhood mortality rates in-spite of all the preventive and interventional measures to reduce this ugly trend. Patients and Methods: Childhood mortality data was obtained from the medical records department and post-mortem records of the pathology departments over a 5-year period from January 2007 to December 2011. The selection criteria include all case notes with mortality records involving children admitted into the paediatrics department through the labour ward and the obstetrics theater, children emergency unit (CHER), paediatric out-patient clinic. Results: A total of 12,442 children were admitted during this period. Of this, 711 paediatric deaths were documented accounting for 17.5%. The male to female mortality ratio was 1.4:1. The age range was from birth to 17 years. Neonatal deaths accounted for the most common cause of death constituting 344 (48.4%) of all deaths. Among the neonatal mortality patterns, severe birth asphyxia/perinatal asphyxia was the most common cause of early neonatal deaths accounting for 97 (28.2%). Septicaemia accounted for the most frequent cause of infant mortality accounting for 28 (21.8%). Among the under-5 age group, severe malaria constituted the most common cause of death accounting for 52 (36.6%) cases while malignancy topped the list of 5-17 years mortality rate constituting 15 (15.4%) cases. Conclusion: Perinatal and neonatal deaths constitute the vast majority of death in our environment with most of the deaths resulting from severe birth asphyxias, prematurity. Again in the post-neonatal period, infections and other preventable diseases constitute the most common cause of death in children of under age group of five years. Above 5 years childhood malignancies constitutes the highest mortality pattern.

Malignant Skin Tumors in Benin City, South-South, Nigeria

OBJECTIVE Malignant skin tumors rank amongst the most common forms of cancer worldwide and constitute a major challenge in dermatopathology and oncology research. This study aims to determine the frequency and patterns of malignant skin tumors at the University of Benin Teaching Hospital, Benin City, Nigeria. METHODS A 25-year (1982-2007) retrospective study of surgical day books and slides of all patients presenting with skin lesions was conducted at the Surgical and Pathology Departments of University of Benin Teaching Hospital. RESULTS A total of 694 skin biopsies were seen at the department during the study period; of these, 187 cases were malignant constituting 27% of all skin lesions. The majority of the malignant skin tumors (48%) occurred between the third and fifth decades with a male to female ratio of 1.4:1 and a mean age of 47 ± 29 years. Malignant melanoma was the most common skin malignancy, accounting for (n=61; 33%). Kaposi sarcoma constituted the second majority of the cases (n=56; 30%), with a markedly increased incidence between 2000 and 2008. This was consecutively followed by squamous cell carcinoma (n=45; 24%), basal cell carcinoma (n=18; 10%) and dermatofibrosarcoma protuberans (n=7; 4%). The leg and foot were the most common sites for malignant skin tumors. CONCLUSION Malignant melanoma was the most common skin malignancy in this study. However, an increasing incidence of all malignant skin tumors was observed. This was particularly noticeable with Kaposi sarcoma, which may be attributed to the increasing prevalence of HIV/AIDS in Nigeria.

Quality assurance for african laboratories: How soon can this be accomplished?

Dear Editor, This paper is intended to raise concern on how feasible institutional laboratories in Africa would be able to achieve efficient quality control (QC) with the full justification of credible and authentic results that can stand the test of time anywhere globally. This goal appears to be a very difficult task due fundamentally to myriads of inherent challenges to be curtailed with. Basically, most results emanating from most African institutional laboratories lack consistency, accuracy with the fact that sensitivity and specificity are highly compromised. Laboratory physicians and scientists give so many excuses for such regular deficiencies. On so many occasions reagents are not available even if they are accessible some are not properly stored and preserved. Again majority of such reagents may have expired and in a bid to replace them, the consistency may have been interfered with, thus prolonging the turn-around-time (TAT). Such prolonged laboratory reports would have lost its value before the attending clinician who may have treated his patient empirically. On the other hand reagents that are not properly stored or that have expired or nearly expired would produce many highly compromised false positive and false negative results. Studies have shown that most reports turned out by European or American institutional laboratories are timely and credible.[1] The reasons for this is due to the fact that quality assurance (QA) is a routine practice as most of the recommendations of Association of Directors of Anatomic and Surgical Pathology (ADASP) have been strictly followed. These includes pathology departmental document on QC and QA (QC/QA) including all the indicators and establishment of QC/QA monitoring committee. Practically speaking, the driving force of reliable QC/QA involves the application of standard operational procedures (SOPs) for all laboratory methodological procedures viz-a-viz proper calibration of equipments and machines, adequacy and proper storage of reagents, handling of specimens with stepwise preanalytic, analytic, and postanalytical procedures are optimally adhered to in developed countries laboratories. However, this assertion cannot be made for laboratories operating in most developing counties as the recommendations by ADASPs have not been fully carried out due to so many local inherent problems. The use of electronic gadgets including the intranet and internet facilities had all contributed immensely to the credibility and authenticity of these results. For example in most developed countries institutional laboratories, results of blood and other body fluid tests ordered for are usually been displayed on the electronic medical records through the intranet few minutes to hours as the patients is been examine by the attending physicians.[1,2] Yet again, 48 h after a patient undergoes breast lumpectomy, a pathologist report showing invasive ductal carcinoma of no special type (NST) including the Nottingham grading and the estrogen receptor (ER), progesterone receptor (PR), and Her-2-neu with all red score report would have been available to the surgeon for definitive treatment and prognostication. Reports by Amukele et al.,[2] have shown that if African institutional laboratories have the full resources and opportunities, results that would emanate from these laboratories would be timely, effective, precise, and specific. According to Amukele et al.,[2] the United States Presidents Emergency Plan for AIDS Relief (PEPFAR) multicentric laboratories located in many African countries have stood the test of times by all standards in the area of research. PEPFAR laboratories in Africa have been able to demonstrate consistency, precision, and reliability in the results that emanate from its laboratory. The reason for this is that SOPs are strictly maintained with strict adherence to external and internal QCs. All PEPFAR centers are fully equipped with electronic media for rapid results issuance, adequate archiving, and efficient bilateral communication with the sponsors. Again, the laboratories machines and equipments have been fully automated to reduce results bias in most analytic procedures as against manual and semiautomations seen in most other local laboratories. Over the years these systematic approach to accuracy in preanalytic, analytic, and postanalytic procedures have justify the high confidence placed on the PEPFAR results. Nonetheless one major challenge is how to flawlessly integrate this confidence and reliability in PEPFAR research works into routine laboratory works and how to expand and extend collaboration of PEPFAR to cover more grounds in other African institutional laboratories. The role of PEPFAR was further supported by the medical education partnership initiative (MEPI). The MEPI main goal is to work in partnership with African countries to improve the quality and quantity of medical and healthcare-related professionals.[1,3] With the view that more laboratory physicians and scientists will be trained and retrained to be able to tackle imminent challenges and set-backs facing African laboratories. In addition MEPI mandate to upturn the challenges of prolong TAT, instruments/equipments maintenance and calibration, and constant supply of reagents has not been fully justified.[2,3] Based on these, hospital administrators must make resources always available because the importance of the laboratories cannot be overemphasized to the management of patients. The African Society of Laboratory Medicine (ASLM) was inaugurated in 2011 in Addis-Ababa, Ethiopia with the mandate of advancing laboratory medical practice in African countries including continuing medical laboratory education. Again, it is aimed at collaborating with other international organization like the WHO in ensuring that quality standards are maintained in African laboratories.[4] Futhermore the ASLM vision 2020 include: Developing strong, harmonized regulatory systems for diagnostic products as defined by the Global Harmonization Taskforce Transforming laboratory testing quality by enrolling laboratories in quality improvement programs to achieve accreditation by international standards Strengthening laboratory workforce by training and certifying laboratory professionals and clinicians through standardized frameworks Building a network of national public health reference laboratories to improve early disease detection and collaborative research.[4,5] ASLM currently have aimed to maintain movement toward accreditation and improved laboratory systems have gained significant momentum in the past few years. Again this organ is currently addressing the challenges of working in collaboratively with governments, local and international organizations, implementing partners, and the private sector to achieve the following goals by 2020. Nevertheless, these challenges have not been fully tackled by ASLM because of poor funding, lack of man power and political will by some governmental bodies. It is recommended that ASLM should be able to achieve its goal of advancing the standards and quality of laboratories in African continents. This can be done through stepwise guiding approach recommended by the WHO known as the Stepwise Laboratory Improvement Process Towards Accreditation (WHO AFRO SLIPTA).[1,3,4,5] Now, other supportive organizations like the International Academy of Pathologist (IAP) and the friends of Africa initiative are all striving hard to improve the quality of laboratories and to advance professional laboratory best practices in Africa. However, this recently has shown some commitments in fostering a constant relationship between Africa and America and the rest of the world. Still, the challenges are numerous as a great deal is yet to be achieved by these collaborators as healthcare and standard best practices in our laboratories still remain a luxury. We indeed look forward for more proper coordination and collaboration of IAP in the nearest future. So many other challenges plaguing the health sector have contributed to the near stagnancy witnessed in most African laboratories. In spite of already tailored job description in the pathology departments, there is still workplace crisis between laboratory scientists and pathologists particularly over the headship of the institutional laboratories. This impending danger has dramatically disharmonized the expected cordial relationship that existed among them. This is not so in most developed countries.[5,6] For example, the American Society for Clinical Pathology (ASCP) has homogeny in work relationship among pathologists and scientist. In conclusion, it is imperative that institutional laboratories in Africa should advocate and strive towards having QA in spite of the so many challenges. However, these challenges can be surmounted if ASLM, PEPFAR, IAP, ASCP, ADASP, and other agencies including the WHO collaborate effectively to enhance standardized laboratory practice that would eventually transform African laboratories to produce efficient and high quality results that can stand the test of time globally.

Histopathological profile of breast cancer in an African population

Background: Currently breast cancer (BRCA) still remain the most commonly diagnosed female cancer globally with a significant geographic, racial and ethnical variations in its incidence. Aim: This article examines the frequency and histological types and grades of BRCA in a pioneer teaching Hospital in Delta State, Nigeria. Materials and Methods: H and E stained-slides of breast biopsies diagnosed at the Central Hospital, Warri from 2005 to 2011 were archived and studied. Request forms were scrutinized for clinical bio-data, diagnosis and histological sections were analyzed. Data obtained were analyzed using the Statistical Package for the Social Sciences version 17 statistical package (SPSS) Incorporated, Chicago, Illinois, USA, and value presented descriptively. Results: During this period, 905 breast lesions were seen. Out of this, 261 were BRCAs, of which 260 cases were females and one case was a male. The peak age incidence for BRCA and its variants was 40-49 years accounting for (n = 94/261; 36%). The mean age of BRCA was 46 years (6.2). Invasive carcinoma of no special type (NST) was the most commonly encountered histological group of breast carcinoma constituting (n = 203/261, 77.7%) with the high grade invasive ductal carcinoma as the leading diagnosis. Conclusion: Majority of BRCAs encounter was invasive ductal carcinoma of NST with bulk of patients presenting in Stages III and IV.

Diseases mortality patterns in elderly patients: A Nigerian teaching hospital experience in Irrua, Nigeria

Background: Currently, in developing countries, there is a paradigm shift in the mortality patterns from communicable to non-communicable diseases. Objective: This study is aimed at providing a broad spectrum on the mortality patterns in elderly within a 5-year-period in a tertiary healthcare provider in Nigeria. Materials and Methods: This study is a retrospective review of mortality patterns of elderly patients from January 2007 to December 2011 occurring in Irrua specialist teaching hospital, (ISTH), Irrua and its environs. Information derived from the request cards include age, sex, clinical history, diagnosis, duration and cause of death. Results: During this period a total of 3,002 elderly (>65 years) admissions were seen. Of this, 561 patients were confirmed dead. Among this, 317 and 244 cases were elderly male and female patients, respectively. Hence the ratio of male to female was 1.3:1.0. The peak age group was 65-70 years accounting for 147 patients (26.2%). The age range of patients was 65-104 years while the modal and mean ages were 69 years and 74 years ΁ 4.2 standard deviation (SD), respectively. The most commonly encountered cause of mortality was cerebrovascular accident constituting 141 (25.1%) cases. The 2nd and 3rd majority of mortality cases were malignancies and diabetes mellitus (metabolic disorder) accounting for 85 (15.2%) and 45 (8%) cases, respectively. Others include congestive cardiac failure 35 (6.2%), Septicaemia 29 (5.2%), trauma 26 (4.6%) while chronic renal failure and chronic obstructive pulmonary disease consist of 22 cases (3.9%) each. Conclusion: Non-communicable diseases particularly cerebrovascular diseases and malignancies were the most commonly encountered cause of elderly mortality in our environment. Notwithstanding a large percentage of mortality patterns also results from communicable diseases with sepsis as the leading cause of mortality.

Histopathological review of breast tumours in children and adolescents in Delta State Nigeria

Background: Breast swellings in children and adolescents may be overlooked on assumption that they are physiological enlargement. Pathologic swellings including cancers have however been encountered in this age group. This study highlighted the spectrum of tumours in childhood and adolescents. Materials and Methods: This was a 7 year retrospective analysis of all histologically diagnosed breast tumours in people aged 0 - 19 years. Results: There were 134 breast tumour diagnoses occurring in 133 females and 1 male (gynaecomastia). One hundred and nineteen cases (88.8%) were recorded in the 10 - 14 year age group and 15 cases (11.2%) in the 15 - 19 year age group. No case was found in children aged less than 10 years. The most common tumour was fibroadenoma accounting for 75.4% (n = 101) of all tumours followed by tubular adenoma (n = 11; 8.2%) and adenosis (n = 10; 7.4%). No case of malignancy was recorded in this study. Conclusion: Fibroadenoma is the most common breast tumour in children and adolescents in our environment.

Trends and Histopathological Patterns of Kaposi Sarcoma at The University of Benin Teaching Hospital, Benin City, Nigeria

Objectives Kaposi sarcoma (KS) shows greater geographic variation in incidence than almost any other vascular tumor globally. KS is common in parts of Sub-Saharan Africa accounting for 9% of all diagnosed cancer cases in men in the early 1990s in Uganda and Zaire. KS is classified by the World Health Organization as a borderline vascular tumor. We aimed to determine the trends and histopathological patterns of KS as seen in the University of Benin Teaching Hospital in Benin City, Nigeria, and to compare with similar work in other centers. Methods We conducted a retrospective analysis of all histologically confirmed KS seen over a 20-year period at the Pathology Department of the University of Benin Teaching Hospital. Results A total of 269 histologically diagnosed vascular tumors were analyzed. Of these, borderline tumors constituted 30.9% (n = 83). KS constituted 79 (95.2%) out of the 83 borderline vascular tumors. Out of the 79 cases of KS, 76 (96.2%) cases were confirmed in HIV/AIDS patients on highly active antiretroviral therapy. The male to female ratio of KS was 1.1:1.0 while the mean age was 39.2±3.6 years. There was a sharp rise in the trend of KS from 2005 to a peak in 2008. The leg and foot region was the most common site of occurrence. There were two cases seen in the cervical lymph node in the pediatric age group. Conclusions KS was the most common borderline vascular tumor with almost all cases confirmed as HIV/AIDS patients. The mean age of presentation was in the fourth decade of life with a sharp rise in its incidence from 2005 with a peak incidence in 2008. This was followed by a slight decline from 2009 to 2013. Mixed and nodular KS were the most frequently encountered types and patterns, respectively.

Adequacy of clinical information supplied by clinicians for histopathologic diagnosis: The university of Benin teaching hospital experince

Background: The volume of workload in histopathology laboratories need to be accurately measured so that resources can be used appropriately in a challenging clinical environment. Aims: The main objective of this work is to assess the adequacy of clinical information provided by clinicians requesting for histopathological investigations. Materials and Methods: A total of 1659 sequential histopathological request forms sent to Department of Histopathology of the University of Benin Teaching Hospital between January 1, and December 31, 2005, were retrospectively studied and analyzed. The provision of data by surgeons and physicians were compared in a Microsoft Excel 2000 Spreadsheet using the Chi-square test with Yatess correction where appropriate. Given the number of variables being assessed, a Bonferonni correction was applied, and a value of P = 0.001 was therefore considered the limit of significance. Results: A total of 1659 pathology request cards were audited in this study. Of these, 1382 cases accounting for 83.3% were a request made by surgeons while 277 constituting 16.7% were a request sent by physicians. Hence, the ratio of a request made by surgeons and physicians were 5:1. Among the request made by surgeons, the most common request was from the Surgery Department accounting for 783 (47.2%) of all requests. Among the 277 requests made by physicians, the department of internal medicine had the highest volume accounting for 122 (7.35%) of all cases. A total of 1415 out of 1659 were found to be inadequately completed accounting for 85.3%. There were significant differences in the information on ethnicity, date, time and clinical summary recorded by surgeons and physicians and the P < 0.001, respectively. Conclusion: Majority of the pathology request cards sent by clinicians are inadequately completed with an extremely high preanalytic phase errors.

A descriptive study of bladder tumors in Benin City, Nigeria: An analysis of histopathological patterns

Aims and Objectives: This study is aimed at determining the frequency and histopathological patterns including grading and staging of bladder tumors as seen in University of Benin Teaching Hospital, Benin City, Nigeria and to compare with similar research works elsewhere. Materials and Methods: A retrospective study of all data of surgical excision and cystoscopic bladder biopsies received over a 10-year period (2003-2012) at the Department of Histopathology, University of Benin Teaching Hospital, Benin City, Nigeria. Histological criteria published by the World Health Organization/International Society of Urological Pathology were used for the diagnosis and grading of these tumors. Results: A total of 75 bladder lesions were received in the Pathology Department. Of these, 64% were males and 36% were females giving a male to female ratio of 1.7:1.0. The peak and mean age incidence of urothelial bladder lesions was 60-69 years and 54.9 years ± 8.6 standard deviation, respectively. Bladder tumors accounted for 74.7% of all bladder lesions. Fifty-one (68%) cases out of 75 lesions were malignant tumors. Transitional cell carcinoma (TCC) was the most commonly encountered histological pattern accounting for 64.7% of bladder cancer. High grade papillary urothelial carcinoma was the most common tumor grade accounting for 51.4%. Only 40.6% cases were urothelial confined carcinoma (PTa) while 29.7% each accounted for lamina propria (PT1) and muscle (PT2) invasive carcinoma. Conclusion: Bladder tumors are more commonly encountered in males with the majority of cases occurring in the 7 th decade. Both high-grade TCC in stage (PT2) and low-grade carcinomas stage (PTa) were relatively common patterns seen in this study.

Ovarian tumors among Nigerian females: A private practice experience in Benin-City, Nigeria

Background: Ovarian tumors ranked high among gynecological tumor globally. Reports have it that ovarian tumors cut across all age groups, but more common in adult females. Currently, ovarian cancer is the 4th most common cancer in terms of incidence and mortality patterns in women globally. To highlight the frequency and histological types of ovarian tumors in a private practice establishment in Benin-City, Southern Nigeria. Materials and Methods: Hematoxylin and eosin stained-slides of ovarian biopsies diagnosed at the Ashamas Foundation Diagnostic Centre, Benin-City for 10 years were archived and studied. Request forms were analyzed for clinical bio-data, diagnosis and nature of biopsies. Ovarian tumors were classified according to the World Health Organization manual series. Results: A total of 236 of all ovarian lesions were encountered in this study. Of these, 200 (84.7%) were benign lesions while malignant lesions accounted for 36 (15.3%). Of this, 200 benign lesions 79 accounting for (39.5%) were a benign neoplastic tumor. The ratio of benign to malignant tumors was 5.6:1.0. The mean age of benign neoplastic tumor was 31.6 years ± 10.4 standard deviation (SD). Out of the 79 benign neoplastic tumors; germ cell tumors was the most common accounting for 49 (62%). The mean age of the 36 malignant ovarian tumors was 40.1 years ± 16.2 SD with the majority as malignant surface epithelial tumors accounting for (n = 16; 44.4%). The malignant germ cell tumor was the most common constituting 10 (27.7%). Conclusion: Germ cell tumor was the most common with the majority occurring in reproductive age. Our finding is a reversal of what obtains in the western countries where surface epithelial tumor was the most common with the majority occurring in elderly females.