Volume 27, Number 3 July, 2020 Volume 27, Number 3 July, 2020 THE TROPICAL JOURNAL OF HEALTH SCIENCES Official Publication of the College of Health Sciences, University of Ilorin
EDITORIAL BOARD
EDITOR-IN-CHIEF A.B. Okesina
ASSOCIATE EDITORS K.W. Wahab O.T. Adedoyin O.B. Akinola
BUSINESS/CIRCULATION MANAGER M.B. Uthman
CONSULTING EDITORS
Prof. Egon Amann GERMANY
Rania Mohammed El’-Sharkawy EGYPT
Prof. J.O. Obafunwa NIGERIA
Prof. Akin Osibogun NIGERIA
Prof. R. T. Erasmus SOUTH AFRICA
Prof. Bappa Adamu NIGERIA
ii AIMS AND he Tropical Journal Of Health Sciences (TJHS) is an international journal which provides a forum for exchange of ideas to those SCOPE Tengaged in the Health Sciences and related fields. The journal intends to publish high quality papers on original research, case reports, short communications, commentary, review articles, editorials, correspondence and book reviews. TJHS is an official organ of the College of Health Science (A WHO Collaborating Center for Research and Manpower Development), University of Ilorin, Ilorin, Nigeria and will also serve as a medium for disseminating information on the activities of the college . Editorial notices The journal will be published quarterly with four issues making one volume with effect from January, 2017. TJHS invites manuscripts from the Health Sciences and related disciplines. Subscription per journal issue: Faculty staff (=N=1,000.00); student (=N=500.00); private individuals (=N=1,500,00); Institution/Libraries (=N=2,000.00); Overseas subscription ($ 20.00 or equivalent).
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The Tropical Journal of Health Sciences ISSN 1117-4153
iii THE TROPICAL JOURNAL OF HEALTH SCIENCES Volume 27 Number 3 July, 2020
CONTENTS
Editorial comments v
Research papers The Effect of Training on The Knowledge and Practice of Occupational Health and Safety Measures among Poultry Farm Workers in Kaduna State, Nigeria N.O.Usman, A.U.Shehu, A.G.Nmadu, V.N.Omole 1
Maternal Knowledge and Perception TowardsChildhood Immunization in a Health Facility in Delta State, Nigeria. E.G. Moke, K.E.Edje, E.K. Umukoro, P.Y.Toloyai, T.M.E. Daubry, A.I. Omogbiya, B.E Oshevirhe. 9
Assessment of Level of Depression Among HIV/AIDS Patients Attending HIV Clinic at Murtala Mohammed Specialist Hospital, Kano. H.H. Murtala, M.M. Haddad, B.A. Attahir, A.H. Ibrahim, V.O. Olisah, A.Shehu, F. Balarabe, N.S. Bawa. 15
Clinical Manifestations of Hypovitaminosis-D in Paediatric Patients Attending Nizamiye Hospital, Abuja: A 2-Years' Appraisal. S.A Biliaminu, M.T Lawan, L Cam, E.O Sanni, J. Imran, I.M AbdulAzeez, A.B Okesina, J.O Yusuff, I.B Aremu 21
Delivery Pattern and Perinatal Outcome in a Nigerian Tertiary Health Institution: A Five Year Review O.A.Ogunlaja, Y.T.Olasinde, I.P.Ogunlaja, A.Olasinde,M.O.Bojuwoye. 26
Evaluating Effect of Prolonged Alcohol Consumption On Serum Gastrin and Secretin and Histo-archiecture of the Stomach and Duodenum In Rats
A.E. Ojieh, E.C. Adegor, J.I. Wilson,, E.Agbonifo-Chijiokwu, E.G. Moke 31
Case reports Radiological Findings in Aqueductal Stenosis in a Preterm Infant. H.J. Akande, B.B. Olafimihan. P.N. Omefe, A.T. Ifarinola 36
Malignant Fibrous Histiocytoma of the Jaws: A Follow-up Study of 5 Cases and Review of Related Literature B.E. Edetanlen, T.T.Izegaegbe 40
Medical Management of Ectopic Gestation Following a Failed Bilateral Tubal Ligation. O.O. Ogunbode, S.A. Adeyanju. 45
iv elcome to the reading of July 2020 edition of The Tropical Journal of EDITORIAL Health Sciences. Prevention is the best form of treatment, not only for WCOVID -19, whose pandemic the world is currently facing but it is also COMMENTS true for many other diseases. The first two articles in this edition has to do with preventive measures against occurrence of diseases. The objective of the first study was to assess the effect of training on the knowledge and practice of occupational health and safety measures among poultry farm workers in Kaduna state. The result showed that there was a statistically significant difference when post intervention mean knowledge scores were compared between the study and control groups. The authors concluded that training on occupational health and safety led to an increase in knowledge and practice among poultry farm workers. It was therefore suggested that it is of utmost importance that periodic training and retraining exercises be provided. Another study related to prevention, investigated knowledge and perception towards childhood immunization among mothers receiving antenatal care (ANC) at the General Hospital Abraka, Delta State, Nigeria. The result of the study showed that there was good maternal knowledge and positive perception towards childhood immunization, although, there is need for appropriate education of mothers about vaccine-preventable diseases (VPDs) and vaccination schedule. Presence of depression among patients suffering from HIV is a common occurrence. It is projected that the level of depression among HIV/AIDS patients would increase to about 60% by the year 2030.An article in this edition, assessed the presence of depression and factors that contribute to the development of depression among HIV/AIDS patients attending HIV clinic in Murtala Mohammed Specialist Hospital, Kano. The conclusion from the results of the study was that management of HIV patients should include health education of the patients on ways of reducing the level of depression through elimination or modification of factors contributing to incidence of depression. It is essential that hospitals carry our clinical audit of various department in order to assess their performance over a giving period of time. This will provide information on the efficiency of the hospital in caring out its functions. Audit of clinical events helps the clinician to critically appraise the level of care rendered in a health system with the aim of improving the quality of care. A study from Ogbomoso audited the obstetrics practice in an hospital over a five-year period. Foetal outcome was significantly associated with mode of delivery and this study observed that Caesarean section had better outcome. Vitamin D, from various studies have been shown to affect pattern of many diseases in humans. Hypovitaminosis D in children is a common disorder in developing countries with a myriad of non-bony clinical manifestations. A study reported in this edition examined non-bony clinical manifestations of hypovitaminosis D in paediatric patients in Nigeria. Conclusively, this study observed that hypovitaminosis D has myriads of non-bony clinical presentations in children with the frequencies and severity more in females than males. Routine
serum vitamin D3 measurements should be encouraged to rule out hypovitaminosis D in paediatric patients with unusual clinical presentations.
Happy reading
A.B OKESINA Editor In Chief
v The Effect of Training on The Knowledge and Practice of Occupational Health and Safety Measures among Poultry Farm Workers in Kaduna State, Nigeria
1N.O.Usman, 2A.U.Shehu, 1A.G.Nmadu, 1V.N.Omole, 1.Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna State, Nigeria 2.Department of Community Medicine, College of Medicine, Ahmadu Bello University, Kaduna State, Nigeria
Abstract Introduction Poor compliance to occupational health and Occupational health deals with health and safety measures contributes to the high prevalence of safety in the workplace with emphasis on primary workplace accidents and occupational illnesses prevention of occupational hazards.1The safety and especially in the informal sector.The objective of this health conditions in the workplacevary between and study was to assess the effect of training on the within countries, economic sectors and social groups. knowledge and practice of occupational health and The health problems emanating from the workplace are safety measures among poultry farm workers in to a large extent preventable and could be prevented by Kaduna state. using a multifaceted approach involving; legislative, The study was quasi-experimental with technical, research, training and education, baseline, intervention and post-intervention information, and economic instruments.2Globally, an components carried out in poultry farmsin two Local estimated 2.78 million deaths occur annually from Government Areas, a study and a control; Kaduna work-related diseases or accidents with an additional North LGA and Sabon Gari LGA respectively. A multi- 374 million non-fatal (causing at least 4 days of staged sampling technique was used to select a total of absence) occupational injuries and/or accidents 140 participants (70 participants per group; from the occurring in the same time period.3Deaths and injuries study and control group) from whom data were take a particularly heavy toll in developing countries, obtained using a pretested, semi-structured like Nigeria, where a large part of the population is questionnaire. The intervention done was by carrying engaged in activities, such as agriculture, fishing and out training on occupational health and safety in the mining.4Poultry farm workers are subject to study group. Three months after the training, post- occupational and environmental hazards on a daily intervention data were collected from the study and basis because, conditions at the poultry farm expose control groups. The data was analysed using SPSS them to numerous agents affecting the skin, respiratory, version 21. gastrointestinal and musculoskeletal systems.5They There was a statistically significant difference commonly have contact with live sick and dying birds when post intervention mean knowledge scores were and as such are at greater risk for zoonotic diseases. compared between the study and control groups These and other hazards in poultry farms must be (p<0.0001). The increase in the proportion of poultry addressed through improvement in the working farmers with adequate knowledge of occupational environment. In order to achieve this, both employers hazards and of OHS was also statistically significant and employees must be involved.6There is inadequate (p<0.0001). There was statistically significant increase knowledge of Occupational Health and safety (OHS) in some preventive practices (hand washing p=0.0158; and poor practice of safety measures among poultry changing work clothes p=0.0048). farm workers in Nigeria and other developing Training on occupational health and safety led countries.Illiteracy, unavailable protective devices and to an increase in knowledge and practice among poultry low awareness about the danger of pesticide farm workers. It is therefore of utmost importance that contamination were given by the poultry farm workers periodic training and retraining exercises be provided. as the reason for poor practice.7,8,9,10 It should be stressed that when health is Keywords: Occupational health, safety, poultry farm, addressed, so is safety, because a healthy workplace is workers, Kaduna. by definition also a safe workplace.11When workers have poor knowledge, attitude and practice of Correspondence to: Occupational Health and Safety (OHS), it Dr N.O. Usman compromises any effort to create a safe Department of Community Medicine, workplace.Studies have shown that 90% of accidents happen because of unsafe behaviour and human College of Medicine, Kaduna State University, 12,13 Kaduna State, Nigeria error. Surveys have shown that the level of Cellphone Phone:+234 8035905729 knowledge and awareness of agricultural health and E-mail address :[email protected] safety risks, disease, and injury prevention among farmers is low.14,15 A good knowledge score has been 01 N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) shown to be a predictor for practice of preventive This was followed by eight training sessions using the measures.16 training module adapted from the ILO training module The poor OHS regulatory system in the on poultry farm workplace health and safety and the country does not encourage mandatory reporting of framework for the design of the World Health accidents, which OHS regulations require.17There is Organisation modules in occupational health. The need for interventional studies on OHS among poultry poultry farm workers were divided into two groups of farm workers considering their peculiar situation of 35 participants each. This was to ensure ease of being exposed to hazards for several hours on a daily interaction. The training was conducted on Mondays basis. However, there is paucity of data on this subject. and Tuesdays for one group and the other group was This study aims at determining the effect of training on Wednesdays and Thursdays. One module was taken per knowledge and practice of OHS among poultry farm week. Each group had 8 training sessions and 35 workers. participants were trained per session. The training was carried out for two hours per day (12pm to 2pm) on two Methods days per week for four consecutive weeks and it was The study was conducted in Kaduna North and conducted in Hausa (local language). Sabon Gari Local Government Areas (LGAs), which Prior to the commencement of data collection are semi urban communities in Kaduna state, north there was an advocacy visit to the Head of Department west Nigeria. This study was quasi experimental with of Agriculture of the selected LGA and to the baseline, intervention and post-intervention chairperson of the poultry farmers association where components. The sample size for poultry farmworkers the selected farms were located. Permission was also was determined using the formula for comparison of sought from the owners of the farms. proportions in the baseline and post-intervention Data was collected three months after the 2 18 training from both study and control groups using the components of a study, (Z1-á+ Z1-â){(p1q1+p2q2) / (p1-p2) } with the probability score at 95% interval and a same data collection tools and research team used to precision level of 5%. Where n = minimum sample collect the pre-intervention data. The questionnaires were manually checked for accuracy and sizefor each group, Z1- á = standard normal deviate corresponding to the 95% confidence interval for the completeness; data was analysed electronically using Statistical Package for Social Sciences (SPSS) version study i.e. 1.96, Z1- â = standard normal deviate corresponding to 80% power of study i.e. 0.840, p = 21. The mean and standard deviation were obtained for 1 the knowledge score as well as independent t-test used proportion of poultry farm workers with good 19 to compare mean knowledge score between the study knowledge at baseline from a previous study i.e. 0.59 and control group pre-intervention and post- p = expectedlevel of knowledgeat the end of the study 2 . intervention. Chi square test was used to compare the An increase of 20% (i.e. 0.20) in knowledge was similarity of the socio-demographic variables (age expected at the end of the study. A minimum sample group, marital status, educational status, tribal size of 63 poultry farm workers was thus calculated for distribution etc.) in both groups (study and control). each group. This increased to 70 poultry farm workers The difference in the knowledge and compliance with when provision of 10% non-response rate was made. occupational health and safety measures in the baseline Poultry farm workers who had been working and post intervention survey was determined using for at least 1 year were included in the study. Those appropriate standard tests like Chi square test (÷2)to poultry farm workers who were not directly involved in determine the difference and check if it was statistically handling the birds were excluded from the study. significant at 95% confidence level. Multistage sampling was used to select poultry farm The questions for knowledge were scored one workers. In the first stage, two LGAs (Kaduna North mark for each correct answer, while incorrect or 'don't and Sabon Gari) were selected from a list of the 23 know' responses were scored zero. The correct scores LGAs in Kaduna State by balloting. With the toss of a were summed and calculated as a percentage of the coin, the study and control groups were selected; total to know which category the level of knowledge or Kaduna North became the study LGA and Sabon Gari practice belongs. The total score for the knowledge the control. The second stage involved, the selection of questions was 48. Those scoring less than 50% were farms. The farms were randomly selected from the list classified as poor, the scores equal to or above 50% of poultry farms by balloting. A total of 70 poultry were classified as good knowledge. farms were selected in each local government area. In Ethical clearance was obtained from the the third stage, one eligible farmer was selected from Ahmadu Bello University Teaching Hospital Ethical each poultry farm by balloting (each farm had between and Scientific Committee before the commencement of 1 to 3 poultry farm workers). Data was collected using the study. Permission from the poultry farm owners and pre-tested, interviewer administered, paper based, the LGA through the Department of Agriculture was structured questionnaire, from the poultry farm sought. All information obtained during the study was workers in both the study group and control at baseline. 02 N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) treated with confidentiality. Information about the p=0.0030 and noisep <0.0001). At the pre-intervention study was provided to each participant and their phase of the study, the differences in knowledge of anonymity, confidentiality of their responses, their routes of exposure to chemical hazards between study voluntary participation and right to withdraw at any and control group were not statistically significant stage was emphasized, following which informed (inhalation 0.590). However, the post-intervention written consent was obtained. The poultry farmers in stage revealed a statistically significant difference the control group did not receive the training until after (ingestion, inhalation, absorption; p=0.0003, the post intervention data collection was carried out in p<0.0001,p <0.0001 respectively). (Table 2) both the study and control areas. At the pre-intervention stage, there was no statistically significant difference between the study Results and control group respondents' knowledge of OHS The mean age of the respondents in the study measures (wear PPE, early reporting of symptoms, group and control group was 29.66 ±6.30 years and keeping clothes separate from PPE; p=0.462, p=0.708 28.93 ±6.21 years respectively (p=0.492). All the and p=0.380 respectively). Post-intervention, the respondents in the study and control groups were male. differences noted were statistically significant (wear Majority of the respondents in the study and control PPE, early reporting of symptoms, washing hands and group (61.4% and 58.6% respectively) had only faces with soap and water, keeping clothes separate Quranic education. There were no statistically from PPE; p=0.00173, p=0.0091, p=0.0042 and significant differences in the socio-demographic p=0.0048 respectively). (Table 3) characteristics of respondents in the study and control At the post-intervention stage, there was a groups, showing they were comparable (Table 1). statistically significant difference between the Pre-intervention, the differences in knowledge proportion of those with good and poor knowledge of physical hazards such as harsh weather,noise, and between the study and control group (p<0.0001). trauma between the study and control group were not (Table 4) This was also detected in the statistically statistically significant (p=0.862, p=0.718 and p=0.718 significant difference in the knowledge scores between respectively). Post-intervention, the differences noted the study and control groups at the end of the study were statistically significant (musculoskeletal (p<0.0001). (Table 5) problems 0.0014, harsh weather p<0.0001, trauma There was a statistically significant difference
Table 1: Socio-demographic profile of the study and control groups Variable Category Study group type Test statistic
Study (n=70) Control (n=70) ÷2 p-value Frequency (%) Frequency (%) Age group < 20 years 3 (4.3) 3 (4.3) 0.49a 0.921 20-29 years 32 (45.7) 36 (51.4) 30-39 years 29 (41.4) 26 (37.1)
≥40 years 6 (8.6) 5 (7.1) Ethnic group Hausa 50 (71.4) 48 (68.6) 2.12a 0.713 Fulani 14 (20.0) 17 (24.3) Yoruba 3 (4.3) 2 (2.9)
Igbo 0 (0.0) 1 (1.4) Others 3 (4.3) 2 (2.9) Religion Islam 65 (92.9) 66 (94.3) 0.12a 0.730
Christianity 5 (7.1) 4 (5.7) Marital status Single 19 (27.1) 12 (17.1) 1.49b 0.222 Married 51 (72.9) 58 (82.9) Highest level of Quranic 43 (61.4) 41 (58.6) 0.13b 0.937
education Primary 18 (25.7) 19 (27.1)
Secondary 9 (12.9) 10 (14.3) a- Fisher’s Exact b- Pearson chi square 03
N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Table 2: Comparison of study and control group knowledge of occupational hazards at pre-intervention and post-intervention (n=70) Pre-Intervention Post-Intervention Study Control p-value Study Control p-value Variable Frequency Frequency Frequency Frequency (%) (%) (%) (%)
Physical Hazards Musculoskeletal 47 (67.1) 50 (71.4) 0.500 66 (94.3) 51 (72.9) 0.0014 problems Harsh we ather 30 (42.9) 29 (12.9) 0.862 66 (94.3) 28 (40.0) <0.0001 Trauma 47 (67.1) 49 (70.0) 0.718 63 (90.0) 49 (70.0) 0.0030 Noise 22 (31.4) 24 (34.3) 0.718 54 (77.1) 22 (31.4) <0.000 1 Route of Exposure to Che mical Hazar ds Ingestion 43 (61.4) 43 (61.4) 1.000 61 (87.1) 42 (60.0) 0.0003 Inhalation 25 (35.7) 22 (31.4) 0.590 51 (72.9) 22 (31.4) <0.0001 Cuts 10 (14.3) 11 (15.7) 1.000 29 (41.4) 11 (15.7) 0.0007 Absorptio n 6 (8.6) 4 (5.7) 0.740 * 27 (38.6) 4 (5.7) <0.0001 * Biol ogical Hazards Infection fr om 47 (67 .1) 48 (68 .6) 1,000 65 (92.9) 48 (68 .6) 0.0003 sick birds Lung infection 46 (65.7) 47 (67.1) 1.000 63 (90.0) 47 (67.1) 0.0009 from dust Infection from 42 (60.0) 43 (61.4) 1.000 61 (87.1) 43 (61.4) 0.0005 handling bird waste Infection from 38 (54.3) 41 (58.6) 0.729 59 (84.3) 41 (58.6) 0.0008 unsafe water Infect ion from 18 (25.7) 23 (32.9) 0.353 53 (75.7) 23 (32.9) <0.0001 direct contact with cages Table 3:Comparison of study and control group kno wledge of OHS at pre-interv ention and post -intervention (n=70)
Var iables Pre-intervention Post-intervention Study Control p-value Study Control p-value Training and 65 (92.9) 67 (95.7) 0.718 70 (100.0) 67 (95.7) 1.000 retraining of staff Follow 53 (75.7 ) 55 (78.6 ) 0.689 63 (90.0 ) 55 (78.6 ) 0.0632 employers’ instruction Use or wear PPE 51 (72.9) 47 (67.1) 0.462 65 (92.9) 47 (67.1) 0.0173 Reporting any 49 (70.0) 51 (72.9) 0.708 63 (90.0) 51 (72.9) 0.0091 symptoms noticed early Wash hand s and 44 (62.9) 47 (67.1) 0.597 62 (88.6) 48 (68.6) 0.0042 face with soap Never eat or 43 (61.4) 38 (54.3) 0.393 60 (85.7) 38 (54.3) <0.0001 drink at work Keep clothin g 42 (60.0) 47 (67.1) 0.380 61 (87.1) 47 (67.1) 0.0048 separate from PPE Use foot bath 40 (57.1) 35 (50.0) 0.396 63 (90.0) 35 (50.0) <0.0001 before entering poultry Use foot bath 40 (57.1) 35 (50.0) 0.396 59 (84.3) 35 (50.0) <0.0001 when leaving Read ing and 37 (52.9) 39 (55.7) 0.729 59 (70.0) 39 (55.7) 0.0002 understanding information Test sta tistic:? 2 test 04
N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Table 4: Comparison of study and control group knowledge of occupational hazards and OHS practices at pre-intervention and post-intervention (n=70)
Pre intervention Post intervention Variable Category Study Control p- Study Control p-value Frequency Frequency value Frequency Frequency (%) (%) (%) (%) Score Poor 31 (41.4) 28 (20.0) 0.601 3 (2.8) 28 (20.0) <0.0001* Good 39 (58.6) 42 (60.0) 62 (88.6) 42 (60.0)
? 2 test; *Fisher’s exact test
Table 5: Comparison of study and control group knowledge scoreat pre -intervention and post- intervention (n=70) Test Group Mean and standard deviation Test statistics* and p- Variable value
Study Control Knowledge Pre 27.49±4.01 27.11±3.20 0.7325 s core in tervention Post 39.23±3.84 28.04±3.61 <0.0001 intervention
Independent t-test* Table 6: Comparison of study and control group practice of OHSat pre-intervention and post -intervention (n=70 )
Pre intervention Post intervention Study Control p-value Study Control p-value Variables Frequency Frequency Frequency Frequency
(%) (%) (%) (%) Change 45 (64 .3) 47 (67 .1) 0.718 61 (87 .1) 47 (67 .1) 0.0048 clothes
Wash hands 44 (62.9) 48 (68.6) 0.475 60 (85.7) 48 (68.6) 0.0158 with soap and water Eating or 43 (61.4) 37 (52.9) 0.305 37 (52.9) 37 (52.9) 1.000 drinking while working Use foot 23 (32.9) 21 (30.0) 0.718 38 (54.3) 21 (30.0) 0.0036 bath
Wea r face 13 (18.6) 11 (15.7) 0.654 14(20) 11 (15.7) 0.507 mask Wear gloves 11(15.7) 9 (12.9) 0.631 13 (18.6 ) 9 (12.9) 0.354
Wear boots 4 (5.7) 1 (1.4) 0.365* 4 (5.7) 1 (1.4) 0.365*
Wear apron 1 (1.4) 1 (1.4) 1.000* 1(1.4) 1 (1.4) 1.000*
? 2 test; *Fisher’s exact test in the self-reported practice of handwashing and use of Discussion foot baths at the end of the study between the study and All the respondents in the study and control control group (p=0.00158 and p=0.0036 respectively). groups were male. This is similar to studies carried out (Table 6) in Sokoto and Zaria.10,20The job is known to be male- 05 N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) dominated21consequent upon the fact that poultry farm likelihood of exposure. workers resume work very early and spend between 8 There was a statistically significant difference to 12 hours at work. This is time spent away from the in the mean knowledge score in the study and control home and most females might find this inconvenient groups post-intervention (Table 4) with about half of especially in this sub-region. Majority of the the respondents in the study group having good respondents had only Quranic education which is knowledge of occupational health and safety measures similar to findings from studies carried out in this sub- associated with poultry farming. At the end of the region.10,20 This is not surprising as educational intervention study in Sokoto there was a 35% increase attainment in the North western part of Nigeria is in the proportion of respondents with good especially low22 and with menial jobs, education is not a knowledge.10The proportionate increase in respondents prerequisite. with good knowledge was comparable to a study At the end of the study there was a statistically carried out in Ontario Canada where there was a 27% significant increase in knowledge of physical hazards, increase in farmers' knowledge after educational biological hazards and routes of exposure to chemical intervention.25This shows the effectiveness of training hazards. (Table 2) This is similar to studies carried out as an appropriate tool to improve knowledge. in Egypt where there was a statistically significant At baseline, the self-reported use of personal increase in knowledge of hazards at the end of the protective equipment was 18.6%, 15.7%, 5.7% and study.23 Similarly, a study carried out in Thailand 1.4% for face masks, gloves, boots and apron among showed a statistically significant increase in the respondents in the study group (Table 6). This was knowledge about agrochemicals following heath similar to a study carried out in Sokoto where the use of education.24The study showed that about two-thirds of hand gloves was 16%.10However the use of boots, face respondents in the study group knew that hand washing masks and aprons was 21%, 53% and 17%. This was an important preventive measure (Table 3). This disparity could be due to the fact that when the study in was similar to a study carried out in Zaria where 60.7% Sokoto was carried out, the government in the state had of the respondents knew about hand washing.20This distributed free personal protective equipment to the was also similar to a study carried out in Benin where various farms in the state. It also differed from a study 59.1% of the respondents knew that hand washing was in Nepal where 30.2% used gloves, 27.1% used face necessary preventive measure.The study showed that mask and 7.3% used boots.8This disparity could be about two-thirds of respondents in the study and control attributed to the difference in educational level of the groups knew that hand washing was an important respondents; the lack of availability of adequate preventive measure (Table 3). This was similar to a personal protective equipment and due to the fact that study carried out in Zaria where 60.7% of the these studies were carried out when there was a global respondents knew about hand washing.20 This was also spotlight on poultry farming due to the emergence of similar to a study carried out in Benin where 59.1% of avian influenza (bird flu). As a result of the inadequate the respondents knew that hand washing was necessary use of PPEs these poultry farm workers are at an preventive measure.19 However the proportion who increased risk for numerous occupational knew about hand washing was lower than that obtained injuries/accidents and diseases. At the end of the study in a study in Nepal, where 88.5% knew about the there was a statistically significant increase in the importance of hand washing.8This could be due to the proportion of workers who changed clothes, washed fact that majority of the respondents in that study had hands with soap and delayed eating till they were out of higher level of education. Knowledge on hand-washing the poultry (Table 6). There was no significant change is essential to maintain good health as these workers in the use of PPEs likely due to the fact that they were come in contact with faeces and urine of the livestock not provided by the farm owners. This highlights the as well as coming in contact with sick and/or dying need to involve employers in any intervention planned. birds. If the workers are not aware when and how frequently they should wash their hands, they are at risk Limitation of the Study of various diseases. Due to poor registration practices, the list of The study showed that baseline majority of poultry farms within each LGA was inaccurate. Farm respondents in the study group knew the importance of owners did not provide PPEs for their workers as a training and retraining on occupational health and result it would affect the post-intervention utilisation of safety measures (Table 3). The findings differ from a PPEs. study carried out in Benin city where only 31.9% of respondents knew that training on occupational health Conclusion and safety measures was necessary.19Training and re- At baseline both study and control groups had training is necessary to enlighten them on the hazards low levels of knowledge and poor observed and self- they would face in the course of their work and the reported practice. Post-intervention, a statistically preventive measures they need to take to reduce the significant difference was observed between the study 06 N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) and control groups in terms of knowledge and some of farmers and poultry traders in Ikorodu, Lagos state, the self-reportedpractices. Thus, the educational Nigeria. 2013;5(4):202–7. intervention was effective in improving the knowledge 10. Oche MO, Junaidu AU, Mainasara AS, and practice of occupational health and safety in the Ndakotsu MA. Using health education intervention to study group. improve knowledge and practice of prevention of avian influenza among bird handlers in Sokoto, Nigeria. References 2013;5(9):122–7. 1. WHO | Occupational health WHO. 2014; 11. Ametepeh RS, Adei D, Arhin AA. Available from: http://www.who.int/topics Occupational health hazards and safety of the informal /occupational_health/en/ [accessed Oct 27 2018] sector in the Sekondi-Takoradi Metropolitan Area of 2. WHO | Global strategy on occupational health Ghana. Res Humanit Soc Sci. 2013;3(20):87–99. for all: The way to health at work. WHO 2012; 12. Aluko OO, Adebayo AE, Adebisi TF, Available from: http://www.who.int/occupational_ Ewegbemi MK, Abidoye AT, Popoola BF. Knowledge, health/publications/globstrategy/en/index4.html attitudes and perceptions of occupational hazards and [accessed Oct 27 2018] safety practices in Nigerian healthcare workers. BMC 3. Jukka PH, Tan T, Kiat B. Global Estimates of Res Notes. 2016;9:71. Available from: http://www. Occupational Accidents and Work-related Illnesses ncbi.nlm.nih.gov/pubmed/26852406 (accessed Oct 27 [Internet]. Singapore; 2017 [cited 2019 Jul 22]. 2018) Available from: www.wsh-institute.sg 13. Anderson M. Behavioural Safety and Major 4. Abdalla S, Apramian SS, Cantley LF, Cullen Accident Hazards. Process Saf Environ Prot. MR. Occupation and Risk for Injuries [Internet]. 3rd 2005;83(2):109–16. Available from: http://www. ed. Injury Prevention and Environmental Health. sciencedirect.com/science/article/pii/S095758200571 Washington DC: The International Bank for 2246 Reconstruction and Development / The World Bank; 14. Lunner-Kolstrup C, Ssali TK. Awareness and 2017 Available from: http://www.ncbi.nlm.nih.gov/ Need for Knowledge of Health and Safety among Dairy pubmed/30212110 [accessed Jul 22 2019]. Farmers Interviewed in Uganda. Front public Health. 5. Hamid A, Ahmad A, Khan N, Hamid A, Ahmad 2016;4:137. Available from: http://www.ncbi.nlm. A, Khan N. Respiratory and Other Health Risks among nih.gov/pubmed/27446901(accessed Oct 27 2018) Poultry-Farm Workers and Evaluation of Management 15. Oduwaiye M, Akangbe J, Komolafe S, Ajibola Practices in Poultry Farms. Rev Bras Ciência Avícola. B. Assessment of Knowledge of Farming-Related 2018 Mar;20(1):111–8. Hazards and Precautionary Practices of Farmers in 6. Awosile BB, Oseni SO, Omoshaba E. Hazards Kwara State , Nigeria. J Res For Wildl Environ. Exposures of Workers of Animal Related Occupations 2015;7(2):27–35. in Abeokuta Southwestern, Nigeria Antimicrobial 16. Fatiregun AA, Saani MM. Knowledge, resistance in generic fecal Escherichia coli from dairy attitudes and compliance of poultry workers with calves View project Antimicrobial resistance in preventive measures for avian influenza in Lagelu, Oyo bacteria isolated from companion and food animals State, Nigeria. J Infect Dev Ctries. 2008;2(2):130–4. from the Atlantic Provinces, Canada (1994-2013). 17. Okoye A. The Need for Environmental and 2013. Available from: https://www.researchgate.net/ Safety Consciousness for Sustainable Industrial publication/267338474[accessed Oct 27 2018] Development in Nigeria: A Review. Eur Sci J. 7. Gaber S, Abdel-Latif SH. Effect of education 2017;13(26):345–54. and health locus of control on safe use of pesticides: a 18. Taofeek I. Research methodology and cross sectional random study. J Occup Med Toxicol. Dissertation Writing for Health and Allied Health 2012 25;7:3. Professionals. First. Abuja: Cress Global Link limited 8. Neupane D, Khanal V, Ghimire K, Aro AR, Publishers; 2009. 70–75 p. Leppin A. Knowledge, attitudes and practices related to 19. Adam V, Qasim A. Assessment of the avian influenza among poultry workers in Nepal: A knowledge of poultry farmers and live poultry sellers to cross sectional study. BMC Infect Dis. 2012;12:76 preventive and control measures on bird flu, Benin 9. Dairo MD, Elelu N. Journal of Public Health City, Nigeria. Epidemiol Res Int. 2014;38–41. and Epidemiology Knowledge and preventive 20. Abdullahi MI, Oguntunde O, Habib AG. practices related to Avian influenza among livestock 07 N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)
Knowledge, Attitudes, and Practices of Avian Influenza 23. Mohsen MM, Salah R, Mohamed E, Hafez SH. among Poultry traders in Nigeria. Internet J Infect Dis The Effect of Health Hazards Intervention on the [Internet]. 2010;9(1):32-35 Farmer ' s knowledge , Practice and Self- Reported 21. Okoh SO, Rahman SA IH. Gender Symptoms of Pesticides Exposure. 2016;3(2):196–209 participation in commercial poultry production in Karu 24. Raksanam B, Taneepanichskul S, Siriwong W, and Lafia Areas, Nasarawa State, Nigeria. Livest Res Robson M. Multi-approach model for improving Rural Dev. 2010;22(9). agrochemical safety among rice farmers in 22. NDHS. Nigeria Demographic and Health Pathumthani, Thailand. Risk Manag Health Policy Survey 2013. Niger Demogr Heal Surv 2013 Natl 2012 30(5): 75-82 Popul Comm Fed Repub Niger. 2014;1–400.
08 Maternal Knowledge and Perception Towards Childhood Immunization in a Health Facility in Delta State, Nigeria.
1E. G. Moke, 1K. E. Edje, 1E. K. Umukoro, 2P. Y. Toloyai,3T. M. E. Daubry, 1A.I. Omogbiya, 1B. E. Oshevirhe. 1.Department of Pharmacology and Therapeutics, Faculty of Basic Medical Sciences, Delta State University, Abraka, Nigeria. 2.Department of Medical Biochemistry, Delta State University, Abraka, Delta State, Nigeria. 3.Department of Human Physiology, Delta State University, Abraka, Delta State, Nigeria. Abstract Introduction Immunization is still one of the most Immunization is still one of the most imperative public health interventions, which is cost- imperative public health interventions, though cost- effective and has helped in reducing both the morbidity effective, that has helped in reducing both the and mortality associated with infectious diseases. It is morbidity and mortality associated with infectious essential that pregnant women accept this health diseases.1 It greatly reduces the burden of infectious scheme which is of great benefit for their children. This diseases as it has aided in averting over two million study investigated knowledge and perception towards deaths yearly.1,2Immunization is the process whereby a childhood immunization among mothers receiving person is made immune or resistant to an infectious antenatal care (ANC) at the General Hospital Abraka, disease, typically by the administration of a vaccine. Delta State, Nigeria. One Hundred mothers receiving Vaccines stimulate the body's own immune system to ANC between March and April 2018 at the General protect the person against later infection or disease. Hospital Abraka were randomly selected and Immunization prevents illness, disability and death administered a well-structured questionnaire which from vaccine-preventable diseases (VPDs) including was used to collect data for the study. Data was diphtheria, measles, pertussis, pneumonia, polio, presented as percentage using descriptive statistics. rotavirus diarrhea, rubella and tetanus. The The respondent's mean age was 27.05±1.89years and immunization routine schedule is shown below (Table majority had post-primary education (62%). 1). Majority(90%) knew that immunization was used to Usually immunization comprises “active prevent childhood diseases, and a larger proportion immunization” when there is exposure to an agent (92%) agreed that immunization was necessary. (immunogen/antigen) which then fortify the immune Majority (90%) believed that immunization was more system against such similar infectious agents, and beneficial than harmful; most correctly identified “passive immunization” which involves giving the measles(78%), yellow fever (40%) and polio (36%) as subject protective antibodies developed by someone diseases that could be prevented by immunization, else or another organism.3Thus, by controlled exposure although 12% thought same about malaria. Almost of an individual to an immunogen will help the every respondent agreed that compliance to (96%) and individual's immune system protect itself from completion of (98%) the immunization schedule was infection in the future.4 so important. There was good maternal knowledge and Childhood vaccination is generally considered positive perception towards childhood immunization, to be 'overwhelmingly good' by the scientific although, there is need for appropriate education of community.5Epidemiological study has shown a much mothers about vaccine-preventable diseases (VPDs) decline in child mortality as a result of preventable and vaccination schedule. disease vaccination in developing countries across Africa and Asia.6. The Expanded Programme on Keywords: Childhood immunization, vaccine, Immunization (EPI) was established in 1974 by the antenatal care, vaccination schedule, Abraka. WHO in partnership with UNICEF and Rotary International as part of the child survival initiative programs, which has amplified the extent of immunization of the world's children from 5% to 80% in 30 years.7With the extent of success following immunization initiative worldwide, the situation is Correspondence to: quite different in developing countries especially in Africa where vaccine-preventable diseases (VPDs) E.G. Moke contribute significantly to mortality among under-five 8 Department of Pharmacology and Therapeutics children. Nigeria like many other countries in Africa is Faculty of Basic Medical Sciences making continuous efforts to strengthen its health Delta State University, Abraka, Nigeria system so as to achieve sufficient routine immunization E-mail: [email protected] to lessen the burden of VPDs. However, certain Tel: +234-7061040692 elements such as inadequate funding, poor level of 09 E.G. Moke et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) education and awareness, inadequate infrastructure Delta State University, Abraka, Nigeria. A well- and equipment, lack of political will, shortage of health structured questionnaire was used to collect data for the personnel, unavailability of vaccines at scheduled study from participants who gave informal oral times, and indirect costs of immunization have consent. Information collected comprised the socio- contributed to the low level of immunization coverage demographic data, knowledge on immunization, and in Nigeria.8-10Surveying the knowledge and attitude perception toward childhood immunization. Data was towards childhood immunization is an important first presented as percentage using descriptive statistics. step towards understanding the factors that influence Slovin's formula: n = N / [1 + N(e)2]; where N - vaccine non-acceptance in a particular setting11, hence population size, n - sample size, e - significance level t h e n e e d t o u n d e r t a k e r e s e a r c h e s i n t o (for this study 0.05) parents'(maternal) knowledge and perception towards childhood immunization essentially at the communal Results level. The results obtained showed that mothers Although researches have been published on attending antenatal care at the General Hospital Abraka parents' knowledge, attitudes and practices regarding have a mean age of 27.05 years. Majority of the childhood vaccination, little or no such studies have respondents (86%) were married, with only a few been reported in Abraka, Ethiope-East Local (12%) being single. About two?thirds of the Government Area of Delta State, Nigeria. Thus, this respondents (62%) had post-primary education, and a study was undertaken to assess maternal knowledge larger percentage (58%) of them were into business and perception on childhood immunization among (Table 2). mothers attending antenatal clinicin General Hospital The result revealed that majority of the Abraka, Delta State, Nigeria. respondents (90%) knew that immunization was used to prevent childhood diseases, and majority (94%) Materials and Methods agreed that immunization can be done at the hospital A cross-sectional descriptive study design was (94%), however 6% of them thought their children can adopted to assess the knowledge and perception among be immunized in a community pharmacy. Eighty mothers attending antenatal clinic in the General percent (80%) heard about Immunization first from the Hospital, Abraka, Delta State. The antenatal clinic of hospital, while fewer proportion (12%)had heard via the General Hospital, Abraka receives an average media (radio and television), with 8% of the 120patients monthly (consisting both old and new respondents informed about immunization by friends cases). An estimated sample size of 92 was obtained (Table 3).Majority of the respondents (78%)indicated using Slovin's formula for calculation of sample size, measles as a disease that could be prevented by which was then rounded up to 100. The survey was immunization, while 40% (yellow fever), 36% (polio), conducted by coding the weekly attendance to 24% (tetanus), 22% (tuberculosis), 16% (hepatitis B), randomly select 100 mothers receiving antenatal care 10% (meningitis), and another 10% (diphtheria) between March and April 2018 at the General Hospital indicated other diseases. Twelve percent (12%) of the Abraka. Ethical approval was obtained from the ethical mothers thought that malaria could be prevented by committee of the Faculty of Basic Medical Sciences, immunization, while a lesser number of the
Table 1: Routine immunization schedule (extracted from the National Primary Health Care Development Agency’s Child Health Card version 2017)
Vaccine Birth 6w 10w 14w 6m 9m 12 m 18 m BCG HepB OPV 0 1 2 3 PENTA 1 2 3 PCV 1 2 3 ROTA 1 2 3 IPV v Measles 1 2 Vitamin A 1 2 Yellow fever Meningitis BCG - Bacillus Calmette-Guérin; HepB - Hepatitis B Vaccine; OPV - Oral Polio Vaccine; PENTA - Pentavalent Vaccine against Haemophilus influenzae type B; PCV- Pneumococcal Conjugate Vaccine; ROTA - Rotavirus vaccine; IPV - Inactivated polio vaccine; w–we eks; m – months. 10 E.G. Moke et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Table 2: Socio-demographic characteristic s Variable Frequency Percentage (n=100) Age(years) 21-2 5 44 44 26-30 36 36 31-35 15 15 36-40 5 5 Mean age (±SD) 27 .05 ± 1.89 Marit al Status Married 86 86 Single 12 12 Widowe d 2 2 Educational Status No for mal 20 20 Primary 1 8 18 Secondary 30 30 Tertiary 32 32 Occupa tion Professional 8 8 Business w omen 58 58 Civil se rvant 18 18 Self-employ ed 18 18 Farmer 8 8
Table 3: Knowledge of respondents on childhood immunization
Variable Frequency Percentage (n=100) Purpose To prevent childhood diseases 90 90 To he lp children grow fast 6 6 To make children intelligent 4 4 Place for immunization Hospital 94 94 Commun ity pharmacy 6 6 Source of information abou itm munization Hospital staff 80 80 Radio 10 10 Friends 8 8 Television 2 2 Diseases prevented by immunization* Measles 78 78 Yellow Fever 40 40 Polio 3 6 3 6 Tetanus 24 24 Tuberc ulosis 22 22 Hepatiti s B 16 16 Malaria (Tricky Option) 12 12 Meningitis 10 10 Diphtheria 1 0 1 0 No Idea 4 4 *Multiple resp onses given. respondents (4%)had no idea on any of the diseases that administered at 6 weeks and 10 weeks after birth can be prevented by immunization (Table 3). respectively. Also, 30% and 36% knew that measles Thirty-two percent (32%) and six percent (6%) vaccine and yellow fever vaccine could be given at 9 of the respondents knew that BCG vaccine and months after birth, whereas 28% of the respondents had Hepatitis B vaccine could be given at birth, no idea of when immunization could be given (Table respectively, while 10% knew that rotavirus vaccine 4).Fifty-four pe rcent (54%) an d 40% of the could be given by 6 weeks after birth. Also, 28% and respondents knew that vaccines could be administered 34% knew tha t OPV-1 and OPV-2 could be by injections and mouth drops respectively . Twenty administered at 6 weeks and 10 weeks after birth, while percent of the respondents thought vaccines can be 28% and 20% knew that Penta-1 and Penta-2 could be taken in syrup form, while 10% had no knowledge on 11 E.G. Moke et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Table 4: Knowledge of mothers on vaccination schedule and routes of administrati on.
Variable Frequency Percentage (n=100) Vaccination schedule* BCG vaccine is admini steredat birth 3 2 3 2 Hepatitis B vaccine is admin istered at birth 6 6 Rotavirus vaccine is administered at 6 we eks after birth 10 1 0 OPV-1 vaccine is administered at 6 weeks after birth 28 28 OPV-2 vaccine is administered at 10 weeks after bi rth 34 34 Penta-1 vaccine is administered at 6 weeks after birt h 28 28 Penta-2 vaccine is administered at 10 weeks after birth 20 20 Measles vaccine is administered at 9 months after b irth 30 30 Yellow fever vaccine is administered at 9 months aft er birth 36 36 No idea 28 28 Routes of administration of vaccine* Injectio ns 54 54 Mouth drops 4 0 4 0 Syrup 20 20 No idea 10 10 *Multiple re sponses given.
Table 5: Perceptionof respondents towards childhood immuniza tion Variable Frequency Percentage (n=100) It is necessary to im munization children against VPDs Agree 92 92 Disagree 8 8 Immunization is more beneficial t han harmful Agree 90 90 Disag ree 2 2 No idea 8 8 Would y ou like to comply to immunization schedule Yes 9 6 9 6 No 4 4 Would you like to complete the immunization process (full immunization) for children Yes 9 8 9 8 No 2 2 Pos sible reason for non-completion of immunization pro cess (n=2) Far distance to place of immunization 2 1 00 the routes of administration of vaccines (Table 4). is made immune or resistant to an infectious disease, Most of the respondents (92%) agreed that typically by the administration of a vaccine. It greatly immunization was necessary, with only 8% who reduces the burden of infectious diseases as it has aided 2 disagreed. Majority (90%) believed that immunization in averting over two million deaths yearly. Assessment was more beneficial than harmful, 2% thought of the level of knowledge and perception by parents otherwise, while 8% had no idea if immunization was towards childhood immunization is an important tool actually more beneficial than harmful. Almost every of in ascertaining the extent of vaccine acceptance and the the respondents (96%) agreed that compliance to the effectiveness of the immunization programme immunization schedule was important; likewise,a total especially at the communal level.11The study was of 98% agreed that it was important to complete the carried out to investigate maternal knowledge and immunization schedule, while the remaining 2% would perception towards childhood immunization among prefer not to complete the immunization schedule, with mothers receiving antenatal care in the General their sole reason being long distance to the place of Hospital Abraka, Ethiope-East Local Government immunization (Table 5). Area of Delta state. The mean age of the respondents in this study was 27.05 years, with majority being Discussion married, and have had at least a secondary education. Immunization is the process whereby a person This indicates a high level of maturity and literacy 12 E.G. Moke et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) among the respondents. diagnosis as such mothers may provide an erroneous The study revealed that a high proportion of the immunization history in the future.3 respondents have good knowledge of and are very According to the present study, maternal aware of immunization. They knew its purpose was for perception towards childhood immunization of the prevention of childhood disease (90%), thus stated that mothers attending antenatal clinic in the General is was very necessary (92%). This high level of Hospital Abraka was positive as majority saw the maternal knowledge has also been reported by other immunization process as a necessity, which would be studies. 8 , 1 2 - 1 4 High maternal knowledge on beneficial to the health of their children. Almost all the immunization is important as study among mothers in a respondents agreed to comply with the immunization rural setting in Western Uganda showed that mothers schedule and even complete the process. Similar with fundamental understanding of immunization were studies have reported a positive maternal attitude to more probable to have timely and full vaccination of childhood immunization.14, 18-20Only a small percentage their children.11This discovery demands for targeted of the mothers (2%) expressed the fears of not information, education and communication on completing the immunization process as a result of the childhood immunization. There is also need to increase long distance to the place of immunization. It is awareness via the media as this study showed that a important to note that cost of immunization was not an fewer number of the respondents' source of information issue for the mothers as the Federal government had concerning immunization was from the radio and provided free immunization programme at the health television. However, this indicates that enough facility. However, other barriers such as inadequate awareness was being done at the antenatal care clinic. funding of the immunization programme, inadequate The findings of this study also revealed that infrastructure and equipment, shortage of health most (77%) of the respondents commonly identified personnel, and even unavailability of vaccines at measles as vaccine-preventable diseases (VPDs), as scheduled times could contribute to low level of well as yellow fever (40%) and polio (36%). Few others immunization coverage in Nigeria.8-10 indicated tetanus, tuberculosis, hepatitis B, meningitis, and diphtheria as VPDs, while some(12%)thought Conclusion malaria could be prevented by immunization. A little Conclusively, this study has shown that fraction (4%) of the respondents could not mention any mothers are very concerned in ensuring that their VPD. This unfolds the fact the mothers, though knew children are immunized as majority of the mothers had the importance of immunization, could not tell which good knowledge and positive perception towards type of disease could be prevented. This is in sharp childhood immunization. However, their knowledge of contrast with other studies14,15 which revealed a high vaccine-preventable diseases (VPDs) and vaccination maternal knowledge of vaccine-preventable diseases. schedule was poor, hence, the need for appropriate The small proportions of the respondents that did not education of mothers about immunization possible know any VPD as reported in this study was dissimilar through media and printed 'take-home' pamphlets in with other study where about 61% of the respondents simple language. This survey is imperative for the could not mention even one VPDs.16Thus, it is exigent proper designing and execution of the national for health professionals to provide mothers with immunization programme. adequate information on the VPDs and benefits of immunization in order to improve acceptance of and Acknowledgements compliance to immunization, hence promoting the We wish to acknowledge the support of Dr. success of immunization. Basil Ekuerhare of the University Health Services, Furthermore, the present study showed that Delta State University, Abraka, Delta State, Nigeria. fewer than half ratio of the mothers knew the appropriate schedule for vaccine administration. This Conflict of interest: outcome is consistent with the reports of similar The authors declare no conflicts of interest. study3which showed that most mothers did not know when each vaccines could be administered. Likewise, References about half proportion of the respondents correctly 1. World Health Organization. Health Topics pointed out injections and mouth drops as the routes of ( I m m u n i z a t i o n ) . A v a i l a b l e a t : administering vaccines. This is different from findings 14 http://www.who/int/topics/immunization/ en/. of a study among rural mothers in Lagos where 83.2% (Accessed on 23 Apr 2020). and 77.6% knew both correct routes respectively, 17 2. WHO, UNICEF, World Bank. State of the world's although, another study observed far more little knowledge (4.8%). Some mothers could feel that their vaccines and immunization. 3rd edition. 2009. children are being immunized when administered A v a i l a b l e a t : syrup for other treatments, thus, complicating doctor's http://whqlibdoc.who.int/publications/2009/9789241
13 E.G. Moke et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) 563864_eng.pdf.(Accessed on 23 Apr 2020). 12. Abidoye AO, Odeyemi KA. Knowledge, attitude 3. Awodele O, Oreagba IA, Akinyede A, Awodele and practice of mothers to childhood immunization in DF, Dolapo DC. The Knowledge and Attitude towards Kosofe local government area of Lagos state, Nigeria. Childhood Immunization amongst Mothers Attending Int J Basic Appl Innovative Res. 2013;2:66-72. Antenatal Clinic in Lagos University Teaching 13. Chris-Otubor GO, Dangiwa DA, Ior LD, Anukam Hospital. Tanzania Journal of Health Research. 2010; NC. Assessment of Knowledge, Attitudes and Practices 12: 3. of Mothers in Jos North Regarding Immunization. 4. Blakemore C, Jennett S. The Oxford Companion IOSR Journal of Pharmacy. 2015; 5(6): 34-45 to the Body. New York: Oxford University Press; 2001. 14. Adefolalu OA, Kanma-Okafor OJ, Balogun MR. 5. Global Immunization Vision and Strategy Maternal knowledge, attitude and compliance (GIVS). Global Immunization Vision and Strategy regarding immunization of under five children in 2006-2015. Geneva: WHO/UNICEF. 2005. Available Primary Health Care centres in Ikorodu Local at: http://whqlibdoc.who.int/hq/2005/WHO. Government Area, Lagos State. J Clin Sci. 2019;16:7- (Accessed on 23 Apr 2020). 14. 6. Global Immunization Vision and Strategy 15. Ramadan HA, Soliman SM, El-Kader RG. (GIVS). Progress report and strategic direction for the Knowledge, attitude and practice of mothers toward Decade of Vaccines. 2011. Available at: children's obligatory vaccination. IOSR J Nurs Health https://apps.who.int/gb/ebwha/pdf_files/WHA64/A64 Sci. 2016;4:22-28 _14-en.pdf?ua=1. (Accessed on 23 Apr 2020). 16. Angadi MM, Jose AP, Udgiri R, Masali KA, 7. Mapatano MA, Kayembe K, Piripiri L, Nyandwe Sorganvi V. A study of knowledge, attitude and K. Immunisation-related knowledge, attitudes and practices on immunization of children in urban slums practices of mothers in Kinshasa, Democratic Republic of Bijapur city, Karnataka, India. J Clin Diagn Res. of the Congo. SA Fam Pract. 2008;50:61. 2013;7:2803-2806. 8. Adeyinka DA, Oladimeji O, Adeyinka FE, 17. Taiwo L, Idris S, Abubakar A, Nguku P, Nsubuga Aimakhu C. Uptake of childhood immunization among P, Gidado S, et al. Factors affecting access to mothers of under-five in South Western Nigeria. information on routine immunization among mothers Internet J Epidemiol. 2009;7:1-5 of under 5 children in Kaduna State Nigeria, 2015. The 9. Oku A, Oyo-Ita A, Glenton C, Fretheim A, Eteng Pan African Medical Journal. 2017; 27: 186. G, Ames H, et al. Factors affecting the implementation 18. Awosan KJ, Ibrahim MTO, Yunusa EU, Isah BA, of childhood vaccination communication strategies in Raji MO, Abubakar N. Knowledge, attitude and Nigeria: a qualitative study. BMC Public Health. 2017; compliance with full immunization of children against 17(1): 200. vaccine preventable diseases among pregnant mothers 10. Akwataghibe NN, Ogunsola EA, Broerse JEW, in Sokoto, Nigeria. International Journal of Popoola OA, Agbo AI, Dieleman MA. Exploring Contemporary Medical Research. 2018;5(6):F10-F16. Factors Influencing Immunization Utilization in 19. Enwonwu KG, Ilika A, Ifeadike C, Aniemena C, Nigeria – A Mixed Methods Study. Frontiers in Public Egeonu RO. Perception of Childhood Immunization Health. 2019; 7: 392. among Mothers of Under-Five Children in Onitsha, 11. Vonasek BJ, Bajunirwe F, Jacobson LE, Twesigye Anambra State. Afrimedic Journal. 2018; 6(1): 59-64 L, Dahm J, Grant MJ, et al. Do maternal knowledge and 20. Verulava T, Jaiani M, Lordkipanidze A, attitudes towards childhood immunizations in rural Jorbenadze R, Dangadze B. Mothers' Knowledge and Uganda correlate with complete childhood Attitudes Towards Child Immunization in Georgia. The vaccination? PLoS One. 2016;11:e0150131. Open Public Health Journal. 2019; 12: 232-237
14 Assessment of Level of Depression Among HIV/AIDS Patients Attending HIV Clinic at Murtala Mohammed Specialist Hospital, Kano.
1H.H. Murtala,2M.M. Haddad, 2B.A. Attahir, 2A.H. Ibrahim, 3V.O. Olisah,4A.Shehu,5F. Balarabe,6N.S. Bawa. 1School of Nursing, College of Nursing and Midwifery, Birnin-Kudu, Jigawa State. 2Department of Nursing Science, Faculty of Allied Health Science, College of Health Science, Bayero University Kano 3Department of Psychiatry, Ahmadu Bello University Teaching Hospital, Zaria-Nigeria 4Department of Nursing,Federal Medical Centre, Birnin Kudu, Jigawa state 5Department of Nursing Science, Faculty of Allied Medical Science, College of Health Science, Ahmadu Bello University Zaria. 6Department of Nursing Sciences, Faculty of clinical sciences, College of Health sciences, UsmanuDanfodiyo University, Sokoto Abstract Introduction Mental health and Human Immunodeficiency Depression is closely related with patients with Virus/Acquired Immune Deficiency Syndrome Human Immunodeficiency Virus/Acquired Immune (HIV/AIDS) are closely related, in that interplay exists Deficiency Syndrome (HIV/AIDS)1 and the two between the two. Worldwide, 33 million people are exacerbate each other with associated deleterious living with comorbid condition of HIV/AIDS and consequences.2 HIV/AIDs contributes significantly to depression. Besides, it is projected that the level of mental health morbidity across the globe and mental depression among HIV/AIDS patients would increase health problems are associated with an increased risk of by about 60% by the year 2030. This study assessed the devastating HIV/AIDS conditions and interfere with presence of depression and factors that contribute to the treatment.3,4Centre for infection and disease control development of depression among HIV/AIDS patients (CDC) acknowledged that the presence of depression attending HIV clinic in Murtala Mohammed Specialist among patients with problems like HIV/AIDs Hospital, Kano. Cross-sectional descriptive design was adversely affect the management of those kind of used. A total of 73 patients were recruited for the study conditions [5].Another study reported that patients with using systematic random sampling technique. A comorbid disorder of HIV/AIDs and depression have structured interviewer administered questionnaire was been reported to have increased level of other used for data collection. Data were analyzed with SPSS psychological distress which is associated with the version 2.0 and results were presented using frequency severity of the HIV infection.6 distribution tables and percentages, and chi-square. Depression is the most commonly reported The prevalence of depression was 50.7% of which psychiatric disorder among all ages and yet its 67.6% of them had mild depression and 37.0% had prevalenceis commonly under diagnosed and moderate depression. Factors contributing to the consequently untreated in general medical development of depression are stigma faced from population.6Nigeria has high number of new HIV people in the community (37.0%), financial problem/ infections reported each year with an estimated 3.7% of lack of employment (23.3%), lack of partner in its population living with HIV.7,8In the context of marriage (20.6%)and belief that disease may not be HIV/AIDS, depression is often overlooked without cured (12.3%).Conclusionwas that management of considering the fact that it is a potentially dangerous HIV patients should include health education of the condition that is capable of influencing not only the patients on ways of reducing the level of depression quality of life, relationship, employment and adherence through elimination or modification of factors to medical care, but also perhaps, the survival of the contributing to depression. affected population,9 it was further added by another study thatdepression coexisting with HIV/AIDS is Keywords: Depression, HIV/AIDs Patient, Factors associated with failure to maintain adequate and proper contributing, Prevalence diet, exercise regimen and adherence to medical care, this thus further deteriorates the condition.10 Evidences have revealed that depression among people with HIV/AIDS is very high which affect about 121 million people globally. Worldwide, it Correspondence to: was reported thatabout 33 million HIV/AIDS patients suffer from depression and it is responsible for 850,000 HH Murtala suicides each year among them with the highest burden School of Nursing, coming from developing countries[11, 12]. Additionally, in College of Nursing and Midwifery, low income countries, Nigeria inclusive, it is projected Birnin-Kudu, that the level of depression among HIV/AIDS patients Jigawa State would increase by about 60% by the year 2030.13This [email protected], +2348060102360 thus constitute a more debilitating burden of diseases 15 H.H. Murtala et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) than maternal, communicable, nutritional and perinatal this study in order to assess the presence of depression conditions and alarmingly, depression occurrence in and factors contributing to the development of people living with HIV (PLHIV) leads to an alteration depressionamong HIV/AIDS patients attending HIV of economic productivity, decrease of working clinic in Murtala Mohammad Specialist Hospital, Kano abilities, social isolation, physical decline and 14 (MMSH). difficulties in solving problems. In Nigeria, studies have established that Materials and Methods depression is about 5 times more common among 6 Study setting: The study area was Murtala PLHIV, than in apparently healthy individuals. Mohammad specialist hospital, Kano. This hospital is Different researches revealed different presence of the biggest specialist hospital in Kano state and is one depression among HIV patients. Olisah, Adekeye& 15 of the training ground for nursing, midwifery and Sheikh in a study in Nigerian University teaching medical students. The hospital was first established in hospital showed that, among 310 HIV-infected the year 1926 by the colonial government for its participants assessed for depression, 14.2% had current 7 African workers and community at large. In 1952, the depressive disorder. Furthermore, Chinyereet al. in native authority took over the hospital from the colonial another study conducted in Imo state revealed that,of central government with capacity of 60 beds. With the total 212 HIV/AIDs patients, 106 (39.1%) were independence and creation of regions in 1960-1979, the depressed, out of which 26 (24.5%) were mildly newly created Kano state government took over the depressed, 53 (50.0%) were moderately depressed hospital.In 1979, the hospital was named after the late while 27 (25.4%) were severely depressed. Another military head of state government Murtala Ramat study on prevalence and severity of depression among Mohammad. In 1990, the hospital was upgraded to people with HIV/AIDS in a tertiary hospital by Adiari& 5 specialist hospital. The hospital has capacity of 688 Campbell also revealed the presence of depression to beds and 1,200 staffs with many units, clinics and be 14.4% among 220 participants recruited with the departmentsincluding, HIV clinic thatruns for three mild category (9.5%) as the predominant subtype. days weekly (Monday, Tuesday and Wednesday), There are several factors contributing to consulting an average number of 50 clients. The HIV development of depression PLHIV and these factors unit has 6 medical officers, 2 visiting consultant include lack of partner in marriage, unemployment and psychiatrists, 2 Nurses. There were no professional 11 [16] loss of mother in childhood , stigma . Additionally, counsellors in the unit. 5 Adiari& Campbell addedbeingin bereavement, poor The patient population consisted of both adults adherence to antiretroviral medication and a poor level and children, without any special grouping for of social support among the factors associated with the treatment risk of developing depression among PLHIV.Another Research design: A cross-sectional descriptive study reported that gender is an important factor as research designs was employed to identify the level of women who have HIV are about 2 times at risk for depression, factors contributing to the development of depression than men[17] however, that was countered by depression, and relationship between age, occupational another study which reported that sometimes male status and development of depression among PLHIV are more likely to develop depression (about HIV/AIDs patients. 1.6 times) with the reason not well understood [18]. Study population and Sampling: The study Furthermore, another study trying to depict the population was all patients attending HIV clinic in mixed nature and poor scientific consensus on factors Murtala Mohammad specialist Hospital, Kano, who associated with depression among PLHIV revealed that met the study criteria; Inclusion criteria: at least 6 while high level of depression in HIV patients was weeks' post-diagnosis, not seriously sick, whereas, found among those with low level of education, other exclusion criteria: irrespective of type of medications studies found higher rates among those with higher use, presence of comorbid illness, presence of level of education.13Mohammed et. al.,3 in their study in complications of HIV, those that were seriously sick Ethiopia, reported that,widowed and divorced PLHIV Systematic random sampling technique was are more likely to have depression than patients who employed for the selection of respondents and the list of are single and another study revealed that,high level of all the registered patients formed the sampling frame, depression among married PLHIV is more likely which was calculated by dividing the desired sample (about 6 times) compared to single PLHIV.3 size in a clinic day by the total number of eligible Depression is a mental disorder that coexists respondents, where, after the first caregiver was with HIV/AIDS, but receives less attention and hence selected using balloting, four (4)patients were skipped little is known about it5and there is a dearth of studies on and the subsequent one was selected to serve as the widely reported comorbidity in Kano state, the most respondents until the desired sample size was achieved. populous state in Nigeria. Thus, the researchers spurred A total of 73HIV/AIDs patients were recruited for the study based on 95%prevalence rate of depression and 16 H.H. Murtala et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) associated factors among HIV patients,3using Cochran 2 2 Table 1: Respondents Socio-Demographic formula n=z pq/d . Characteristics (n=73) Where n = minimum sample size, Z = 1.96 Variables Frequency Percentage (%) (standard normal deviation for 95% confidence Age(Years) interval level), p = proportion of population with Less than 15 8 11 prevalence rate of depressed patients studied (95.0%) 15-25 17 23.3 3,q = complementary probability = (100 - P) = (100 - 95) 26-35 24 32.9 = 5, e=precision required (tolerable sampling error) = 36-45 17 23.3 2 2 5%,Therefore, n = (1.96) × 5 (100 - 5)/5 = 72.96, 46 and above 7 9.6 approximately 73 G ender Research instrument: The Data were collected using Male 18 24 .7 Hospital Anxiety and Depression scale (HADs) Fema le 55 75.3 questionnaire adapted from Sale.18This instrument is used as a screening tool for anxiety and depression, M arital status although only the depression subscale of HADS was Married 25 34 .2 analysed. The interview guided questionnaire consists Single 30 41.1 of three sections. Section A, section B and section C. Divorc ed 9 12.3 Section A address socio-demographic characteristics, Widow 6 8.2 section B addressed presence of depression using Widow er 3 4.1 Hospital Anxiety and Depression Scale and Section C addressed factors contributing to the development of L evel of education depression. Section B comprised seven questions for Primary 14 19 .2 Secondary 33 45.2 depression, and respondent take like 2–5minutes to complete. Questions depression were scored Tertiary 17 23.3 Non-forma l 9 12.3 separately. The total score of each depression range from 0 - 21. The scalewas categorized as no case (0-7), mild (8-10), moderate (11-14), and severe (15-21). Religion
Validity of the instrument was ensured Islam 44 63 by five jurists from the Department of Nursing Christian ity 27 3 7 Sciences, Bayero University Kano. A pilot study was conducted using split half reliability method and Tribe Cronbach alpha value of 0.67 was obtained. H ausa 43 58 .9 Fulan i 5 6. 8 Method of data analysis: Data was analyzed using Igbo 10 13.7 Yoruba 11 15.1 statistical package for social sciences version 20. The Others 4 5.1 data was then displayed using frequencies and percentages. Chi-square test was used to test the Occup ation relationship between age and development of House wife 15 21.9 depression as well as occupational status and S tudent 12 16.4 development of depression. Civil servan t 14 19 .2 Petty trader 28 38.4 Ethical consideration: Ethical approval was secured Farmer 3 4.1 from the health research ethics committee of ministry of health Kano state (Ethical Clearance Reference No: Monthly in come MOH/Off/797/T. I/869). Murtala Mohammed No inco me 25 34.2 Specialist Hospital Management and study participants L ess than 20,000 32 43 .8 also gave permissions and consents respectively. 20,000-40,000 10 13 .7 40,000-60,0 00 5 6.8 Result More than 60,00 0 1 1.4 Respondents Socio-demographic Characteristics The findings from the study shows that Majority of the respondents had secondary school leaving certificate (45.2%), only (12.3%) had informal majority of the respondents (32.9%) were within the age range of 26-36 years. Female respondents formed education. Most (63 %) were Muslims, while others 75.3% of the study participants whereas male (33%) were Christians, 38.4% reported being petty respondents constituted the rest of 24.7%. Also, most traders. Majority of them had an income of 17 H.H. Murtala et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Table 2: Factors Contributing to theD evelopment ofD epression Contributing Factors of Depressio n Frequency Percentage (% ) Stigma faced from people in the communi ty 27 37.0 Lack of employmen/t Financial problem 17 23.3 Belief that disease may not be cured 9 12.3 Lack of partner in marriage 15 20.6 Lack of communitys upport 5 6.8 Table 3: Relationship Between Age, Occupation and Development of Depression 2 Variables Presence of Depression Degree of ÷ P value Freedom Yes No Age(In years) Less than 15 4 4 15-2 5 10 8 26-35 12 7 6 9.6 54 0.0 99 36-45 10 8 46 and above 1 9 Occupation House wife 4 10 Student 10 8 Civil servan t 12 5 5 9.4 03 0.0 68 Pettytrader s 10 13 Farmer 1 0 ABSENCE OF DEPRESSION 36 PRESENCE OF DEPRESSION 37 30 0% 67.6% 25 20 Y N C 49.3% E 50.7% U 15 Q E 32.4% R F 10 5 0 Mild Moderate LEVEL OF DEPRESSION Figure 2: Bar Chart Showing Distribution ofR espondents Based on Level of Depression Figure 1: PieC hart Showing Distribution ofR espondents Based on Presence of Depression 1). between occupational status and development of depression(÷2=9.654, p=0.068). Presence of Depression The study result revealed that most (50.7%)of the Discussion respondents haddepression, out of which, (67.6%) The findings revealed that about half were mildly depressed whereas 32.4% were (50.7%)of the respondents had depression and this can moderately depressed (Fig. 1 and 2). be connected to the psychological burden of being diagnosed with a potentially deadly disease and an Factors contributing to the development of illness that carry a tag of social stigma, low educational depression qualification as about half of the respondents had Table2 revealed the factors contributing to the secondary school leaving certificate as highest development of depression as stigma faced from people educational qualification and another proportion have i n t h e c o m m u n i t y ( 3 7 . 0 % ) , l a c k o f no formal education completely and in addition, with employment/financial problem (23.3%), lack of female being the majority of the respondents whom partner in marriage (20.6%), and belief that disease several studies in Nigeria usually described as the may not be cured (12.3%). victims of most social injustices and prejudices and often have lower source of income and poor coping Relationship between age, occupational status and skills. However, the depression can also be linked to the development of depression fact that, human immunodeficiency virus enters the Table 3 above shows statistically significant brain and is able to alter the CNS immune environment association was not found between age and allowing reactivation of latent or entry of new development of depression (÷2=9.654, p=0.099) and p a t h o g e n s r e s u l t i n g i n n e u r o c o g n i t i v e 18 H.H. Murtala et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) impairment1].This finding, although not in stark patients as such health workers should routinely screen contrast, but is much higher than what was found in patients with HIV/AIDS for comorbid depression to studies by Getiye & Selamawit9 in Northwest Ethiopia enhance early detection and treatment and health and studies here in Nigeria by Chinyere et al.,7 in Imo educate (special programs in mass media like Radio State, and Adiari & Campbell5in a Nigerian Tertiary and television) the HIV/AIDs patients on ways of Hospital who variously reported the burden of reducing the level of depression through eliminating or depression 11.7%, 39.1% and 14.4% respectively. modifying factors contributing to depression.Family However, the findings are in closer agreement with and community members should support HIV/AIDS those reported by Shittuet al.,[6]in a study conducted in patients to overcome stigmatization in the community, North Central Nigeria who found the burden of marital and financial challenges. depressionas56.7% among HIV patients. The findings also revealed a proportion of respondents with mild References depression that is higher than what was reported by 1. Pleasure, A.N., Peter, N.F., Roland C.N., Chinyere et al.,7 (24.6%) though the proportion of those Vincent, S.V. &Henri, N.L.Depression a m o n g with moderate depression (50%) was much higher than HIV/AIDS patients on Highly Active Antiretroviral what was found in this study Therapy in the Southwest Regional Hospitals of On the factors contributing to the development Cameroon: A Cross-Sectional Study. Journal o f of depression, the findings revealed stigma faced from Neurology and therapy, 2017, 6(1): 103–114. people in the community (37.0%), financial problem 2. Abdulateef, E. &Hyder, M. Depression among and lack of employment (23.3%), lack of partner in Human Immuno deficiency Vi r u s / A c q u i r e d marriage (20.6%) and believe that disease may not be Immune Deficiency Syndrome among Sudanese cured (12.3%).While stigma makes patients to be patients: a cross- sectional analytic study and isolated mostly due to fear of being blamed and a need related review.The Pan African Medical to maintain moral credibility in the community, journal,2017, 26(43):109-119. financial problems and lack of employment 3. Mohammed, M. Mengistie, B. Dissie, H. consequently manifest in irritability and poor regiment &Godana, A. Prevalence of depression a n d compliance in general patient population .The finding associated factors among HIV patients seeking spartly agree with those from a study by Bernard et treatment in Anti-etroviral T r e a t m e n t al.,10in sub-Saharan Africa, who reported that economic Clinic(ART) at Harar town, eastern Ethiopia. Journal status (20%) and low social support (15%) as the of AIDS and Clinic Research, 2015, 2155-6113 contributing factors to depression among other factors. 4. World Health Organization. Key facts about In addition, Adiari & Campbel5in another study Depression and Human I m m u n o d e f i c i e n c y identified lack of social support which manifest in Virus/Acquired Immune Deficiency Syndrome, 2018. social isolation as contributing factor. Retrieved from www.ilo.org/global/about-the-ilo- Similar to what was found in previous studies multimedia. Accessed 6th June, 2018. across different parts of the globe by Pleasure et al.,1 in a 5. Adiari, O. & Campbell, P.C. Prevalence and study conducted in Cameroun (OR 2.13; 95% CI Severity of Depression among People Living with 20 Human Immuno-deficiency Virus/Acquired Immune 1.20–3.70), Abebe et al., in Addis Ababa (AOR= 2.20, 21 Deficiency Syndrome in a Tertiary Hospital. African 95% CI: 1.33, 3.62), Kim et al., in Malawi (OR 1.23; 22 journal online, 2014, 14(1):18-24 95 % CI 1.07-1.42) and Mellins & Malee in United 6. Bhatia, M. S. &Munjal, S. Prevalence of States of America who reported the existence of depression in people living with H u m a n relationship between increased age and depression, this immunodeficiency Virus/Acquired Immune study also found a statistically significant relationship 2 Deficiency Syndrome undergoing Anti-retroviral between the variables (÷ =9.654, p=0.099). treatment and factors associated with it. Journal of Furthermore, occupation in this study was also found to clinical diagnosis and research, 2014, 8(10):23-26. have a significant relationship with development of 7. Shittu, R.O., Issa, B.A., Olanrewaju, G.T., depression among the respondents in agreement to Mahmoud, A.O., Odeigah, L.O., Salami, A . K . , what was found in another study in Cameroun 1 &Aderibigbe, S.A. Prevalence and Correlates of conducted by Pleasure et al., who reported the presence Depressive Disorders among People Living with of association between depression and unemployment HIV/AIDS North Central Nigeria. Journal of AIDS and (OR 2.38; 95% CI 1.26–4.50). Clinical Research,2013, 4:251-259 8. Chinyere, M. A., Richard, U.U., Chukwuma, Conclusion B. D., Kevin, C. D., Justine, K. A. Okezie, O. E. & There is higher Level of depression among Emmanuel, O. O. Prevalence and Socio-demographic HIV/AIDS patient with several factors like stigma and Determinants of Depression among Patients Attending lack of employment contributing to its development. HIV/AIDS Clinic in a Teaching Hospital in Imo State, Thus, show huge gap in treatment rendered to the 19 H.H. Murtala et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Nigeria. American journal of medical science and 16. David, A. & Casey, M.D. Depression in the medicine, 2015, 3(6):106-122 e l d e r l y : A r e v i e w a n d u p d a t e , 2 0 0 8 . 9. Getiye, D. K. &Selamawit, Z. S. Prevalence https://onlinelibrary.wiley.com/doi/abs/10.1111/j.175 and Associated Factors of Depression among HIV 8-58722012.00191 Infected Patients in Debre Markos Town Northwest 17. Charles, B., Jeyaseelan, L., Pandian, A.K., Ethiopia. International Journal of Emergency Mental Sam, A.E., Thenmozhi, M. &Jayaseelan, V . Health and Human Resilience, 2018, 3(1): 213-220 Association between stigma, depression and quality of 10. Bernard, C. Dabis, F.& de Rekeneire, A. life of people living with HIV/AIDS (PLHA) in South Prevalence and factors associated with depression in India – a community based cross sectional people living with HIV in sub-Saharan Africa: A study. BMC Public Health 2012, 12:463 systematic review and meta-analysis. PLoS http://www.biomedcentral.com/1471- 2458/12/463 one,2017, 12(8): 234-240 18. Sale, S.,Dankishiya, F.S. & Gadanya, 11. Nyirenda, M., Chatterji, S., Rochat, T., M.Validation of Hospital anxiety and Depression rating Mutevedzi. &Newella, M. Prevalence and scale among HIV/AIDs Patients in Aminu Kano correlates of depression among HIV-infected and Teaching Hospital, Kano, North-Western, affected older people in rural south Africa. Journal of Nigeria.Journal of Therapy and Management in HIV affective disorders,2013, 151(1):31-38 Infection, 2014, 2(2):45-49. 12. Silveira, M. P., Guttier, P.C., Pinheiro, C.A., 19. Luminita, E. Human Immunodeficiency Virus Pereira, T.V., Cruzeiro, A.L. & Moreira, L . B . in the Brain—Culprit or Facilitator? I n f e c t i o u s Depressive symptoms in HIV infected patients treated Disease: research and treatment. 2018, 11: 1-9. DOI: with highly active antiretroviral therapy. Brazilian 10.1177/1178633717752687 Journal of Psychiatry,2012, 34(2):162- 167 20. Abebe, H., Shumet, S., Nassir, Z., Agidew, M., 13. Salihu, A.A. &Udofia, O. Prevalence and &Abebaw, D. Prevalence of D e p r e s s i v e Associated Factors of Depression a m o n g Symptoms and Associated Factors among HIV- General Outpatients in a Tertiary Institution in Kano, Positive Youth Attending ART Follow-Up in North-Western Nigeria. Open Journal Psychiatry, AddisAbaba, Ethiopia. HindawiAIDS Research a n d 2016, 6(3), 228-236 Treatment,2019, 1-7 14. Benoite, U. Exploring depression among 21. Kim, M. H., Mazenga, A. C., Yu, X., people with HIV/AIDS and attending a p r i m a r y Devandra1, A., Nguyen, C., Ahmed, S., K a z e m b e , health care centre in Kigali, Rwanda: A descriptive P.N. and Sharp, C. Factors associated with depression cross sectional study, 2010. Retrieved from among adolescents living with HIV in Malawi. BMC https://researchspace.ukzn.ac.za/xmlui/handle/10413/ Psychiatry, 2015, 15(1):122-130 893. Accessed 6th June, 2018. 22. Mellins C. A. &Malee, K. M. Understanding 15. Olisah, V.O., Adekeye, O. & Sheik, T.I. the mental health of youth living with perinatal HIV Depression and CD4 cell count among patients with infection: lessons learned and current challenges. HIV in a Nigerian University Teaching Hospital. Journal of the International AIDS Society, 2013, 16(1): International Journal of psychiatry in medicine, 2015, 231-240 48(4):253-261 20 Clinical Manifestations of Hypovitaminosis-D in Paediatric Patients Attending Nizamiye Hospital, Abuja: A 2-Years' Appraisal. 1S.A Biliaminu, 2M.T Lawan, 2L Cam, 3E.O Sanni, 4J. Imran, 1I.M AbdulAzeez, 1A.B Okesina, 5J.O Yusuff, 6I.B Aremu 1Department of Chemical Pathology and Immunology, University of Ilorin, Ilorin, Kwara State. 2Paediatric Unit, Nizamiye Hospital, Abuja. 3Department of Haematology, Nile University, Abuja. 4Department of Medical Microbiology, Nile University, Abuja. 5Department of Chemical Pathology and Immunology, University of Ilorin Teaching Hospital, Ilorin, Kwara State. 6Department of Radiology, University of Ilorin, Ilorin, Kwara State, Abstract Conclusively, hypovitaminosis D has myriads of Vitamin D is an extremely important vitamin non-bony clinical presentations in children with the that has powerful effects on several systems throughout frequencies and severity more in females than males. the body. Hypovitaminosis D in children is a prevalent Routine serum vitamin D3 should be encouraged to rule disorder in developing countries with a myriad of non- out hypovitaminosis D in paediatric patients with bony clinical manifestations. unusual clinical presentations. This study examined non-bony clinical manifestations of hypovitaminosis D in paediatric K e y w o r d s : C l i n i c a l M a n i f e s t a t i o n s , patients in Nigeria. It was cross-sectional and Hypovitaminosis-D, Paediatric Patients, Nizamiye retrospective done between January 2018 to December Hospital, Appraisal. 2019 involving 48 paediatric patients age range 8- 16years. Each of them presented with myriad of non- Introduction specific clinical symptoms with laboratory results Vitamin D is an extremely important vitamin that showing deficient serum vitamin D3 and the symptoms has powerful effects on several systems throughout the disappearing after administering vitamin D3. Serum body. Its roles in the body include modulation of cell Vitamin D3 was assayed for using CLIA method. Data growth, neuromuscular and immune function, and analysis was done using SPSS Version 20. reduction of inflammation.1,2,3 Many genes encoding The mean age of all the patients was 12.7±2.6years. proteins that regulate cell proliferation, differentiation, Twenty-two (46%) of them were males with the mean and apoptosis are also modulated in part by vitamin D. age of 13.4±2.8years while the remaining 26 (54%) Many cells have vitamin D receptors, and some convert 1 were females with mean age of 12.0±2.1years with no 25(OH)D to 1,25(OH)2D. significant difference when compared at p>0.05. Other Vitamin D deficiency, or hypovitaminosis D is anthropometric parameters like weight, height and defined as a vitamin D level that is below normal. It is BMI were equally not statistically different between widespread irrespective of age, gender, race and the two genders at p>0.05. Mean serum vitamin D3 was geography and has emerged as an important area of lower in females 16.5±4.8ng/ml than males research. Hypovitaminosis D is frequently observed in 18.8±3.5ng/ml which was not statistically significantly Europe in the elderly, particularly in the different between the two genders at p>0.05. The institutionalized population, but is also seen in commonest clinical manifestations among all the otherwise healthy younger adults.4 An estimated 40% paediatric patients were fatigue, headaches and of the young European population has some degree of backaches at frequencies of 83%, 79.2% and 75% hypovitaminosis D.4 Surprisingly, it is more frequent in respectively, while the less common ones are mood sunny Mediterranean countries than in certain northern swings, poor sleeps and dizziness at frequencies of countries such as Norway.4 The lower incidence 62.5%, 52.1% and 41.7% respectively. Generally, observed in the United States is probably related to the frequencies and severity of clinical manifestations are vitamin D supplementation of the American diet. more in females than males. Hypovitaminosis D in Africa and the Middle-East is also an important problem, being considered to be one of the five most prevalent childhood diseases in developing countries.4 In developing countries, the Correspondence to: prevalence of hypovitaminosis D varies widely by and within regions; prevalence ranges between 30-90%, Dr. SA Biliaminu according to the cut-off value used within specific Department of Chemical Pathology regions, and is independent of latitude.5 and Immunology, Hypovitaminosis D most commonly occurs in University of Ilorin, Ilorin, Nigeria. people when they have inadequate sunlight exposure [email protected]. (in particular sunlight with adequate ultraviolet B Mobile phone No: - +2348060885920 21 S.A. Biliaminu et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) rays).6 Nutrient deficiencies are usually the result of age range between 8-16years were recruited following dietary inadequacy, impaired absorption and use, Ethical Approval by the hospital for the study. Twenty- increased requirement, or increased excretion. A six of them were females while the remaining 22 were vitamin D deficiency can occur when usual intake is males. Those included presented with myriad of non- lower than recommended levels over time, exposure to specific clinical symptoms with laboratory results sunlight is limited, the kidneys cannot convert showing deficient serum vitamin D3 and the symptoms 25(OH)D to its active form, or absorption of vitamin D disappeared after administering vitamin D3. Laboratory from the digestive tract is inadequate. Vitamin D- results and other vital information were retrieved from deficient diets are associated with milk allergy, lactose the folders of the participants. Serum Vitamin D3 was 7 intolerance, ovo-vegetarianism, and veganism. assayed for using CLIA method. Data analysis was Clinical manifestations of hypovitaminosis D done using Statistical Software for Social Sciences include musculoskeletal disorders, such as nonspecific (SPSS Version 20). muscle pain, poor muscle strength and low bone mass density, as well as non-musculoskeletal disorders, such Results as an increased risk of respiratory infections, diabetes A total of 48 paediatric patients were recruited for mellitus and possibly cardiovascular diseases.5 There the study. Twenty-two (46%) of them were males while are other non-specific clinical manifestations of the remaining 26 (54%) were females as shown in fig 1. hypovitaminosis D apart from the well-known This study had mean age of 12.7±2.6years, while the musculoskeletal presentations, predisposition to youngest of them was 8 the oldest was 16 years old. respiratory infections and non-communicable diseases The mean age of the females was 13.4±2.8years while like diabetes mellitus and cardiovascular diseases. that of males was 12.0±2.1years. The mean ages of the Surprisingly, most clinicians may not be conversant two genders were not statistically different at p-value of with them. 0.078. This study aimed at determining other non-specific The mean±SD of weights of females and males clinical manifestations of hypovitaminosis D, so as to were 56.7±13.6 and 51.9±20.0Kg respectively and assist in ruling out patients that will need Vitamin D3 for there was no significant difference when both were early diagnosis and management of hypovitaminosis D compared at p-value of 0.584. The mean±SD of heights in paediatric patients with unusual clinical of females and males were 1.58±0.11 and 1.49±0.19M presentations. respectively which was not significant when compared at p-value of 0.115. Materials and Methods The mean±SD of BMI of females and males were The study was a retrospective one between January 22.3±4.3 and 25.0±5.1Kg/M2 respectively and when 2018 to December 2019 carried out at Nizamiye compared was not statistically significant at p-value of Hospital, Abuja. A total of 48 paediatric patients with 0.050. The mean±SD of BMI of females and males Table 1: Showing Mean±SD of Anthropometric Parameters and Serum Vitamin D Parameters All Hypo- Female Hypo- Male Hypo- p-Value vitaminosis-D vitaminosis-D vitaminosis-D Patients Patients Patients Age(Years) 12.7±2.6 13.4±2.8 12.0±2.1 0.078 Weight(Kg) 53.5±16.5 56.7±13.6 51.9±20.0 0.584 Height(M) 1.58±0.15 1.58±0.11 1.49±0.19 0.115 2) BMI(Kg/M 22.3±3.8 22.3±4.3 25.0±5.1 0.050* 17.4±4.4 16.5±4.8 18.8±3.5 0.108 Serum VitaminD(ng/ml) T able 2: Showing Frequency of Clinical Manifestations of Hypovitaminosis-D in all the Paediatrics Patients and Based on Gender. Clinical All Patients Females Males Manifestations Frequency % Frequency % Frequency % Backaches 36 75.0* 20 76.9* 16 72.7 Fatigue 40 83.3* 20 76.9 20 90.9* Mood swings 30 62.5 18 69.2* 12 54.5 Poor sleep 25 52.1 15 57.7* 10 45.5 Headaches 38 79.2* 20 76.9 18 81.8* Dizziness 20 41.7 12 46.2* 8 36.4 22 S.A. Biliaminu et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Table 3: Showing Rank Correlation of Serum Vitamin D and Clinical Manifestations of Hypovitaminosis D and Pearson Correlation for Age in all the Subje cts Correlation Age Back Fatigue Mood Poor Head Dizziness Parameters ache Swing Sleep Ache ‘r’ -0.481 0.177 0.185 -0.150 0.159 0.092 0.185 p-value 0.001* 0.228 0.208 0.310 0.279 0.533 0.207 Table 4: Showing Rank Correlation of Serum Vitamin D and Clinical Manifestations of Hypovitaminosis D and Pearson Correlation for Age in Female Subje cts Correlation Age Back Fatigue Mood Poor Head Dizziness Parameters ache Swing Sleep Ache ‘r’ -0.417 0.183 0.183 -0.049 -0.013 0.183 0.350 p-val ue 0.034* 0.371 0.371 0.812 0.951 0.371 0.080 Table 5: Showing Rank Correlation of Serum Vitamin D and Clinical Manifestations of Hypovitaminosis D and Pearson Correlation for Age in Male Subjects Correlation Age Back Fatigue Mood Poor Head Dizziness Parameters ache Swing Sleep Ache ‘r’ -0.489 0.226 0.052 -0.222 0.615 -0.104 0.005 p-val ue 0.021* 0.311 0.819 0.320 0.002* 0.646 0.984 were 16.5±4.8 and 18.8±3.5ng/ml respectively and Pearson correlation for age in all the subjects. (Table 3) when compared there was no statistically significant There was a statistically significant negative difference at p-value of 0.108. (Table 1) correlation between serum vitamin D3 and age at 'r' The types and frequency of clinical manifestations value of -0.481 and p-value of 0.001. The similar of hypovitaminosis-D in paediatrics patients as well as negative correlation between serum vitamin D3 and gender distribution in Table 2. The frequency of mood swings was however not significant statistically backaches as a clinical presentation was found in at 'r' value of -0.150 and p-value of 0.310. 36(75%) out of 48 in all the patients. It was higher for Other clinical manifestations such as backache, the females at frequency of 20(76.9%) and 16(72.7%) fatigue, poor sleep, headache and dizziness had for the males. (Table 2) positive correlation with serum vitamin D3 but they For fatigue as a clinical presentation, it was a were not of any statistical significance. frequency of 40(83.3%) in all the patients. The The rank correlation of serum vitamin D3 and clinical frequency was higher for the males at frequency of manifestations of hypovitaminosis D and Pearson 20(90.9%) than females' own of 20(76.9%). correlation for age in female subjects was shown in Mood swings had a frequency of a clinical Table 4. presentation of 30(62.5%) in all the patients. It was There was a statistically significant negative however more common for the females at frequency of correlation between serum vitamin D3 and age at 'r' 18(69.2%) than 12(54.5%) for the males. value of -0.417 and p-value of 0.034. The similar The frequency of poor sleep as a clinical negative correlation between serum vitamin D versus presentation 25(52.1%) in all the patients. It was also 3 mood swings and poor sleep were not significant higher for the females at frequency of 15(57.7%) and statistically. 10(45.5%) for the males. Other clinical manifestations such as backache, Headaches as a clinical presentation had a fatigue, headache and dizziness had positive frequency of 38(79.2%) in all the patients. It was a bit correlation with serum vitamin D but they were not of higher for the males at frequency of 18 out of 3 22(81.8%) and 20 out of 22(76.9%) for the females. any statistical significance. (Table 4) The rank correlation of serum vitamin D and Dizziness had a frequency 20(41.7%) in all the patients. 3 It was also higher for the females at frequency of clinical manifestations of hypovitaminosis D and 12(46.2%) and 8(36.4%) for the males. Pearson correlation for age in male subjects Table 5. Generally, frequencies and severity of clinical There was a statistically significant negative manifestations are more in females than males. correlation between serum vitamin D3 and age at 'r' value of -0.489 and p-value of 0.021. The similar The rank correlation of serum vitamin D3 and clinical manifestations of hypovitaminosis D and negative correlation between serum vitamin D3 versus 23 S.A. Biliaminu et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) mood swings and headache were not significant that 89% of the nurses were deficient.16 statistically. In this study, backache was also one of the Other clinical manifestations such as backache, commonest presentation in hypovitaminosis D fatigue, headache and dizziness had positive paediatric patients. Frequency of presentation was a correlation with serum vitamin D3 but they were not of little bit more in females than males. Large any statistical significance. (Table 5) observational studies have found a relationship between a deficiency and chronic lower back pain.17,18,19 Discussion Talking about mood swings and depression, it is Vitamin D is a steroid hormone which is available moderately common in all the patients in this study but in limited quantity in fortified dairy products and is more frequent in females than males. In review studies, synthesized mainly in the skin, from cholesterol, by researchers have also linked vitamin D deficiency to exposure to the ultraviolet radiation of sunlight.8,9,10 depression, particularly in older adults.20 In one Hydroxylation of vitamin D is done in the liver and analysis, 65% of the observational studies found a kidneys, which is then transported to target tissues relationship between low blood levels and depression. containing vitamin D receptors. Calcium homeostasis On the other hand, most of the controlled trials, which from the kidneys, bones, parathyroid gland, and carry more scientific weight than observational studies, intestine is maintained by vitamin D, playing a pivotal didn't show a link between the two.20 role in mineralization of bones.11 In term of correlation, there was a statistically Vitamin D deficiency, or hypovitaminosis D is significant negative correlation between serum vitamin defined as a vitamin D level that is below normal. It is D3 among all the patients irrespective of their gender. widespread irrespective of age, gender, race and Similar correlation also occurred for the two genders. geography and has emerged as an important area of Other clinical manifestations such as backache, research. Hypovitaminosis D is frequently observed in fatigue, headache and dizziness had either positive or Europe in the elderly, particularly in the negative correlation with serum vitamin D3 but they institutionalized population, but is also seen in were not of any statistical significance. 4 otherwise healthy younger adults. There was negative correlation between serum Clinical manifestations of hypovitaminosis D vitamin D and mood swing although not statistically include musculoskeletal disorders, such as nonspecific significant. Studies have shown a link between vitamin muscle pain, poor muscle strength and low bone mass D deficiency and depression. Researchers behind a density, as well as non-musculoskeletal disorders, such 2013 meta-analysis noticed that study participants with as an increased risk of respiratory infections, diabetes depression also had low vitamin D levels. The same mellitus and possibly cardiovascular diseases.5 There analysis found that, statistically, people with low are other non-specific clinical manifestations of vitamin D were at a much greater risk of depression. hypovitaminosis D apart from the well-known The researchers believe that because vitamin D is musculoskeletal presentations, predisposition to important to brain function, insufficient nutrient levels respiratory infections and non-communicable diseases may play a role in depression and other mental like diabetes mellitus and cardiovascular diseases. illnesses. An earlier study21 identified vitamin D Most clinicians may not be conversant with them. receptors in the same areas of the brain associated with This study was done to determine other non- depression. specific clinical manifestations of hypovitaminosis D There was a non-statistically significant negative in Nizamiye Hospital Abuja, Nigeria. correlation between serum vitamin D3 and sleep In this study, the serum vitamin D which was <20 disorder for the female patients while positive one was ng/mL deficient for all the paediatric patients found in males. A meta-analysis study suggest that irrespective of their gender.12 The females' vitamin D vitamin D deficiency is associated with a higher risk of was however lower than males'. This might be sleep disorders.22 connected with the fact that male children are usually C o n c l u s i v e l y, t h i s s t u d y s h o w s t h a t allowed more to stay and play outside more than hypovitaminosis D has myriads of clinical females. presentations in children which may not be the usual Fatigue, happened to be the commonest bony manifestation like rickets and other skeletal presentation for all the patients in this study. The symptoms. The frequencies and severity of these frequency was however the same for the two genders. clinical presentations are more in females than males. Case studies have also shown that very low blood levels Routine serum vitamin D3 should be encouraged to rule can cause fatigue that has a severe negative effect on out hypovitaminosis D in paediatric patients with 13,14 quality of life. A study also found that women with unusual clinical presentations. blood levels lower than 20 ng/ml or 21–29 ng/ml were more likely to complain of fatigue than those with References 15 blood levels over 30 ng/ml. A similar study also found 1.Institute of Medicine, Food and Nutrition Board. 24 S.A. Biliaminu et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Dietary Reference Intakes for Calcium and Vitamin D. 12.Gupta A. "Vitamin D deficiency in India: Washington, DC: National Academy Press, 2010. prevalence, causalities and interventions". Nutrients. 2.Holick MF. Vitamin D. In: Shils ME, Shike M, (February 2014) 6 (2): 729-775. Ross AC, Caballero B, Cousins RJ, eds. Modern 13.Johnson K, Sattari M. Vitamin D deficiency and Nutrition in Health and Disease, 10th ed. Philadelphia: fatigue: an unusual presentation. Springerplus. Lippincott Williams & Wilkins, 2006. 2015;4:584. 3.Norman AW, Henry HH. Vitamin D. In: Bowman 14.McCarty D.E. Resolution of hypersomnia BA, Russell RM, eds. Present Knowledge in Nutrition, following identification and treatment of vitamin d 9th ed. Washington DC: ILSI Press, 2006. deficiency. J Clin Sleep Med. 2010;6(6):605-608. 4.Gannagé-Yared MH, Tohmé A, Halaby G. 15.Ecemis G.C, Atmaca A. Quality of life is impaired Hypovitaminosis D: a major worldwide public health not only in vitamin D deficient but also in vitamin D- problem [Article in French]. Presse Med. 2001 Apr insufficient pre-menopausal women. J Endocrinol 7;30(13):653-658. Invest. 2013;36(8):622-627. 5.Asma A, Rola E, Ghada A.E.F Hypovitaminosis D 16.Masoudi A.N, Madani M, Sadat Z, Haddad K.H, in developing countries Prevalence, risk factors and Reza S.M. Fatigue and Vitamin D Status in Iranian outcomes. Nature Reviews Endocrinology. 2010 Female Nurses. Glob J Health Sci. 2015;8(6):196-202. 6(10):550-561. 17.Ghai B, Bansal D, Kapil G, Kanukula R, Lavudiya 6.Holick MF, Chen TC (April 2008). "Vitamin D S, Sachdeva N. High Prevalence of Hypovitaminosis D deficiency: a worldwide problem with health in Indian Chronic Low Back Patients. Pain Physician. consequences". The American Journal of Clinical 2015;(5):E853-862. Nutrition. 87 (4) 1080S-6S. 18.Erkal MZ, Wilde J, Bilgin Y, Akinci A, Demir E, 7.Cranney C, Horsely T, O'Donnell S, Weiler H, Ooi Bödeker RH, Mann M, Bretzel RG, Stracke H, Holick D, Atkinson S, et al. Effectiveness and safety of vitamin MF. High prevalence of vitamin D deficiency, D. Evidence Report/Technology Assessment No.158 secondary hyperparathyroidism and generalized bone prepared by the University of Ottawa Evidence-based pain in Turkish immigrants in Germany: identification Practice Center under Contract No. 290-02.0021. of risk factors. Osteoporos Int. 2006;17(8):1133-1140. AHRQ Publication No. 07-E013. Rockville, MD: 19. Silva A.V, Lacativa P.G, Russo L.A, de Gregório Agency for Healthcare Research and Quality, 2007. L.H, Pinheiro R.A, Marinheiro L.P. Association of 8.Cashman KD. Vitamin D: dietary requirements and back pain with hypovitaminosis D in postmenopausal food fortification as a means of helping achieve women with low bone mass. BMC Musculoskelet adequate vitamin D status. J Steroid Biochem Disord. 2013;12;14:184. Molecular Biol. 2015; 148:19–26. 20.Ju S.Y, Lee Y.J, Jeong S.N. Serum 25- 9.Saraff V, Shaw N. Sunshine and vitamin D. Arch hydroxyvitamin D levels and the risk of depression: a Dis Child. 2016;101(2):190–192. systematic review and meta-analysis. J Nutr Health 10.Kuwabara A, Tsugawa N, Tanaka K, Uejima Y, Aging. 2013;17(5):447-455. Ogawa J, Otao N, et al. High prevalence of vitamin D 21.Eyles D.W, Smith S, Kinobe R, Hewison M, deficiency in patients with xeroderma pigmetosum-A McGrath J.J. Eyles D.W, Smith S, Kinobe R, Hewison under strict sun protection. Eur J Clin Nutr. M, McGrath J.J. Distribution of the vitamin D receptor 2015;69(6):693–696. and 1 alpha-hydroxylase in human brain. J Chem 11.Priemel M, Damorus CV, Klatte TO, Kessler S, Neuroanat. 2005 Jan;29(1):21-30. Schille J, Meier S, et al. Bone mineralization defects 22.Gao Q, Kou T, Zhuang B, Ren Y, Dong X, Wang Q. and vitamin D deficiency; histomorphometric analysis The Association between Vitamin D Deficiency and of iliac crest bone biopsies and circulation 25 Sleep Disorders: A Systematic Review and Meta- hydroxyvitamin D in 675 patients. JBMR. Analysis. Nutrients. 2018;10(10):1395. 2010;25(2):305-312. 25 Delivery Pattern and Perinatal Outcome in a Nigerian Tertiary Health Institution: A Five Year Review 1O.A.Ogunlaja, 2Y.T.Olasinde, 3I.P.Ogunlaja, 4A.Olasinde,5M.O.Bojuwoye. 1Department of Obstetrics and Gynaecology, Bowen University Teaching Hospital, Ogbomoso, Oyo state. 2Department of Paediatrics, Bowen University Teaching Hospital, Ogbomoso, Oyo state. 3 Department of Obstetrics and Gynaecology, General Hospital, Ilorin, Kwara State. 4 Department of Obstetrics and Gynaecology, Civil Service Hospital, Ilorin, Kwara State. 5Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Kwara state. Abstract This is particularly important in resource poor settings Audit of clinical events helps the clinician to where 94% of global maternal deaths related to critically appraise the level of care rendered in a health pregnancy and child birth occur.2 Furthermore, Nigeria system with the aim of improving the quality of care. reportedly has one of the poorest perinatal indices in the This study aimed to audit the obstetrics practice in our world.3 hospital over a five-year period. Pregnancy is a physiological process which is This was a retrospective study carried out from associated with much apprehension by the family January 2014 to December 2018 in Bowen University members. Childbirth processes entail physical, Teaching Hospital, Ogbomoso. Information was emotional, social, physiological, cultural, and obtained from the Health Information Department of psychological dimensions hence childbirth can be a the hospital. Data were analysed using IBM SPSS critical and sometimes unpleasant experience for version 20. Delivery outcomes were named as birth mothers.1 weight, type of gestation, and baby's outcome, either a Methods of delivery include spontaneous live birth or stillbirth. vaginal delivery, assisted vaginal delivery and There were 3,892 births during the review Caesarean section. Caesarean section refers to the period. The Caesarean section rate in this study was delivery of the foetus, placenta, and membranes 37.7%. The prevalence of multiple gestation in our through an abdominal and uterine incision.4 It is hospital was 3.9%. We recorded 197(5.9%) stillbirths, performed when vaginal delivery is perceived to be this was significantly higher among mothers that had dangerous to the mother or her unborn child. It is spontaneous vaginal births when compared with those reportedly the commonest major surgery in obstetrics.1 who had Caesarean section and instrumental vaginal The preferred method of childbirth by a woman is 2 deliveries (÷ =8.060 p=0.018).The relationship affected by many factors, some of which include between birth weight and the mode of delivery was obstetric, medical, social or psychological reasons.5 2 statistically significant (÷ =73.479, p<0.001). Perception of pain is also known to significantly affect Foetal outcome was significantly associated women's decision on the preferred mode of delivery with mode of delivery and this study suggests that and this perception is influenced by physical, Caesarean section had the better outcome in our psychological, environmental, cultural and supporting environment. factors such as the presence of a doula in labour.5 The high rate of Caesarean section in the Keywords: Caesarean section, Instrumental delivery, United States is related to the small family size and delivery outcome probably the fear of medico-legal repercussion if not performed.6 The incidence is about 15% to 21% in most Introduction West African countries and would have been higher if Audit of clinical events helps the clinician to there had not been acceptance of vaginal birth after critically appraise the level of care rendered in a Health Caesarean section and conduct of assisted breech Centre over a given time with the ultimate aim of 4 1 deliveries. Furthermore, the reported increasing rate of improving the quality of services delivered. Caesarean section in our environment may be attributable to improving surgical skills, increasing incidence of obstetrics complications such as Correspondence to: cephalopelvic disproportion, obstructed labour and foetal distress.7 This is in contrast to what obtains in the Dr. O.A. Ogunlaja, developed climes in which preference of mothers for Department of Obstetrics and Gynaecology, Caesarean delivery is a means of escape from labour Bowen University Teaching Hospital, pain.8 Nevertheless, the incidence is about 20 to 30% in Ogbomoso, Oyo state. most teaching hospitals in Nigeria, with different rates E-mail: [email protected] from different regions of the country.6 Adekanle et al9 Telephone: +2348052273290 reported a rate of 35.5% in the South Western part of the 26 O.A. Ogunlaja et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) country, Isah et al6reported a rate of 21.4% in Abuja, house officers. Paediatricians carry out postnatal North-central part of the country and Ugwu et al10 rounds and newborn examination on the postnatal reported a rate of 27.6% in Enugu, Southwest Nigeria; wards daily before the babies are discharged home. however Daniel and Singh11 reported a much lower rate The perinatal outcome measures that were of 11.3% from the Northwestern part of the country. determined in this study were method of delivery, Common perinatal outcome measures include baby's birth weight value, sex, baby's outcome and type the sex of the newborn, birth weight, gestational age at of gestation. delivery, whether the newborn was live birth or a still Ethical clearance was obtained from the birth, Apgar scores, early neonatal death, the need for Hospital Research Ethics Committee before embarking admission into the neonatal intensive care unit and so on this study. Data obtained were analysed using the on. SPSS version 20.0 software. Continuous variables This study aimed at determining the prevailing were presented as means and standard deviation (SD) modes of delivery and perinatal outcomes and assess whereas categorical variables were presented as the relationship between them in a tertiary health centre proportions or percentages. in Southwest Nigeria. The Chi-Square test was used to compare the mode of delivery with baby's outcome and birthweight. Materials and Method Statistical significance was established at p < 0.05. This was a retrospective study carried out over a period of five years, from January 2014 to December Results 2018 in Bowen University Teaching Hospital, During the 5-year review period, there was a Ogbomoso. Information was retrieved from the Health total of three thousand eight hundred and ninety-two Information Management Unit of the hospital. (3892) childbirths with an average of 778.4 births per The Bowen University Teaching Hospital is a year. Of these, 2075 were male births while 1817 were private tertiary centre with Specialists in different females; giving a male to female ratio of 1.14:1. departments and facilities to train medical students and Three thousand one hundred and ninety five residents in family medicine. The hospital also serves (3195) newborns were within the normal birth weight as a referral centre to primary and secondary health care range of 2.50-3.99kg; this accounted for 82.1% of the facilities in and around Ogbomoso, including newborns, while very low birth weight babies (birth neighbouring states like Osun. weight <1.5 kg) accounted for 186(4.8%) of the births. The maternity unit consists of the labour ward, The mean (SD) birth weight was 3.82 (1.73) kg. Three the labour ward theatre, antenatal and postnatal wards, thousand six hundred and ninety-five (94.1%) of the manned by Consultants, residents, medical officers and pregnancies resulted in live births, while 197 (5.9%) Table 1: Characteristics of deliveries over the five-year period. Variable Frequency Percentage % Sex 2075 53.3 Male 1817 46.7 Female Birthweight(kg) <1.50 186 4.8 1.50-2.49 366 9.4 2.50-3.99 3195 82.1 >4.0 145 3.7 Mean (SD) birthweight 3.82(1.73) kg Baby’s Outcome Live birth 3695 94.9 Still birth 197 5.1 Type of Birth Singleton 3739 96.1 Multiple 153 3.9 Total 3892 100 Very low birth weight: <1.50kg; Low birth weight: 1.50-2.49kg; normal birthweight: 2.50-3.99kg; macrosomia>4.0kg 27 O.A. Ogunlaja et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Figure 1: Methods of delivery SVD: spontaneous vaginal delivery; Assisted VD: assisted vaginal delivery;C/S : Caesarean section Table 2: Relationship between mode of delivery and neonatal outco me Spontaneous Caesarean Assisted Total Chi P vaginal delivery section vaginal square value delivery N (%) N (%) N (%) N(%) Neonatal outcome Live birth 2217(60.0) 1409(38.1) 69(1.9) 3695(100) 8.060 0.018 Stillbirth 137(69.5) 59(30.0) 1(0.5) 197(100) Table 3: Relationship between mode of delivery and birthweight Spontaneous Caesarean Assisted Total Chi P vaginal delivery section vaginal square value delivery N (%) N (%) N (%) N(%) Birthweight <1.50 kg 1 12(60.2) 7 2(38.7) 2 (1.1) 1 86(100) 5 6.58 < 0.001 1.50-2.49 kg 164(44.8) 195(53.3 ) 7(1.9) 366(100) 2.50-3.99 kg 2008(62.8 ) 1131(35.4 ) 56(1.8 ) 3195(100 ) >/ 4.0 kg 70(48.3) 70(48.3) 5(3.4) 145(100) Very low birth weight: <1.50kg; Low birth weight: 1.50-2.49kg; normal birthweight: 2.50-3.99kg; macrosomia>4.0kg were still births. One hundred and fifty-three (153) the mode of delivery, there was a higher number of pregnancies resulted in multiple births giving the stillbirths 137 (69.5%) following vaginal delivery prevalence rate of multiple gestation as 3.9% and an when compared with Caesarean section 59 (30.0%) and incidence of 39.3 per 1000 births Other details are as instrumental vaginal delivery 1 (0.5%), and this was shown in Table 1 statistically significant. (÷2=8.060, p=0.018). This is as During the review period, 2,354 (60.5%) shown in Table 2. patients delivered via spontaneous vaginal delivery, Birthweight was also found to have a while 1468 (37.7%) and 70 (1.8%) were through significant relationship with mode of delivery. Caesarean section and assisted vaginal delivery, (÷2=73.479, p<0.001) Other details are as shown in respectively. This is as shown in Figure 1 Table 3. When outcome of babies was compared with 28 O.A. Ogunlaja et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Discussion research work in Nigeria23,24However, this is higher This study was embarked upon to determine than the value 30.1 per 1000 births obtained from other the pattern of childbirth and perinatal outcome in a developing countries.25 Furthermore, more still births tertiary health centre in Nigeria. Bowen University were recorded from the group of women that had Teaching Hospital, Ogbomoso formerly referred to as spontaneous vaginal delivery than those who had Baptist Medical Centre, Ogbomoso is renowned for Caesarean section. being the second hospital in Nigeria after Sacred heart The implication of the findings from this study Hospital, Abeokuta. It was established by the Southern is that many of the observed variables were in keeping Baptist Convention of America in 1907. The hospital is with those of other studies previously conducted in a major referral centre and many of the cases referred Nigeria.12,17,18 Nonetheless, it may be proper to infer that here are those whom cannot be managed by primary or the stillbirth rate is a measure of the quality of maternity secondary health care givers or those that have suffered care in our locality. some complications in the hands of traditional birth The consequence of the results obtained from attendants or even quacks. our study reminds us of the need to continue to pay Over the years, remarkable success has been attention to improving maternity care in Nigeria. achieved in health care management of patients in all As a result of the above the following fields of medicine. This study is an appraisal of the recommendations can be made. There is need for maternity care rendered in the facility over a period of 5 clinicians to conduct regular clinical audit of their years. During this period, there was a total of three centres as this will allow for prompt evaluation and thousand eight hundred and ninety-two (3892) critical appraisal of the practice in a particular health deliveries with an average of 778.4 per year. On the care centre with the aim of improving. There is also a average, there were more male births than female births need for improved investment in health care delivery in (1.14:1), this finding is consistent with the observation our environment in order to improve the current of previous studies on human sex ratio at birth in maternal and child health indices. There should be Nigeria.12,13Majority (82.1%), of the newborns had their programs organized to frequently train and retrain birth weights within the normal limits, this was because health care givers in the areas of maternal and child a large proportion of these deliveries occurred at term. health care delivery. The above finding is in keeping with the observation In conclusion, foetal outcome was made in similar research work in the past.14 The significantly associated with mode of delivery and this observed Caesarean section rate in this study was study suggests that Caesarean section had the better higher than 19.5% previously reported by Eze et al14 in outcome in our environment. This is a welcome a tertiary institution in South-East Nigeria, but similar development and should be the reason why we need to the 42% reported by Jyotsana et al15in India. This is tostep up our advocacy for reduction in the existing much higher than the World Health Organization aversion for surgical intervention especially Caesarean (WHO) recommended Caesarean section rate (CSR) of section amongst the population. 10-15%; this increase has also been reported from other Countries.1,5 The higher cost of health care services and Limitations the complications associated with Caesarean section Data such as Socio-demography of subjects, make this increase to be a public health problem.16 risk factors for stillbirths, the indications for caesarean The prevalence rate of multiple gestation was section and assisted delivery, mode of anaesthesia, 3.9%, this is similar though higher than the value of Cadre of doctors performing the caesarean section, 2.3% and 3.2% which were obtained from different Apgar scores, neonatal admissions and neonatal deaths tertiary health centres in Nigeria.17,18 This value is very were not available due to the retrospective nature of the close to what has been previously reported in study. Ogbomoso, the present study site by Akinboro et al19 The proximity of the study site to Igboora, a city which Acknowledgement is considered as the twin capital of the world20,21 may be The authors acknowledge thestaff of the responsible for this higher rate of multiple gestation Health Information Department of the Bowen when compared with the aforementioned studies. University Teaching Hospital and the House officers Furthermore, the Yoruba tribe (the predominant tribe in for the assistance rendered during the collection of the present study site) of the Southwestern part of these data. Nigeria have been reported to have the highest twinning rates in the world.19 Conflict of interest: The authors have none to declare The observed stillbirth rate was 49.8 per 1000 births was similar to 52 per 1000 births observed in a References previous study,22 though lower than 87.5/1000 total 1 Peng F-S, Lin H-M, Lin H-H, Tu F-C, Hsiao C-F, births or 85 per 1000 births obtained from previous 29 O.A. Ogunlaja et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Hsiao S-M. Impact of clinical audits on cesarean Nigeria's sex ratio at birth: Factors and implications. section rate. Taiwan J Obstet Gynecol 2016; 55: Afr J Reprod Health 2015; 19: 17–33. 530–533. 14 Eze A, Lawani LO, Ukaegbe CI, Anozie OB, 2 WHO. Maternal mortality. WHO Fact sheet. Iyoke CA. Association between time of delivery and 2 0 1 9 . w w w . w h o . i n t / n e w s - r o o m / f a c t - poor perinatal outcomes -An evaluation of deliveries in sheets/detail/maternal-mortality (accessed 29 a tertiary hospital, South-east Nigeria. PlosOne 2019; Mar2020). 14: e0217943. 3 Ugwu A. Perinatal mortality in Nigeria the State 15 Jyotsana, Kapadia LD, Vohra H. Study of o f t h e n a t i o n . A f r i b a r y. c o m . A f r i b a r y. maternal and perinatal outcome of referred patients in 2018.https://afribary.com/works/perinatal-mortality- tertiary health centre. Int J Reprod Obstet Gynaecol in-nigeria-the-state-of-the-nation-3460 (accessed 29 2017; 6: 5363–5367. Mar2020). 16 Ugwa E, Ashimi A, Abubakar MY. Caesarean 4 Kwawukume E, Laryea H. Caesarean section. In: section and perinatal outcomes in a sub-urban tertiary Kwawukume E, Ekele B, Danso K, Emuveyan E (eds). hospital in North-West Nigeria. Niger Med J 2015; 56: Comrehensive Obstetrics in theTropics. Asante and 180–184. Hittscher printing press: Accra, 2015, pp 105–114. 17 Attah R, Mohammed Z, Gobir M. A review of 5 Zakerihamidi M, Roudsari RL, Khoei EM. twin deliveries in Aminu Kano Teaching Hospital, Vaginal delivery vs. Cesarean section: A focused North-west Nigeria. Niger J Basic Clin Sci 2014; 11: ethnographic study of women's perceptions in the 3–7. North of Iran. Int J Community Based Nurs Midwifery 18 Oraekwe O. Appraisal of maternal outcome of 2015; 3: 39–50. twin gestation. Saudi J Heal Sci 2018; 7: 163–166. 6 Isah AA., Adewole N, Zaman J. A five-year 19 Akinboro A, Azeez MA, Bakare A. Frequency of survey of cesarean delivery at a Nigerian tertiary twinning in Southwest Nigeria. Indian J Hum Genet hospital. Trop J Obstet Gynaecol 2018; 35: 14–17. 2008; 14: 41–47. 7 Akinola OI, Fabamwo AO, Tayo AO, Rabiu KA, 20 Nigeria's twin town:Igbo-Ora has an nusually Oshodi YA, Alokha ME. Caesarean section - an h i g h b i r t h r a t e . B B C A f r i c a . appraisal of some predictive factors in Lagos Nigeria. 2018.www.bbc.com/news/world-africa-45979768 BMC Pregnancy Childbirth 2014; 14: 217. (accessed 28 Mar2020). 8 Ji H, Jiang H, Yang L, Qiang X, Tang S. Factors 21 Agoi JO. Nigerian town celebrates claim as 'twins contributing to the rapid rise of Caesarean section: a c a p i t a l ' o f w o r l d . J a k a r t a P o s t . prospective study of primiparous Chinese women in 2019.www.thejakartapost.com/life/2019/10/20 Shanghai. BMJ Open 2015; 5: e008994. (accessed 28 Mar2020). 9 Adekanle DA, Adeyemi AS, Fasanu AO. 22 Ibekwe P, Ugboma H, Onyire N, Muoneke U. Caesarean section at a tertiary institution in Perinatal mortality in southern Nigeria; less than half a Southwestern Nigeria—A 6-year audit. Open J Obstet decade to the Millennium Development Goals. Ann Gynecol 2013; 3: 357–361. Med Health Sci Res 2011; 1: 215–222. 10 Ugwu E, Obioha K, Okezie O, Ugwu A. A Five- 23 Njokanma O, Sule-Odu A, Akesode F. Perinatal year Survey of Caesarean Delivery at a Nigerian mortality at the Ogun State University Teaching Tertiary Hospital. Ann Med Health Sci Res 2011; 1: Hospital, Sagamu, Nigeria. J Trop Paediatr 1994; 40: 77–83. 78–81. 11 Daniel CN, Singh S. Caesarean delivery: An 24 Suleiman M, Mokuolu O. Perinatal mortality in a experience from a tertiary institution in North Western Northwestern Nigerian city. FrontPaediatr 2014;8:105 Nigeria. Niger J Clin Pract 2016; 19: 18–24. 25 Manadhar S, Manadhar D, Baral M, Pandey S, 12 Azeez M, Akinboro, A Bakare A. Human sex ratio Padhey S. One year audit of perinatal mortality at at birth in South west Nigeria. Indian J Hum Genet Kathmandu Medical College Hospital. Kathmandu 2007; 13: 59–64. Univ Med J 2004;2:198-202. 13 Kaba AJ. Explaining the rapid increase in 30 Evaluating Effect of Prolonged Alcohol Consumption On Serum Gastrin and Secretin and Histo-archiecture of the Stomach and Duodenum In Rats 1 1 2 1 3 A.E. Ojieh, E.C. Adegor, J.I. Wilson, E.Agbonifo-Chijiokwu, E.G. Moke 1.Department of Physiology, Faculty of Basic Medical Sciences, Delta State University, Abraka, Nigeria: 2.Department of Anatomy and Cell Biology, Faculty of Basic Medical Sciences, Delta State University, Abraka, Nigeria 3.Department of Pharmacology & Therapeutics, Faculty of Basic Medical Sciences, Delta State University, Abraka, Nigeria: Keywords: Acohol, Gastrin, Secretin, Omega-3 Abstract Alcoholic beverages are amongst the liquid Introduction most consumed globally and prolonged alcohol Alcohol ranks amongst the most abused drugs consumption can result in injuries to the globally, but is not often thought of as a drug because of gastrointestinal tract mucosa of an individual.It can its use in religious and social settings in most parts of also exhibit its effect on digestion and absorption. This 1 research investigated the effects of long term varying the world . Based on their alcohol content, alcoholic doses of alcohol on two digestive hormones and the beverages are categorized into three groups; wines, histological integrity of the stomach and duodenum in beers and spirits (gin or whisky). Fermentation forms adult male Wistar rats. Forty adult male Wistarrats the basis of all alcoholic beverages formation. weighing 150-230g were used. The animals were Alcohol is usually consumed orally and being randomly selected into eight groups comprising five the first point of contact, the gastrointestinal tract often rats each. Group 1 served as the control, while Groups bears the brunt of first pass phenomenon along with the 2, 3 and 4 received 0.5ml of 5%, 20% and 40% alcohol liver. The effect of alcohol consumption on the intestinal tract often affects the health of an individual (0.05g/kg, 0.2g/kg and 0.4g/kg) respectively; Groups 2 5,6 and 7 were given 5% alcohol+Omega-3, 20% through its effect on digestion and absorption. Alcohol alcohol+Omega-3 and 40% alcohol+Omega-3 has been known at high concentration to distort the respectively while Group 8 was given Omega-3 alone. mucosa of the oesophagus, stomach and small Omega-3 was administered at a dose of0.01ml of intestine, along with its deleterious effect on the pancreas and liver.2, 3 0.2g/kg body weight. Treatment lasted for 12 weeks, 4 following which serum gastrin and secretin levels, as In their study, Singer et al. noted that well as the histology of the stomach and duodenum intravenous, intragastric or alcohol ingestion at low were analysed. Findings showed that serum levels of concentrations of up to 5% stimulated gastric acid gastrin and secretin hormones increased with secretion, while higher doses either exerted no effect, increasing alcohol concentration. Histology of the or showed inhibitory actions. Same study also showed stomach and duodenum showed necrosis and atrophy gastric emptying to be enhanced by low dose alcohol, of epithelial and submucous cells and this was more while gastric emptying and motility were reduced by 5 evident with higher alcohol concentration. Omega-3 high dose. In their own study, Oluwoleet al. found that was used as an ameliorating agent in this study to an alcoholic beverage was able to enhance gastric mitigate the effect of alcohol and result showed that its mucus secretion. Alcohol consumption has frequently effect was dependent on alcohol concentration. This been identified as the cause gastritis in alcoholics and in study concludes therefore that consumption of alcohol individuals who regularly consume alcohol. especially in high doses has the capacity to elevate Some commonly observed symptoms amongst serum levels of gastrin and secretin probably due to its heavy alcohol users are diarrhea, and mal-absorption, ability to cause disruption of the architecture of the occasioned by alterations in food digestion and mucosa and submucosa of the stomach and duodenum absorption. Hence this study was carried out to as seen in this study. These deleterious actions of investigate the effects of long term consumption of alcohol are often not ameliorated by use of anti- alcohol at varying concentrations 5%, 20% and 40% oxidants such as Omega 3 used in this study. (0.05g/kg, 0.2g/kg and 0.4g/kg) respectively, on two digestive hormones, serum gastrin and secretin, while Correspondence to: also examining the histological architecture of the stomach and small intestines. A.E. Ojieh Department of Physiology, Materials and Methods Faculty of Basic Medical Sciences, Chemicals: Delta State University, Analytical grade alcohol, Omega 3 fish oil Abraka, Nigeria supplement from BR Pharmaceuticals, Enzyme- linked [email protected], [email protected] immunosorbent assay kit from Hangzhou Phone: 08037006974; 09013527119 Eastbiopharm Co. Ltd (Xihu district, Hiangzhou 31 A.E. Ojieh et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Zhejiang, China), 10% Formal Saline, Haematoxylin- plus omega-3,Group 7 rats received 0.4g/kg bw alcohol Eosin Stain and Phenolphtalein indicator. plus omega-3 and Group 8 rats received only omega- 3.The rats were allowed free access to food with water Reconstitution of Alcohol: ad libitum. The treatment lasted for twelve weeks. The various concentrations of alcohol were reconstituted as follows: 5% alcohol concentration was Sample Collection derived from 5ml absolute alcohol mixed with 95ml of At the end of twelve weeks, the final weights of distilled water, and the rest were derived similarly. all the animals were taken. They were fasted overnight and sacrificed via cervical dislocation. Laparotomy Experimental Animals: was done to reveal their internal organs. Blood was Forty (40) male Wistar rats weighing collected by cardiac-puncture into clean plain bottles 150–230g were used for this study. The rats were and centrifuged at 4000rpm for 10min to obtain the procured from the animal section of the Faculty of serum. The stomachs and intestines were carefully Basic Medical Sciences of Delta State University, harvested and rinsed with normal saline. Abraka. They were housed in metabolic cages, fed with commercial chow and allowed free access to drinking Assay of Serum Gastrin and Secretin: water. The animals were handled accordance to the Serum gastrin and secretin were measured with the aid guidelines for animal handling by Ward and Elsea.6 of ELISA kits. Also adopted for this research was NIH Guide for Laboratory Animals Care and Utilization. The Histopathological Examination: experimental protocol on handling laboratory animals Samples of tissues from the stomach and was endorsed by the institutions ethical committee. duodenum of the rats were harvested. These were fixed in 10% formalin, dehydrated, cleared in xylene and Experimental Protocol: embedded in paraffin. Afterwards, they were sectioned The rats were randomly selected into eight (8) with the aid of a microtome to 5µm thick sections, groups of five (5) rats each (n = 5). The alcohol stained with Haematoxylin-Eosin stain, and viewed concentrations (5%, 20% and 40%), represents the under a light microscope. Finally, photomicrographs level commonly associated with the frequently were taken. consumed alcoholic beverages namely beer, alcoholic Statistical Analysis wine, spirits (brandy, whisky, vodka or gin). The The results were expressed as Mean ± Standard Error of alcohol was purchased from an authorized the Mean (SEM). The means of the treated and control pharmaceutical company (BR Pharmaceutical). The groups were then compared using ANOVA with rats received single daily alcohol oral dose of 0.5ml of Fisher's Post-Hoc. P-values of less than 0.05 were 0.05g/kg, 0.2g/kg and 0.4g/kg respectively, using an considered statistically significant. oro-gastric cannula. They also received 0.01ml of 0.2g/kg body weight of Omega-3 fatty acid. The Results treatment groups are as follows: Group 1, rats received Gastrin and Secretin only clean drinking water and normal feed, Group 2 rats Result from this study showed an increase in received 0.05g/kg bw alcohol,Group 3 rats received serum gastrin with increasing alcohol concentration 0.2g/kg bw alcohol, Group 4 rats received 0.4g/kg bw (Fig1). Co-administration of omega-3 with alcohol in alcohol,Group 5 rats received 0.05g/kg bw alcohol plus all groups showed increased gastrin secretion omega-3 only,Group 6 rats received 0.2g/kg bw alcohol compared to control and omega-3 alone. 0.05g/kg bw Fig. 2: Effects of alcohol on the level of serum secretin in experimental rats Fig.1: Effect of alcohol on the level of serumgastrin in experimental rats expressed as Mean±S.E.M. Keys: Ù: Omega-3, ALC: Alcohol expressed as Mean±S.E.M. Keys: Ù: Omega-3, ALC: Alcohol, 32 A.E. Ojieh et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Effect of Alcohol Administration on Histomorphologic integrity of the stomach sections from Experimental Rats (figs 3a – 3g) Fig.3a Control; Mucous cells F i g . 3 b S t o m a c h , s h o w i n g Fig.3c Stomach – showing Fig. 3d Stomach- showing (black arrow) Parietal cells (blue hyperplastic mucous cells (top- atrophy of parietal cells (arrows) hyperplasia of mucous cells arrow). H&E x400 arrows) and normal parietal cells in rats treated with 5% alcohol (arrow) of rats treated with 20% (bottom-arrow) in rats treated with alone. H&E x400 alcohol and omega-3. H&E x400 5% alcohol and omega-3. H&E x400 Fig.3e stomach- showing necrosis of Fig.3f Stomach- showing diffuse necrosis Fig.3g Stomach- showing atrophy of mucous mucous (red arrow) and parietal cells of fundic cells (arrow) of rats treated with neck cells (arrow) of rats treated with 40% (black arrow) of rats treated with 20% 40% alcohol alone. H&E x400 alcohol and omega-3. H&E x400 alcohol alone. H&E x400 Effect of Alcohol Administration on Histo-architecture of the duodenum in Experimental Rats (Figs 4a -4g) F i g . 4 a : C o n t r o l R a t s - Fig.4b Duodenum- showing mild Fig.4c Duodenum- showing diffuse Fig.4d Duodenum- Showing Duodenum- showing tall villi diffuse atrophy of brunner's glands atrophy of Brunner's glands(arrows) necrosis of crypts and glandular (arrow). H&E x100 (arrow) in rats treated with 5% in rats treated with 5% alcohol alone. cells in rats treated with 20% alcohol and omega-3. H&E x100 H&E x100 alcohol. H&E x100 Fig.4e Duodenum- Showing Fig.4f Duodenum showing mild diffuse F i g . 4 g D u o d e n u m s h o w i n g mild resolution of the necrosis in atrophy of brunner's gland in rats treated congestion and diffuse atrophy rats treated with 20% alcohol and with 40% alcohol and omega-3 H&E x100 treated with 40% alcohol H&E x100 33 A.E. Ojieh et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) alcohol+omega-3 treatment showed increased gastrin with higher ethanol content such as whisky, gin, or secretion compared with 0.05g/kg bw alcohol alone. vodka may actually inhibit gastric acid secretion or 0.4g/kg bw alcohol+omega-3 treatment showed release of gastrin7.in this study, co-administration of decreased gastrin secretion compared with 0.4g/kg bw omega-3 to alcohol treated rats did not improved serum alcohol alone gastrin level in high dose alcohol (40%). The mechanism behind the action of Omega-3 in causing Secretin decrease in gastrin is unclear but may be attributed to The result showed an increase in serum the action of Omega-3 in ameliorating the damage to secretin with increasing dose of alcohol (Fig. 2). the gastric parietal cells caused by high dose alcohol. Treatment with 0.2g/kg bw alcohol + omega and Therefore, it is possible that Omega-3 prevents back 0.4g/kg bw alcohol alone caused increased secretin diffusion of H+ ions secondary to disruption of the level compared with control and omega alone. 0.2g/kg mucosal barrier and thus plays a part in stimulating bw alcohol + omega treatment showed increased gastric acid secretion. Also, release of gastric acid secretin level compared with 0.2g/kg bw alcohol alone. inhibitors such as somatostatinwhich mediate the 0.4g/kg bw alcohol + omega treatment showed inhibitory effect on the parietal cells by binding to decreased secretin level compared with 0.4g/kg bw parietal cells via G-coupled receptor to reduce alcohol alone. secretion may be blocked by Omega-3 which will ultimately cause decrease in gastrin secretion. Lianus et Histopathological studies al,13 reported that in humans plasma secretion level In the stomach with 0.05g/kg bw alcohol increases significantly from a basal of 1.21±14 to treatment, there were no marked alterations. There was 1.64±24pg/ml at 60mins after oral ingestion of alcohol. atrophy and necrosis of the parietal and mucus cells Alcohol increases the emptying of acidic chyme into with 0.2g/kg bw alcohol treatment and diffuse necrosis the duodenum stimulating the release of secretin by the of these cells with 0.4g/kg bw alcohol treatment (Fig3a S-cells of the duodenum. Result from figure 2 shows an – Fig3g). In the duodenum, there was mild diffuse increase in secretin level with increasing concentration atrophy of the brunner's gland with 0.05g/kg bw of alcohol, and in combination with Omega-3, showing alcohol treatment, necrosis of crypts and glandular similar increase in secretion like gastrin with increasing cells with 0.2g/kg bw alcohol. This showed some concentrations (5%, 20% and 40%). This is in resolution in the 0.2g/kg bw alcohol+omega-3 group. congruent with the findings of Nishiwakiet al.14 who In the 0.4g/kg bw alcohol group, there was diffuse reported that alcohol stimulates release of endogenous atrophy of the brunner's gland, there was no resolution secretin and pancreatic secretion by increasing seen with treatment with omega-3 in the 0.4g/kg bw duodenal acid load from the stomach. However, alcohol+omega-3 group (Fig4a – Fig4g). secretin has an inverse action to gastrin, as it inhibits gastric secretion and motility but stimulates increased Discussion bicarbonate rich pancreatic juice, which is important Alcohol beverages with low ethanol content for digestion. like beer and wine are strong stimulant of gastrin Alcohol consumption has been associated with release. Whereas beverages with high ethanol content assault on the cellular integrity of the pancreas and is an like whisky and gin do not stimulate gastric acid independent risk factor for the development of 7 secretion or release of gastrin. Mild to moderate pancreatitis.15 Alcohol consumption especially in high consumption of low dose alcohol could possess health doses can result in inflammation of the gastric mucosa. 8 benefits, however when consumed in high According to Chi- chang et al,16 a reduction in gastric concentration especially over a long time, it could mucous has been implicated in alcohol-induced gastric 9 result in multiple pathologies. High doses, greater 10% ulcers. Azzumet al.17 in their study reported that an 10 has been associated with mucosal damage. These optimal gastric mucus secretion remains a vital factor observation and many other reported alcohol induced protecting the gastric mucosa. pathologies have not discouraged the heavy From the histological slides, reduced small c o n s u m p t i o n o f a l c o h o l i c b e v e r a g e s intestinal enterocytes could also be responsible for the globally.11Documented literature shows that alcohol decrease in the enterocytes turnover in the small interferes with gastrin and secretin secretion on a intestine. This could also be the cause for the impaired concentration dependent manner. absorptive function.18 Result from the histologic studies Results from this study reveal a dose- reveal that alcohol poses histopathological threat to soft dependent increase in gastrin levels, with 40% alcohol tissues, causing excoriation of stomach and intestine. group having the highest level of gastrin secretion These account for the altered secretory functions of the when compared with control. This is in line with the GIT. Omega-3 administration to alcohol treated rats findings of Vera et al,12 who also observed an increase in showed potency for the improvement/amelioration of gastrin level with increasing alcohol dosage. Beverages soft tissue damage such as the pancreatic tissue as 34 A.E. Ojieh et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) 19 suggested by, however, this was not clearly seen in this gastric acid secretion in humans”. Gut. 1993; 34(6): study. 843-847. 8) Bienia, A, Sodoiski, W andLuchowska, M.“The Conclusion effect of chronic alcohol abuse on gastric acid duodenal Persistent ingestion of alcohol over time mucosa”. Annual Universal Mariae Curie Sklodowska especially highly concentrated forms (gin, whisky Medicine. 2002; 57(2); 570-582. vodka), can distort the mucosa and submucosa of the stomach and duodenum, resulting amongst other 9) Dasarathy, S and McCullough, AJ. “Alcoholic liver disease. In E. R. Schiff, M. F. Sorrell and W. C. symptoms in the elevation of serum levels of gastrin th and secretin. Gastrin is essential in the digestion of Maddrey (Eds.), Schiff's diseases of the liver(10 ed.). meat protein while secretin is needed for regulation of Philadelphia: Lippincott Williams & Wilkins. 2007. pancreatic secretions especially bicarbonate. Elevation 10) Davenport, HW.“Ethanol damage to canine in serum gastrin levels can trigger abdominal pain, oxyntic glandular mucosa”. Experimental Medical diarrhea, decrease appetite and unintended weight loss Biology. 1997; 126: 657-62. due to poor nutritional digestion and absorption and 11) Ustun, TB. “WHO multi-country survey study on these deleterious actions of alcohol are often not health system Responsiveness”. 2000 ameliorated by use of anti-oxidants Such as Omega-3. 12) Vera T, Vesna K., Mirela B.“G cells and Grastrin The findings from this study will help shield some light in chronic alcohol treated rats”.Journal of alcohol. on the reason for malnourishment seen with long-term 2008;42(1): 37-45 consumption of concentrated alcohol. 13) Lianus OL, Swierczek JS, Teichnann RR. et al. “Effect of alcohol on the release of secretin and References pancreatic secretion”. Surgery. 1977;81(6): 661-667. 1) Bujanda, L. The effects of alcohol consumption 14) Nishiwaki H, Lee KY, Chey WY (1984) Effect of upon the gastrointestinal tract.American Journal of alcohol on plasma secretin concentration and Gastroenterology. 2000;95(12): 3374–3382. pancreatic secretion in dogs.Surgery;95(1):85-89. 2) Chacin, J., Cardenas, P., Lobo, P. et al.“Secretory 15) Chowdhury P and Gupta P. “Pathophysiology of and metabolic effects of ethanol in the isolated alcoholic pancreatitis: An overview”. World Journal of amphibian gastric mucosa”.Gastroenterology. 1991; Gastroenterology. 2006; 12(46): 7421–7427 100: 1288-1295. 16) Chi-Chang, H, Yi-Ming, C, Dean-Chuan, W et al. 3) Maria, B., Monika, R., Benedicte, D., et “Cytoprotective Effect of American Ginsing in a rat al.“Chronic alcohol consumption affects ethanol gastric ulcer model”. Molecules. 2014; 19:316- gastrointestinal motility and reduces the proportion of 326. neuronal NOS-immunoreactivemyenteric neurons in 17) Azzum YT, Ichikaw, K and Ishihara. “The the murine jejunum”. The Anatomical Record. 2010; validity of the ethanol precipitation method for the 293: 1536 – 1542 measurement of mucin content in human gastric juices 4) Singer MV, Leffmann C, Eysselein VE, et al. and its relationship to gastroduodenal disease”. “Action of ethanol and some alcoholic beverages on gastric acid secretion and release of gastrin in humans”. Clinical.Chim. Acta. 1993; 221: 219 – 225 Gastroenterology. 2003; 93: 1247–1254. 18) Adebiyi OA.Okolie-Alfred UV, Godstime C. et 5) Oluwole, FS, Omolaso, BO and Ayo, JA. al. “Performance and Gut Morphometry of Broiler Fed “Methanolic extract of Entandrophragmaangulense Maize Based Diets Supplemented with Charcoal and induces gastric mucus cell counts and gastric mucus Honey as Anti-aflatoxin”. American Journal of secretion”. Journal of Biological Sciences. 2007;7(8): Experimental Agriculture. 2015;7(3):163-169. 1531-1534. 19) Meganathan M, MadhanaK, Gopal, P. 6) Ward JW and Elsea JR. “Animal case and use in “Evaluation of Hepatoprotective Effect of Omega 3- drug fate and metabolism. Methods and techniques”. Fatty Acid against Paracetamol Induced Liver Injury in Vol 1 Ed Edward R. Garrette and Jean L. Hirtz. Marcel Albino Rats”. Global Journal of Pharmacology. 2011; Dekker, New York, 1997;pp 372 -390. 5(1): 50-53 7) Charis S, Teyssen S and Singer MV. “Alcohol and 35 Radiological Findings in Aqueductal Stenosis in a Preterm Infant. 1H.J. Akande,2B.B. Olafimihan2P.N. Omefe, 2A.T. Ifarinola Departments of Radiology, 1College of Health sciences, University of Ilorin and 2University of Ilorin Teaching Hospital, Ilorin,Nigeria Abstract Introduction Hydrocephalus is a common finding on The aqueduct of Sylvius, named after transfontanelle ultrasound scan (TFUS),accurate Franciscus Sylvius, is a connection that allows the flow diagnosis and treatment are vital in improving patient of cerebrospinal fluid (CSF) from the third ventricle to outcome.Aqueductal stenosis is one of the known the fourth ventricle. Aqueductal stenosis is a partial or causes of hydrocephalus and the most common cause complete obliteration of the lumen of the aqueduct of of congenital hydrocephalus.1-3 The aqueduct of Sylvius. Congenital aqueductal stenosis (CAS) has Sylvius transmits cerebrospinal fluid from the third been reported as the most frequent cause of congenital ventricle to the fourth ventricle and develops at 6th week hydrocephalus.1,2 Hydrocephalus is a common finding gestation age and gradually decreases in size till birth during obstetric ultrasound scan (USS) but the cause with luminal patency.4 However, it may become may be difficult to identify. Increased intracranial stenotic as a consequence of compression from mass pressure (ICP) can result from ventriculomegaly with lesions or because of an intrinsic pathology. In about its associated complications. three quarters of patients, the etiology of the disorder is Congenital aqueductal stenosis has an not known and this is referred to as idiopathic estimated incidence of 0.5-1: 1,000 births.2 It was found aqueductal stenosis.5This condition constitutes a as the commonest congenital anomaly and the significant burden of morbidity in patients with commonest cause of congenital hydrocephaly in local hydrocephalus. studies.3,7Rarely, it may be inherited in an X-linked Congenital aqueductal stenosis has an recessive manner (Bickers-Adams-Edwards estimated incidence of 0.5-1 in 1,000 births in the syndrome).4 developed world and congenital hydrocephalus an Imaging plays a vital role in diagnosing this incidence of 145 in 100,000 live births in Africa.4,6In anomaly thus radiologists must be familiar with the this index case, the right and left frontal horns of the imaging features. This case highlights the imaging lateral ventricles and third ventricle were dilated with a findings on both transfontanelle (TFUS) and magnetic normal sized 4th ventricle on transfontanelle ultrasound resonance imaging (MRI). (TFUS). No focal mass lesion was seen and the aqueduct was not well demonstrated. Brain MRI was Case report requested, which confirmed the diagnosis of congenital M.N. presented to the neonatal intensive care aqueductal stenosis with obstructive hydrocephalus. unit (NICU) as a four-hour-old preterm male neonate The treatment of CAS is by endoscopic third delivered via spontaneous vaginal delivery at a private ventriculostomy (ETV) or ventriculo-peritoneal (VP) facility. Mother drained liquor six days prior to delivery shunting. Patient was planned for ventriculo-peritoneal at 33 weeks 5 days (ultrasound estimated gestational (VP) shunt, however, this could not be done due to age). She received 12 mg of IM dexamethasone on financial constraint. account of preterm premature rupture of membranes. Child cried immediately at birth with Apgar scores of 8 Keywords: Congenital aqueduct stenosis, Infant, and 9 at the 1st and 5th minutes respectively and birth Imaging Findings weight of 1.8kg. Baby was referred to our facility on account of prematurity. At presentation, the Ballard EGA was 33 weeks. Pregnancy was booked at 7 months and mother did not have any obstetric ultrasound scan, nor received Correspondence to: IM tetanus toxoid (TT) or intermittent malaria Dr. H. J. Akande prophylaxis (IPP). She is not a known hypertensive or +ve Department of Radiology, diabetic. Her blood group is O , genotype AA. Faculty of Clinical Sciences, Pregnancy was uneventful except for the spontaneous College of Health Sciences, premature rupture of membranes which occurred University of Ilorin. following a stressful journey and necessitated Email: [email protected] presentation at a health facility. No history of fever, Phone No: +2348035967327. rash, urinary tract infection, par vaginam (PV) 36 H.J. Akande et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Figure 1A: Anterior coronal TFUSview showing the frontal horns of the lateral ventricles severely dilated. Figure 2A: Sagittal T1 FLAIR MRI showing narrowed aqueduct (arrow) with dilated lateral and 3rd ventricles. Figure1B: Right and left para-sagittal TFUS views showing dilated lateral ventricles. Figure 2B: Sagittal T2-W showing no CSF signal in the region of the aqueduct with dilated lateral and 3rd ventricles and prominent supraoptic and infundibular recesses (arrows). Figure 1C: Midline sagittal TFUS view showing dilated 3rd ventricle. The massa intermedia is shown. The 4th ventricle is normal. Figure 2C: Coronal T2-W MRI showing dilated lateral and 3rd ventricles with funneling appearance of the proximal aqueduct. bleeding. (Temperature-36.20), not dehydrated, no pedal edema. Mother is a 23-year-old undergraduate and father is a Weight-1.8 kg, length-42 cm, SpO2-99% in room air, 27-year-old graduate. occipito-frontal circumference (OFC)-31 cm. Examination revealed a conscious child, not in Examination of the abdomen, respiratory and distress, not pale, anicteric, acyanosed, afebrile cardiovascular systems was normal. Central nervous 37 H.J. Akande et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) system examination revealed a conscious child with patient had delayed developmental milestones, he normotensive anterior fontanelle, no head lag, good didn't start crawling until about 8 months and started suck and appropriate tone. An initial assessment of sitting with support just a month before his last clinic prematurity with risk for sepsis in a four-hour-old 33 visit (10 months old). Patient was lost to follow up due week Ballard gestational age (GA) male was made. to relocation of the parents to another state. Child was admitted in the neonatal intensive care unit (NICU) and packed cell volume, full blood count & Discussion differentials with blood culture were requested for. He Aqueductal stenosis can be complete or partial, was placed on 10% dextrose water, parenteral drugs absence of significant increasing head size and including calcium gluconate, vitamin K, sonographic appearance of arrested hydrocephalus on aminophylline and antibiotics. The vital signs were follow up suggest a partial stenosis in this case. closely monitored. Prophylactic phototherapy was also Congenital aqueductal stenosis (CAS) is the most commenced. Feeding (expressed breast milk) was also common cause of prenatal non communicating graded. Blood culture yielded no growth. PCV - 45%. hydrocephalus.1,2,8The aqueduct may become stenotic Patient was discharged on the 8th day of admission after because of extrinsic mass lesions (tumoral) or as completing 7 days of antibiotics as a feeder grower. At a consequence of intrinsic pathology (non-tumoral month's follow up clinic appointment, examination aqueductal stenosis). Intrinsic aqueductal stenosis may revealed a conscious child with bulging anterior be congenital or acquired, idiopathic or secondary to a fontanelle, sutural diasthesis, head lag and poor suck. known etiology.9Intrinsic congenital causes are Transfontanelle ultrasound scan (TFUS) revealed commonly from aqueductal webs or diaphragms while severely dilated lateral (right and left frontal horns a c q u i r e d c a u s e s a r e f r o m i n f e c t i o n s measured 2.52 &2.54 cm respectively) and third (meningitis/ventriculitis) and intraventricular ventricles with a normal sized 4th ventricle. No focal hemorrhage. The extrinsic causes include tectal plate mass lesion was seen and the aqueduct was not well glioma, periaqueductal vascular malformation, pineal demonstrated. (Figures 1 A-C). A diagnosis of tumor and posterior fossa tumor.10,11 The inherited congenital aqueduct stenosis to rule out intracranial recessive X-linked form (Bickers-Adams-Edwards hemorrhage grade 3 was made. Patient was then syndrome) is usually transmitted from a carrier female referred to the neurosurgeons. Examination at the to her male child. There is a slight male prevalence.4,12 neuro-surgery clinic revealed a conscious child with a The etiology in this case is intrinsic congenital and the patent, full and soft anterior fontanelle, OFC 38 cm. patient being male tallies with the gender Brain MRI was requested and showed dilated lateral predominance. and third ventricles, absence of cerebrospinal fluid The symptoms of CAS depends on the severity (CSF) signal in the proximal 2/3rds of the aqueduct and age of presentation. These are usually as a result of demonstrated on the T1-W, T2-W and FLAIR raised intracranial pressure (ICP) from the obstructive sequences. A diagnosis of congenital aqueductal hydrocephalus, insidious in onset and include rapid stenosis with obstructive hydrocephalus was made. head growth, developmental delay and seizures. These Patient was planned for ventriculo-peritoneal features were present in this case. In addition, other (VP) shunt but due to financial constraint, this was not symptoms in children and adolescents are headache, done. visual disturbance, endocrine abnormalities, and ocular At 4 months of age, patient presented to the movement disorders amongst others. Profound hospital on account of afebrile seizure of 2-weeks intellectual disability and bilateral adducted thumbs are duration. At this time, he was yet to achieve neck seen in patients with the X-linked form. control. Examination of the central nervous system The imaging modalities in evaluating CAS are revealed the anterior fontanelle to be patent, full but brain ultrasound scan (USS), computed tomography normotensive, measuring 5 cm in diameter. Sutural (CT) scan and magnetic resonance imaging (MRI). diasthesis was noted. However, there was no MRI has become a major problem-solving tool in the significant increase in head circumference. Tone and evaluation of ventriculomegaly based on its ability to reflexes were normal. No abnormality was detected in define the underlying etiology, especially in infants and other systems. The seizure was controlled and mother children as it is safer without the exposure to ionizing counselled for surgery (VP shunt) but again declined on radiation.13 financial grounds. A TFUS done at this visit showed no On USS, the lateral ventricles and third progression in the ventriculomegaly. Based on this, an ventricles are seen to be dilated with a normal size assessment of non- progressive (arrested) fourth ventricle. The dilatation could be mild, moderate hydrocephalus secondary to aqueduct stenosis was or severe. The cerebral mantle can also be assessed for made. Patient was subsequently discharged on the 4th thinning as a result of the hydrocephalus. This can be day of admission on medication (phenobarbitone). shown both on fetal (obstetric) or transfontanelle USS. Follow up visits up to 11 months of age showed However, it may not be able to identify the cause of the 38 H.J. Akande et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) ventriculomegaly but it is valuable as a follow up 3. Saidu SA, Maaji SM, Nzeh DA, Shehu BB, imaging tool to monitor the progress of 3 Ismail NJ. Sonographic pattern of hydrocephalus ventriculomegaly especially after treatment. USS was among under five children in Sokoto North Western able to detect ventriculomegaly of the lateral and third Nigeria. Sahel Med J 2015; 18: 172-6. ventricles in this patient. 4. Dahnert W. Disorders of the Central Nervous Magnetic resonance imaging is the preferred th System. In: Radiology Review Manual. 8 edition, imaging modality. It depicts the extent of the dilated ventricles and often the etiology. In CAS, the entire Philadelphia: Wolters Kluwer, 2017:331-32. length of the aqueduct can be visualized, funneling of 5. Jenkinson MD, Hayhurst C, Al-Jumaily M, the superior aspect of the aqueduct, downward bulge of Kandasamy J, Clark S, Mallucci CL: The role of the floor of the third ventricle, prominence of the endoscopic third ventriculostomy in adult patients with recesses of the third ventricle will be demonstrated. hydrocephalus. J Neurosurg 2009; 110: 861-866. Secondary effects of the hydrocephalus such as 6. Dewan MC, Rattani A, Mekary R, Glancz LJ, ventricular diverticula, cortical thinning amongst Ismaeel Y, Baticulon RE et al. Global hydrocephalus others will be shown if present. The fourth ventricle epidemiology and incidence: systematic review and will be normal in size. The T2-W mid-sagittal view best meta-analysis. J Neurosurg 2019; 130:1065-1079. demonstrates the absence flow-void signal intensity in aqueductal stenosis and other features as demonstrated 7. Nzeh DA, Saidu SA, Erinle SA, Pam SD. in this case. Sagittal constructive interference steady Sonographic Diagnosis of Congenital Brain state (CISS) sequence will best demonstrate Malformations: The Ilorin Experience. Niger Postgrad obstructing web. CSF flow study on MRI can also be Med J 2006; 13: 57-60. used to quantify aqueductal stroke volume and peak 8. Cinalli G, Spennato P, Nastro A, Aliberti F, systolic velocity which will be reduced.14 Trischitta V, Ruggiero C et al.Hydrocephalus in Computed tomography is another useful aqueductal stenosis. Childs Nerv Syst 2011; imaging modality in adults but not advocated in 27:1621–42. neonates and children because of effects of ionizing 9. Jellinger G: Anatomopathology of nontumoral radiation. It demonstrates ventriculomegaly, possible aqueductal stenosis. J Neurosurg Sci 1986; 30: 1-16. causes and the effects of the dilated ventricles. 10. Barkovich A J, Newton TH. M R of aqueductal The differential diagnosis of CAS include stenosis: evidence of a broad spectrum of tectal intracranial hemorrhage grade III (intraventricular distortion. AJNR Am J Neuroradiol 1989; 10: 471-76. hemorrhage with dilatation), brainstem glioma, 11. Marcorelles P, Fallet-Bianco C, Oury J F, Van meningitis and ventriculitis. Wallenghem E, Parent P, Labadie G et al. Fetal The treatment of CAS is by endoscopic third aqueductal glioneuronal harmartoma: A ventriculostomy (ETV) or ventriculo-peritoneal (VP) clinicopathological and physiopathological study of shunting. In a study, aqueductal stenosis was the most three cases. Clin Neuropathol 2005; 24: 155-62. common indication for endoscopic interventionwith a 12. Hirsch JF, Hirsch E, Sainte-Rose C, Renier D, high endoscopic third ventriculostomy success score Pierre-Khan A: Stenosis of the aqueduct of Sylvius, (ETVSS). 15There is a small recurrence risk (~4%) for Etiology and Treatment. J Neurosurg Sci 1986; 30: 29- congenital cases even when it is not X linked. VP shunt 39. was offered as a treatment modality for this patient but 13. Sefidbakht S, Dehghani S, Safari M, Vafaei H, was not done due to financial constraints. Kasraeian M. Fetal central nervous system anomalies In conclusion, aqueductal stenosis remains the detected by magnetic resonance imaging: a two-year commonest cause of congenital hydrocephalus and experience. Iran J Pediatr 2016; 26: e4589. confident diagnosis can only be established by accurate 14. Stoquart-El Sankari S, Lehman P, Gondry- radiological diagnosis. Jouet C, Fichten A, Godefroy O, Meyer M-E, Baledent O. Phase-contrast MR Imaging Support for the References Diagnosis of Aqueductal Stenosis. AJNR Am J 1. Heaphy-Henault KJ, Guimaraes CV, Neuroradiol 2009; 30:209-14. Mehollin-Ray AR, Cassady CI, Zhang W, Desai NK et al. Congenital Aqueductal Stenosis: Findings at Fetal 15. Uche EO, Okorie E, Emejulu J, Ajuzieogu O, MRI That Accurately Predict a Postnatal Diagnosis. Uche NJ. Challenges and outcome of cranial AJNR Am J Neuroradiol 2018; 1-7. neuroendoscopic surgery in a resource constrained 2. B e e g h l y M , W a r e J , S o u l J . developing African country. Niger J Clin Pract 2016; Neurodevelopmental outcome of fetuses referred for 19: 811-5. ventriculomegaly. Ultrasound Obstet Gynecol 2010; 35: 405-16. 39 Malignant Fibrous Histiocytoma of the Jaws: A Follow-up Study of 5 Cases and Review of Related Literature 1 2 B.E. Edetanlen, T.T.Izegaegbe 1. Department of Oral and Maxillofacial surgery, Faculty of Dentistry, College of Medical Sciences, University of Benin, Benin-city, Edo state, Nigeria. 2.Department of Oral and Maxillofacial Surgery, University of Benin Teaching Hospital,Benin-city, Edo state, Nigeria. Abstract The term malignant fibrous histiocytoma Malignant fibrous histiocytoma (MFH) is an (MFH) was first coined by Ozzello et al3 in 1963 and aggressive, high-grade tumor with poor prognosis. It is described by O'Brien and Stout4 in 1964. In 1970s, the most common soft tissue sarcoma in adults, usually Feldman and Norman described the first primary tumor occurring in retroperitoneum and extremities. MFH of of bone that satisfied the histological criteria of MFH.5 the head and neck is rare.All cases in the records of the Malignant fibrous histiocytoma (MFH) is the most Department of Oral and Maxillofacial Surgery of the common soft-tissue sarcoma occurring in late adults.6 University of Benin Teaching Hospital which were Malignant fibrous histiocytoma commonly arises from histologically diagnosed were retrieved. Information the soft tissues, tendons, bones and joints. It commonly retrieved were age, sex, site, duration of swelling, affects extremities and retroperitoneum. Seventy signs/symptoms, prediagnostic metastasis, percent of these tumors are primary tumors while the prediagnostic antibiotic administration, treatment and other 30% are associated with pre-existing conditions the outcome. Age ranged between 25- and 33 years such as prior radiation therapy of the region.7 with three female and two males. Three of the cases In the head and neck region, the nasal cavity were in the maxilla while two cases involved the and the paranasal sinuses are the most commonly mandible. Duration of lesion ranged from 3-24 months. affected sites (54.3%), and can lead to subsequent Two cases were misdiagnosed as orofacial cellulitis. involvement of the maxillary alveolar bone.8 The All cases except one recurred and died of the occurrence of MFH in membranous bones including lesion.Five case series of histologically diagnosed mandible is quite unusual.9 Involvement of the MFH of jaws were presented, demonstrating their rare mandible accounts for only 3% of all MFH bone occurrence, highly aggressive nature, high local lesions.10 Larynx, maxillary sinus, and mandibles have recurrence rate, and tendency for early metastasis to the worst prognosis in the head and neck lesion.11 lungs. Recommendation is that such jaw lesions require MFH of the jaws is extremely rare and most of early radical surgery with minimum of 3 cm tumor 1- 45 the documented are case reports. Only 5 cases of margins, followed by radiotherapy and chemotherapy, MFH, from the South West region, have been reported when indicated and very close follow-up is also 22 in Nigeria so far. This case series highlight the clinico- mandatory epidemiologic characteristics of the 5 cases of MFH diagnosed in a regional university teaching hospital in Keywords: Malignant, fibrous, histiocytoma, jaws south-southern Nigeria. Review of the literature was also done with emphasis on clinical features, Introduction radiological features, histological features, treatment, Tumors composed of cells differentiating as and prognosis. both fibroblasts and histiocytes have been designated fibrous histiocytoma.1 Only a small percentage of these Case reports lesions behave in a malignant fashion; they are called 2 Case 1:A case of 33-year-old female who was initially malignant fibrous histiocytoma (MFH). Malignant seen in our clinic with a7-month swelling of the left fibrous histiocytoma (MFH) originates from primitive lower jaw (Figure 1). And presented again after 2 weeks mesenchymal cells and has the capacity for dual of being on antibiotic given outside our clinic for histiocytic and fibroblastic differentiation. It is also misdiagnosis of orofacial abscess (Figure2). The known as undifferentiated high-grade pleomorphic 2 history of trauma or irradiation was negative.The sarcoma. patient's medical history and a general physical Correspondence to: examination revealed no abnormal findings. Chest radiograph shows no pulmonary metastasis. Dr. B E Edetanlen Extraorally, examination revealed a massive swelling Department of Oral and Maxillofacial Surgery, measuring about 7x10 cm in the greatest dimension Faculty of Dentistry, with surface ulceration (Figure 2). Regional lymph College of Medical Sciences, nodes were not palpable. There was numbness of the University of Benin, Benin-city, Edo state, lower lip. Intraorally, the swelling was located in the Nigeria. premolar-molar region with no surface ulceration but [email protected] No: +2348024223651 40 B.E. Edetanlen et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Figure 3: Computed tomogram showing infiltrative lesion. Figure 1: Early malignant fibrous Figure 2: Rapidly growing lesion in same histiocytoma, misdiagnosed as orofacial patient in figure 1 abscess outside our hospital due to pain and shiny and stretched skin surfaces. Figure 4: Section shows sheets of spindle cells Figure 5: High-power view illustrating large Figure 6:PA radiograph of the chest having hyperchromatic nuclei and moderate pleomorphic bizarre malignant cells (H &E, X 350) with pulmonary metastasis cytoplasm admixed with multinucleated giant cells (H and E, X 40) mobility of associated teeth. CT scan of the lower jaw On examination the swelling was located on the showed osteolytic infiltrative lesion with extension to posterior maxilla with mobility of the related teeth. surrounding soft tissues. The margins were ill-defined Chest radiograph shows no pulmonary metastasis. (Figure 3). An incisional biopsy was done for Craniofacial computed tomography revealed an histological examination that revealed mainly spindle extensive ill-defined radiolucency without marginal cells and atypical multinucleated cells. The spindle sclerosis and periosteal reaction. A definitive diagnosis cells were arranged in a storiform pattern (Figure 4 and of storiform-pleomorphic malignant fibrous 5). Immunohistochemistry that was required to rule out histiocytoma was made base on histology of the other possibilities is not available presently in our incisional biopsy. Hemi-maxillectomy was performed centre. With histological examination, a diagnosis of but patient died 12 months post-surgery from local storiform-pleomorphic malignant fibrous histiocytoma recurrence. was made. Hemi-mandibulectomy with disarticulation was performed to allow for safety margin. Patient Case 3: A 27-year- old female was seen in our clinic presented with a local recurrent and pulmonary with three-month history of a painful enlarging lump on metastasis after 9 month of surgery (Figure 6). The the right side of the mandible in the premolar/molar patients was subsequently referred to the Department region. The patient was otherwise healthy though she of Oncology for radiotherapy but died 15 days after was previously placed on antibiotic in a clinic outside presentation. for a misdiagnosis of the swelling as dentoalveolar abscess. On examination swelling appears shiny Case 2: A 23-year-old female presented to our clinic without ulceration and was hard with no tenderness. with a painful swelling of the upper jaw. There was no The associated teeth were mobile. Panoramic history of pre-existing trauma or irradiation exposure. radiography showed findings were irregular bone or 41 B.E. Edetanlen et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) moth-eaten margins with root resorption. With 15%), oral cavity (5-15%), pharynx, ear and eyelid.35 histological examination, a diagnosis of storiform- Maxilla is more commonly involved than the pleomorphic malignant fibrous histiocytoma was mandible.36 In our case series, MFH affect the maxilla made. Segmental resection was done but patient more. Clinical presentation of MFH is variable and is presented with recurrence after 8 months of surgery. A dependent on the site and nature of the tumor, presence second surgery of hemi-mandibulectomy with of metastasis, and release of inflammatory mediators disarticulation was performed with radiotherapy. The among other factors.37 Clinically, the common signs patient was disease free after 5-year follow-up. and symptoms of MFH occurring the jaws consist of a gradually progressing swelling that may be tender on Case 4: A male patient of 25 years old presented to with palpation and the surface of the swelling may or may right upper jaw swelling of 3 month duration. There not be ulcerated.38 Fracture may be the first sign when was no history of trauma. On examination the swelling the tumor occurs as primary neoplasm in bone.39 In case was located on the posterior maxilla with mobility of where the tumor is involving the maxillary sinus, there the associated teeth. Chest radiograph shows no may be associated symptoms like nasal obstruction, pulmonary metastasis. Craniofacial computed nasal discharge and epistaxis associated with the onset tomography revealed an extensive ill-defined of the swelling.40 Less frequently, the presenting radiolucency without marginal sclerosis and periosteal symptom may be a persistent toothache or non-healing reaction. A definitive diagnosis of storiform- extraction socket.39 The reported interval between first pleomorphic malignant fibrous histiocytoma was made symptoms and diagnosis is 1.5 to 3.5 months.41 base on histology of the incisional biopsy. After hemi- According to Kanazawa et al,28 clinical symptoms were maxillectomy procedure patient was sent to oncology usually present from 2 weeks to 6 month before unit for post-operative radiotherapy. Patient presented 42 diagnosis . Other reported signs and symptoms are with local recurrence after 18 month and died despite pain, paresthesia and mobility of tooth. In our study commencement on chemotherapy. only 2 cases present with pain. The borders of the swelling may be well-defined or diffuse and the Case 5: A 32-year-old male presented to our clinic with overlying skin may appear glossy/shiny and a painful swelling of the left upper jaw of 6 month taut/stretched with firm consistency and area of duration. There was no history of pre-existing trauma 43 fluctuancy, thereby mimicking cervicofacial abscess. or irradiation exposure. Medical history was Two cases in our study were misdiagnosed as dental unrevealing. On examination the swelling was located abscess and treated with prolong antibiotic outside our on the posterior maxilla with mobility of the related hospital causing late presentation. MFH has got a male teeth. Chest radiograph shows no pulmonary predilection 2 6 and commonly occur in late metastasis. CT scan of the upper jaw revealed an 12,36 extensive ill-defined radiolucency without marginal adulthood. However, 90% of our cases were female sclerosis and periosteal reaction. A definitive diagnosis patients in their late adulthood. In plain radiograph, the imaging features of of storiform-pleomorphic malignant fibrous 44 histiocytoma was made base on histology of the MFH is not specific. Most of the reported lesion have incisional biopsy. Hemi-maxillectomy was performed presented as an extensive ill-defined radiolucency but patient died 12 months post-surgery from local without marginal sclerosis and periosteal reaction and recurrence and pulmonary metastasis. in few cases it can appear as well defined radiolucent lesion.34 Reported radiographic findings were irregular Discussion bone margin, a moth-eaten appearance, erosion of The clinical features, radiological features, cortex, pathological fracture and tooth root resorption. histological features, and treatment of published case The reported CT and MRI imaging features of MFH 44 reports and series of MFH involving the jaws were have also not been specific. On CT scans, MFH is identified from the PubMed database using the MeSH usually seen as a large lobulated soft-tissue mass, terms Histiocytoma, Malignant Fibrous, Jaws, which is isoattenuated to muscle. Calcification or Mandible, Maxilla. ossification can be detected in 5%-20%. The centre of In the head and neck region, MFH has been the lesion often has diminished attenuation due to 44 reported to involve the nasal cavity and paranasal necrosis, haemorrhage, or myxoid material. On MF sinuses most frequently, accounting for 30% of all image, MFH is typically seen as a mass that is cases.33In the sinonasal tract, it occurs most commonly isointense to muscle on T1-weighted images and in the maxillary sinus, followed by the ethmoidal sinus, heterogeneously hyperintense on T2-weighted 44 nasal cavity, sphenoid sinus, and frontal sinus34. Other images. reported site in the head and neck include the It is worth nothing that diagnosis based solely craniofacial bones (15-25%), larynx (10-15%), soft on clinico-radiological presentation may result in high- tissue of the neck (10-15%), major salivary gland (5- rate of initial misdiagnosis of MFH, and light 42 B.E. Edetanlen et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) microscopy with or without immunohistochemical histiocytoma of bone: clinicopathologic study of 18 investigations is therefore desirable for suspicious soft patients. N Y State J Med 1976; 76:552-559. tissue and bone lesions23. MFH has a complex 45 7. Albright J, Terry B et al. Mandibular juvenile histological components . For definite diagnosis, fibrous histiocytoma with ossification: a case report. J Heamatoxylin and eosin staining of the specimens Maxillofac Surg 1976; 4: 120-123. demonstrated a proliferation of histiocytic spindle- 8. Webber WB, Wienke EC. Malignant fibrous shape cells and fibroblast-like cells with clear and histiocytoma of the mandible. Case report. Plast vesiculated spindle-shaped nucleus. MFH has four morphologic patterns, recognized as the storiform - Reconstr Surg 1977; 60:629-634 pleomorphic, myxoid, giant cell, and inflammatory.45 9. Kasat VO, Saluja H, Rudagi BM, Kalburge JV, The most common type is storiform-pleomorphic. It is Sachdeva S. Malignant fibrous histiocytoma of common for several patterns to be observed within one maxillary alveolar ridge extending to the hard palate. J lesion. The explanation of the multiple patterns Cancer Res Ther. 2014; 10(2):422-424. observed morphologic for MFH is related to 10. Happonen RP, Ekfors T, Suonpa J, Forsell K. predominance of cellular differentiation.9,8 Malignant fibrous histiocytoma of the jaws: report of The management of MFH of the jaws requires two case. J Oral Maxillofac Surg 1988; 46:690-693 early radical surgery including removal of adjacent 11. Anavi Y, Herman G, Graybill S, Macintosh RB. normal tissues, with a minimum of 3cm tumor-free Malignant Fibrous Histiocytoma Of the mandible. Oral margins26. The efficacy of radiotherapy and Surg Oral Med Oral Pathol1989;68:436-443 chemotherapy treatments for MFH of jaws is not yet 12. Satomi T, Watanabe M, Kaneko T, Matsubayashi J, 26 well established . The decision of whether to submit a Nagao T, Chiba H. Radiation-induced malignant patient to radiation therapy depends on the size, site, fibrous histiocytoma of the maxilla. Odontology. 2011; 33 histological grade, and the width of surgical markings. 99:203-208. Based on the follow-up data from the reported MFH 13. Shahoon H, Esmaeili M, Nematollahi M. Eight- cases of the jaws, MFH is associated with high risk of year Follow-up of Malignant Fibrous Histiocytoma local recurrence and early distant metastasis. It is (Undifferentiated High-grade Pleomorphic Sarcoma) therefore vital to diagnose MFH early and aggressively of the Maxilla: Case Report and Review of the treated with radical surgery with or without neck d i s s e c t i o n a n d a d j u n c t p o s t - s u r g i c a l Literature. J Dent Res Dent Clin Dent Prospects. chemo/radiotherapy. It is of utmost importance that the 2009;3:32-35. treated MFH cases are kept under close follow up for a 14. Sato T, Kawabata Y, Morita Y, Noikura T, Mukai H, minimum period of 5years, to detect any post-surgical Kawashima K, Sugihara K. Radiographic evaluation of recurrence or metastasis. Also there should be a high malignant fibrous histiocytoma affecting maxillary index of suspicion of any painful orofacial swellings alveolar bone: a report of 2 cases. Oral Surg Oral Med with glossy and stretched skin surface to reduce Oral Pathol Oral Radiol Endod. 2001; 92:116-123. unnecessary prolonged antibiotic therapy delayed, and 15. Severson SG, Ruskin JD, Tu HK, Markin R S. misdiagnosis. Malignant Fibrous Histiocytoma Presenting in the right mandibular alveolar ridge and left lung: report of a Reference case. J Oral Maxillofac Surg 1987:45:955-958 1. Agbara R, Fomete B, Obiadazie AC, Omeje KU, 16. Sohail D, Kerr R, Simpson R H, Babajews A V. Samaila MO, Ajike SO. Fibrous histiocytoma of the Malignant Fibrous Histiocytoma of the mandible: the orofacial region in Nigerians. A retrospective review of importance of an accurate histopathological diagnosis. 11 cases Sahel Med J 2019; 22: 127-133. Br J Oral Maxillofac Surg 1995;33(3):166-168 2. Agnihotri R, Bhat KM, Bhat GS. A rare case of 17. Lin SK, How SW, Wang JT, Liu BY, Chiang CP. malignant fibrous histiocytoma of the gingiva. J Oral post-radiation malignant fibrous histiocytoma: a Periodontol. 2008;79:955-60. . clinicopathological study. J Oral Pathol Med. 1994; 3. Ozzello L, Stout AP, Murray MR. Cultural 23:324-9. characteristics of malignant histiocytomas and fibrous 18. Maisel RH, Manivel JC, Porto DP, Stanley M. xanthomas. Cancer 1963. 16:331–344. Post-irradiation sarcomas of the head and neck. Ear 4. O'Brien J E, Stout A P. Malignant fibrous Nose Throat J. 1989; 68:684-686. xanthomas. Cancer 1964. 17:1445–14455. 19. Ireland AJ, Eveson JW, Leopard PJ. Malignant 5. Feldman F, Norman D. Intra and extra osseous fibrous histiocytoma: a report of two cases arising in malignant histiocytoma (fibrous xanthoma) of bone. sites of previous irradiation. Br J Oral Maxillofac Surg. Radiology 1972:104:497-499 1988; 26: 221-227. 6. Huvos AG, Primary malignant fibrous 20. Dineshkumar T, Rekha M, Neelakandan RS, 43 B.E. Edetanlen et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) Sarawathy T R. Malignant Fibrous Histiocytoma of the 32. Kim C H, Jang J W, Kim M Y, Kim H G, Kim J H. mandible: a rare case report with review of the Undifferentiated Pleomorphic Sarcoma in Mandible. literature .Oral Maxillofac Pathol J 2017; 8:39-42. Maxillofac Plast Reconstr Surg 2014;36(6): 303-307 21. Satomi T, Watanabe M, Kaneko T, Matsubayashi J, 33. Vargas A, Echevarria E, Guzman J E. Primary Nagao T, Chiba H. Radiation-induced malignant malignant histiocytoma of the mandible: surgical fibrous histiocytoma of the maxilla. Odontology. 2011; approach and report of a case. J Oral Maxillofac Surg 99:203-8. . 1987; 45:634-638. 22. Effiom OA1, Ajayi OF, Nwoga MC, Ogundana 34. Senel FC, Bektas D, Caylan R, Onder E, Gunhan O M , A d e y e m o W L , K o l a d e M T . O . M al ig na nt f ibrous histiocytoma of the mandible. Clinicohistopathological analysis of 5 Nigerian cases Dentomaxillofac Radiol 2006; 35:125-128. of malignant fibrous histiocytoma of the jaws. Nig Q 35. Kiesel L, Willnow et al. Malignant fibrous J Hosp Med. 2012; 22:109-12. histiocytoma of the mandible in as 16/12year old boy . 23. Doyle LA. Sarcoma classification: an update based Z Kinderchir 1987; 42:40-42. on the 2013 World Health Organization classification 36. Sidhu SS, Bansal BP, et al Primary malignant of tumors of soft tissues and bone. Cancer 2014; fibrous histiocytoma of the maxilla. J Dent 1978; 216- 120:1763-1774. 264. 24. Kasat VO1, Saluja H, Rudagi BM, Kalburge JV, 37. Besly W, Wiensenfield D et al., Malignant fibrous Sachdeva S. Malignant fibrous histiocytoma of histiocytoma of the maxilla. A report of two cases. Br J maxillary alveolar ridge extending to the hard palate. J Oral Maxillofac Surg 1993;31:45-48 Cancer Res Ther. 2014; 10: 422-4. 38. Colmenero C, Garcia Rodejas E. Osteogenic 25. Al-Salihi K.A., Samsudin A.R. Malignant fibrous sarcoma of the jaws: malignant fibrous histiocytoma histiocytoma (MFH) of the mandible and subtype. J Oral Maxillofac Surg 1990; 48: 1323-1328. submandibular salivary gland: report of a case. Oral 39. Daou RA, Attia E L. Malignant fibrous Oncol. 2004;40:123–125 histiocytoma of the head and neck. J Otolaryngol 1983; 26. Lambade P.N., Lambade D., Saha T.K., Bande 12:383-388 C.R., Ramakrishana A. Malignant fibrous 40. Narvaez JA, Muntane A. Malignant fibrous histiocytoma: an uncommon sarcoma with histiocytoma of the mandible. Skeletal Radiol 1996; pathological fracture of mandible. J Maxillofac Oral 25:96-99. Surg. 2015; 14: 283–287. 41. Yoshimura Y T, Kawano et al. Malignant Fibrous 27. Abdul-Karim F.W., Ayala A.G., Chawla S.P., Jing Histiocytoma of the temporomandibular Joint. Report B.S., Goepfert H. Malignant fibrous histiocytoma of of a case.” Int J Oral Surg 1978; 7(6): 573-579. jaws. A clinicopathologic study of 11 cases. Cancer. 42. Onyango JF, Awange DO. Primary malignant 1985; 56:1590–1596. fibrous histiocytoma of the mandible: a case report. 28. Kanazawa H, Watanabe T, Kasamatru A. Primary East Afr Med J. 1993; 70:460-3. malignant fibrous histiocytoma of the mandible: 43. Naik S, Rao D, Hegde S. Malignant fibrous review of the literature and report of case. J Oral histiocytoma clinically mimicking dental abscess in a Maxillofac Surg 2003;2013:1224–7 child: report of an unusual case. J Mass Dent Soc. 2014; 29. Huang H, Li D, Wang X, Wu Y, Liu S, Xu Z. 63:32-34. Treatment outcomes of malignant fibrous histiocytoma 44. Park SW, Kin HJ, Lee HJ, Ko YH. Malignant of the maxillary sinus. J Can Res Ther 2017; 13:660-3. fibrous histiocytoma of the head and neck: CT ad MR 30. Abdul-Karim FW, Ayala A G, Chawla S P, Jing B imaging findings. ANJR Am J Neuroradiol 2009; S, Goepfert, H. Malignant fibrous histiocytoma of 30:71-76 jaws. A clinicopathologic study of 11 cases. Cancer 45. Sarode SC, Sarode GS, Ingale Y, Ingale M, Raj T, 1985; 56; 1590–1596. Patil S. Malignant fibrous histiocytoma of the 31. Zohreh D, Nooshin M, Farnaz F, Farnaz B, Tahereh mandible. A Case report and review of published case N. Malignant Fibrous Histiocytoma of Mandible: A reports. J Oral Biol Craniofac Res.2019; 9:221-225 Review of Literature and Report of a Case . Australian J Basic Appl Sci 2011; 5:936-42 44 Medical Management of Ectopic Gestation Following a Failed Bilateral Tubal Ligation. 1O.O. Ogunbode, 2S.A. Adeyanju. 1. Department of Obstetrics and Gynaecology,College of Medicine, University of Ibadan, Ibadan, Nigeria. 2. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria. Summary means or even by expectant management; all these The objective of this paper is to emphasize that have specific criteria4,8. If pregnancy occurs following ectopic pregnancy can occasionally occur after a tubal ligation, the risk of it being an ectopic is 12.5%9. previous bilateral tubal ligation. Affected women may In this report, we present medical management of be reluctant to undergo a repeat surgery and medical ectopic pregnancy following a failed caesarean management is an acceptable approach in suitable bilateral tubal ligation. cases. The case was a40-Year-old G5P4+0 (3A) woman who presented to gynaecology clinic with 7- Case Summary weeks history of amenorrhoea and 1day history of Mrs O.E was a 40-Year-old G5P4+0 (3A) bleeding from the vagina. She has had two previous woman who presented to the gynaecology clinic on caesarean section and bilateral tubal ligation during her 6/11/2019with 7weeks history of amenorrhoea and last confinement in 2018. Ectopic pregnancy was 1day history of bleeding from the vagina. There was no confirmed, and she was medically managed with passage of blood clot or vesicles, no dizziness or methotrexate.Pregnancy after bilateral tubal ligation is fainting attacks, no abdominal pain. She had performed rare and when it occurs are rarely ectopic pregnancy. urine pregnancy test on two different occasions before Medical management can be offered to suitable presenting, and both were positive. patients where there is facility for follow-up. In 2011 she conceived spontaneously and had induction of labour at gestational age of 40 weeks in a Key words: Methotrexate, Ectopic pregnancy, private hospital because of severe preeclampsia but she Bilateral tubal ligation, Serum Beta HCG, Caesarean gave birth to a fresh stillborn baby. She had no Section puerperal problem.In 2012, she conceived spontaneously and presented to hospital with labour Introduction: pain at gestational age of 39weeks and 1 day but the Bilateral tubal ligation (BTL) is a form of baby developed heart irregularities and she permanent contraceptive technique commonly subsequently had emergency caesarean delivery of a recommended to women with completed family size. live male neonate with birth weight of 3Kg. He is alive Though with declining rates over the past 20 years, it is and well. In 2015, she conceived spontaneously again the commonest contraceptive used worldwide, and received adequate antenatal care, initially accounting for 23.7% of women using contraceptive, scheduled to have trial of vaginal birth after caesarean but with about the least uptake in Sub-Saharan Africa1. section, but however had elective caesarean section at Newer methods of sterilization have evolved over the gestational age of 41weeks and 3 days because of years with a shift towards minimally invasive 1previous caesarean section and postdatism and was techniques, however in Nigeria, mini-laparotomy and delivered of a live female neonate with birthweight of caesarean BTL are the common methods using the 3.4Kg. Puerperium was uneventful and baby is alive Pomeroy's technique2,3. and well. As effective as it is, it has a failure rate of 0.5%4- In 2018, she conceived spontaneously, and 6A failure rate of 0.1-0.8% in the first year after tubal booked for antenatal care at gestational age of 20 weeks sterilization has also been reported.7. Ectopic and 4 days; She was counselled for permanent pregnancy could be managed surgically, by medical contraception at the time of delivery which she and her husband consented to. In October 2018, she was Correspondence to: admitted at gestational age of 38-weeks and had elective caesarean section with bilateral tubal ligation Dr. S.A. Adeyanju on account of 2 previous caesarean section and Department of Obstetrics and Gynaecology, complete family size. The tissue specimens taken were University College Hospital, Ibadan. sent for histology which showed tubular structures in Phone: +234-7037992746 keeping with the fallopian tube. E-Mail:[email protected] She was not a known hypertensive, diabetic, asthmatic or peptic ulcer disease patient. She had not 45 O.O. Ogunbode et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) previously had blood transfusion. She neither smoked Douglas. The ultrasound diagnosis was right ectopic cigarette nor drank alcohol. She did not have any pregnancy, in view of a positive pregnancy test and a known drug allergy. differential diagnosis of enlarged right ovary. Clinical examination revealed a young She had a serum beta human chorionic woman, not pale, anicteric, afebrile, well hydrated with gonadotrophin (hCG) done which was 8,900 IU/L and no pedal oedema. Her respiratory rate was 18/min, with this was repeated in72 hours and found to be 8,874 clinically clear chest. Her pulse rate was 80/min, blood IU/L. She was then counselled on medical management pressure: 120/70mmHg, the first and second heart and was appropriately investigated. She had a Full sounds were heard with no added sounds. Her abdomen Blood Count (FBC) and differentials (Haematocrit was full and moved with respiration, Pfannenstiel scar [HCT] 35.5%, White Blood Count [WBC] 5.6 X was noted. There were no areas of tenderness and no 103/ml, Neutrophils 60%, Lymphocytes 30%, palpable mass; neither the uterus nor the intra- Monophils 5.3%, Platelets[PLT] count 424 x 103/ml), abdominal organs were palpable Vaginal examination Liver Function Tests (LFT)(Alanine transaminase showed a normal vulva and vagina. Cervix was firm, [ALT] 14mmol/l, Aspartate aminotransferase [AST] posterior and os closed. Uterus was not palpable by 19mmol/l, Alkaline phosphatase [ALP] 65mmol/l, bimanual examination, adnexa were free, cervical total protein 7.5g/l, Albumin 4.0g/l, Bilirubin motion tenderness test was negative and the pouch of 0.2mg/dl), Serum Electrolytes and Urea(Sodium Douglas was flat. There was minimal blood stain on 139mmol/l,Potassium 3.6mmol/l, Chloride 98mmol/l, gloved fingers. A diagnosis of threatened miscarriage Bicarbonate 24mmol/l , Urea 40mg/dl) done and these to rule out ectopic gestation was made were also within normal limit. Repeat pregnancy test was positive. Pelvic She was planned for single agent ultrasound done showed normal size uterus measuring intramuscular Methotrexate at a dose of 50mg/ Body 4.6 x 5.5 x 12.3cm, endometrium was 4mm and normal. Surface area (BSA). She had pre-chemotherapy Right ovary not seen separately from a 31 x 30 x 52 mm medication with two intravenous doses each of = 26cm3 oval rounded vascular heterogeneous solid Ranitidine 50mg, Ondansetron 8mg and mass in the region of the right fallopian tube. Left ovary Dexamethasone 8mg given slowly 8 hours apart on measured 24 x 15 x 16 mm = 3.3cm3. Normal pouch of each day of chemotherapy. She always had 500ml each Tabl e 1: Serial quantification of Serum beta human chorioni c gonadotrophin (âhCG). Date Serum âhCG % drop in Intervention level (IU/L) âh CG level 08/11/2019 (Pre-Presen tation) 8874 -- Ni l st 12/11/2019( 96hrs later) 5969 32.74 (over 4 days) 1 course 18/11/2019 2522 57.75 2nd course 25/11/2019 338.7 86.57 3rdcourse 09/12/2019 16.6 95.10 4th course 17/01/2020 0.2 98.80 No more chemotherapy hCG level(IU/L) 10000 9000 8000 ) /L 7000 U (I 6000 ls ve 5000 le G 4000 C h B 3000 2000 1000 0 0 20 40 60 80 100 120 Time of chemotherapy administration (Days) Figure 1: A graph showing the relationship between the serum beta hCG (vertical axis) and Time (in days) of administration of chemotherapy (Methotrexate). 46 O.O. Ogunbode et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) of normal saline and 4.3% dextrose saline given over 1- termed the implantation of a fertilized ova outside the 2 hours before commencing the premedication.The endometrial lining of the uterine cavity and it is a life- intramuscular methotrexate was then administered threatening event. It's morbidity and mortality increase about 15-30 minutes after the second doses of when patients present with ruptured ectopic pregnancy. premedication. Depending on the presentation, ectopic pregnancy She was managed on an out-patient basis with could be managed conservatively, medically or the patient admitted in the ward as a day case on the day surgically. Mrs O.E presented with features suggestive of chemotherapy and then discharged home about half of unruptured ectopic pregnancy, so she was an hour post chemotherapy. With a BSA of 1.62, she considered suitable for medical management. received 85mg of methotrexate. About 96 hours after Medical management of ectopic gestation the first dose, there was approximately 57.75% decline often involves the use of systemic methotrexate8.The in the level of serum hCG from 5969 to 2522 IU/L. benefits of the medical management are that it She was scheduled for weekly serum hCG potentially causes less tubal damage, avoids the risk of assay and for repeat weekly methotrexate until the morbidity associated with surgery and anaesthesia and serum beta hCG becomes undetectable. Prior to each is cost-effective which makes it more relevant in low course of chemotherapy, she had repeat FBC + resource countries. It however has its own draw backs differentials, LFTs and Serum E&Udone,and they were from the side effects of the medications given and that it all within normal limit. She came weekly for the second may require prolonged hospitalization but and third doses but defaulted because of financial improvements in the protocol over the years have made reasons for a period of two weeks before the fourth it possible for single dose outpatienttherapy18. dose. The serum level of beta hCG dropped The patient must satisfy the criteria for medical precipitously after each dose of methotrexate. After the management of ectopic pregnancy which include being second dose, 86.57% fall, 95.10% decline after the clinically stable with no significant pain, having an third dose and 98.80% fall after the fourth dose at which unruptured tubal ectopic with adnexal mass smaller point the hCG level had returned to normal level. She than 35mm with no visible heartbeat, and serum hCG did not develop any side effect of methotrexate level less than 1,500IU/L, ultrasound confirmation of throughout the period of treatment and follow up. absent intrauterine gestation and a patient who was She was counselled on the need for alternative willing to return for follow up8.Although the patient in contraceptive method and the option of vasectomy for question did not meet all the above criteria, in view of her husband. Additionally, she was counselled on the her haemodynamic stability, ultrasound findings risk of future ectopic pregnancy and the need to present (including lack of a fetal heart tone and absence of early after missing her period. She was then given a 3- evidence of rupture),and willingness to come for months clinic appointment for follow-up. follow-up, even though the serum beta hCG level was high (8874 IU/L) and the size of the ectopic sac could Discussion not be ascertained since it could not be delineated from Tubal ligation is a common surgical procedure the right ovary, medical management was still offered aimed at permanently blocking the fallopian tubes to to this patient. prevent spermatozoa from reaching an ovum for The patient received intramuscular fertilization. It involves the tubes being cut and tied, Methotrexate at a dose of 50mg/ Body Surface area cauterized, blocked with rings or clips and intratubal (BSA). With a BSA of 1.62, she received 85mg of injection or insertion of sclerosants or devices8. It is methotrexate. About 96 hours after the first dose, there commonly done by mini-laparotomy or was approximately 57.75% decline in the level of laparoscopically but recently through hysteroscopic serum hCG. After the second dose, 86.57% fall, methods10,11. It is an effective method of contraception, 95.10% decline after the third dose and 98.80% fall but method failure has been reported as low as 7 after the fourth dose at which point the hCG level had pregnancies per 1000 procedures12-14 The failure rates returned to normal level. Although, there is no vary among the different methods and higher failure consensus on whether to use a single dose or multiple rates has been documented amongst BTL done at courses of chemotherapy, the multiple course regimen caesarean section15. has been documented to be associated with greater Pregnancy occurring after BTL can be success and it was adopted in the management of Mrs. emotionally disturbing to the woman and are O.E18. mostlyintrauterine16,17. In 12.5% of cases, these could be The initial intention was to perform weekly ectopic pregnancy and heterotopic pregnancy serum hCG level assessment and administer following BTL has also been reported8. The occurrence intramuscular Methotrexate weekly but because of of ectopic pregnancy after BTL may be due to financial constraint, she could not catch up with that spontaneous tubal recanalization or the formation of pace. However, because of good and on-going tubo-peritoneal fistula9,16. An ectopic pregnancy is counselling the patient was able to continue the 47 O.O. Ogunbode et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020) management to this satisfactory point without 42(4): 713–724. defaulting. 5. Roeckner JT, Sawangkum P, Sanchez-Ramos Side effects of methotrexate include blood disorders (bone marrow suppression), liver damage, L, Duncan JR. Salpingectomy at the time of caesarean pulmonary toxicity; gastrointestinal disturbances such delivery A systematic review and meta-analysis. as stomatitis and diarrhoea renal failure, skin reactions, Obstetrics & Gynaecology. 2020; 135(3): 550-557. alopecia, osteoporosis, arthralgia, myalgia and ocular 6. Clark NV, Endicott SP, Jorgensen EM, Hur H, irritation18. However, throughout the period of Lockrow EG, Kern ME. et al. Review of sterilization treatment, the patient did not have any of these techniques and clinical updates. Journal of Minimally symptoms or signs and the pre-chemotherapy Invasive Gynecology. 2018; 25(7): 1157-1164. investigations were within normal limit. She was 7. Date SV, Jyoti Rokade J, Dandapannavar S. hydrated and had pre-chemotherapy medications with Ranitidine, Ondansetron and Dexamethasone. The aim Female sterilization failure: Review over a decade and of this was to reduce to the barest minimum the possible its clinicopathological correlation. Int J Appl Basic side effects of the chemotherapeutic agent used. Med Res. 2014; 4 (2): 81-85. She was counselled on the need for alternative 8. Ectopic pregnancy and miscarriage: diagnosis contraceptive method and she has chosen to use and initial management NICE guideline [NG126] combined oral contraceptive pills for now. Though she Published date: 2019. was counselled on the need for long acting reversible 9. Shah JP, Parulekar SV, Hinduja IN. Ectopic contraception, but because of her previous unpalatable pregnancy after tubal sterilization. J Postgrad Med. experience of excessive bleeding with injectables and abnormal vaginal discharge with copper-containing 1991;37(1):17-20. intrauterine devices she did not want them. She wanted 10. Kumbak B, Ozkan ZS, Simsek M. Heterotopic some more time to think on implants though she was pregnancy following bilateral tubal ligation: Case afraid of weight again and abnormal menses as her Report. The European Journal of Contraception and friends narrated their experiences to her. Another Reproductive Health Care. 2011; 16:319-321. possible option is to counsel her husband for 11. Mao J, Guiahi M, Chudnoff S, Schlegel P, vasectomy, however the cultural acceptability is low in Pfeifer S, Sedrakyan A. Seven-Year Outcomes After this environment. In conclusion, no contraceptive method is Hysteroscopic and Laparoscopic Sterilizations. Obstet 100% safe. Where failure occurs and pregnancy results, Gynecol. 2019;133(2):323-331. early diagnosis and prompt management is key so as to 12. Clark NV, Endicott SP, Jorgensen EM, Hur H, reduce the possible morbidity and mortality that may Lockrow EG, Kern ME. et al. Review of sterilization ensue, and where medical management could replace techniques and clinical updates. Journal of Minimally surgical care, clinician should carefully select the Invasive Gynecology. 2018; 25(7): 1157-1164. patient and apply medical rather than operative care, 13. Peterson HB. Sterilization. Obstetrics & especially when it may not significantly improve the Gynecology 2008; 111(1):189–203. patient's outcome. 14. Date SV, Rokade J, Mule V, Dandapannavar S. References Female sterilization failure: Review over a decade and 1. United Nations, Department of economic and its clinicopathological correlation. Int J Appl Basic social affairs. Contraceptive use by method 2019. Med Res. 2014;4(2):81-85. https://www.un.org/en/development/desa/population/ 15. Sefogah PE, Onuzo CK, Gordon AS. Ectopic publications/pdf/family/ContraceptiveUseByMethod pregnancy after bilateral tubal ligation. Postgraduate DataBooklet2019.pdf. Medical Journal of Ghana. 2017;6(1);59-62. 2. Igberase GO, Ebeigbe PN, Umeora OUJ, 16. Naqvi SSB. Ectopic pregnancy after bilateral Abedi HO. Bilateral tubal ligation in a rural hospital in tubal ligation. Pakistan Armed Forces Medical Journal. the Niger Delta, Nigeria. Nigerian Journal of Clinical 2014; 64(2): 378- 379. Practice 2011; 14(2):137-139. 17. Awonuga AO, Imudia AN, Shavell VI, Berman 3. Swende TZ, Hwande TS. Female sterilization J, Diamond MP, Puscheck EE. Failed Female by tubal ligation at caesarean section in Makurdi, sterilization. A review of pathogenesis and subsequent Nigeria. Annals of African Medicine. 2010; 9(4): 246- contraceptive options. The Journal of Reproductive 250. Medicine. 2009; 54(9):541- 547. 4. Moss C, Isley MM. Sterilization: A review and 18. Lesavre M, Curinier S, Capmas P, Rabischong update. Obstetrics & Gynaecology Clinics. 2015; B, Fernandez H. Treatment of tubal ectopic pregnancy by methotrexate. J Gynecol Obstet Biol Reprod. 48