Mobolaji A. Oludara

Pedestrian Injuries in the Most Densely Populated City in Nigeria—An Epidemic Calling for Control

Objectives: Since the first pedestrian road fatality of 1896, pedestrians still remain vulnerable, with fatalities in Africa being 55% of global statistics. Many previous reports from Nigeria have emphasized passengers and drivers over pedestrians; this study was done in the most densely populated Nigerian city with no previous publication exclusively dedicated to pedestrians—the megacity has been projected by the World Bank to be the third largest in the world by 2015 (after Tokyo and Mumbai), so the study results would aid injury control and reduce morbidity and mortality. Methods: This is a one-year prospective study on pedestrians attending the surgical emergency room of the busiest referral hospital in Lagos, Nigeria, detailing age, sex, occupation, regions injured, injury mechanism, incident vehicles, highway collisions, and immediate outcomes. Results: Some 702 pedestrians were seen, including 494 (70%) males with overall peak incidence in the third decade, but the peak incidence among females is lower and in the first decade. Common injuries sustained were to the head (40%), lower limbs (35%), upper limbs (9%), multiple regions (6%), pelvis (3%), and others (7%). Gender differences also were noted—the predominant injury location in males was the head, followed by lower limbs; the opposite was true for females, though both regional injuries were fewer in females than in males. Students were 20% of the entire pedestrians, with nearly half of them injured by a motorcycle. The mechanism of injury included crossing a highway (63%), walking along the pavement (17%), standing by a bus stop (12%), at a shop/house (5%), and others (3%). However, 76% injuries occurred on highways, 22% on inner city roads, and 2% elsewhere. Vehicles included motorcycles (33%), cars (27%), buses (22%), trucks (6%), tricycles (2.4%), and other (9%). Overall fatality was 10% and about half were due to being knocked down by buses and cars. Conclusions: This study suggests a high incidence and significant underreporting of pedestrian injuries. A reduction in morbidity and mortality is possible (from head and lower limb injuries) by traffic calming techniques in crossing the highway, especially injuries due to being struck by motorcycles, cars, and buses.

Radiation therapy: A major factor in the five-year survival analysis of women with breast cancer in Lagos, Nigeria

PURPOSE This retrospective study was carried out to examine five-year survival from breast cancer cases diagnosed between 2005 and May 2008 in Nigerian women. MATERIAL AND METHODS Two hundred and twenty-four patients were entered into the study. Five-year survival was evaluated using proportional hazard model proposed by Cox to assess variables such as age of diagnosis, menopausal status, and stage of the disease in the two treatment groups: surgery/chemotherapy or surgery/chemotherapy/radiotherapy. RESULTS Findings revealed that the different staging of disease and treatment are independent predictors of disease outcome whereas age of diagnosis and menopausal status although associated with low hazards, are not significant. TNM Stage I (Hazard Ratio=0.153, 95% CI 0.45-0.51, P=0.003), II (Hazard Ratio=0.245, 95% CI 0.12-0.46, P=0.0001), and III (Hazard Ratio=0.449, 95% CI 0.31-0.46, P=0.0001) showed significantly greater survival rates compared to TNM Stage IV for patients receiving surgery/chemotherapy. Similarly, for patients receiving surgery/chemotherapy/radiotherapy TNM Stage II (Hazard Ratio=0.110, 95% CI 0.02-0.46, P=0.003) and III (Hazard Ratio=0.238, 95% CI 0.07-0.73, P=0.012) also showed significantly greater survival rates compared to TNM Stage IV. Treatment had a significant impact on survival independent of stage, age, and menopausal status. Patients receiving surgery/chemotherapy/radiotherapy had a significant increase in survival outcome for TNM Stage (II, P=0.045; III, P=0.0001); age groups (40-49, P=0.021; 50-59, P=0.016; 60-69, P=0.017; >70, P=0.025); and menopausal status (premenopausal, P=0.049; postmenopausal, P=0.0001) compared to those receiving surgery/chemotherapy. CONCLUSION The five-year breast cancer survival rate in Lagos, Nigeria 24.1% (54/224) is relatively poor compared to most countries in the world and needs to be improved. Poor survival rates are mainly attributed to late presentation and poor follow-up, hence early detection through breast cancer awareness programs, appropriate logistics and better management of patients through guidelines for the treatment of breast need to be implemented to improve survival.

Non-trauma surgical emergencies in adults: Spectrum, challenges and outcome of care

Introduction Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. Methods A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. Results Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. Conclusion Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital.

Road Traffic Injury in Lagos, Nigeria: Assessing Prehospital Care

Introduction Injuries are the third most important cause of overall deaths globally with one-quarter resulting from road traffic crashes. Majority of these deaths occur before arrival in the hospital and can be reduced with prompt and efficient prehospital care. The aim of this study was to highlight the burden of road traffic injury (RTI) in Lagos, Nigeria and assess the effectiveness of prehospital care, especially the role of Lagos State Ambulance Service (LASAMBUS) in providing initial care and transportation of the injured to the hospital. METHODS A three-year, retrospective review of road traffic injured patients seen at the Surgical Emergency Room (SER) of the Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria, from January 1, 2012 to December 31, 2014 was conducted. Parameters extracted from the Institution Trauma Registry included bio-data, date and time of injury, date and time of arrival in SER, host status, type of vehicle involved, and region(s) injured. Information on how patients came to the hospital and outcome in SER also were recorded. Results were analyzed using Statistical Package for Social Sciences (SPSS; IBM Corporation; Armonk, New York USA) version 16. RESULTS A total of 23,537 patients were seen during the study period. Among them, 16,024 (68.1%) had trauma. Road traffic crashes were responsible in 5,629 (35.0%) of trauma cases. Passengers constituted 42.0% of the injured, followed by pedestrians (34.0%). Four wheelers were the most frequent vehicle type involved (54.0%), followed by motor cycles (30.0%). Regions mainly affected were head and neck (40.0%) and lower limb (29.0%). Less than one-quarter (24.0%) presented to the emergency room within an hour, while one-third arrived between one and six hours following injury. Relatives brought 55.4%, followed by bystanders (21.4%). Only 2.3% had formal prehospital care and were brought to the hospital by LASAMBUS. They also had significantly shorter arrival time. One hundred and nine patients (1.9%) died in the emergency room while 235 bodies were brought in dead. CONCLUSION Less than three percent among the victims of road crashes had formal prehospital care and shorter hospital arrival time. Current facilities for emergency prehospital care in Lagos are inadequate and require improvement. Training lay first-responders, who bring the majority of the injured to hospital, in basic first-aid may improve prehospital care in Lagos. Ibrahim NA , Ajani AWO , Mustafa IA , Balogun RA , Oludara MA , Idowu OE , Solagberu BA . Road traffic injury in Lagos, Nigeria: assessing prehospital care. Prehosp Disaster Med. 2017;32(4):424-430.

Commencing open heart surgery in resource limited countries: lessons from the LASUTH experience.

The challenge of commencing cardiac surgery in developing countries of Africa is onerous. We present a model from the experience of carrying out open cardiac surgical procedures at the Lagos State University Teaching Hospital (LASUTH) with three separate missions between 2004 and 2006. This paper details the challenges of starting open heart surgery in a resource limited environment. We propose that owing to the huge financial investment needed, government sponsorship as well as collaboration with overseas based and local non-governmental agencies may be required to jump start the process of open cardiac surgery. Local staff training opportunities are also provided by such missions and this can further be complemented by overseas exposure in areas of need for capacity building. In our centre, the initial investment has led to the recruitment of additional trained staff including 2 cardiothoracic surgeons. Further benefits of training of 2 perfusionists and a nurse has improved capacity in cardiac surgery service at our center.

Breast Cancer among Urban Nigerian Women: Appraising Presentation and the Quality of Care

Breast Cancer among Urban Nigerian Women: Appraising Presentation and the Quality of Care Introduction: Late presentation is the hallmark of breast cancer among Nigerians. Awareness of the disease is low and care of this condition has not received adequate attention from Government. Health education to improve awareness was intensified in the last 2 decades. This study aims to assess the current state of care and presentation of breast cancer in Lagos, Nigeria. Patients and Methods: A prospective study of 350 breast cancer patients seen over a period of four years at a General Surgical unit out-patient clinic of LASUTH was carried out. Data on patient characteristics, presentation, diagnosis and treatment were obtained and analyzed. Results: Average duration of symptoms was 46.48 weeks. One fifth presented within 3 months while 17% presented after 1 year. Lumps were self-detected in 96% and 287 (82%) presented with advanced disease (stages III & IV). Two hundred and thirty seven patients (67%) received treatment and 175 (74%) among them had mastectomy. None had breast conservation surgery. One hundred and fourteen patients (48%) absconded and did complete treatment. Conclusion: The trend of late presentation has not changed with current efforts to improve breast cancer awareness. Quality of care for our breast cancer patients is not satisfactory and needs improvement.

Breast cancer receptor status assessment and clinicopathological association in Nigerian women: A retrospective analysis

Background: Breast cancer markers are becoming increasingly important in breast cancer research due to their impact on prognosis, treatment and survival. The present retrospective study was carried out to quantify the proportion of estrogen (ER), progesterone (PR), and human epithelial receptor 2 (HER2) expressions and their association with tumour grade, age, and tumour size in breast cancer patients in Nigeria. Materials and methods: The paraffin embedded tissue sections were analysed for breast cancer markers using monoclonal antibody SP1 for ER and SP2 for PR and polyclonal antibody ErbB2 for HER2. Results: A total of 286 breast cancer paraffin wax tissue sections were analysed for ER, PR and HER2 expression. Of all the tissue samples examined, 20 (7%) were ERpositive, 6 (2.1%) were PR-positive, 11 (3.8%) were HER2-positive whereas 248 (87%) were triple-negative breast carcinoma. ER- and PR-positivity was associated with early grade I and II tumours (P  0.010-0.009) and tumour sizes of  50mm (p  0.001). HER2positivity was positively (P  0.009) associated with grade II tumours and negatively (P  0.0001) associated with grade III tumours. Triple-negative breast cancer was associated with grade III tumours (P  0.0001) and larger tumour sizes of  50mm (P  0.0001). Conclusion: A small proportion of Nigerian women with breast cancer are ER/PR-positive which are associated with less aggressive, better prognosis and benefit from endocrine therapy. An even smaller proportion of patients with aggressive tumors were HER2posivite but responsive to Herceptin treatment. Unfortunately, a very high proportion of cases were triple-negative which is associated with very aggressive tumours and no targeted treatment, which may explain the high mortality rates from breast cancer in Nigeria.

Characterization of Nigerian breast cancer reveals prevalent homologous recombination deficiency and aggressive molecular features

Racial/ethnic disparities in breast cancer mortality continue to widen but genomic studies rarely interrogate breast cancer in diverse populations. Through genome, exome, and RNA sequencing, we examined the molecular features of breast cancers using 194 patients from Nigeria and 1037 patients from The Cancer Genome Atlas (TCGA). Relative to Black and White cohorts in TCGA, Nigerian HR + /HER2 − tumors are characterized by increased homologous recombination deficiency signature, pervasive TP53 mutations, and greater structural variation—indicating aggressive biology. GATA3 mutations are also more frequent in Nigerians regardless of subtype. Higher proportions of APOBEC-mediated substitutions strongly associate with PIK3CA and CDH1 mutations, which are underrepresented in Nigerians and Blacks. PLK2, KDM6A, and B2M are also identified as previously unreported significantly mutated genes in breast cancer. This dataset provides novel insights into potential molecular mechanisms underlying outcome disparities and lay a foundation for deployment of precision therapeutics in underserved populations.Research on racial and ethnic influence on breast cancer mortality is stymied by a lack of genomic studies in diverse populations. Here, the authors genomically interrogate 194 Nigerian breast cancers, unveiling molecular features that could explain the high mortality rate from breast cancer in an indigenous African population.

Concomitant bipolar radiofrequency ablation for atrial fibrillation in patients undergoing surgery for rheumatic Valvular disease in Sub-Saharan Africa

The rhythm after valve surgery has been shown to impact on long-term outcome with increased thromboembolic risk in patients with persistent atrial fibrillation (AF) despite anticoagulation. Concomitant Cox maze IV (CMPIV) or pulmonary vein isolation using bipolar radiofrequency ablation has been demonstrated to reduce stroke risk when successful in restoring stable sinus rhythm. We report the case of a 27-year-old male with rheumatic mitral stenosis, persistent AF, and left atrial thrombus who underwent concomitant CMPIV radiofrequency ablation during mechanical mitral valve replacement and has subsequently remained in sinus rhythm and free from thromboembolism 10 years postoperatively. Strategies aimed at addressing AF and the left atrial appendage at the time of valve surgery may be beneficial in reducing embolic stroke and should be part of the contemporary surgeons armamentarium. Concomitant ablation when the capacity and expertise is locally available should therefore be considered in low-risk patients without severe left ventricular dysfunction or severe pulmonary hypertension during valve surgery in patients with persistent AF. When ablation is not feasible or equipment unavailable, consideration should then be given at a minimum to excision or exclusion of the left atrial appendage which is the most common source of emboli in AF as an alternative stroke reduction strategy.

Emergency Medical Services Outcome Assessment in Lagos, Nigeria: Review of Cases of ''Brought in Dead'' Patients

Abstract BACKGROUND: This study sets out to establish a database of BID patients presenting at the Lagos State University Teaching Hospital (LASUTH). METHOD: A retrospective study of consecutive ‘’Brought in Dead‘’ (BID) patients seen from April to November 2011 at the surgical emergency room of the Lagos State University Teaching Hospital (LASUTH) was done using a validated questionnaire. RESULTS: A total of 144 BID patients were seen during the study period. There were 112 males or 78% and 32 females or 22% of the total (M:F=3:1). The age group with the largest number of victims was the 31-40 age groups; and there were 37 patients (30.8% of 120 cases captured under age group). Trauma also accounted for 104 patients (72.2%) with 52 (36.1%, 50% of trauma cases) of these caused by Road traffic injuries (RTI), and Gunshot injuries accounting for 21 (14.6%, 20.2% of trauma cases). Among the Trauma BID cases from RTI, 4-wheeled vehicles accounted for 20 cases (19.2%, 40% of RTI), whilst motor cycle injuries accounted for 12 cases (11.5%, 24% of RTI). CONCLUSION: The study shows that road traffic injuries and gunshot injuries, accounted for 70% of BID cases presenting at LASUTH. Majority of cases of RTI are from 4 wheeler vehicles (40%) and motorcycles (24%).