BACKGROUND:End-of-life (EOL) care involves providing quality medical attention to the dying patient. It is fraught with some ethical challenges, often underexplored in African settings. This communication presents a qualitative analysis of ethical issues encountered by caregivers and their patients receiving EOL care in a teaching hospital in Nigeria. METHODS:Ethical issues in EOL care encountered by 40 people (dying patients, their families, nurses and doctors) at the University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria, were explored over 2 months. The participants' sociodemographic data were analysed using descriptive statistics, while qualitative data were analysed using a thematic framework. The transcripts were coded using NVivo V.12 software. RESULTS:All participant groups encountered commonly reported ethical challenges in EOL care, including issues of medical futility, treatment refusal, truthful disclosures, families requesting that a competent patient not be informed about their condition, confidentiality, limiting or withdrawing a treatment, limited or insufficient pain management, conflicting interests in care, an unfair financial burden without the patient consent and an unfair burden on the healthcare system. Additionally, the uncommon issues included the patient's unwillingness to discuss their terminal status, families withdrawing due care and support prematurely and delayed referrals. CONCLUSION:Ethical issues are commonly encountered in caring for the patient at EOL in the Nigerian environment, notwithstanding the paucity of literature on them. This underscores the importance of adopting known preventive measures to eliminate or minimise these issues.

Variability and inadequacies in the contents of informed consent documents (ICDs) affect the quality of the informed consent (IC) process. This study assessed the content and readability of the 241 ICDs approved for biomedical research in South-East Nigeria from 2019 to 2021. The presence of basic elements for IC in the revised Common Rule and National Code was assessed, and the Flesh readability scores measured. Only 2 (0.8%) of the ICDs had all basic elements required by the Common Rule. Most ICDs fall below recommended readability indices. To improve the quality of the IC process, HRECs are to ensure that, while upholding research validity and credibility, ICDs are easy-to-read yet contain the basic information needed for decision-making by participants.

BackgroundInadequate trauma care training opportunities exist in Low- and Middle-Income Countries. Jos University Teaching Hospital and the West African College of Surgeons (WACS) have synergized, over the past 15 years, to introduce a yearly, certified, multidisciplinary Trauma Management Course. We explore the history and evolution of this course.MethodsA desk review of course secretariat documents, registration records, schedules, pre- and post-course test records, post-course surveys, and account books complemented by organizer interviews was carried out to elaborate the evolution of the Trauma Management Course.ResultsThe course was started as a local Continuing Medical Education program in 2005 in response to recurring cycles of violence and numerous mass casualty situations. Collaborations with WACS followed, with inclusion of the course in the College's yearly calendar from 2010. Multidisciplinary faculty teach participants the concepts of trauma care through didactic lectures, group sessions, and hands-on simulation within a one-week period. From inception, there has been a 100% growth in lecture content (from 15 to 30 lectures) and in multidisciplinary attendance (from 23 to 133 attendees). Trainees showed statistically significant knowledge gain yearly, with a mean difference ranging from 10.1 to 16.1% over the past 5 years. Future collaborations seek to expand the course and position it as a catalyst for regional emergency medical services and trauma registries.ConclusionsMultidisciplinary trauma management training is important for expanding holistic trauma capacity within the West African sub-region. The course serves as an example for Low- and Middle-Income contexts. Similar contextualized programs should be considered to strengthen trauma workforce development.

Inaugural speech of the 32nd President of the West African College of Surgeons..

Background : Breast cancer risk is associated with body composition indices especially waist-hip ratio-≥0.85 (which defines central adiposity), body mass index ≥30Kg/m2 (which defines obesity), percentage body fat mass-≥25Kg/m2 (which defines general adiposity), and physical inactivity (defined as <600(MET-min/week or ≤7999 step counts/day). Physical inactivity promotes inflammatory micro-environment, oxidative stress and diminish antioxidant (superoxide dismutase) level, similar to adiposity but unlike physical activity. Therefore, a pedometer-based walking programme may improve body composition, physical activity and Superoxide dismutase levels in breast cancer survivors, thus preventing breast cancer recurrence. Methods: This study is a single-blind randomized controlled trial involving 80 participants from the Oncology Clinic, who were consecutively stratified according to their baseline physical activity level (MET-min/week), and step count/day obtained using a Fitbit Charge HR pedometer. The experimental group received an intervention programme to improve physical activity level by setting weekly targets of additional 1500 steps to the baseline value, while the control group did not change their physical activity tasks for the duration of the study. Data were collected with the short form of International Physical Activity Questionnaire at baseline and the 6 th week, and weekly from the Fitbit server/data centre, which receives transmitted data from the pedometer customised to each participant. Data were analysed using simple descriptive statistics, multiple regression analysis, and independent t-test at p<0.05, one-tailed test. Results: There was a significant increase in step counts/day (p=0.0002), physical activity level(MET-min/week) (p=0.006), and Superoxide dismutase level(p=<.0001), with a decrease in waist-Hip Ratio (p=0.002), and percentage body fat mass (p=0.01), unlike the body mass index (p=0.09) in the intervention group compared to control. Conclusion: Physical activity, Superoxide dismutase level and body composition may be improved through a pedometer-based walking programme and possibly the prognosis of breast cancer recurrence. Trials Registration number: PACTR202001542824141.

Purpose. Beans intake has been associated with reduced risk of breast cancer (BRCA), however; only few studies considered molecular subtypes status and none in African women. Therefore, the purpose of this study was to examine the associations between dietary intake of beans and BRCA including its subtypes in Nigerian women. Methods . Overall, 472 newly diagnosed patients with primary invasive BRCA were age-matched (±5 years) with 472 controls from the Nigerian Integrative Epidemiology of Breast Cancer (NIBBLE) Study from 01/2014-07/2016. We collected dietary intake of beans using a food frequency questionnaire (FFQ). Beans intake was categorized into three levels of never (never in the past year), low (≤1 portion/week) and high intake (>1 portions/week). We used conditional and unconditional logistic regression models to estimate the Odds Ratio (OR) of beans intake and the risk of overall BRCA and by its molecular subtypes. Results. The mean (SD) age of cases was 44.4(10.0) and of controls was 43.5(9.5) years. In the case group, more than half (51.1%) has never consumed beans alone in the past year compared to 39.0% in the control group. In multivariable models, we found significant inverse associations between beans intake and overall BRCA risk (OR=0.57; 95%CI: 0.38-0.85), hormone receptor-positive BRCA (OR=0.45, 95%CI: 0.23-0.90) and triple-negative BRCA (OR=0.47 95%CI: 0.25-0.88). Conclusion. Dietary intake of beans of more than one portions a week is associated with reduced risk of BRCA in African women and it may play a significant role in reducing the incidence of BRCA particularly of the more aggressive triple-negative subtype, which is more prevalent in SSA.

Background: Sentinel lymph node biopsy is the current standard of care for axillary staging and further treatment planning in patients with clinical axillary node-negative breast cancer. Sentinel node (SN) biopsy was designed to accurately stage the axilla and minimize the side effects of conventional axillary-lymph-node dissection without sacrificing oncologic outcomes. Sentinel lymph node biopsy is normally performed with nuclear scan and patent blue violet or isosulfan blue. These are expensive and not commonly available in resource-poor regions such as West Africa. Methylene blue dye is a commonly used agent in a wide range of clinical diagnostic procedures and has been used by other investigators to perform this procedure. This study was designed to demonstrate the feasibility and effectiveness of SN biopsy in the management of axillary node-negative breast cancer in resource-limited populations using methylene blue dye. Aim: To determine the efficacy of methylene blue dye as a single tracer in lymphatic basin mapping and sentinel lymph node biopsy in patients with clinical axillary node-negative breast cancer. Methods: This was a prospective, case-controlled study involving 28 consecutively presenting female patients with clinical axillary node-negative breast cancer at the University of Nigeria Teaching Hospital, Enugu. Each of the patients had lymphatic basin mapping and sentinel lymph node biopsy with a sub-areola-subdermal injection of methylene blue dye. The SN (s) were then removed using the dye as the marker. Each patient then had a mastectomy or wide local excision as appropriately planned and conventional levels I and II axillary dissection was performed in the same sitting. The SNs and other axillary nodes were reviewed independently by our institution's pathologist. Each patient's axillary dissection specimen acted as her control for the study. Results: The SNs were identified in 24 (85.7%) patients. There was a demonstrable learning curve with an improvement in identification rate in the later half of the cases (92.9%) compared to the earlier half of the cases (78.6%). A range of 1–3 nodes and a mean of 1.78 nodes were obtained. A sensitivity of 90.9%, specificity of 79.6%, false-positive rate of 28.6%, false-negative rate of 9.1%, and accuracy of 95.8% were obtained. There was no incidence of allergic/hypersensitivity reaction. Conclusion: Sentinel lymph node biopsy with methylene blue dye can be applied with high accuracy within resource-limited environments. However, there is a definite short learning curve that must be overcome and the procedure validated before clinical application in decision-making.

Breast cancer is now the commonest cancer in most sub-Saharan African countries. Few studies of the epidemiology and genomics of breast cancer and its molecular subtypes in these countries have been done. The African Female Breast Cancer Epidemiology (AFBRECANE) study, a part of the Human Heredity and Health in Africa (H3Africa) initiative, is designed to study the genomics and epidemiology of breast cancer and its molecular subtypes in Nigerian women. We link recruitment of breast cancer cases at study sites with population-based cancer registries activities to enable ascertainment of the incidence of breast cancer and its molecular subtypes. We use centralized laboratory processing to characterize the histopathological and molecular diagnosis of breast cancer and its subtypes using multiple technologies. By combining genome-wide association study (GWAS) data from this study with that generated from 12,000 women participating in our prospective cohort study of cervical cancer, we conduct GWAS of breast cancer in an entirely indigenous African population. We test associations between dietary intakes and breast cancer and focus on vitamin D which we measure using dietary intakes, serum vitamin D, and Mendelian randomization. This paper describes the AFBRECANE project, its design, objectives and anticipated contributions to knowledge and understanding of breast cancer.

Background Physical activity is associated with reduced risk of breast cancer and its various subtypes but this association is less known in African women, particularly with triple-negative breast cancer that occurs more frequently in Sub-Saharan Africa compared to developed countries. In this study, we examined the association between leisure-time physical activity (LTPA) and breast cancer in total and by its subtypes in Nigerian women. Methods Overall, 630 newly diagnosed patients with primary invasive breast cancer were age-matched (±5years) with 630 controls from the Nigerian Integrative Epidemiology of Breast Cancer (NIBBLE) Study from 01/2014-07/2016. We derived the average amount of time spent on LTPA per week over the past year using a modified Nurses’ Health Study-II physical activity questionnaire. We calculated the total metabolic equivalents (METs) for each reported LTPA per hour/week (i.e. walking, cycling, and dancing) and compared odds of breast cancer among participants who attained the World Health Organization (WHO) physical activity(PA) recommendations of at least 150 minutes of moderate-intensity or/and 75 minutes of vigorous-intensity aerobic activity/week with those who did not. In addition, we evaluated this by categories of LTPA in quartiles of METs. We used conditional and unconditional logistic regression models to estimate the adjusted Odds Ratio(OR) of LTPA with overall breast cancer and by hormone receptor-positive and triple-negative breast cancer. Results The mean ages of cases and controls were similar after matching, 42.5±10.1 and 41.5±9.2 years (mean±SD), respectively. Women who attained the WHO PA recommendations had a 42% reduction in the odds of having breast cancer(OR=0.58 95% CI:0.43-0.78) compared with those who did not. LTPA was associated with reduced odds of having hormone receptor-positive by 41% and significantly associated with reduced odds of having triple-negative breast cancer by 45%. In addition, a significant dose-response relationship was observed, women with higher levels of LTPA had lower odds of having overall breast cancer as well as having triple-negative and hormone receptor-positive breast cancer. Conclusions Increasing LTPA in African women can play a significant role in reducing the incidence of breast cancer, particularly of the more aggressive subtype as triple-negative, which is more prevalent in Sub-Saharan Africa.

548 Background: Modern management of breast cancer requires proper subtyping of the breast tumor to guide appropriate treatment and prognostication. However, there are barriers to availability of this resource in low- and middle-income countries (LMIC) which contributes to global inequalities in breast cancer management and outcomes. The non-availability is due to high cost, and lack of personnel and infrastructure required for immunohistochemistry (IHC), the current gold standard for subtyping. IHC results are affected by pre-analytic and analytic handling and are subjective. Alternative methods that are more objective, cost less and require less infrastructure and skilled personnel will improve access and reduce disparities. Methods: In the AFBRECANE Project, we compared the results of ER and PR subtyping of 1,000 breast cancer tumors from patients recruited from 5 clinical sites in Nigeria using IHC and Cepheid GeneXpert RNA STRAT4 biomarker assay at ACCME Lab in Nigeria and University of Maryland. Results: For ER, the sensitivities, specificities, and agreement between IHC and STRAT4 ranged from 50.0%, 71.4% and 59.4% to 77.1%, 80.0% and 78.5% while for PR, they ranged from 58.1%, 66.7% and 62.5% to 84.6%, 84.2% and 84.4%. Conclusions: The wide range of sensitivities, specificities, and agreement between IHC and STRAT4 in this study confirms the challenges of molecular subtyping of breast cancer in LMICs like Nigeria. Sustainable objective methods are sorely needed to improve diagnosis, treatment and prognostication, and reduce global disparities.

PURPOSE:In the past decade, developments in the field of Assisted Reproductive Technology (ART) have intensified the hopes and the desires of infertile people to overcome infertility, resulting in an increasing demand for such services worldwide. However, as developments in ART have evolved rapidly, so have ethical, social, and political controversies surrounding many aspects arisen. It is known that societal ethics is dependent on the values and culture of a given group. We sought to explore how practitioners and clients in Nigeria perceive some Key ethical issues surrounding ART.MATERIALS AND METHODS:This was an explorative descriptive study involving in-depth interview of three ART providers and eight female ART clients, all domiciled in Southeastern Nigeria. Sampling was by purposive and snowballing techniques for providers and clients, respectively. Ethical approval was obtained from University of Ibadan/University College Hospital and University of Nigeria Teaching Hospital Research Ethics Committees. Responses were grouped into themes for ease of discussion.RESULTS:Providers and clients were in support of sex selection for family balancing, and multiple embryo transfers. They also perceive that the health of the woman should be the factor considered and not biological age for service provision. However, views differed on marital status as an access factor. Participants were in support of legally binding regulations to guide practice.CONCLUSION:A culturally sensitive national regulation is recommended to guide practice in this vital area of reproduction.

ER/PgR testing are now routinely performed in breast cancer evaluation in Southeastern Nigeria. ER is predictive to show beneficiaries of hormonal therapy and a prognostic marker to establish tumors that will resist paclitaxel induced apoptosis so a cost effective combination of anthracylines can be used as treatment in our low resource setting thus improving survival, reducing recurrence, and cost. Four hundred seventeen cases of breast cancer seen over a period of 3 years were routinely tested for ER/PgR. ER positivity was defined as nuclear positivity of 1% in the presence of internal and external controls. Four hundred seventeen patients with Ductal Carcinoma participated. Majority were females 98.3%. Majority 60.2% were between 31 and 50 years old. Mean age was 33.5 ± 6.4 years. Two hundred fifty-seven (61.6%) were positive both for ER/PgR. 70.3% of age group 41–50 years had positive ER, age groups 20–30, and >70 years had positive ER also. ER positive cancer was 60.2%. Fifty-seven were 1%–9% positive. Most positive estrogen receptors were seen between 41 and 50 years at 70.3%. Least was seen at 31–40 years at 51.4%. Study provides an objective basis for using hormonal manipulation and makes cost affordable with appropriate chemotherapeutic agents in our low resource setting. Presentations were typically late. Seventy-six percent of stage 2 disease survived after 6 years compared with only 56% of stage 2 disease prior to immunotyping and radiotherapy in 2007. Both stage 3 and 4 had remarkable survival too at 55% and 33% respectively when compared with 2007 figures at 33% for stage 3 and 9.2% at stage 4.

Background: Africa and the Caribbean are projected to have greater increases in Head and neck cancer (HNC) burden in comparison to North America and Europe. The knowledge needed to reinforce prevention in these populations is limited. We compared for the first time, incidence rates of HNC in black populations from African, the Caribbean and USA. Methods: Annual age-standardized incidence rates (IR) and 95% confidence intervals (95%CI) per 100,000 were calculated for 2013-2015 using population-based cancer registry data for 14,911 HNC cases from the Caribbean (Barbados, Guadeloupe, Trinidad & Tobago, N = 443), Africa (Kenya, Nigeria, N = 772) and the United States (SEER, Florida, N = 13,696). We compared rates by sub-sites and sex among countries using data from registries with high quality and completeness. Results: In 2013-2015, compared to other countries, HNC incidence was highest among SEER states (IR: 18.2, 95%CI = 17.6-18.8) among men, and highest in Kenya (IR: 7.5, 95%CI = 6.3-8.7) among women. Nasopharyngeal cancer IR was higher in Kenya for men (IR: 3.1, 95%CI = 2.5-3.7) and women (IR: 1.5, 95% CI = 1.0-1.9). Female oral cavity cancer was also notably higher in Kenya (IR = 3.9, 95%CI = 3.0-4.9). Blacks from SEER states had higher incidence of laryngeal cancer (IR: 5.5, 95%CI = 5.2-5.8) compared to other countries and even Florida blacks (IR: 4.4, 95%CI = 3.9-5.0). Conclusion: We found heterogeneity in IRs for HNC among these diverse black populations; notably, Kenya which had distinctively higher incidence of nasopharyngeal and female oral cavity cancer. Targeted etiological investigations are warranted considering the low consumption of tobacco and alcohol among Kenyan women. Overall, our findings suggest that behavioral and environmental factors are more important determinants of HNC than race.

Introduction: Inguinal hernia repair is one of the most frequently performed surgical procedures in general surgery. Over millions of hernia repairs are performed per year globally. In Africa due to poor documentation, the number of inguinal hernia repair per year is unknown. Estimated values showed 175 per 100000, per year. In spite of this number, in Africa the most appropriate repair technique (including incision choice) is yet to be decided. In open inguinal hernia repair, two known incisions are commonly used: Transverse and Oblique groin incisions. Statistical evidence has not shown any added advantages in choosing any of the incisions except for a better scar appearance in using transverse skin crease incision. Objective: To determine whether a transverse or oblique incision conferred any advantages to the patients, who underwent inguinal herniorraphy in terms of operating time, and quality of life. Method: All patients aged 16 years or older with uncomplicated inguinal hernia presenting at surgical outpatient clinic, who were physically stable and gave informed consent were recruited. These patients were grouped into TEST and CONTROL. An open and close-ended proforma was used both from the clinic, morning of surgery and during follow-up visits to assess the outcome measures. Results: Of the 107 patients recruited, 90 (84.1%) were males while 17 (15.9%) were females. Their ages ranged from 16 years to 85 years with median age of 48 years (53.3%) of these 55 (51.4%) had direct hernia, 39 (36.4%) had indirect and 13 (12.2%) had both. Same surgeon operated on all the patients. Fifty four (54) patients were recruited for the transverse group while fifty three (53) patients had their hernias repaired with oblique incision. Mean operating time for transverse group was 46.89 minutes while that for oblique group was 61.17 minutes (p=0.000). Postoperative pain assessment was not significantly different between the two groups (p=0.148). Patients in the transverse group had better quality of life than the oblique group (p=0.011). Conclusion: Transverse skin incision affords shorter operating time, and better quality of life compared to oblique skin incision in inguinal hernioraphy surgeries.

Background: Overweight and obesity are known risk factors for chronic diseases including cancers. In this study, we evaluated the age standardized incidence rates (ASR) and proportion of cancers attributable to overweight and obesity in Nigeria. Methods: We obtained incidence data from the databases of two population-based cancer registries (PBCRs) in Nigeria (Abuja and Enugu cancer registries), on cancer site for which there is established evidence of an association with overweight or obesity based on the International Agency for Research on Cancer (IARC) and the World Cancer Research Fund (WCRF) classification. We analyzed the data using population attributable fraction (PAF) for overweight or obesity associated cancers calculated using prevalence data and relative risk estimates in previous studies. Results: The two PBCRs reported 4,336 new cancer cases (ASR 113.9 per 100,000) from 2012 to 2014. Some 21% of these cancers were associated with overweight and obesity. The ASR for overweight and obesity associated cancers was 24.5 per 100,000; 40.7 per 100,000 in women and 8.2 per 100,000 in men. Overall, only 1.4% of incident cancers were attributable to overweight and obesity. The ASR of cancers attributable to overweight and obesity was 2.0 per 100,000. Postmenopausal breast cancer was the most common cancer attributable to overweight and obesity (n = 25; ASR 1.2 per 100,000). Conclusion: Our results suggest that a small proportion of incident cancer cases in Nigeria are potentially preventable by maintaining normal body weight. The burden of cancer attributed to overweight and obesity in Nigeria is relatively small, but it may increase in future.

Training Program in Nigeria for Non-Communicable Diseases Research (TRAPING NCD) grant number FIC/NIH D43TW009106 from the Fogarty International Centre. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Fogarty International Centre or the National Institutes of Health.

BACKGROUND:Cataract, glaucoma, and conjunctivitis are common causes of ocular morbidity in Nigeria. A major obstacle in reducing the burden of ocular morbidity in rural areas is access to eye care services. Up to 80% of the population in developing countries use traditional medications for their primary healthcare needs because they are accessible, available, and affordable. The aim of this study is to evaluate the content and cost of commercialized traditional medications used in the treatment of common eye conditions in Nigeria. PATIENTS AND METHODS:All the registered traditional healers (THs) at an International Trade Fair in Enugu who treated eye problems were identified. Data on their location and scope of their practice were collected by the researchers. Proxy patients consulted THs in the trade fair with simulated cataract, glaucoma, and bacterial conjunctivitis, and treatment was sought. Medication for the treatment of the simulated disorders was paid for and procured. The mode of administration and the cost of the drugs were recorded by proxy patients. Each medication was labeled with a code and sent to the laboratories of the National Agency for Drug Administration and Control for analysis. Data were entered into a database on Microsoft Access and transferred to STATA V12.1 (StataCorp) for analysis. RESULTS:Cataract was treated by 87.5% of all the traditional eye healers interviewed. A total of 32 samples were collected and analyzed. These comprised mainly oral (53.1%) and topical traditional medications (43.8%). The pH of the topical samples ranged from 3.5 to 10, while the mean microbiological load per topical solution was 3.3 × 104 cfu/mL ± 0.96. The cost of treatment of cataract ranged from 4 to 70 USD. CONCLUSION:The content of the majority of the samples of traditional eye medications in this study had high extremes of pH and/or had a high microbial content. The practice of THs should be regulated.