Oladejo O. Lawal

Characterization of Colonizing Staphylococcus aureus Isolated from Surgical Wards' Patients in a Nigerian University Hospital

In contrast to developed countries, only limited data on the prevalence, resistance and clonal structure of Staphylococcus aureus are available for African countries. Since S. aureus carriage is a risk factor for postoperative wound infection, patients who had been hospitalized in surgical wards in a Nigerian University Teaching Hospital were screened for S. aureus carriage. All S. aureus isolates were genotyped (spa, agr) and assigned to multilocus sequence types (MLST). Species affiliation, methicillin-resistance, and the possession of pyrogenic toxin superantigens (PTSAg), exfoliative toxins (ETs) and Panton-Valentine Leukocidin (PVL) were analyzed. Of 192 patients screened, the S. aureus carrier rate was 31.8 % (n = 61). Of these isolates, 7 (11.5%) were methicillin-resistant (MRSA). The isolates comprised 24 spa types. The most frequent spa types were t064, t084, t311, and t1931, while the most prevalent MLST clonal complexes were CC5 and CC15. The most frequent PTSAg genes detected were seg/sei (41.0%) followed by seb (29.5%), sea (19.7%), seh (14.7%) and sec (11.5). The difference between the possession of classical and newly described PTSAg genes was not significant (63.9% versus 59.0% respectively; P = 0.602). PVL encoding genes were found in 39.3% isolates. All MRSA isolates were PVL negative, SCCmec types I and VI in MLST CC 5 and CC 30, respectively. Typing of the accessory gene regulator (agr) showed the following distribution: agr group 1 (n = 20), group II (n = 17), group III (n = 14) and group IV (n = 10). Compared to European data, enterotoxin gene seb and PVL-encoding genes were more prevalent in Nigerian methicillin-susceptible S. aureus isolates, which may therefore act as potential reservoir for PVL and PTSAg genes.

Breast Cancer in Nigeria: Is Non‐Adherence to Chemotherapy Schedules a Major Factor in the Reported Poor Treatment Outcome?

To the Editor: Mortality from breast cancer has been declining steadily in many countries. This has been attributed to early detection, accurate diagnosis and prompt treatment (1,2). This is not the case in most developing countries. Breast cancer is now the leading female malignancy in Nigeria and the leading cause of cancer mortality among women seen in many centers across the country (3). The patients are young; they present late and have an overall poor survival. Various reports from Nigeria have shown a high incidence of tumors with unfavorable histopathological and molecular characteristics (4–6). Although a number of studies have attributed the poor treatment outcome to tumor biology, late presentation and poor knowledge of breast cancer (7), to the best of our knowledge, none has examined the phenomenon of non-adherence to therapeutic regimes and its possible effects on treatment outcome. This study examines the reasons for, and the frequency of occurrence of non-adherence to chemotherapeutic regimes among Nigerian women diagnosed with breast cancer. We also suggest ways to address the problem. A retrospective review of the case notes of patients who have been diagnosed with breast cancer and placed on cyclical chemotherapy regimes between January 1996 and December 2005 was carried out. We were specifically interested in the number of treatment cycles missed or delayed. We were also interested in the reasons why they were missed or delayed. The specific drug combinations were not analyzed, but the most commonly used regime in this centre is a course of six cycles of Cyclophosphamide, Methothrexate and 5-Fluorouracil (CMF). Modified radical mastectomy, axillary sampling and simple mastectomy are the commonest surgical procedures for confirmed breast cancer in the centre. A total of 188 cases were reviewed. Their ages ranged between 27 and 81 years with a mean of 49 (SD 10.3) years. One hundred and five (56%) of them were less than 50 years of age, and only 22 (11.7%) were aged above 65 years (elderly). One hundred and sixty-three (86%) of them presented with late stage (stages 3 & 4) disease. A total of 152 patients (80%) reported non-adherence to treatment at one stage or the other. There was no significant association between age or stage at presentation and non-adherence to treatment (v = 4.390, p = 0.624 and v = 5.465, p = 0.141, respectively). The reasons for non-adherence were available in only 110 patients. Among these patients, 21% received less than 75% while 55% received 50% or less of the expected cycles. About 52% of all patients who failed to take five or all of the six cycle of treatment did so because they could not afford the drugs. Paradoxically, 16% of all non-adherences to the regime was due to patients’ feeling well and did not think it important to continue the schedule. This was seen mostly commonly after the third cycle. Most of these patients however, returned and continued the cycle. About 13% of the patients opted out of treatment regime in order to attend faith ⁄ spiritual healing. About 10% experienced severe adverse effects of drug treatment like severe diarrhea, vomiting, and neutropenia. These patients either withdrew themselves from further treatment or their physician officially delayed their treatment. Other reasons for non-adherence to treatment include hospital staff strikes, unavailability of the drugs to buy, patients forgetting treatment cycle and lack of transportation to the treatment centre. These account for about 19% of non-adherence to treatment. Adequate adjuvant chemotherapy unequivocally improves outcome for breast cancer patients (8). This Address correspondence and reprint requests to: Isaac D. Gukas, BM; Bch, FMCS, MRCSEd, PhD, MA (Higher Education Practice), School of Medicine, Health Policy and Practice, Biomedical Research Centre (BMRC), University of East Anglia, Norwich NR4 7TJ, UK, or e-mail: i.gukas@uea. ac.uk.

Particle-induced X-ray emission (PIXE) analysis of minor and trace elements in gallstones of Nigerian patients.

Gallstone disease is a major health problem in many parts of the world. In Nigeria, however, only a few cases of gallstone disease are reported. Minor/trace elements are reported to play a significant role in the formation of gallstones. This study was conducted to assess the minor elements in gallstone of Nigerian patients who had cholecystectomy in our institution using particle-induced X-ray emission (PIXE) technique. We also compare the findings with previous reports from outside Nigeria. Fourteen patients who had cholecystectomy for calculous cholecystitis at Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria, between March 2006 and July 2008, had the stone retrieved. The stones were analyzed for trace elements at the Center for Energy Research and Developments of the University using PIXE experiments. Certified standard reference material, NIST 1577a (bovine liver), was equally analyzed to confirm the accuracy of the experimental procedure. Computer code GUPIXWIN was used to analyze the data. Fourteen elements, phosphorus, sulfur, chlorine, potassium, calcium, manganese, iron, copper, zinc, bromide, lead, titanium, rubidium, and strontium, were detected in most of the samples. The concentrations of the elements varied in the different samples, ranging from a few parts per million to a few percent. Ca was the major constituent of all samples. The black sand-like samples had very high levels of P, S, K, and Pb, which were different from a previous report. The distribution of trace elements in stones in Nigeria patients is different from previous report outside Nigeria, and this may have some role in the occurrence of gallstones in the black African.

Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting: OLASEHINDE et al.

Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria.

A middle aged woman presenting with massive empyema of the gallbladder: a case report

Empyema of gallbladder is generally a rare disease and it is even rarer in the traditional African population where incidence of cholelithiasis is much lower compared with the Caucasian population. This is a presentation to highlight massive empyema of the gallbladder in a 58 year old woman who had no prior history of gallstone disease and who was treated with open cholecystectomy. The outcome was successful and she was followed up for a year.