Volume 27, Number 3 July, 2020 - Bowen University

Volume 27, Number 3

July, 2020

Volume 27, Number 3July, 2020

THE TROPICAL JOURNAL OF HEALTH SCIENCES

Official Publication of the College of Health Sciences, University of Ilorin

EDITORIAL BOARD

EDITOR-IN-CHIEFA.B. Okesina

ASSOCIATE EDITORS

K.W. WahabO.T. AdedoyinO.B. Akinola

BUSINESS/CIRCULATION MANAGERM.B. Uthman

CONSULTING EDITORS

Prof. Egon Amann GERMANY

EGYPT

NIGERIA

NIGERIA

SOUTH AFRICA

NIGERIA

Rania Mohammed El’-Sharkawy

Prof. J.O. Obafunwa

Prof. Akin Osibogun

Prof. R. T. Erasmus

Prof. Bappa Adamu

ii

he Tropical Journal Of Health Sciences (TJHS) is an international

journal which provides a forum for exchange of ideas to those 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).

Editorial and all other correspondence should be sent to:

The Editor-in-Chief,

The Tropical Journal of Health Sciences,

% Office of the Provost,

College of Health Sciences,

University of Ilorin,

P.M.B. 1515,

Ilorin,

Nigeria.

E-mail: [email protected],

[email protected]

All Rights Reserved

No part of this journal may reproduced, stored in retrieval system or

transmitted in any form or by any means electronic, mechanical,

photocopying, recording or otherwise without permission of the publisher.

The Tropical Journal of Health Sciences

ISSN 1117-4153

AIMS AND SCOPE

iii

THE TROPICAL JOURNAL OF HEALTH SCIENCES

Volume 27 Number 3 July, 2020

CONTENTS

Research papers

Editorial comments v

iv

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

Radiological Findings in Aqueductal Stenosis in a Preterm Infant. H.J. Akande, B.B. Olafimihan. P.N. Omefe, A.T. Ifarinola 36

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

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

1

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

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

Case reports

Medical Management of Ectopic Gestation Following a Failed Bilateral Tubal Ligation.O.O. Ogunbode, S.A. Adeyanju. 45

EDITORIALCOMMENTS

elcome to the reading of July 2020 edition of The Tropical Journal of Health Sciences. Prevention is the best form of treatment, not only for COVID -19, whose pandemic the world is currently facing but it is also W

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 D measurements should be encouraged to rule out hypovitaminosis D 3

in paediatric patients with unusual clinical presentations.

Happy reading

A.B OKESINAEditor In Chief

v

Correspondence to:

01

Abstract IntroductionPoor 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 1workplace accidents and occupational illnesses prevention of occupational hazards. The 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, 2baseline, intervention and post-intervention information, and economic instruments. Globally, 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

3140 participants (70 participants per group; from the occurring in the same time period. Deaths 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

4out training on occupational health and safety in the mining. Poultry 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,

5version 21. gastrointestinal and musculoskeletal systems. They 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

6hazards and of OHS was also statistically significant and employees must be involved. There 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

7,8,9,10periodic training and retraining exercises be provided. as the reason for poor practice.It should be stressed that when health is

Keywords: Occupational health, safety, poultry farm, addressed, so is safety, because a healthy workplace is 11workers, Kaduna. by definition also a safe workplace. When workers

have poor knowledge, attitude and practice of Occupational Health and Safety (OHS), it compromises any effort to create a safe workplace.Studies have shown that 90% of accidents happen because of unsafe behaviour and human

12,13error. Surveys have shown that the level of knowledge and awareness of agricultural health and safety risks, disease, and injury prevention among

14,15farmers is low. A good knowledge score has been

1 2 1 1N.O.Usman, A.U.Shehu, A.G.Nmadu, V.N.Omole,

Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna State, NigeriaCellphone Phone:+234 8035905729E-mail address :[email protected]

Dr N.O. Usman

The Effect of Training on The Knowledge and Practice

of Occupational Health and Safety Measures

among Poultry Farm Workers in Kaduna State, Nigeria

1.Department of Community Medicine, College of Medicine, Kaduna State University, Kaduna State, Nigeria2.Department of Community Medicine, College of Medicine, Ahmadu Bello University, Kaduna State, Nigeria

N.O. Usman et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)

02

shown to be a predictor for practice of preventive This was followed by eight training sessions using the 16 training module adapted from the ILO training module measures.

on poultry farm workplace health and safety and the The poor OHS regulatory system in the framework for the design of the World Health country does not encourage mandatory reporting of

17 Organisation modules in occupational health. The accidents, which OHS regulations require. There is poultry farm workers were divided into two groups of need for interventional studies on OHS among poultry 35 participants each. This was to ensure ease of farm workers considering their peculiar situation of interaction. The training was conducted on Mondays being exposed to hazards for several hours on a daily and Tuesdays for one group and the other group was basis. However, there is paucity of data on this subject. Wednesdays and Thursdays. One module was taken per This study aims at determining the effect of training on week. Each group had 8 training sessions and 35 knowledge and practice of OHS among poultry farm participants were trained per session. The training was workers.carried out for two hours per day (12pm to 2pm) on two days per week for four consecutive weeks and it was Methodsconducted in Hausa (local language).The study was conducted in Kaduna North and

Prior to the commencement of data collection Sabon Gari Local Government Areas (LGAs), which there was an advocacy visit to the Head of Department are semi urban communities in Kaduna state, north of Agriculture of the selected LGA and to the west Nigeria. This study was quasi experimental with chairperson of the poultry farmers association where baseline, intervention and post-intervention the selected farms were located. Permission was also components. The sample size for poultry farmworkers sought from the owners of the farms.was determined using the formula for comparison of

Data was collected three months after the proportions in the baseline and post-intervention 2 18 training from both study and control groups using the components of a study, (Z + Z ){(p q p q ) / (p p ) } 1-á 1-â 1 1+ 2 2 1- 2

same data collection tools and research team used to with the probability score at 95% interval and a collect the pre-intervention data. The questionnaires precision level of 5%. Where n = minimum sample were manually checked for accuracy and sizefor each group, Z = standard normal deviate 1- á

completeness; data was analysed electronically using corresponding to the 95% confidence interval for the Statistical Package for Social Sciences (SPSS) version study i.e. 1.96, Z = standard normal deviate 1- â 21. The mean and standard deviation were obtained for corresponding to 80% power of study i.e. 0.840, p = 1 the knowledge score as well as independent t-test used

proportion of poultry farm workers with good to compare mean knowledge score between the study 19

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 study2 . 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 2appropriate standard tests like Chi square test (÷ )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.

N.O. Usman / The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)et al

03

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

Variable Category Study group type Test statistic

Study (n=70)

Frequency (%)

Control (n=70)

Frequency (%)

÷2 p-value

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 education

Quranic 43 (61.4) 41 (58.6) 0.13b 0.937

Primary 18 (25.7) 19 (27.1)

Secondary

9 (12.9)

10 (14.3)

a- Fisher’s Exact b- Pearson chi square

Table 1: Socio-demographic profile of the study and control groups


04

Variable

Pre-Intervention Post-Intervention Study Frequency (%)

Control Frequency (%)

p-value Study Frequency (%)

Control Frequency (%)

p-value

Physical Hazards Musculoskeletal

problems

47 (67.1)

50 (71.4)

0.500

66 (94.3)

51 (72.9)

0.0014

Harsh weather

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)

<0.0001

Route of Exposure to Chemical Hazards

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

Absorption

6 (8.6)

4 (5.7)

0.740*

27 (38.6)

4 (5.7)

<0.0001*

Biological Hazards

Infection from sick birds

47 (67.1)

48 (68.6)

1,000

65 (92.9)

48 (68.6)

0.0003

Lung infection from dust

46 (65.7)

47 (67.1)

1.000

63 (90.0)

47 (67.1)

0.0009

Infection from handling bird waste

42 (60.0)

43 (61.4)

1.000

61 (87.1)

43 (61.4)

0.0005

Infection from unsafe water

38 (54.3)

41 (58.6)

0.729

59 (84.3)

41 (58.6)

0.0008

Infection from direct contact with cages

18 (25.7)

23 (32.9)

0.353

53 (75.7)

23 (32.9)

<0.0001

Table 2: Comparison of study and control group knowledge of occupational hazards at

pre-intervention and post-intervention (n=70)

Table 3:Comparison of study and control group knowledge of OHSat pre-intervention and post-intervention (n=70)

Variables

Pre-intervention

Post-intervention

Study

Control

p-value

Study

Control

p-value

Training and retraining of staff

65 (92.9)

67 (95.7)

0.718

70 (100.0)

67 (95.7)

1.000

Follow employers’ instruction

53 (75.7)

55 (78.6)

0.689

63 (90.0)

55 (78.6)

0.0632

Use or wear PPE

51 (72.9)

47 (67.1)

0.462

65 (92.9)

47 (67.1)

0.0173

Reporting any symptoms noticed early

49 (70.0)

51 (72.9)

0.708

63 (90.0)

51

(72.9)

0.0091

Wash hands and face with soap

44 (62.9)

47 (67.1)

0.597

62 (88.6)

48 (68.6)

0.0042

Never eat or drink at work

43 (61.4)

38 (54.3)

0.393

60 (85.7)

38 (54.3)

<0.0001

Keep clothing separate from PPE

42 (60.0)

47 (67.1)

0.380

61 (87.1)

47 (67.1)

0.0048

Use foot bath before entering poultry

40 (57.1)

35 (50.0)

0.396

63 (90.0)

35 (50.0)

<0.0001

Use foot bath when leaving

40 (57.1)

35 (50.0)

0.396

59 (84.3)

35 (50.0)

<0.0001

Reading and understanding information

37 (52.9)

39 (55.7)

0.729

59 (70.0)

39 (55.7)

0.0002

Test statistic:? 2 test

in the self-reported practice of handwashing and use of Discussionfoot 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

10,20(Table 6) in Sokoto and Zaria. The job is known to be male-


05

Table 4: Comparison of study and control group knowledge of occupational hazards and OHS practices at pre-intervention and post-intervention (n=70) Variable

Category

Pre intervention Post intervention Study

Frequency (%)

Control Frequency

(%)

p-value

Study Frequency

(%)

Control Frequency

(%)

p-value

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 Variable

Group Mean and standard deviation Test statistics* and p-value

Study

Control

Knowledge score

Pre intervention

27.49±4.01 27.11±3.20 0.7325

Post intervention

39.23±3.84 28.04±3.61 <0.0001

Independent t-test*

Table 6: Comparison of study and control group practice of OHSat pre-intervention and post-intervention (n=70)

Variables

Pre intervention Post intervention Study Control p-value Study Control p-value

Frequency (%)

Frequency (%)

Frequency (%)

Frequency (%)

Change clothes

45 (64.3)

47 (67.1)

0.718

61 (87.1)

47 (67.1)

0.0048

Wash hands with soap and water

44 (62.9)

48 (68.6)

0.475

60 (85.7)

48 (68.6)

0.0158

Eating or drinking while working

43 (61.4)

37 (52.9)

0.305

37 (52.9)

37 (52.9)

1.000

Use foot bath

23 (32.9)

21 (30.0)

0.718

38 (54.3)

21 (30.0)

0.0036

Wear face mask

13 (18.6)

11 (15.7)

0.654

14(20)

11 (15.7)

0.507

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

21 likelihood of exposure.dominated consequent upon the fact that poultry farm There was a statistically significant difference workers resume work very early and spend between 8

in the mean knowledge score in the study and control to 12 hours at work. This is time spent away from the groups post-intervention (Table 4) with about half of home and most females might find this inconvenient the respondents in the study group having good especially in this sub-region. Majority of the knowledge of occupational health and safety measures respondents had only Quranic education which is associated with poultry farming. At the end of the similar to findings from studies carried out in this sub-

10,20 intervention study in Sokoto there was a 35% increase region. This is not surprising as educational in the proportion of respondents with good attainment in the North western part of Nigeria is

1022 knowledge. The proportionate increase in respondents especially low and with menial jobs, education is not a with good knowledge was comparable to a study prerequisite.carried out in Ontario Canada where there was a 27% At the end of the study there was a statistically increase in farmers' knowledge after educational significant increase in knowledge of physical hazards,

25intervention. This shows the effectiveness of training biological hazards and routes of exposure to chemical as an appropriate tool to improve knowledge.hazards. (Table 2) This is similar to studies carried out

At baseline, the self-reported use of personal in Egypt where there was a statistically significant protective equipment was 18.6%, 15.7%, 5.7% and increase in knowledge of hazards at the end of the

23 1.4% for face masks, gloves, boots and apron among study. Similarly, a study carried out in Thailand respondents in the study group (Table 6). This was showed a statistically significant increase in the similar to a study carried out in Sokoto where the use of knowledge about agrochemicals following heath

1024 hand gloves was 16%. However the use of boots, face education. The study showed that about two-thirds of masks and aprons was 21%, 53% and 17%. This respondents in the study group knew that hand washing disparity could be due to the fact that when the study in was an important preventive measure (Table 3). This Sokoto was carried out, the government in the state had was similar to a study carried out in Zaria where 60.7%

20 distributed free personal protective equipment to the of the respondents knew about hand washing. This various farms in the state. It also differed from a study was also similar to a study carried out in Benin where in Nepal where 30.2% used gloves, 27.1% used face 59.1% of the respondents knew that hand washing was

8mask and 7.3% used boots. This disparity could be necessary preventive measure.The study showed that attributed to the difference in educational level of the about two-thirds of respondents in the study and control respondents; the lack of availability of adequate groups knew that hand washing was an important personal protective equipment and due to the fact that preventive measure (Table 3). This was similar to a these studies were carried out when there was a global study carried out in Zaria where 60.7% of the

20 spotlight on poultry farming due to the emergence of respondents knew about hand washing. This was also avian influenza (bird flu). As a result of the inadequate similar to a study carried out in Benin where 59.1% of use of PPEs these poultry farm workers are at an the respondents knew that hand washing was necessary

19 increased risk for numerous occupational preventive measure. However the proportion who injuries/accidents and diseases. At the end of the study knew about hand washing was lower than that obtained there was a statistically significant increase in the in a study in Nepal, where 88.5% knew about the

8 proportion of workers who changed clothes, washed importance of hand washing. This could be due to the hands with soap and delayed eating till they were out of fact that majority of the respondents in that study had the poultry (Table 6). There was no significant change higher level of education. Knowledge on hand-washing in the use of PPEs likely due to the fact that they were is essential to maintain good health as these workers not provided by the farm owners. This highlights the come in contact with faeces and urine of the livestock need to involve employers in any intervention planned.as well as coming in contact with sick and/or dying

birds. If the workers are not aware when and how Limitation of the Studyfrequently they should wash their hands, they are at risk

Due to poor registration practices, the list of of various diseases.poultry farms within each LGA was inaccurate. Farm The study showed that baseline majority of owners did not provide PPEs for their workers as a respondents in the study group knew the importance of result it would affect the post-intervention utilisation of training and retraining on occupational health and PPEs.safety measures (Table 3). The findings differ from a

study carried out in Benin city where only 31.9% of Conclusion respondents knew that training on occupational health

19 At baseline both study and control groups had and safety measures was necessary. Training and re-low levels of knowledge and poor observed and self-training is necessary to enlighten them on the hazards

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

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: ht tp: / /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/S095758200571Washington DC: The International Bank for 2246Reconstruction 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


08

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.

Correspondence to:

09

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 IntroductionImmunization 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

1essential that pregnant women accept this health diseases. 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

1,2study investigated knowledge and perception towards deaths yearly. Immunization 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

3diseases that could be prevented by immunization, else or another organism. Thus, 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

4completion of (98%) the immunization schedule was infection in the future.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

5although, there is need for appropriate education of community. Epidemiological 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

6Africa and Asia. . 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%

7in 30 years. With the extent of success following immunization initiative worldwide, the situation is quite different in developing countries especially in Africa where vaccine-preventable diseases (VPDs) contribute significantly to mortality among under-five

8children. Nigeria like many other countries in Africa is making continuous efforts to strengthen its health system so as to achieve sufficient routine immunization to lessen the burden of VPDs. However, certain elements such as inadequate funding, poor level of

Maternal Knowledge and Perception Towards Childhood

Immunization in a Health Facility in Delta State, Nigeria.

1 1 1 2 3 1 1E. G. Moke, K. E. Edje, E. K. Umukoro, P. Y. Toloyai, T. M. E. Daubry, A.I. Omogbiya, B. E. Oshevirhe.

E.G. MokeDepartment of Pharmacology and TherapeuticsFaculty of Basic Medical SciencesDelta State University, Abraka, NigeriaE-mail: [email protected]: +234-7061040692

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 –weeks; m – months.

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

8-10 perception toward childhood immunization. Data was in Nigeria. Surveying the knowledge and attitude presented as percentage using descriptive statistics.towards childhood immunization is an important first

2step towards understanding the factors that influence N / [1 + N(e) ]11vaccine non-acceptance in a particular setting , hence

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 parents'(maternal) knowledge and perception towards

Resultschildhood immunization essentially at the communal level.

Although researches have been published on parents' knowledge, attitudes and practices regarding childhood vaccination, little or no such studies have been reported in Abraka, Ethiope-East Local Government Area of Delta State, Nigeria. Thus, this study was undertaken to assess maternal knowledge and perception on childhood immunization among

The result revealed that majority of the mothers attending antenatal clinicin General Hospital respondents (90%) knew that immunization was used Abraka, Delta State, Nigeria.to prevent childhood diseases, and majority (94%) agreed that immunization can be done at the hospital Materials and Methods(94%), however 6% of them thought their children can A cross-sectional descriptive study design was be immunized in a community pharmacy. Eighty adopted to assess the knowledge and perception among percent (80%) heard about Immunization first from the mothers attending antenatal clinic in the General hospital, while fewer proportion (12%)had heard via Hospital, Abraka, Delta State. The antenatal clinic of media (radio and television), with 8% of the the General Hospital, Abraka receives an average respondents informed about immunization by friends 120patients monthly (consisting both old and new (Table 3).Majority of the respondents (78%)indicated cases). An estimated sample size of 92 was obtained measles as a disease that could be prevented by using Slovin's formula for calculation of sample size, immunization, while 40% (yellow fever), 36% (polio), which was then rounded up to 100. The survey was 24% (tetanus), 22% (tuberculosis), 16% (hepatitis B), conducted by coding the weekly attendance to 10% (meningitis), and another 10% (diphtheria) randomly select 100 mothers receiving antenatal care indicated other diseases. Twelve percent (12%) of the between March and April 2018 at the General Hospital mothers thought that malaria could be prevented by Abraka. Ethical approval was obtained from the ethical immunization, while a lesser number of the committee of the Faculty of Basic Medical Sciences,

Slovin's formula: n = ; where N - population size, n - sample size, e - significance level (for this study 0.05)

The results obtained showed that mothers attending antenatal care at the General Hospital Abraka have a mean age of 27.05 years. Majority of the respondents (86%) were married, with only a few (12%) being single. About two?thirds of the respondents (62%) had post-primary education, and a larger percentage (58%) of them were into business (Table 2).

E.G. Moke et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)

10

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 percent (54%) and 40% of the could be given by 6 weeks after birth. Also, 28% and respondents knew that vaccines could be administered 34% knew that 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

Table 2: Socio-demographic characteristics

Variable Frequency (n=100)

Percentage

Age (years)

21-25

44

44

26-30

36

36

31-35

15

15

36-40

5

5

Mean age

(±SD)

27.05 ± 1.89

Marital Status

Married

86

86

Single

12

12

Widowed

2

2

Educational Status

No formal

20

20

Primary

18

18

Secondary

30

30

Tertiary

32

32

Occupation

Professional

8

8

Business women

58

58

Civil servant

18

18

Self-employed

18

18

Farmer

8

8

Table 3: Knowledge of respondents on childhood immunization

Variable

Frequency

(n=100)

Percentage

Purpose

To prevent childhood diseases

90

90

To help children grow fast

6

6

To make children intelligent

4

4

Place for immunization

Hospital

94

94

Community pharmacy

6

6

Source of information about immunization

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

36

36

Tetanus

24

24

Tuberculosis

22

22

Hepatitis B

16

16

Malaria (Tricky Option)

12

12

Meningitis

10

10

Diphtheria

10

10

No Idea

4

4

*Multiple responses given.

E.G. Moke / The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)et al

11

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 2disagreed. 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

11immunization schedule was important; likewise,a total especially at the communal level. The 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

Table 4: Knowledge of mothers on vaccination schedule and routes of administration.

Variable Frequency (n=100)

Percentage

Vaccination schedule* BCG vaccine is administered

at birth

32

32

Hepatitis B vaccine is administered at birth

6

6 Rotavirus vaccine is administered at 6 weeks after birth

10

10

OPV-1 vaccine is administered at 6 weeks after birth

28

28

OPV-2 vaccine is administered at 10 weeks after birth

34

34

Penta-1 vaccine is administered at 6 weeks after birth

28

28

Penta-2 vaccine is administered at 10 weeks after birth

20

20

Measles vaccine is administered at 9 months after birth

30

30

Yellow fever vaccine is administered at 9 months after birth

36

36

No idea

28

28

Routes of administration of vaccine*

Injections

54

54

Mouth drops

40

40

Syrup

20

20

No idea

10

10

*Multiple responses given.

Table 5: Perception

of respondents towards childhood immunization

Variable

Frequency (n=100)

Percentage

It is necessary to immunization children against

VPDs

Agree

92

92

Disagree

8

8

Immunization is more beneficial than harmful

Agree

90

90

Disagree

2

2

No idea

8

8

Would you like to comply to immunization schedule

Yes

96

96

No

4

4

Would you like to complete the immunization process

(full immunization) for children

Yes

98

98

No

2

2

Possible reason for non-completion of immunization process (n=2)

Far distance to place of immunization

2

100


12

among the respondents. diagnosis as such mothers may provide an erroneous 3The study revealed that a high proportion of the immunization history in the future.

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

8 , 1 2 - 1 4studies. 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

14, 18-20more probable to have timely and full vaccination of childhood immunization. Only a small percentage 11

their children. This 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

8-10well as yellow fever (40%) and polio (36%). Few others immunization coverage in Nigeria.indicated tetanus, tuberculosis, hepatitis B, meningitis, and diphtheria as VPDs, while some(12%)thought Conclusionmalaria 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

14,15contrast with other studies 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

16 proper designing and execution of the national could not mention even one VPDs. Thus, it is exigent immunization programme.for health professionals to provide mothers with

adequate information on the VPDs and benefits of Acknowledgements immunization in order to improve acceptance of and

We wish to acknowledge the support of Dr. compliance to immunization, hence promoting the Basil Ekuerhare of the University Health Services, success of immunization.Delta State University, Abraka, Delta State, Nigeria.Furthermore, the present study showed that

fewer than half ratio of the mothers knew the Conflict of interest: appropriate schedule for vaccine administration. This

The authors declare no conflicts of interest.outcome is consistent with the reports of similar 3study which showed that most mothers did not know

References when each vaccines could be administered. Likewise, 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 http://www.who/int/topics/immunization/ en/.

14of a study among rural mothers in Lagos where 83.2% (Accessed on 23 Apr 2020).and 77.6% knew both correct routes respectively,

2. WHO, UNICEF, World Bank. State of the world's 17although, another study observed far more little vaccines and immunization. 3rd edition. 2009. knowledge (4.8%). Some mothers could feel that their A v a i l a b l e a t : children are being immunized when administered http://whqlibdoc.who.int/publications/2009/9789241syrup for other treatments, thus, complicating doctor's


13


14

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. Avai lable 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

Correspondence to:

15

Assessment of Level of Depression Among HIV/AIDS

Patients Attending HIV Clinic at Murtala Mohammed

Specialist Hospital, Kano. 1 2 2 2 3 4 5 6H.H. Murtala, M.M. Haddad, B.A. Attahir, A.H. Ibrahim, V.O. Olisah, A.Shehu, F. Balarabe, N.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-Nigeria4Department 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

HH MurtalaSchool of Nursing, College of Nursing and Midwifery, Birnin-Kudu, Jigawa [email protected], +2348060102360

Abstract Introduction Mental health and Human Immunodeficiency Depression is closely related with patients with

Virus/Acquired Immune Deficiency Syndrome Human Immunodeficiency Virus/Acquired Immune 1(HIV/AIDS) are closely related, in that interplay exists Deficiency Syndrome (HIV/AIDS) and the two

between the two. Worldwide, 33 million people are exacerbate each other with associated deleterious 2living with comorbid condition of HIV/AIDS and consequences. 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

3,4presence of depression and factors that contribute to the treatment. Centre 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

[5]used. A total of 73 patients were recruited for the study conditions .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

6version 2.0 and results were presented using frequency severity of the HIV infection.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

6development of depression are stigma faced from population. Nigeria has high number of new HIV people in the community (37.0%), financial problem/ infections reported each year with an estimated 3.7% of

7,8lack of employment (23.3%), lack of partner in its population living with HIV. In 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

9contributing to depression. affected population, 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,

10this thus further deteriorates the condition.

Evidences have revealed that depression among people with HIV/AIDS is very high which affect about 121 million people globally. Worldwide, it was reported thatabout 33 million HIV/AIDS patients suffer from depression and it is responsible for 850,000 suicides each year among them with the highest burden

[11, 12]coming from developing countries . Additionally, in low income countries, Nigeria inclusive, it is projected that the level of depression among HIV/AIDS patients

13would increase by about 60% by the year 2030. This thus constitute a more debilitating burden of diseases

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

(MMSH).14difficulties in solving problems.In Nigeria, studies have established that

Materials and Methods depression is about 5 times more common among

Study setting: The study area was Murtala 6 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& of the training ground for nursing, midwifery and 15Sheikh 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 African workers and community at large. In 1952, the

7 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& specialist hospital. The hospital has capacity of 688

5 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.5Adiari& 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 treatmentrisk 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

[17]depression than men 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.

[18]1.6 times) with the reason not well understood . 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

13 3et. al., complications of HIV, those that were seriously sicklevel of education. Mohammed in their study in

Systematic random sampling technique was Ethiopia, reported that,widowed and divorced PLHIV employed for the selection of respondents and the list of are more likely to have depression than patients who all the registered patients formed the sampling frame, are single and another study revealed that,high level of which was calculated by dividing the desired sample depression among married PLHIV is more likely

3 size in a clinic day by the total number of eligible (about 6 times) compared to single PLHIV.respondents, where, after the first caregiver was Depression is a mental disorder that coexists selected using balloting, four (4)patients were skipped with HIV/AIDS, but receives less attention and hence

5 and the subsequent one was selected to serve as little is known about it and there is a dearth of studies on respondents until the desired sample size was achieved.the widely reported comorbidity in Kano state, the most A total of 73HIV/AIDs patients were recruited for the populous state in Nigeria. Thus, the researchers spurred study based on 95%prevalence rate of depression and

H.H. Murtala / The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)et al

16

https://www.omicsonline.org/clinical-depression.php

3associated factors among HIV patients, using Cochran

2 2formula n=z pq/d .

Where n = minimum sample size, Z = 1.96 (standard normal deviation for 95% confidence interval level), p = proportion of population with prevalence rate of depressed patients studied (95.0%) 3,q = complementary probability = (100 - P) = (100 - 95) = 5, e=precision required (tolerable sampling error) =

2 25%,Therefore, n = (1.96) × 5 (100 - 5)/5 = 72.96, approximately 73

Research instrument: The Data were collected using Hospital Anxiety and Depression scale (HADs)

18questionnaire adapted from Sale. This instrument is used as a screening tool for anxiety and depression, although only the depression subscale of HADS was analysed. The interview guided questionnaire consists of three sections. Section A, section B and section C. Section A address socio-demographic characteristics, section B addressed presence of depression using Hospital Anxiety and Depression Scale and Section C addressed factors contributing to the development of depression. Section B comprised seven questions for depression, and respondent take like 2–5minutes to complete. Questions depression were scored 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).

Validity of the instrument was ensured by five jurists from the Department of Nursing Sciences, Bayero University Kano. A pilot study was conducted using split half reliability method and Cronbach alpha value of 0.67 was obtained.

Method of data analysis: Data was analyzed using statistical package for social sciences version 20. The data was then displayed using frequencies and percentages. Chi-square test was used to test the relationship between age and development of depression as well as occupational status and development of depression.

Ethical consideration: Ethical approval was secured from the health research ethics committee of ministry of health Kano state (Ethical Clearance Reference No: MOH/Off/797/T. I/869). Murtala Mohammed Specialist Hospital Management and study participants also gave permissions and consents respectively.

Result Respondents Socio-demographic Characteristics

Majority of the respondents had secondary school The findings from the study shows that leaving certificate (45.2%), only (12.3%) had informal majority of the respondents (32.9%) were within the education. Most (63 %) were Muslims, while others age range of 26-36 years. Female respondents formed (33%) were Christians, 38.4% reported being petty 75.3% of the study participants whereas male traders. Majority of them had an income of <N 20,000 respondents constituted the rest of 24.7%. Also, most (43. 8%) while 34.2% had no source of income (Table (41.1%,) were singleand (2.7%) being the widower.

Variables Frequency Percentage (%) Age(Years) Less than 15 15-25 26-35 36-45

46 and above

8 17 24 17

7

11

23.3 32.9 23.3

9.6

Gender

Male Female

18 55

24.7

75.3

Marital status Married

Single

Divorced

Widow

Widower

25 30

9

6

3

34.2

41.1

12.3

8.2

4.1

Level of education

Primary

Secondary

Tertiary

Non-formal

14

33

17

9

19.2

45.2

23.3

12.3

Religion

Islam

Christianity

44

27

63

37

Tribe

Hausa

Fulani

Igbo

Yoruba

Others

43

5

10

11

4

58.9

6.8

13.7

15.1

5.1

Occupation

House wife

Student

Civil servant

Petty trader

Farmer

15

12

14

28

3

21.9

16.4

19.2

38.4

4.1

Monthly income

No income

Less than 20,000

20,000-40,000

40,000-60,000

More than 60,000

25

32

10

5

1

34.2

43.8

13.7

6.8

1.4

Table 1: Respondents Socio-Demographic Characteristics (n=73)


17

1). between occupational status and development of 2depression(÷ =9.654, p=0.068).

Presence of DepressionThe 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

2development of depression (÷ =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

Table 2: Factors Contributing to the Development of Depression Contributing Factors of Depression Frequency Percentage (%) Stigma faced from people in the community Lack of employment/ Financial problem

Belief that disease may not be cured Lack of partner in marriage

Lack of community support

27 17

9 15 5

37.0 23.3

12.3 20.6 6.8

Table 3: Relationship Between Age, Occupation and Development of Depression

Variables

Presence of Depression

Degree of Freedom

÷2

P value

Yes

No

Age

(In years)

Less than 15

4

4

15-25

10

8

26-35

12

7

6

9.654

0.099

36-45

10

8

46 and above

1

9

Occupation

House wife

4

10

Student

10

8

Civil servant

12

5

5

9.403

0.068

Pettytraders

10

13

Farmer

1

0

Figure 2: Bar Chart Showing Distribution of Respondents Based on Level of Depression

67.6%

32.4%

0

5

10

15

20

25

30

Mild Moderate

FREQUECNY

LEVEL OF DEPRESSION

Figure 1: Pie Chart Showing Distribution of Respondents Based on Presence of Depression

50.7%49.3%

0%ABSENCE OF DEPRESSION 36 PRESENCE OF DEPRESSION 37


18

1] patients as such health workers should routinely screen impairment .This finding, although not in stark patients with HIV/AIDS for comorbid depression to contrast, but is much higher than what was found in

9 enhance early detection and treatment and health studies by Getiye & Selamawit in Northwest Ethiopia 7 educate (special programs in mass media like Radio and studies here in Nigeria by Chinyere et al., in Imo

5 and television) the HIV/AIDs patients on ways of State, and Adiari & Campbell in a Nigerian Tertiary reducing the level of depression through eliminating or Hospital who variously reported the burden of modifying factors contributing to depression.Family depression 11.7%, 39.1% and 14.4% respectively. and community members should support HIV/AIDS However, the findings are in closer agreement with

[6] patients to overcome stigmatization in the community, those reported by Shittuet al., in a study conducted in marital and financial challenges. North Central Nigeria who found the burden of

depressionas56.7% among HIV patients. The findings References also revealed a proportion of respondents with mild 1. Pleasure, A.N., Peter, N.F., Roland C.N., depression that is higher than what was reported by

7 Vincent, S.V. &Henri, N.L.Depression a m o n g Chinyere et al., (24.6%) though the proportion of those HIV/AIDS patients on Highly Active Antiretroviral with moderate depression (50%) was much higher than Therapy in the Southwest Regional Hospitals of what was found in this studyCameroon: A Cross-Sectional Study. Journal o f On the factors contributing to the development Neurology and therapy, 2017, 6(1): 103–114. of depression, the findings revealed stigma faced from 2. Abdulateef, E. &Hyder, M. Depression among people in the community (37.0%), financial problem Human Immuno deficiency Vi r u s / A c q u i r e d and lack of employment (23.3%), lack of partner in Immune Deficiency Syndrome among Sudanese marriage (20.6%) and believe that disease may not be patients: a cross- sectional analytic study and cured (12.3%).While stigma makes patients to be re la ted rev iew.The Pan Afr ican Medical isolated mostly due to fear of being blamed and a need journal,2017, 26(43):109-119.to maintain moral credibility in the community, 3. Mohammed, M. Mengistie, B. Dissie, H. financial problems and lack of employment &Godana, A. Prevalence of depression a n d consequently manifest in irritability and poor regiment associated factors among HIV patients seeking compliance in general patient population .The finding treatment in Anti-etroviral T r e a t m e n t spartly agree with those from a study by Bernard et

10 Clinic(ART) at Harar town, eastern Ethiopia. Journal al., in sub-Saharan Africa, who reported that economic of AIDS and Clinic Research, 2015, 2155-6113status (20%) and low social support (15%) as the 4. World Health Organization. Key facts about contributing factors to depression among other factors.

5 Depression and Human I m m u n o d e f i c i e n c y In addition, Adiari & Campbel in another study Virus/Acquired Immune Deficiency Syndrome, 2018. identified lack of social support which manifest in Retrieved from www.ilo.org/global/about-the-ilo-social isolation as contributing factor.multimedia. Accessed 6th June, 2018.Similar to what was found in previous studies

, 1 5. Adiari O. & Campbell, P.C. Prevalence and across different parts of the globe by Pleasure et al., in a Severity of Depression among People Living with study conducted in Cameroun (OR 2.13; 95% CI Human Immuno-deficiency Virus/Acquired Immune 20

1.20–3.70), Abebe et al., in Addis Ababa (AOR= 2.20, Deficiency Syndrome in a Tertiary Hospital. African 21

95% CI: 1.33, 3.62), Kim et al., in Malawi (OR 1.23; journal online, 2014, 14(1):18-2422

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 Deficiency Syndrome undergoing Anti-retroviral 2between 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 &Aderibigbe, S.A. Prevalence and Correlates of

1conducted 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

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.175and Associated Factors of Depression among HIV 8-58722012.00191Infected 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- 2458/12/463one,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 Hospi tal , 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 10.1177/1178633717752687Journal 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, 1-714. 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 s tudy, 2010. Retr ieved f rom among adolescents living with HIV in Malawi. BMC https://researchspace.ukzn.ac.za/xmlui/handle/10413/ Psychiatry, 2015, 15(1):122-130893. 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, 231-24048(4):253-261


20

Correspondence to:

21

1 2 2 3 4 1 1 5 6S.A Biliaminu, M.T Lawan, L Cam, E.O Sanni, J. Imran, I.M AbdulAzeez, A.B Okesina, J.O Yusuff, I.B Aremu

Clinical Manifestations of Hypovitaminosis-D

in Paediatric Patients Attending Nizamiye Hospital, Abuja:

A 2-Years' Appraisal.

1 2Department of Chemical Pathology and Immunology, University of Ilorin, Ilorin, Kwara State. Paediatric Unit, 3 4Nizamiye Hospital, Abuja. Department of Haematology, Nile University, Abuja. Department of Medical Microbiology,

5Nile University, Abuja. Department of Chemical Pathology and Immunology, University of Ilorin Teaching Hospital, 6Ilorin, Kwara State. Department of Radiology, University of Ilorin, Ilorin, Kwara State,

Dr. SA Biliaminu Department of Chemical Pathology and Immunology,University of Ilorin, Ilorin, [email protected] phone No: - +2348060885920

Abstract Conclusively, hypovitaminosis D has myriads of non-bony clinical presentations in children with the frequencies and severity more in females than males.

Hypovitaminosis D in children is a prevalent Routine serum vitamin D should be encouraged to rule 3

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- Introductionspecific clinical symptoms with laboratory results Vitamin D is an extremely important vitamin that showing deficient serum vitamin D and the symptoms has powerful effects on several systems throughout the 3

disappearing after administering vitamin D . Serum body. Its roles in the body include modulation of cell 3

growth, neuromuscular and immune function, and Vitamin D was assayed for using CLIA method. Data 31,2,3

reduction of inflammation. Many genes encoding analysis was done using SPSS Version 20. proteins that regulate cell proliferation, differentiation, The mean age of all the patients was 12.7±2.6years. and apoptosis are also modulated in part by vitamin D. Twenty-two (46%) of them were males with the mean Many cells have vitamin D receptors, and some convert age of 13.4±2.8years while the remaining 26 (54%)

125(OH)D to 1,25(OH) D.were females with mean age of 12.0±2.1years with no 2

Vitamin D deficiency, or hypovitaminosis D is significant difference when compared at p>0.05. Other defined as a vitamin D level that is below normal. It is anthropometric parameters like weight, height and widespread irrespective of age, gender, race and BMI were equally not statistically different between geography and has emerged as an important area of the two genders at p>0.05. Mean serum vitamin D was 3

research. Hypovitaminosis D is frequently observed in lower in females 16.5±4.8ng/ml than males Europe in the elderly, particularly in the 18.8±3.5ng/ml which was not statistically significantly institutionalized population, but is also seen in different between the two genders at p>0.05. The

4commonest clinical manifestations among all the otherwise healthy younger adults. An estimated 40% paediatric patients were fatigue, headaches and of the young European population has some degree of

4backaches at frequencies of 83%, 79.2% and 75% hypovitaminosis D. Surprisingly, it is more frequent in respectively, while the less common ones are mood sunny Mediterranean countries than in certain northern

4swings, poor sleeps and dizziness at frequencies of countries such as Norway. 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

4developing countries. In developing countries, the prevalence of hypovitaminosis D varies widely by and within regions; prevalence ranges between 30-90%, according to the cut-off value used within specific

5regions, and is independent of latitude. Hypovitaminosis D most commonly occurs in

people when they have inadequate sunlight exposure (in particular sunlight with adequate ultraviolet B

Vitamin D is an extremely important vitamin that has powerful effects on several systems throughout the body.

6 age range between 8-16years were recruited following rays). Nutrient deficiencies are usually the result of Ethical Approval by the hospital for the study. Twenty-dietary inadequacy, impaired absorption and use, six of them were females while the remaining 22 were increased requirement, or increased excretion. A males. Those included presented with myriad of non-vitamin D deficiency can occur when usual intake is specific clinical symptoms with laboratory results lower than recommended levels over time, exposure to showing deficient serum vitamin D and the symptoms sunlight is limited, the kidneys cannot convert 3

25(OH)D to its active form, or absorption of vitamin D disappeared after administering vitamin D . Laboratory 3

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 D was 3

7intolerance, 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 Resultsas an increased risk of respiratory infections, diabetes A total of 48 paediatric patients were recruited for

5 mellitus and possibly cardiovascular diseases. 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 D for there was no significant difference when both were 3

compared at p-value of 0.584. The mean±SD of heights early diagnosis and management of hypovitaminosis D of females and males were 1.58±0.11 and 1.49±0.19M in paediatric patients with unusual clinical respectively which was not significant when compared presentations.at p-value of 0.115.

Materials and Methods The mean±SD of BMI of females and males were 2The study was a retrospective one between January 22.3±4.3 and 25.0±5.1Kg/M 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-vitaminosis-D

Patients

Female Hypo-vitaminosis-D

Patients

Male Hypo-vitaminosis-D

Patients

p-Value

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 BMI(Kg/M2)

22.3±3.8 22.3±4.3 25.0±5.1 0.050* Serum

VitaminD(ng/ml)

17.4±4.4 16.5±4.8 18.8±3.5 0.108

Table 2: Showing Frequency of Clinical Manifestations of Hypovitaminosis-D in all the Paediatrics Patients and Based on Gender.

Clinical

Manifestations

All Patients

Females

Males 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

S.A. Biliaminu / The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)et al

22


23

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 D and age at 'r' 3

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 D and 3

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 D but they 3

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 D and clinical 3

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 D and age at 'r' 3 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 3presentation 25(52.1%) in all the patients. It was also 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 3higher for the males at frequency of 18 out of any statistical significance. (Table 4)22(81.8%) and 20 out of 22(76.9%) for the females.

The rank correlation of serum vitamin D and 3Dizziness had a frequency 20(41.7%) in all the patients. clinical manifestations of hypovitaminosis D and It was also higher for the females at frequency of Pearson correlation for age in male subjects Table 5.12(46.2%) and 8(36.4%) for the males.There was a statistically significant negative Generally, frequencies and severity of clinical correlation between serum vitamin D and age at 'r' 3 manifestations are more in females than males.value of -0.489 and p-value of 0.021. The similar The rank correlation of serum vitamin D and 3

negative correlation between serum vitamin D versus 3clinical manifestations of hypovitaminosis D and

Table 3: Showing Rank Correlation of Serum Vitamin D and Clinical Manifestations of Hypovitaminosis D and Pearson Correlation for Age in all the Subjects

‘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

Correlation Parameters

Age Back ache

Fatigue Mood Swing

Poor Sleep

Head Ache

Dizziness

Table 4: Showing Rank Correlation of Serum Vitamin D and Clinical Manifestations of Hypovitaminosis D and Pearson Correlation for Age in Female Subjects

‘r’

-0.417

0.183

0.183

-0.049

-0.013

0.183

0.350 p-value

0.034*

0.371

0.371

0.812

0.951

0.371

0.080


Age Back ache

Fatigue Mood Swing

Poor Sleep

Head Ache

Dizziness

Table 5: Showing Rank Correlation of Serum Vitamin D and Clinical Manifestations of Hypovitaminosis D and Pearson Correlation for Age in Male Subjects

‘r’

-0.489

0.226

0.052

-0.222

0.615

-0.104

0.005 p-value

0.021*

0.311

0.819

0.320

0.002*

0.646

0.984


Age Back ache

Fatigue Mood Swing

Poor Sleep

Head Ache

Dizziness

16mood swings and headache were not significant that 89% of the nurses were deficient.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 D but they were not of little bit more in females than males. Large 3

observational studies have found a relationship any statistical significance. (Table 5)17,18,19

between a deficiency and chronic lower back pain.Discussion Talking about mood swings and depression, it is

moderately common in all the patients in this study but Vitamin D is a steroid hormone which is available more frequent in females than males. In review studies, in limited quantity in fortified dairy products and is researchers have also linked vitamin D deficiency to synthesized mainly in the skin, from cholesterol, by

20 8,9,10depression, particularly in older adults. In one exposure to the ultraviolet radiation of sunlight. analysis, 65% of the observational studies found a Hydroxylation of vitamin D is done in the liver and relationship between low blood levels and depression. kidneys, which is then transported to target tissues On the other hand, most of the controlled trials, which containing vitamin D receptors. Calcium homeostasis carry more scientific weight than observational studies, from the kidneys, bones, parathyroid gland, and

20intestine is maintained by vitamin D, playing a pivotal didn't show a link between the two.11

In term of correlation, there was a statistically role in mineralization of bones. significant negative correlation between serum vitamin Vitamin D deficiency, or hypovitaminosis D is D among all the patients irrespective of their gender. defined as a vitamin D level that is below normal. It is 3

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 D but they 3

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

5 mellitus and possibly cardiovascular diseases. 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

21like diabetes mellitus and cardiovascular diseases. illnesses. An earlier study 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

12irrespective of their gender. The females' vitamin D vitamin D deficiency is associated with a higher risk of

22was however lower than males'. This might be sleep disorders.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 D should be encouraged to rule 3

can cause fatigue that has a severe negative effect on out hypovitaminosis D in paediatric patients with 13,14quality 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

15blood levels over 30 ng/ml. A similar study also found 1.Institute of Medicine, Food and Nutrition Board.


24

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. (February 2014) 6 (2): 729-775. Holick MF. Vitamin D. In: Shils ME, Shike M, 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. Aging. 2013;17(5):447-455.Kuwabara A, Tsugawa N, Tanaka K, Uejima Y, 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. Neuroanat. 2005 Jan;29(1):21-30.Priemel M, Damorus CV, Klatte TO, Kessler S, 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

Correspondence to:

26

1 2 3 4 5O.A.Ogunlaja, Y.T.Olasinde, I.P.Ogunlaja, A.Olasinde, M.O.Bojuwoye.

Delivery Pattern and Perinatal Outcome in a

Nigerian Tertiary Health Institution: A Five Year Review

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.

Dr. O.A. Ogunlaja,Department of Obstetrics and Gynaecology,Bowen University Teaching Hospital, Ogbomoso, Oyo state.E-mail: [email protected]: +2348052273290

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

2critically appraise the level of care rendered in a health pregnancy and child birth occur. Furthermore, Nigeria system with the aim of improving the quality of care. reportedly has one of the poorest perinatal indices in the

3This study aimed to audit the obstetrics practice in our world. 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

1version 20. Delivery outcomes were named as birth mothers.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

437.7%. The prevalence of multiple gestation in our through an abdominal and uterine incision. 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

1spontaneous vaginal births when compared with those reportedly the commonest major surgery in obstetrics. who had Caesarean section and instrumental vaginal The preferred method of childbirth by a woman is

2deliveries (÷ =8.060 p=0.018).The relationship affected by many factors, some of which include 5between birth weight and the mode of delivery was obstetric, medical, social or psychological reasons.

2statistically 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

5 environment. factors such as the presence of a doula in labour.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

6performed. 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

4Centre over a given time with the ultimate aim of deliveries. Furthermore, the reported increasing rate of 1

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 cephalopelvic disproportion, obstructed labour and

7foetal distress. This is in contrast to what obtains in the developed climes in which preference of mothers for Caesarean delivery is a means of escape from labour

8pain. Nevertheless, the incidence is about 20 to 30% in most teaching hospitals in Nigeria, with different rates

6 9from different regions of the country. Adekanle et al reported a rate of 35.5% in the South Western part of the

6 house officers. Paediatricians carry out postnatal country, Isah et al reported a rate of 21.4% in Abuja, 10 rounds and newborn examination on the postnatal North-central part of the country and Ugwu et al

wards daily before the babies are discharged home.reported a rate of 27.6% in Enugu, Southwest Nigeria; 11 The perinatal outcome measures that were however Daniel and Singh reported a much lower rate

determined in this study were method of delivery, of 11.3% from the Northwestern part of the country.baby's birth weight value, sex, baby's outcome and type Common perinatal outcome measures include of gestation.the sex of the newborn, birth weight, gestational age at

Ethical clearance was obtained from the delivery, whether the newborn was live birth or a still Hospital Research Ethics Committee before embarking birth, Apgar scores, early neonatal death, the need for on this study. Data obtained were analysed using the admission into the neonatal intensive care unit and so SPSS version 20.0 software. Continuous variables on.were presented as means and standard deviation (SD) This study aimed at determining the prevailing whereas categorical variables were presented as modes of delivery and perinatal outcomes and assess proportions or percentages. the relationship between them in a tertiary health centre

The Chi-Square test was used to compare the in Southwest Nigeria.mode of delivery with baby's outcome and birthweight. Statistical significance was established at p < 0.05.Materials and Method

This was a retrospective study carried out over Results a period of five years, from January 2014 to December

During the 5-year review period, there was a 2018 in Bowen University Teaching Hospital, total of three thousand eight hundred and ninety-two Ogbomoso. Information was retrieved from the Health (3892) childbirths with an average of 778.4 births per Information Management Unit of the hospital. year. Of these, 2075 were male births while 1817 were The Bowen University Teaching Hospital is a females; giving a male to female ratio of 1.14:1. private tertiary centre with Specialists in different

Three thousand one hundred and ninety five departments and facilities to train medical students and (3195) newborns were within the normal birth weight residents in family medicine. The hospital also serves range of 2.50-3.99kg; this accounted for 82.1% of the as a referral centre to primary and secondary health care newborns, while very low birth weight babies (birth facilities in and around Ogbomoso, including weight <1.5 kg) accounted for 186(4.8%) of the births. neighbouring states like Osun.The mean (SD) birth weight was 3.82 (1.73) kg. Three The maternity unit consists of the labour ward, thousand six hundred and ninety-five (94.1%) of the the labour ward theatre, antenatal and postnatal wards, pregnancies resulted in live births, while 197 (5.9%) manned by Consultants, residents, medical officers and

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

O.A. Ogunlaja / The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)et al

27

O.A. Ogunlaja et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)

28

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

2shown in Table 1 statistically significant. (÷ =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.

2Caesarean section and assisted vaginal delivery, (÷ =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

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 outcome Spontaneous

vaginal delivery Caesarean section

Assisted vaginal delivery

Total Chi square

P value

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 vaginal delivery

Caesarean section

Assisted vaginal delivery

Total

Chi square

P value

N (%)

N (%)

N (%)

N(%)

Birthweight

<1.50 kg

112(60.2)

72(38.7)

2(1.1)

186(100)

56.58

<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

23,24Discussion research work in Nigeria However, this is higher This study was embarked upon to determine than the value 30.1 per 1000 births obtained from other

25the pattern of childbirth and perinatal outcome in a developing countries. 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

12,17,18a major referral centre and many of the cases referred Nigeria. 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

12,13Nigeria. Majority (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

14made in similar research work in the past. 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

14higher than 19.5% previously reported by Eze et al 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

15 tostep up our advocacy for reduction in the existing to the 42% reported by Jyotsana et al in India. This is aversion for surgical intervention especially Caesarean much higher than the World Health Organization section amongst the population. (WHO) recommended Caesarean section rate (CSR) of

10-15%; this increase has also been reported from other 1,5 LimitationsCountries. The higher cost of health care services and

Data such as Socio-demography of subjects, the complications associated with Caesarean section 16 risk factors for stillbirths, the indications for caesarean make this increase to be a public health problem.

section and assisted delivery, mode of anaesthesia, The prevalence rate of multiple gestation was Cadre of doctors performing the caesarean section, 3.9%, this is similar though higher than the value of Apgar scores, neonatal admissions and neonatal deaths 2.3% and 3.2% which were obtained from different

17,18 were not available due to the retrospective nature of the tertiary health centres in Nigeria. This value is very study.close to what has been previously reported in

19Ogbomoso, the present study site by Akinboro et al AcknowledgementThe proximity of the study site to Igboora, a city which

20,21 The authors acknowledge thestaff of the is considered as the twin capital of the world may be Health Information Department of the Bowen responsible for this higher rate of multiple gestation University Teaching Hospital and the House officers when compared with the aforementioned studies. for the assistance rendered during the collection of Furthermore, the Yoruba tribe (the predominant tribe in these data.the present study site) of the Southwestern part of

Nigeria have been reported to have the highest 19 Conflict of interest: The authors have none to declaretwinning rates in the world.

The observed stillbirth rate was 49.8 per 1000 births was similar to 52 per 1000 births observed in a References

22previous study, 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


30

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;8:105Nigeria. 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

Correspondence to:

31

1 1 2 1 3A.E. Ojieh, E.C. Adegor, J.I. Wilson E.Agbonifo-Chijiokwu, E.G. Moke,

Evaluating Effect of Prolonged Alcohol Consumption

On Serum Gastrin and Secretin and Histo-archiecture

of the Stomach and Duodenum In Rats

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:

A.E. OjiehDepartment of Physiology, Faculty of Basic Medical Sciences, Delta State University, Abraka, [email protected], [email protected]: 08037006974; 09013527119

Keywords: Acohol, Gastrin, Secretin, Omega-3Abstract

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 1the world . Based on their alcohol content, alcoholic research investigated the effects of long term varying beverages are categorized into three groups; wines, doses of alcohol on two digestive hormones and the beers and spirits (gin or whisky). Fermentation forms histological integrity of the stomach and duodenum in the basis of all alcoholic beverages formation. adult male Wistar rats. Forty adult male Wistarrats

Alcohol is usually consumed orally and being weighing 150-230g were used. The animals were the first point of contact, the gastrointestinal tract often randomly selected into eight groups comprising five bears the brunt of first pass phenomenon along with the rats each. Group 1 served as the control, while Groups liver. The effect of alcohol consumption on the 2, 3 and 4 received 0.5ml of 5%, 20% and 40% alcohol intestinal tract often affects the health of an individual (0.05g/kg, 0.2g/kg and 0.4g/kg) respectively; Groups 2through its effect on digestion and absorption. Alcohol 5,6 and 7 were given 5% alcohol+Omega-3, 20% has been known at high concentration to distort the alcohol+Omega-3 and 40% alcohol+Omega-3 mucosa of the oesophagus, stomach and small respectively while Group 8 was given Omega-3 alone. intestine, along with its deleterious effect on the Omega-3 was administered at a dose of0.01ml of

2, 3pancreas and liver.0.2g/kg body weight. Treatment lasted for 12 weeks,

4In their study, Singer et al. noted that following which serum gastrin and secretin levels, as

intravenous, intragastric or alcohol ingestion at low well as the histology of the stomach and duodenum concentrations of up to 5% stimulated gastric acid were analysed. Findings showed that serum levels of secretion, while higher doses either exerted no effect, gastrin and secretin hormones increased with or showed inhibitory actions. Same study also showed increasing alcohol concentration. Histology of the gastric emptying to be enhanced by low dose alcohol, stomach and duodenum showed necrosis and atrophy while gastric emptying and motility were reduced by of epithelial and submucous cells and this was more

5high dose. In their own study, Oluwoleet al. found that evident with higher alcohol concentration. Omega-3 an alcoholic beverage was able to enhance gastric was used as an ameliorating agent in this study to mucus secretion. Alcohol consumption has frequently mitigate the effect of alcohol and result showed that its been identified as the cause gastritis in alcoholics and in effect was dependent on alcohol concentration. This individuals who regularly consume alcohol.study concludes therefore that consumption of alcohol

Some commonly observed symptoms amongst especially in high doses has the capacity to elevate heavy alcohol users are diarrhea, and mal-absorption, serum levels of gastrin and secretin probably due to its occasioned by alterations in food digestion and ability to cause disruption of the architecture of the absorption. Hence this study was carried out to mucosa and submucosa of the stomach and duodenum investigate the effects of long term consumption of as seen in this study. These deleterious actions of alcohol at varying concentrations 5%, 20% and 40% alcohol are often not ameliorated by use of anti-(0.05g/kg, 0.2g/kg and 0.4g/kg) respectively, on two oxidants such as Omega 3 used in this study. digestive hormones, serum gastrin and secretin, while also examining the histological architecture of the stomach and small intestines.

Materials and Methods Chemicals:

Analytical grade alcohol, Omega 3 fish oil supplement from BR Pharmaceuticals, Enzyme- linked immunosorbent assay ki t from Hangzhou Eastbiopharm Co. Ltd (Xihu district, Hiangzhou

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 Collectionderived 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

6 of ELISA kits.guidelines for animal handling by Ward and Elsea. Also adopted for this research was NIH Guide for

Histopathological Examination:Laboratory Animals Care and Utilization. The Samples of tissues from the stomach and experimental protocol on handling laboratory animals

duodenum of the rats were harvested. These were fixed was endorsed by the institutions ethical committee.in 10% formalin, dehydrated, cleared in xylene and embedded in paraffin. Afterwards, they were sectioned Experimental Protocol:with the aid of a microtome to 5µm thick sections, The rats were randomly selected into eight (8) stained with Haematoxylin-Eosin stain, and viewed groups of five (5) rats each (n = 5). The alcohol under a light microscope. Finally, photomicrographs concentrations (5%, 20% and 40%), represents the were taken.level commonly associated with the frequently Statistical Analysisconsumed alcoholic beverages namely beer, alcoholic The results were expressed as Mean ± Standard Error of wine, spirits (brandy, whisky, vodka or gin). The the Mean (SEM). The means of the treated and control alcohol was purchased from an authorized groups were then compared using ANOVA with pharmaceutical company (BR Pharmaceutical). The Fisher's Post-Hoc. P-values of less than 0.05 were rats received single daily alcohol oral dose of 0.5ml of considered statistically significant.0.05g/kg, 0.2g/kg and 0.4g/kg respectively, using an

oro-gastric cannula. They also received 0.01ml of Results 0.2g/kg body weight of Omega-3 fatty acid. The Gastrin and Secretintreatment groups are as follows: Group 1, rats received

Result from this study showed an increase in only clean drinking water and normal feed, Group 2 rats serum gastrin with increasing alcohol concentration received 0.05g/kg bw alcohol,Group 3 rats received (Fig1). Co-administration of omega-3 with alcohol in 0.2g/kg bw alcohol, Group 4 rats received 0.4g/kg bw all groups showed increased gastrin secretion alcohol,Group 5 rats received 0.05g/kg bw alcohol plus compared to control and omega-3 alone. 0.05g/kg bw omega-3 only,Group 6 rats received 0.2g/kg bw alcohol

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,

Fig. 2: Effects of alcohol on the level of serum secretin in experimental rats expressed as Mean±S.E.M. Keys: Ù: Omega-3, ALC: Alcohol

A.E. Ojieh et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)

32

Effect of Alcohol Administration on Histomorphologic integrity of the stomach sections from Experimental Rats (figs 3a – 3g)

Fig.3a Control; Mucous cells (black arrow) Parietal cells (blue arrow). H&E x400

F i g . 3 b S t o m a c h , s h o w i n g hyperplastic mucous cells (top-arrows) and normal parietal cells (bottom-arrow) in rats treated with 5% alcohol and omega-3. H&E x400

Fig.3c Stomach – showing atrophy of parietal cells (arrows) in rats treated with 5% alcohol alone. H&E x400

Fig.3d Stomach- showing hyperplasia of mucous cells (arrow) of rats treated with 20% alcohol and omega-3. H&E x400

Fig.3e stomach- showing necrosis of mucous (red arrow) and parietal cells (black arrow) of rats treated with 20% alcohol alone. H&E x400

Fig.3f Stomach- showing diffuse necrosis of fundic cells (arrow) of rats treated with 40% alcohol alone. H&E x400

Fig.3g Stomach- showing atrophy of mucous neck cells (arrow) of rats treated with 40% alcohol and omega-3. 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 -Duodenum- showing tall villi (arrow). H&E x100

Fig.4b Duodenum- showing mild diffuse atrophy of brunner's glands (arrow) in rats treated with 5% alcohol and omega-3. H&E x100

Fig.4c Duodenum- showing diffuse atrophy of Brunner's glands(arrows) in rats treated with 5% alcohol alone. H&E x100

Fig.4d Duodenum- Showing necrosis of crypts and glandular cells in rats treated with 20% alcohol. H&E x100

Fig.4e Duodenum- Showing mild resolution of the necrosis in rats treated with 20% alcohol and

Fig.4f Duodenum showing mild diffuse atrophy of brunner's gland in rats treated with 40% alcohol and omega-3 H&E x100

F i g . 4 g D u o d e n u m s h o w i n g congestion and diffuse atrophy treated with 40% alcohol H&E x100


33

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

70.4g/kg bw alcohol+omega-3 treatment showed release of gastrin .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 13Histopathological studies al, 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

14resolution in the 0.2g/kg bw alcohol+omega-3 group. congruent with the findings of Nishiwakiet al. 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 15secretion or release of gastrin. Mild to moderate pancreatitis. Alcohol consumption especially in high consumption of low dose alcohol could possess health doses can result in inflammation of the gastric mucosa.

8 16benefits, however when consumed in high According to Chi- chang et al, a reduction in gastric concentration especially over a long time, it could mucous has been implicated in alcohol-induced gastric

9 17result in multiple pathologies. High doses, greater 10% ulcers. Azzumet al. 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

11globally. Documented 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

18concentration dependent manner. absorptive function. 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

12findings of Vera et al, 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


35

19suggested 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 9) Dasarathy, S and McCullough, AJ. “Alcoholic stomach and duodenum, resulting amongst other liver disease. In E. R. Schiff, M. F. Sorrell and W. C. symptoms in the elevation of serum levels of gastrin

thMaddrey (Eds.), Schiff's diseases of the liver(10 ed.). and secretin. Gastrin is essential in the digestion of Philadelphia: Lippincott Williams & Wilkins. 2007.meat protein while secretin is needed for regulation of 10) Davenport, HW.“Ethanol damage to canine pancreatic secretions especially bicarbonate. Elevation oxyntic glandular mucosa”. Experimental Medical in serum gastrin levels can trigger abdominal pain, Biology. 1997; 126: 657-62.diarrhea, decrease appetite and unintended weight loss

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”. 2000ameliorated 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): 37-45consumption 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): 7421–7427100: 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 a l . “Chronic a lcohol consumpt ion a ffec t s

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

Clinical.Chim. Acta. 1993; 221: 219 – 225gastric acid secretion and release of gastrin in humans”. 18) Adebiyi OA.Okolie-Alfred UV, Godstime C. et Gastroenterology. 2003; 93: 1247–1254.al. “Performance and Gut Morphometry of Broiler Fed 5) Oluwole, FS, Omolaso, BO and Ayo, JA. Maize Based Diets Supplemented with Charcoal and “Methanolic extract of Entandrophragmaangulense Honey as Anti-aflatoxin”. American Journal of induces gastric mucus cell counts and gastric mucus Experimental Agriculture. 2015;7(3):163-169.secretion”. Journal of Biological Sciences. 2007;7(8): 19) Meganathan M, MadhanaK, Gopal, P. 1531-1534. “Evaluation of Hepatoprotective Effect of Omega 3-6) Ward JW and Elsea JR. “Animal case and use in Fatty Acid against Paracetamol Induced Liver Injury in drug fate and metabolism. Methods and techniques”. Albino Rats”. Global Journal of Pharmacology. 2011; Vol 1 Ed Edward R. Garrette and Jean L. Hirtz. Marcel 5(1): 50-53Dekker, New York, 1997;pp 372 -390.

7) Charis S, Teyssen S and Singer MV. “Alcohol and

Radiological Findings in Aqueductal

Stenosis in a Preterm Infant.

1 2 2 2H.J. Akande, B.B. Olafimihan P.N. Omefe, A.T. Ifarinola1Departments of Radiology, College of Health sciences, University of Ilorin

2and University of Ilorin Teaching Hospital, Ilorin,Nigeria

Dr. H. J. AkandeDepartment of Radiology, Faculty of Clinical Sciences,College of Health Sciences,University of Ilorin.Email: [email protected] No: +2348035967327.

Correspondence to:

36

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

1-3 Sylvius. Congenital aqueductal stenosis (CAS) has of congenital hydrocephalus. The aqueduct of been reported as the most frequent cause of congenital Sylvius transmits cerebrospinal fluid from the third

1,2th hydrocephalus. Hydrocephalus is a common finding ventricle to the fourth ventricle and develops at 6 week during obstetric ultrasound scan (USS) but the cause gestation age and gradually decreases in size till birth

4 may be difficult to identify. Increased intracranial with luminal patency. However, it may become pressure (ICP) can result from ventriculomegaly with stenotic as a consequence of compression from mass its associated complications.lesions or because of an intrinsic pathology. In about

Congenital aqueductal stenosis has an three quarters of patients, the etiology of the disorder is 2

estimated incidence of 0.5-1: 1,000 births. It was found not known and this is referred to as idiopathic 5 as the commonest congenital anomaly and the aqueductal stenosis. This condition constitutes a

commonest cause of congenital hydrocephaly in local significant burden of morbidity in patients with 3,7

studies. Rarely, it may be inherited in an X-linked hydrocephalus.recessive manner (Bickers-Adams-Edwards Congenital aqueductal stenosis has an

4estimated incidence of 0.5-1 in 1,000 births in the syndrome).developed world and congenital hydrocephalus an Imaging plays a vital role in diagnosing this

4,6 anomaly thus radiologists must be familiar with the incidence of 145 in 100,000 live births in Africa. In imaging features. This case highlights the imaging this index case, the right and left frontal horns of the findings on both transfontanelle (TFUS) and magnetic lateral ventricles and third ventricle were dilated with a

th resonance imaging (MRI).normal sized 4 ventricle on transfontanelle ultrasound (TFUS). No focal mass lesion was seen and the

Case reportaqueduct was not well demonstrated. Brain MRI was M.N. presented to the neonatal intensive care requested, which confirmed the diagnosis of congenital

unit (NICU) as a four-hour-old preterm male neonate aqueductal stenosis with obstructive hydrocephalus. delivered via spontaneous vaginal delivery at a private The treatment of CAS is by endoscopic third facility. Mother drained liquor six days prior to delivery ventriculostomy (ETV) or ventriculo-peritoneal (VP) at 33 weeks 5 days (ultrasound estimated gestational shunting. Patient was planned for ventriculo-peritoneal age). She received 12 mg of IM dexamethasone on (VP) shunt, however, this could not be done due to account of preterm premature rupture of membranes. financial constraint. Child cried immediately at birth with Apgar scores of 8

st th and 9 at the 1 and 5 minutes respectively and birth Keywords: Congenital aqueduct stenosis, Infant, weight of 1.8kg. Baby was referred to our facility on Imaging Findingsaccount 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 IM tetanus toxoid (TT) or intermittent malaria prophylaxis (IPP). She is not a known hypertensive or

+vediabetic. Her blood group is O , genotype AA. Pregnancy was uneventful except for the spontaneous premature rupture of membranes which occurred following a stressful journey and necessitated presentation at a health facility. No history of fever, rash, urinary tract infection, par vaginam (PV)

H.J. Akande et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)

37

0bleeding. (Temperature-36.2 ), not dehydrated, no pedal edema. Mother is a 23-year-old undergraduate and father is a Weight-1.8 kg, length-42 cm, SpO -99% in room air, 2

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

Figure 1A: Anterior coronal TFUSview showing the

frontal horns of the lateral ventricles severely dilated.

Figure1B: Right and left para-sagittal TFUS views showing dilated lateral ventricles.

rdFigure 1C: Midline sagittal TFUS view showing dilated 3 thventricle. The massa intermedia is shown. The 4 ventricle

is normal.

Figure 2A: Sagittal T1 FLAIR MRI showing narrowed rdaqueduct (arrow) with dilated lateral and 3 ventricles.

Figure 2B: Sagittal T2-W showing no CSF signal in the region rdof the aqueduct with dilated lateral and 3 ventricles and

prominent supraoptic and infundibular recesses (arrows).

rdFigure 2C: Coronal T2-W MRI showing dilated lateral and 3 ventricles with funneling appearance of the proximal aqueduct.

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 calc ium gluconate , v i tamin 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

1,2,8graded. Blood culture yielded no growth. PCV - 45%. hydrocephalus. The aqueduct may become stenotic th

Patient was discharged on the 8 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

9fontanelle, sutural diasthesis, head lag and poor suck. known etiology. Intrinsic 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

thventricles with a normal sized 4 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

10,11demonstrated. (Figures 1 A-C). A diagnosis of tumor and posterior fossa tumor. 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

4,12referred to the neurosurgeons. Examination at the to her male child. There is a slight male prevalence. 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

13counselled for surgery (VP shunt) but again declined on radiation.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

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 Ismail NJ. Sonographic pattern of hydrocephalus

3ventriculomegaly 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

Philadelphia: Wolters Kluwer, 2017:331-32.ventricles and often the etiology. In CAS, the entire 5. Jenkinson MD, Hayhurst C, Al-Jumaily M, length of the aqueduct can be visualized, funneling of Kandasamy J, Clark S, Mallucci CL: The role of the superior aspect of the aqueduct, downward bulge of endoscopic third ventriculostomy in adult patients with the floor of the third ventricle, prominence of the hydrocephalus. J Neurosurg 2009; 110: 861-866.recesses of the third ventricle will be demonstrated. 6. Dewan MC, Rattani A, Mekary R, Glancz LJ, Secondary effects of the hydrocephalus such as Ismaeel Y, Baticulon RE et al. Global hydrocephalus ventricular diverticula, cortical thinning amongst

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

7. Nzeh DA, Saidu SA, Erinle SA, Pam SD. aqueductal stenosis and other features as demonstrated Sonographic Diagnosis of Congenital Brain in this case. Sagittal constructive interference steady Malformations: The Ilorin Experience. Niger Postgrad state (CISS) sequence will best demonstrate Med J 2006; 13: 57-60.obstructing web. CSF flow study on MRI can also be 8. Cinalli G, Spennato P, Nastro A, Aliberti F, used to quantify aqueductal stroke volume and peak

14 Trischitta V, Ruggiero C et al.Hydrocephalus in systolic velocity which will be reduced.aqueductal stenosis. Childs Nerv Syst 2011; Computed tomography is another useful 27:1621–42.imaging modality in adults but not advocated in 9. Jellinger G: Anatomopathology of nontumoral neonates and children because of effects of ionizing aqueductal stenosis. J Neurosurg Sci 1986; 30: 1-16.radiation. It demonstrates ventriculomegaly, possible 10. Barkovich A J, Newton TH. M R of aqueductal causes and the effects of the dilated ventricles.stenosis: evidence of a broad spectrum of tectal The differential diagnosis of CAS include distortion. AJNR Am J Neuroradiol 1989; 10: 471-76.intracranial hemorrhage grade III (intraventricular 11. Marcorelles P, Fallet-Bianco C, Oury J F, Van hemorrhage with dilatation), brainstem glioma, Wallenghem E, Parent P, Labadie G et al. Fetal meningitis and ventriculitis.a q u e d u c t a l g l i o n e u r o n a l h a r m a r t o m a : A The treatment of CAS is by endoscopic third clinicopathological and physiopathological study of ventriculostomy (ETV) or ventriculo-peritoneal (VP) three cases. Clin Neuropathol 2005; 24: 155-62.shunting. In a study, aqueductal stenosis was the most 12. Hirsch JF, Hirsch E, Sainte-Rose C, Renier D, common indication for endoscopic interventionwith a Pierre-Khan A: Stenosis of the aqueduct of Sylvius, high endoscopic third ventriculostomy success score

15 Etiology and Treatment. J Neurosurg Sci 1986; 30: 29-(ETVSS). There is a small recurrence risk (~4%) for 39.congenital cases even when it is not X linked. VP shunt 13. Sefidbakht S, Dehghani S, Safari M, Vafaei H, was offered as a treatment modality for this patient but Kasraeian M. Fetal central nervous system anomalies was not done due to financial constraints.detected by magnetic resonance imaging: a two-year In conclusion, aqueductal stenosis remains the experience. Iran J Pediatr 2016; 26: e4589.commonest cause of congenital hydrocephalus and

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

15. Uche EO, Okorie E, Emejulu J, Ajuzieogu O, al. Congenital Aqueductal Stenosis: Findings at Fetal Uche NJ. Challenges and outcome of cranial MRI That Accurately Predict a Postnatal Diagnosis. neuroendoscopic surgery in a resource constrained AJNR Am J Neuroradiol 2018; 1-7. developing African country. Niger J Clin Pract 2016; 2. B e e g h l y M , W a r e J , S o u l J . 19: 811-5.Neurodevelopmental outcome of fetuses referred for

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

Dr. B E Edetanlen Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,College of Medical Sciences,University of Benin, Benin-city, Edo state,[email protected] No: +2348024223651

Correspondence to:

40

1 2B.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 3Malignant fibrous histiocytoma (MFH) is an (MFH) was first coined by Ozzello et al in 1963 and

4aggressive, high-grade tumor with poor prognosis. It is described by O'Brien and Stout in 1964. In 1970s, the most common soft tissue sarcoma in adults, usually Feldman and Norman described the first primary tumor

5occurring in retroperitoneum and extremities. MFH of of bone that satisfied the histological criteria of MFH. the head and neck is rare.All cases in the records of the Malignant fibrous histiocytoma (MFH) is the most

6Department of Oral and Maxillofacial Surgery of the common soft-tissue sarcoma occurring in late adults. 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, prediagnost ic metastasis , percent of these tumors are primary tumors while the prediagnostic antibiotic administration, treatment and other 30% are associated with pre-existing conditions

7the outcome. Age ranged between 25- and 33 years such as prior radiation therapy of the region.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

8Two cases were misdiagnosed as orofacial cellulitis. involvement of the maxillary alveolar bone. The All cases except one recurred and died of the occurrence of MFH in membranous bones including

9lesion.Five case series of histologically diagnosed mandible is quite unusual. Involvement of the MFH of jaws were presented, demonstrating their rare mandible accounts for only 3% of all MFH bone

10occurrence, highly aggressive nature, high local lesions. Larynx, maxillary sinus, and mandibles have recurrence rate, and tendency for early metastasis to 11

the worst prognosis in the head and neck lesion.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- 45the 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,

Introductionradiological features, histological features, treatment,

Tumors composed of cells differentiating as and prognosis.

both fibroblasts and histiocytes have been designated 1fibrous histiocytoma. Only a small percentage of these

Case reports lesions behave in a malignant fashion; they are called

Case 1:A case of 33-year-old female who was initially 2malignant 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 history of trauma or irradiation was negative.The 2sarcoma. patient's medical history and a general physical

examination revealed no abnormal findings. Chest radiograph shows no pulmonary metastasis. Extraorally, examination revealed a massive swelling measuring about 7x10 cm in the greatest dimension with surface ulceration (Figure 2). Regional lymph nodes were not palpable. There was numbness of the lower lip. Intraorally, the swelling was located in the premolar-molar region with no surface ulceration but

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

Figure 1: Early malignant fibrous

histiocytoma, misdiagnosed as orofacial

abscess outside our hospital due to pain and

shiny and stretched skin surfaces.

Figure 2: Rapidly growing lesion in same

patient in figure 1

Figure 3: Computed tomogram showing infiltrative lesion.

Figure 4: Section shows sheets of spindle cells having hyperchromatic nuclei and moderate cytoplasm admixed with multinucleated giant cells (H and E, X 40)

Figure 5: High-power view illustrating large pleomorphic bizarre malignant cells (H &E, X 350)

Figure 6:PA radiograph of the chest with pulmonary metastasis

B.E. Edetanlen et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)

41

35moth-eaten margins with root resorption. With 15%), oral cavity (5-15%), pharynx, ear and eyelid. histological examination, a diagnosis of storiform- Maxilla is more commonly involved than the

36pleomorphic malignant fibrous histiocytoma was mandible. 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

37disarticulation was performed with radiotherapy. The among other factors. 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

38right upper jaw swelling of 3 month duration. There not be ulcerated. Fracture may be the first sign when 39was no history of trauma. On examination the swelling the tumor occurs as primary neoplasm in bone. 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

40tomography revealed an extensive ill-defined of the swelling. Less frequently, the presenting radiolucency without marginal sclerosis and periosteal symptom may be a persistent toothache or non-healing

39reaction. A definitive diagnosis of storiform- extraction socket. The reported interval between first 41pleomorphic malignant fibrous histiocytoma was made symptoms and diagnosis is 1.5 to 3.5 months.

base on histology of the incisional biopsy. After hemi- 28According to Kanazawa et al, 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 43fluctuancy, 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 2 6predilection and commonly occur in late metastasis. CT scan of the upper jaw revealed an 12,36adulthood. However, 90% of our cases were female extensive ill-defined radiolucency without marginal patients in their late adulthood.sclerosis and periosteal reaction. A definitive diagnosis

In plain radiograph, the imaging features of of storiform-pleomorphic malignant fibrous 44MFH is not specific. Most of the reported lesion have histiocytoma was made base on histology of the

presented as an extensive ill-defined radiolucency incisional biopsy. Hemi-maxillectomy was performed without marginal sclerosis and periosteal reaction and but patient died 12 months post-surgery from local in few cases it can appear as well defined radiolucent recurrence and pulmonary metastasis.

34lesion. Reported radiographic findings were irregular bone margin, a moth-eaten appearance, erosion of Discussion cortex, pathological fracture and tooth root resorption. The clinical features, radiological features, The reported CT and MRI imaging features of MFH histological features, and treatment of published case

44have also not been specific. On CT scans, MFH is reports and series of MFH involving the jaws were usually seen as a large lobulated soft-tissue mass, identified from the PubMed database using the MeSH which is isoattenuated to muscle. Calcification or terms Histiocytoma, Malignant Fibrous, Jaws, ossification can be detected in 5%-20%. The centre of Mandible, Maxilla. the lesion often has diminished attenuation due to In the head and neck region, MFH has been

44necrosis, haemorrhage, or myxoid material. On MF reported to involve the nasal cavity and paranasal image, MFH is typically seen as a mass that is sinuses most frequently, accounting for 30% of all

33 isointense to muscle on T1-weighted images and cases. In the sinonasal tract, it occurs most commonly heterogeneously hyperintense on T2-weighted in the maxillary sinus, followed by the ethmoidal sinus,

4434 images.nasal cavity, sphenoid sinus, and frontal sinus . Other It is worth nothing that diagnosis based solely reported site in the head and neck include the

on clinico-radiological presentation may result in high-craniofacial bones (15-25%), larynx (10-15%), soft rate of initial misdiagnosis of MFH, and light tissue of the neck (10-15%), major salivary gland (5-


42

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.

23tissue and bone lesions . MFH has a complex 7. Albright J, Terry B et al. Mandibular juvenile 45histological 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

Reconstr Surg 1977; 60:629-634morphologic patterns, recognized as the storiform - 45 9. Kasat VO, Saluja H, Rudagi BM, Kalburge JV, pleomorphic, myxoid, giant cell, and inflammatory.

Sachdeva S. Malignant fibrous histiocytoma of The most common type is storiform-pleomorphic. It is maxillary alveolar ridge extending to the hard palate. J common for several patterns to be observed within one Cancer Res Ther. 2014; 10(2):422-424. lesion. The explanation of the multiple patterns 10. Happonen RP, Ekfors T, Suonpa J, Forsell K. observed morphologic for MFH is related to

9,8 Malignant fibrous histiocytoma of the jaws: report of predominance of cellular differentiation.two case. J Oral Maxillofac Surg 1988; 46:690-693The management of MFH of the jaws requires 11. Anavi Y, Herman G, Graybill S, Macintosh RB. early radical surgery including removal of adjacent

normal tissues, with a minimum of 3cm tumor-free Malignant Fibrous Histiocytoma Of the mandible. Oral 26margins . 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;

33histological 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

Literature. J Dent Res Dent Clin Dent Prospects. 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 2009;3:32-35. chemo/radiotherapy. It is of utmost importance that the 14. Sato T, Kawabata Y, Morita Y, Noikura T, Mukai H, treated MFH cases are kept under close follow up for a Kawashima K, Sugihara K. Radiographic evaluation of minimum period of 5years, to detect any post-surgical malignant fibrous histiocytoma affecting maxillary recurrence or metastasis. Also there should be a high alveolar bone: a report of 2 cases. Oral Surg Oral Med index of suspicion of any painful orofacial swellings Oral Pathol Oral Radiol Endod. 2001; 92:116-123.with glossy and stretched skin surface to reduce

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 1987:45:955-9581. 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):166-1682. 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

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): 303-30721. 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;31:45-48Cancer 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 12:383-388C.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 30:71-76jaws. 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; 9:221-225Review of Literature and Report of a Case . Australian J Basic Appl Sci 2011; 5:936-42


44

Correspondence to:

45

1 2O.O. Ogunbode, S.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.

Medical Management of Ectopic Gestation Following a Failed Bilateral Tubal Ligation.

Dr. S.A. Adeyanju

Department of Obstetrics and Gynaecology,

University College Hospital, Ibadan.

Phone: +234-7037992746

E-Mail:[email protected]

Summary means or even by expectant management; all these 4,8The objective of this paper is to emphasize that have specific criteria . If pregnancy occurs following

9ectopic pregnancy can occasionally occur after a tubal ligation, the risk of it being an ectopic is 12.5% . 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 Summaryweeks 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

1but with about the least uptake in Sub-Saharan Africa . 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

2,3Pomeroy's technique . and well.4- In 2018, she conceived spontaneously, and As effective as it is, it has a failure rate of 0.5%

6 booked for antenatal care at gestational age of 20 weeks A failure rate of 0.1-0.8% in the first year after tubal 7 and 4 days; She was counselled for permanent sterilization has also been reported. . Ectopic

contraception at the time of delivery which she and her pregnancy could be managed surgically, by medicalhusband consented to. In October 2018, she was admitted at gestational age of 38-weeks and had elective caesarean section with bilateral tubal ligation on account of 2 previous caesarean section and complete family size. The tissue specimens taken were sent for histology which showed tubular structures in keeping with the fallopian tube.

She was not a known hypertensive, diabetic, asthmatic or peptic ulcer disease patient. She had not

Table 1: Serial quantification of Serum beta human chorionic gonadotrophin (âhCG).

Date

Serum âhCG level (IU/L)

% drop in

âhCG level

Intervention

08/11/2019 (Pre-Presentation)

8874

--

Nil

12/11/2019(96hrs later)

5969

32.74 (over 4 days)

1st

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

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

3was noted. There were no areas of tenderness and no 10 /ml, Neutrophils 60%, Lymphocytes 30%, 3palpable mass; neither the uterus nor the intra- Monophils 5.3%, Platelets[PLT] count 424 x 10 /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 s ingle 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

3 = 26cm oval rounded vascular heterogeneous solid Ran i t id ine 50mg, Ondanse t ron 8mg and mass in the region of the right fallopian tube. Left ovary Dexamethasone 8mg given slowly 8 hours apart on

3measured 24 x 15 x 16 mm = 3.3cm . Normal pouch of each day of chemotherapy. She always had 500ml each

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

0 20 40 60 80 100 120

B

hCG

levels (IU/L)

Time of chemotherapy administration (Days)

hCG level(IU/L)

Figure 1: A graph showing the relationship between the serum beta hCG (vertical axis) and Time (in days) of administration of chemotherapy (Methotrexate).

O.O. Ogunbode et al/ The Tropical Journal of Health Sciences Vol 27 No 3 (July 2020)

46

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

8the first dose, there was approximately 57.75% decline often involves the use of systemic methotrexate .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

18reasons for a period of two weeks before the fourth it possible for single dose outpatienttherapy .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

8She was counselled on the need for alternative willing to return for follow up .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 pat ient 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

8injection or insertion of sclerosants or devices . It is methotrexate. About 96 hours after the first dose, there c o m m o n l y d o n e b y m i n i - l a p a r o t o m y o r was approximately 57.75% decline in the level of laparoscopically but recently through hysteroscopic serum hCG. After the second dose, 86.57% fall,

10,11methods . 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

12-14pregnancies per 1000 procedures 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

15 has been documented to be associated with greater caesarean section . success and it was adopted in the management of Mrs. Pregnancy occurring after BTL can be

18emotionally disturbing to the woman and are O.E .

16,17 The initial intention was to perform weekly mostlyintrauterine . In 12.5% of cases, these could be serum hCG level assessment and administer ectopic pregnancy and heterotopic pregnancy

8 intramuscular Methotrexate weekly but because of following BTL has also been reported . The occurrence financial constraint, she could not catch up with that of ectopic pregnancy after BTL may be due to pace. However, because of good and on-going spontaneous tubal recanalization or the formation of

9,16 counselling the patient was able to continue the tubo-peritoneal fistula . An ectopic pregnancy is


47

management to this satisfactory point without 42(4): 713–724.defaulting.

5. Roeckner JT, Sawangkum P, Sanchez-Ramos Side effects of methotrexate include blood

L, Duncan JR. Salpingectomy at the time of caesarean disorders (bone marrow suppression), liver damage, delivery A systematic review and meta-analysis. pulmonary toxicity; gastrointestinal disturbances such Obstetrics & Gynaecology. 2020; 135(3): 550-557.as stomatitis and diarrhoea renal failure, skin reactions,

alopecia, osteoporosis, arthralgia, myalgia and ocular 6. Clark NV, Endicott SP, Jorgensen EM, Hur H, 18irritation . 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

Female sterilization failure: Review over a decade and Ranitidine, Ondansetron and Dexamethasone. The aim its clinicopathological correlation. Int J Appl Basic of this was to reduce to the barest minimum the possible Med Res. 2014; 4 (2): 81-85.side effects of the chemotherapeutic agent used. 8. Ectopic pregnancy and miscarriage: diagnosis She was counselled on the need for alternative

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

1991;37(1):17-20.abnormal vaginal discharge with copper-containing 10. Kumbak B, Ozkan ZS, Simsek M. Heterotopic intrauterine devices she did not want them. She wanted pregnancy following bilateral tubal ligation: Case some more time to think on implants though she was

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.

Hysteroscopic and Laparoscopic Sterilizations. Obstet In conclusion, no contraceptive method is Gynecol. 2019;133(2):323-331.100% safe. Where failure occurs and pregnancy results, 12. Clark NV, Endicott SP, Jorgensen EM, Hur H, early diagnosis and prompt management is key so as to

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.

Female sterilization failure: Review over a decade and Referencesits clinicopathological correlation. Int J Appl Basic 1. United Nations, Department of economic and Med Res. 2014;4(2):81-85.social affairs. Contraceptive use by method 2019. 15. Sefogah PE, Onuzo CK, Gordon AS. Ectopic https://www.un.org/en/development/desa/population/pregnancy after bilateral tubal ligation. Postgraduate publications/pdf/family/ContraceptiveUseByMethodMedical Journal of Ghana. 2017;6(1);59-62.DataBooklet2019.pdf. 16. Naqvi SSB. Ectopic pregnancy after bilateral 2. Igberase GO, Ebeigbe PN, Umeora OUJ, tubal ligation. Pakistan Armed Forces Medical Journal. Abedi HO. Bilateral tubal ligation in a rural hospital in 2014; 64(2): 378- 379.the Niger Delta, Nigeria. Nigerian Journal of Clinical 17. Awonuga AO, Imudia AN, Shavell VI, Berman Practice 2011; 14(2):137-139.J, Diamond MP, Puscheck EE. Failed Female 3. Swende TZ, Hwande TS. Female sterilization sterilization. A review of pathogenesis and subsequent by tubal ligation at caesarean section in Makurdi, contraceptive options. The Journal of Reproductive Nigeria. Annals of African Medicine. 2010; 9(4): 246-Medicine. 2009; 54(9):541- 547.250.18. Lesavre M, Curinier S, Capmas P, Rabischong 4. Moss C, Isley MM. Sterilization: A review and B, Fernandez H. Treatment of tubal ectopic pregnancy update. Obstetrics & Gynaecology Clinics. 2015; by methotrexate. J Gynecol Obstet Biol Reprod.


48

Volume 27, Number 3 July, 2020 - Bowen University

Documents

Transcript of Volume 27, Number 3 July, 2020 - Bowen University