Postgraduate Medical Journal

Contemporary management of retinoblastoma in the context of a low-resource country Dupe S Ademola-Popoola, Enrico Opocher, M Ashwin Reddy Nigerian Postgraduate Medical Journal 2019 26(2):69-79 Retinoblastoma (RB) is the most common ocular cancer, and it typically presents before the age of 5 years in over 90% of cases. In high resource countries, RB patients tend to survive and retain their sight. This is not the case in low-resource countries because of late presentation and delayed intervention arising mostly from sociocultural and socioeconomic challenges. RB has no gender or racial predilection; the incidence is estimated as 1:16,000–1:18,000 live-births or 11/1 million children under 5 years. Most of the world's RB cases are found in Asia and Africa while most RB treatment centres are in America and Europe. RB is easy to detect by caregivers as a glowing white 'cat eye reflex' at night or when captured on camera. Health workers at primary care level can detect RB in early life if red reflex test and/or squint (Hirschberg) tests are deployed as part of wellness checks done especially during routine immunisation and well-baby clinics in the first 24 months of life. In most cases of RB, biopsies for histological confirmation are not required for diagnosis and treatment decisions to be made. Clinical information, ophthalmic evaluation and imaging modalities are typically used. There have been significant changes in the management of RB using various treatment modalities such as enucleation with orbital implant, use of chemotherapy delivered through intravenous, intravitreal, periocular and intra-arterial routes and targeted treatment with laser, cryotherapy and brachytherapy. Algorithm for management and development of the national RB program within the context of a low-resource country is presented from review of data extracted from Mendeley library, PubMed library, Google Scholar and One Network; full-text articles were mostly retrieved through the American Academy of Ophthalmology.

Pattern of prevalent Hepatitis B virus genotypes in Zaria, Nigeria Abdurrahman Elfulaty Ahmad, Adamu Girei Bakari, Bolanle Olufunke Priscilla Musa, Shettima Kagu Mustapha, Bello Yusuf Jamoh, Idris Nasir Abdullahi, Mohammed Ibrahim Tahir, Abdulqadri Olarenwaju Olatunji, Sumayya Hamza Maishanu, Ahmed Babangida Suleiman, Afolaranmi Tolulope, Claudia Hawkins, Atiene Solomon Sagay, Ayuba Zoakah, Adebola Tolulope Olayinka Nigerian Postgraduate Medical Journal 2019 26(2):80-86 Background: Hepatitis B virus (HBV) is hyperendemic in Nigeria. Available literature reveal genotype E as being predominant in West Africa. This study aimed at identifying the current pattern and prevalent genotypes of HBV in Zaria, Nigeria. Materials and Methods: Four millilitre of blood was collected in ethylenediaminetetraacetic acid-container from each of 165 HBV surface antigen-positive participants recruited purposively from the gastroenterology clinic from May to August, 2017. Plasma was separated and frozen at −20°C till analysis. Multiplex-nested polymerase chain reaction using type-specific primers was used to identify the various HBV genotypes. Results: Median (and interquartile range) age of the participants was 31.0 (25.5–39.0) years, with males constituting 107 (64.8%). Majority (83.6%) of the samples analysed were HBV-DNA-positive with 82.6% of the HBV-DNA-positive samples being mixed genotype infections. Irrespective of mode of occurrence, five HBV genotypes were identified with HBV/E (97.1%) being the most predominant, followed by HBV/B (82.6%), HBV/A (24.6%), then HBV/C (17.4%), while HBV/D (0.7%) was the least prevalent. Conclusion: In most (99.1%) of the mixed-infection were a combination of genotype E, the predominant genotype, with other genotypes predominantly genotype B. HBV genotypes E, B, A, C and D are the prevalent genotypes in Zaria, Nigeria, as they occur in single genotype and in mixed-genotypes pattern.

Patient–Doctor relationship in underserved environment: A cross-sectional study of attitudinal orientation, practice inclination, barriers and benefits among medical practitioners in Abia State, Nigeria Gabriel Uche Pascal Iloh, Obianma Nneka Onya, Uche Ngozi Nwamoh, Prince Ezenwa Ndubueze Onyemachi, Miracle Erinma Chukwuonye, Ezinne Uchamma Godswill-Uko Nigerian Postgraduate Medical Journal 2019 26(2):87-93 Background: Healthcare has become complex requiring balance of ever-increasing demands on physicians against humanness of medicine. As the impetus for the delivery of patient-centred care grows, there is need to study the attitude and practice orientations of medical practitioners to patient–doctor relationship (PDR). The study was aimed at describing the attitude, practice, barriers and benefits of PDR among medical practitioners in Abia State. Participants and Methods: A descriptive cross-sectional study was carried out on 210 medical practitioners in Abia State who were consecutively recruited for the study. Data were collected using self-administered questionnaire that elicited information on attitude, practice, barriers and benefits of PDR. Attitude was assessed with the 18-item Patient-Practitioner Orientation Scale (PPOS) with subscales of caring and sharing. Results: The age of the participants ranged from 26 to 77 years with the mean of 36 ± 8.4 years. There were 173 (82.4%) male. The caring attitude score (mean = 3.57 ± 0.80) was higher than sharing (mean = 3.42 ± 0.65) (P = 0.036). Practice was predominantly doctor-centred (86.7%) than patient-centred (64.3%, P < 0.0001). The most common barrier to PDR was patient–doctor communication, while the most common benefit of PDR was improvement in patient satisfaction. Medical practitioners with duration of practice <10 years had significantly higher mean scores in attitudinal subscale of caring when compared with those with duration of practice ≥10 years (P < 0.0001). The study participants with duration of practice ≥10 years had significantly higher adequate practice (75.0%) of patient-centred care when compared with their counterparts with duration of practice <10 years (47.6%) (P = 0.00005). Conclusion: The attitude to caring did not translate to comparative disposition to sharing. The practice was more doctor-centred than patient-centred. The most common barrier and benefit of PDR were communication drawbacks and improvement in patient satisfaction, respectively. Duration of practice was associated with caring attitude and practice of patient-centred care, respectively.

Mycology-related dissertations from the faculty of pathology, national postgraduate medical college of Nigeria (1980-2017): output and scientific communication Iriagbonse Iyabo Osaigbovo Nigerian Postgraduate Medical Journal 2019 26(2):94-99 Background: The actual burden of fungal infections in Nigeria is uncertain due to the dearth of research in medical mycology. Evidence generated from dissertations is often overlooked, becoming moribund if not appropriately disseminated. The objectives of this study were to assess dissertations submitted to the Faculty of Pathology, National Postgraduate Medical College of Nigeria, for medical mycology-centred research and ascertain their dissemination by scientific communication. Materials and Methods: Dissertations accepted by the faculty of pathology from 1980 to 2017 were analysed and categorised into respective subdisciplines. Medical microbiology dissertations were further categorised into bacteriology, parasitology, virology and mycology. The proportion of titles under each subcategory was determined. A literature search was conducted to determine if mycology-related dissertations were published in peer-reviewed journals. Results: Six hundred dissertations were indexed under the faculty of pathology. There were 95 (15.8%) medical microbiology dissertations. The distribution of subject matter was bacteriology 62 (65.3%), parasitology 13 (13.7%), virology 15 (15.8%) and mycology 5 (5.3%). Two dissertations in anatomic pathology dealt with fungi. Mycology-related dissertations accounted for 0.8% of all dissertations submitted. Research focused on Candida, Histoplasma capsulatum var. duboisii, dermatophytes and others. At least 57.1% of mycology-related dissertations were disseminated by means of publication in peer-reviewed journals and/or abstract at scientific conferences. Conclusion: Mycology is a neglected research domain amongst post-graduates in the faculty. Scientific communication of research findings was above average.

Surgical outcome of cutting diathermy versus scalpel skin incisions in uncomplicated appendectomy: A comparative study Chukwuma Eze Okereke, Aba I Katung, Abdulrashid Kayode Adesunkanmi, Olusegun Isaac Alatise Nigerian Postgraduate Medical Journal 2019 26(2):100-105 Background: It is traditionally believed that diathermy skin incisions produce a comparatively poorer surgical outcome despite recent evidences to the contrary. This study set out to compare diathermy and scalpel skin incisions with respect to immediate post-operative pain, surgical-site infection and surgical scar cosmesis. Methodology: This was a randomised, double-blinded study comparing cutting diathermy and scalpel skin incisions in patients undergoing open appendectomies for uncomplicated appendicitis. The post-operative pain was rated with the Visual Analogue Pain Scale 6, 12 and 24 h postoperatively, and 30 day wound infection was rated with the Southampton score. Scar cosmesis was assessed at 3 months, by a plastic surgery trainee, using the Patient and Observer Scar Assessment Scale (POSAS). The patients also self-evaluated their scars using POSAS. Results: A total of 64 patients were randomised to cutting diathermy (32) and scalpel (32) skin incision groups. The mean pain score was higher in the diathermy incised wounds, but this was not statistically significant (P = 0.094). There was one wound infection recorded in the scalpel incision group and none in the diathermy incision group (P = 0.524). At 3 months post-surgery, there was no difference between the diathermy and scalpel incised wounds in mean (±SD) objective POSAS scores (15.64 [±5.98] vs. 17.79 [±6.37], P = 0.228) or subjective POSAS scores (22.44 [±13.13] vs. 22.21 [±13.17], P = 0.951), respectively. The mean scar satisfaction score, as assessed by the patients, was better for the diathermy incised wounds, but this was not statistically significant (P = 0.406). Conclusion: In patients undergoing open appendectomy for uncomplicated acute appendicitis, skin incision with a cutting diathermy is not inferior to the scalpel in surgical outcome, with respect to post-operative pain, wound infection and surgical scar cosmesis.

Uterine and umbilical artery doppler in women with pre-eclampsia and their pregnancy outcomes Ademola Joseph Adekanmi, Adebola Roberts, Janet Adetinuke Akinmoladun, Abiodun Oludotun Adeyinka Nigerian Postgraduate Medical Journal 2019 26(2):106-112 Background: Pre-eclampsia (PE) is an important public health menace in both developed and developing countries with high maternal and perinatal morbidity and mortality globally. A major goal towards improving antenatal management of PE is to develop accurate prediction models that identify women at high risk of this disease for appropriate interventions. Methodology: In a longitudinal cohort study, high-risk singleton pregnant women enroled between April 2015 and February 2016 had uterine and umbilical artery Doppler sonography at 22–24 weeks and 32–34 weeks gestation and had their delivery outcomes documented by the obstetrician and gynaecologist. The peak systolic velocity (PSV), end-diastolic velocity (EDV), Resistivity Index (RI), Pulsatility Index (PI) and the systolic-diastolic ratio (S/D) were recorded. Results: Among the ninety-eight high-risk pregnant women, 61 (62.2%) developed PE and 32 (32.8%) did not have PE. In the PE cases, 15 (24.5%) were mild and 46 (74.5%) were severe PE. The uterine artery PI was significantly associated with PE. A unit increase in uterine PI in high-risk pregnancies, increases the odd of PE by 37.37 times (95% confidence interval; odds ratio = 6.09, 241.9; P < 0.001). The combination of the uterine and umbilical PSV predicted 80.3% of severe PE. All three spontaneous abortions were in women who developed PE, more caesarean section (48.4%) and 69.2% of 45 pre-term deliveries occurred in women with severe PE. Conclusion: The findings from this study show significantly lower uterine and umbilical arteries PSV and EDV but higher RI, PI and S/D in cases that developed PE. The uterine artery PI is the best predictor of PE, whereas the combinations of uterine and umbilical arteries PSV best predict severity of PE among high-risk pregnant Nigeria women.

Factors influencing the outcome of spontaneous intracerebral haematoma in a Neurosurgical Hospital in South-East Nigeria Chika Anele Ndubuisi, Mark Oseghale Okhueleigbe, Tobechi Nwankwo Mbadugha, Kelechi Onyenekeya Ndukuba, Moses Osaodion Inojie, Samuel Chukwunoyerem Ohaegbulam Nigerian Postgraduate Medical Journal 2019 26(2):113-117 Introduction: Spontaneous intracerebral haemorrhage (SICH) is a major cause of stroke worldwide. SICH management is still challenging, especially in developing countries. This study highlights certain factors affecting outcome of SICH managed in a Nigerian Neurosurgical centre, on a background of the modernisation of the patient care facilities. Materials and Methods: Retrospective analysis of patients managed for SICH at Memfys Hospital for Neurosurgery and Neurology in Enugu from years 2009–2016. All patients had computed tomography or magnetic resonance imaging for diagnosis. Treatment included medical, surgical and intensive care unit (ICU) care. Patients with aneurysmal subarachnoid haemorrhage and trauma were excluded. Factors analysed include age, admission Glasgow Coma Score (GCS), haematoma location, complications encountered during admission, duration of hospital stay and 6-month Glasgow Outcome Score (GOS). Results: There were 66 cases, age range of 21–85 years (mean 57 years). A total of 30 (45.5%) patients were admitted with GCS ≤ 8/15; 63.3% of these died within 6 months. The proportion of mortalities was 63.6% (>70 years) and 35.6% (41–70 years). Most commonly associated complication was chest infection 27 (40.9%), with 56.6% mortality. Common haematoma locations were basal ganglia (43.9%) and lobar haemorrhage (40.9%) with a similar effect on outcome (P = 0.098). Outcomes were GOS 1: (43.9%), GOS 5: (30.3%) and GOS 4: (13.6%). Among 42 (63.3%) admitted to ICU, 25 (59.5%) died, while 11 (26.2%) achieved GOS of ≥ 4 at 6 months. Those discharged between days 11 and 20 had 26.7% mortality while 53.3% were independent. Conclusion: Good admission GCS, absence of chest infections, younger age group are predictors of good outcome following SICH. Anatomical location of haemorrhage alone does not have a significant impact on 6 months' mortality.

The effect of the coinheritance of Glucose-6-phosphate dehydrogenase deficiency on the severity of sickle cell disease Foluke Atinuke Fasola, Florence Olamide Fowodu, Wuraola Adebola Shokunbi, Taiwo Rachel Kotila Nigerian Postgraduate Medical Journal 2019 26(2):118-122 Background: Sickle cell disease (SCD) and glucose-6-phosphate dehydrogenase (G6PD) deficiency are inherited disorders associated with chronic haemolysis. Therefore, coinheritance of both disorders could worsen haemolysis in the former and compound a haemolytic crisis. This study compared clinical and laboratory features of deficient and non-deficient SCD patients and the G6PD activities of SCD patients and apparently healthy controls. Materials and Methods: This is a case–control study of 175 SCD patients and 166 non-SCD controls. G6PD assay was carried out on haemolysate from washed red cells. The G6PD activity was measured by spectrophotometry. Results: The mean age of patients and controls was 27.3 ± 9.4 and 35.9 ± 9.7 years, respectively, with 75 (46.2%) and 87 (52.4%) being males, respectively. G6PD activity was similar in cases and controls (6.7 ± 3.3 vs. 6.9 ± 3.0 IU/gHb), respectively (P = 0.6). The prevalence of G6PD deficiency was higher in patients than controls (28.6% vs. 22.3%, P = 0.18), and SCD patients were twice more likely to have enzyme activities below 3.0 IU/gHb. No significant difference was observed in the clinical parameters between deficient and non-deficient patients. Deficient patients were more likely to have lower haematocrit (22.8 ± 3.9% vs. 24.5 ± 5%, P = 0.04) and non-significantly higher bilirubin and reticulocyte counts. Furthermore, in patients, severe deficiency resulted in higher bilirubin than in those with mild deficiency (60.5 vs. 21.7 IU/L, P < 0.001). G6PD activity correlated positively with haematocrit (r = 0.91, P = 0.01) and mean corpuscular haemoglobin concentration (r = 0.17, P = 0.02). Conclusions: Coinheritance of both disorders could worsen haemolysis in SCD patients, and care should, therefore, be taken in the choice of drugs in deficient SCD patients.

Distal symmetrical polyneuropathy and cardiovascular autonomic neuropathy among diabetic patients in Ilorin: Prevalence and predictors Abiodun Bello, Sikiru Biliaminu, Kolawole Wahab, Emmanuel Sanya Nigerian Postgraduate Medical Journal 2019 26(2):123-128 Background: Peripheral neuropathy contributes to morbidity and mortality among diabetic patients. Objectives: We aimed to determine the prevalence of distal symmetrical polyneuropathy (DSP) and cardiovascular autonomic neuropathy (CAN) and their predictors among diabetic patients in Ilorin, North-central Nigeria. Materials and Methods: This was a cross-sectional study in which 175 consenting diabetic patients were recruited consecutively. We assessed DSP using the Michigan Neuropathy Screening Instrument (MNSI), and it was defined by MNSI symptom score ≥7 or physical examination score ≥2. CAN was assessed using five tests of cardiovascular autonomic function, and abnormalities in ≥2 tests defined CAN. Logistic regression analysis was used to identify the predictors of DSP and CAN. Results: The prevalence of DSP and CAN was 41.7% and 26.9%, respectively, while 19.4% had both. Hypertension (odds ratio [OR]: 2.401; 95% confidence interval [CI]: 1.169–4.930, P = 0.017) and poor glycaemic control (OR: 2.957; 95% CI: 1.488–5.878, P = 0.002) independently predicted DSP. Hypertension (OR: 2.215; 95% CI: 1.023–4.414, P = 0.043) and serum creatinine (OR: 1.035; 95% CI: 1.014–1.056, P ≤ 0.001) were independent predictors of CAN. Conclusion: DSP and CAN are common among diabetic patients, and thus efforts should be made to prevent their occurrence by intensifying blood pressure and glucose control while regularly monitoring renal function.

Medication adherence and patient satisfaction among hypertensive patients attending outpatient clinic in Lagos University Teaching Hospital, Nigeria Esther O Oluwole, Olatokunbo Osibogun, Oluseyi Adegoke, Adebola A Adejimi, Ajoke M Adewole, Akin Osibogun Nigerian Postgraduate Medical Journal 2019 26(2):129-137 Background of the Study: Low adherence is an essential element responsible for impaired effectiveness and efficiency in the pharmacological treatment of hypertension. Patient satisfaction is an important measure of healthcare quality and is a crucial determinant of patients' perspective on behavioural intention. Aims: This study determined the association between medication adherence and treatment satisfaction among hypertensive patients attending hypertension outpatient clinic in Lagos University Teaching Hospital (LUTH), Nigeria. Materials and Methods: Setting – The study setting was LUTH; a descriptive cross-sectional study was conducted. Study design – Hypertensive patients were consecutively recruited from the outpatient clinic. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale and treatment satisfaction was assessed using the 14-item Treatment Satisfaction Questionnaire for Medication. Statistical Analysis: Univariate and linear regression analyses were conducted using STATA software version 14.1 (StataCorp LP, College Station, TX, USA). Statistical significance was set at P ≤ 0.05. Results: A total of 500 respondents with a mean age of 58.9 ± 13.3 years participated in the study. Overall, majority (446 [89.2%]) of the respondents in this study had 'moderate' adherence to antihypertensive medication. However, only five (1.0%) respondents reported 'high' adherence. Mean scores were highest in the moderate adherence category for all satisfaction domains and overall domain. Treatment satisfaction was associated with medication adherence, and was statistically significant (P = 0.000). Conclusion: One in every hundred patients had high adherence to hypertensive medication in this study, and there was a positive association between treatment satisfaction and medication adherence. Continuous patient-specific and tailored adherence education and counselling for hypertensive patients is recommended.

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