A case study of ReachAnother Foundation as a change champion for developing spina bifida neurosurgical care and advocating for primary prevention in Ethiopia

Spina bifida is a serious birth defect affecting the central nervous system, characterized by incomplete closure of the neural tube. Ethiopia has a very high prevalence of spina bifida, affecting about 40 cases per 10,000 births. Babies born with spina bifida require early closure surgery, done within the first 2-3 days after birth. Some babies need repeat surgeries to address complications, including hydrocephalus. Without medical care, babies have a high risk of death within the first 5 years of their life. Neurosurgical capacity for spina bifida closure surgery at birth is a relatively new development in Ethiopia. ReachAnother Foundation, a not-for-profit organization based in OR, USA, started work in Ethiopia in 2009 and has been instrumental in training neurosurgeons and improving treatment for spina bifida and hydrocephalus. Along with the development of neurosurgical care, the Foundation has invested in training multi-disciplinary teams to conduct patient aftercare and has launched a platform for improved patient outcomes research. As of year 2022, they support six spina bifida "Centers of Excellence" nationwide and are continuously advocating for primary prevention of spina bifida through mandatory fortification of staple foods in Ethiopia. This paper describes ReachAnother's efforts in Ethiopia in a short interval of time, benefiting numerous patients and families with spina bifida and anencephaly. We document this as a case study for other countries to model where resources are limited and the prevalence of spina bifida and hydrocephalus is high, especially in Asia and Africa.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Projected impact of mandatory food fortification with folic acid on neurosurgical capacity needed for treating spina bifida in Ethiopia

Spina bifida, also known as meningomyelocele, is a major birth defect mostly associated with folate deficiency in the mother early in pregnancy. The prevalence of spina bifida is disproportionately high in Ethiopia compared to the global average; about 10,500 liveborn are affected annually. Many affected infants do not receive timely repair surgery. There are a high number of stillbirths, and neonatal, infant, and under‐five deaths. Mandatory fortification of staple foods such as wheat and maize flour with folic acid, a B vitamin, is an effective primary prevention strategy for spina bifida. Survival in those with spina bifida increases if neurosurgical intervention is available soon after birth, along with continuous surgical and clinical aftercare throughout the lifespan. Currently, Ethiopia does not have mandatory food fortification for primary prevention or adequate neurosurgical capacity to meet the need to prevent adverse outcomes associated with spina bifida. We present in this paper two concurrent and complementary policy and practice solutions occurring in Ethiopia through global partnerships: (1) capacity‐building of neurosurgery care through training programs; and (2) promoting national mandatory folic acid fortification of staples for primary prevention of spina bifida. These two policy and practice interventions ensure all affected infants can receive timely pediatric neurosurgery and sustained surgical aftercare through required neurosurgeon availability, and ensure primary prevention of spina bifida. Primary prevention of spina bifida frees up significant neurosurgical capacity in resource‐poor settings that can then be directed to other critical neurosurgical needs thus lowering child mortality and morbidity.

SHORT-TERM OUTCOME OF OPERATED TRAUMATIC BRAIN INJURY PATIENTS FOR INTRACRANIAL HEMORRHAGE AT TIKUR ANBESSA SPECIALIZED TEACHING HOSPITAL (TASTH), ADDIS ABABA, ETHIOPIA

BACKGROUND

Traumatic brain injury is the leading cause of death and disability in people younger than 40 years of age worldwide.

OBJECTIVE

The study primarily aims at assessing the short-term outcome of patients operated for traumatic intracranial hemorrhage.

PATIENTS AND METHODS

This is a hospital based cross sectional study on patients with traumatic brain injury at Tikur Anbessa Specialized Teaching Hospital in Addis Ababa, Ethiopia, between February 2013 and February 2014. Standardized and structured questionnaire was used to collect sociodemographic data. All patients with traumatic brain injury operated following intracranial hemorrhage were included. Glasgow Coma Scale was used to determine the outcome. Difference in proportions was examined using Chi-square test.

RESULTS

The study reviewed 91 patients with traumatic brain injury. Their age ranged from 13 to 60 years with a mean (SD) of 32.3 (±12.1). Eighty-seven (95.6%) of the cases were males and 4(4.4%) females and 34(37.4%) of them cases had mild and 30(33%) had severe traumatic brain injury. Acute Epidural Hematoma was seen in 79(86.8%), Acute Subdural hematoma had the highest proportion, 4/11(36.4%), of deaths and it was also significantly associated with unfavorable Glasgow Outcoma Scale at 3 months (p=0.03). Overall, the proportion patients who died was 18.7% with older patients (>50 years) had a significantly higher proportion of death (p=0.01). Most of the patients had favorable Glasgow Outcoma Scale ,unfavorable was seen in 22/30 (73.3%) and 17/30 (56.7%) of patients with severe traumatic brain injury at 3 and 6 months, respectively.

CONCLUSION

In conclusion, male predominance was substantially high. Acute Subdural hematoma and old patients had high death rates and unfavorable outcome. Overall the death rate was not different from global figures.

An Ethiopian Training Program in Neurosurgery with Norwegian Support

After a 4-year planning period, a joint Ethiopian/Norwegian training program in neurosurgery was started in June 2006. The collaborating partners were Addis Ababa University; Department of Surgery, Tikur Anbessa Specialized Hospital; University of Bergen; Haukeland University Hospital; and Myungsung Christian Medical Center, a Korean missionary hospital in Addis Ababa, Ethiopia. A memorandum of understanding was signed at dean/chief executive officer levels. Although other initiatives have been involved in supporting neurosurgery in Addis Ababa during the same period, this institutionally founded program has been the main external contributor to neurosurgical capacity building through the education of 21 Ethiopian neurosurgeons, and in supporting a sustainable environment for neurosurgical training within a network of 5 centers in Addis Ababa. This article gives an account of the strategies underlying the program planning, the history of the program, and on the experience gained by it. Finally, ethical problems and challenges encountered in the program are discussed.

REVIEW OF THE CLINICAL, COMPUTERIZED TOMOGRAPHY SCAN AND/OR MAGNETIC RESONANCE IMAGING FINDINGS OF INTRACRANIAL TUBERCULOMA IN AN ETHIOPIAN TEACHING HOSPITAL

ACKGROUND

Ethiopia is one of the countries that has high burden of all forms of tuberculosis and there is no published report on computerized tomography scan and/or magnetic resonance imaging of intracranial tuberculomas. Objective : to review the clinical, computerized tomography and/or magnetic resonance imaging features of intracranial tuberculoma.

METHODS

retrospective review of patient’s medical records of patients operated for intracranial mass that had computerized tomography and/or magnetic resonance imaging brain scans and had histopathological diagnoses, at Tikur Anbessa Specialized Hospital between January 2009 and June 2013.

RESULTS

Of 222 operated cases of intracranial mass subjected to histopathological test 29 (14.6%) were found to have tuberculomas, 28 (14.1%) had caseous necrosis and one was a tuberculous abscess, in 25 cases imaging was available for review and were included in the study . There were 15 males and 10 females with age range being 2 to 65 years and with the Median age being 13 years. Twenty patients had computerized tomography and five patients had magnetic resonance imaging. Seizure 15/25 (60%) and headache 11/25 (44%) were the commonest presentation. Solitary or confluent large lesions were seen in 12/25 (48%) of patients. 14/25 (56%) of the lesions had their size between 2 cm and 5 cm. Majority of the lesions 15/25 (60%) were in the frontal and parietal lobes. The lesions were isodense on CT in 18/25 (72%) of the pre-contrast studies and 21/25 (84%) showed ring or rim enhancement after intravenous administration of the contrast medium.

CONCLUSION

Tuberculoma, more frequently, presented with non-specific clinical findings and chronic seizure disorder and comonly occurred in young patients and often seen infratentorialy. It is often complicated with hydrocephalus in the pediatric age group. Computerized tomography scan and/or magnetic resonance imaging features are not different from reports from other countries.

Outcome of Endoscopic Third Ventriculostomy in Pediatric Patients at Zewditu Memorial Hospital, Ethiopia

OBJECTIVE

To determine short-term outcome of endoscopic third ventriculostomy (ETV) in pediatric patients.

METHODS

This was a hospital-based retrospective study of outcome of ETV performed with or without choroid plexus cauterization (CPC) in pediatric patients at Zewditu Memorial Hospital, Addis Ababa, Ethiopia, between January 2012 and December 2014. Medical records were used to complete a structured questionnaire. Outcomes were graded as success or failure. The difference in proportions was examined using χ(2) test.

RESULTS

Of 122 children, 26 underwent a combined ETV and CPC procedure, and 96 underwent ETV alone. The mean and median ages were 1.89 months and 2.0 months, respectively. Most patients were <6 months old (45.1%); 35.2% were >1 year old. The cause of hydrocephalus was myelomeningocele in 42 (34.4%) patients and aqueductal stenosis in 41 (33.6%) patients. The mean and median follow-up periods were 7.2 months and 3.0 months, respectively. The success rate for combined ETV and CPC (66%) was superior to the success rate for ETV alone (47%) among infants <1 year old (P < 0.0001). The overall surgical mortality rate was 2.4%, and the infection rate was 7%.

CONCLUSIONS

In resource-limited countries, ETV can be performed with acceptable results and less mortality and morbidity. Myelomeningocele and aqueductal stenosis were the most common causes of hydrocephalus. In patients <1 year old, the outcome success in patients undergoing combined ETV and CPC (53%) was significantly better compared with patients undergoing ETV alone (25%).

PATTERN OF SPINE AND SPINAL CORD INJURIES IN TIKUR ANBESSA HOSPITAL, ETHIOPIA

BACKGROUND

Spinal injury is a major cause of morbidity and mortality worldwide. Fall and Road traffic accident are the main etiologic factor.

OBJECTIVE

The aim of this study was to asses local hospital patterns of spinal injury and compare them with published reports.

METHODS AND PATIENTS

This is a hospital based cross sectional study of patterns of patients with spine and spinal cord injury seen at the Emergency OPD, Tikur Anbessa Specialized Teaching Hospital (TASTH), Department of Neurosurgery, Addis Ababa, Ethiopia in the period between April 2008 and March 2012. Data was collected using structured questionnaires. The variables included were the Socio-demographic such as age sex, distance of patients' residence area from the TAH. In addition to the above profiles, causes of injuries, Occupation, diagnosis, time spent between arrival andAdmission and decision taken at OPD level. Differences in proportions were examined using Chi-square test.

RESULTS

A statistically significant male predominance (84.9%) (p, 0.0001) was observed, the mean age was 32.8 years, with range 10 to 84 years. Mean duration of presentation to TASH was 4.3 days with a range 1 hour-60 days, Fall from height (P < 0.001) and Road traffic collisions were the main cause of spine and spinal cord injuries in 36.4% and 32.9% of the patients respectively. Most often the cervical spine was involved (33.0%), Sixty-nine (17.9%) patients had associated injuries, majority of respondents (25.5%) were farmers, Majority belonged to ASIA A grade. All the deaths, 7 (8.3%) occurred in patients with complete cervical spine lesion.

CONCLUSION

Spinal injury was an important indication for neurosurgical consultations in our service. Complete cord injuries were more common than incomplete and the case incidence from fall was remarkably high.

Medical students' choice of specialty and factors determining their choice: a cross-sectional survey at the Addis Ababa University, School oF Medicine, Ethiopia

BACKGROUND

A consideration of the future specialization interests of undergraduate medical students might help in understanding the needs of higher medical education and future manpower availability for healthcare in a country.

OBJECTIVE

This study assessed the career of choice made by medical students of the Addis Ababa University in the year 2012.

METHOD

A cross-sectional study was conducted among 161 medical students of the Addis Ababa University, School of Medicine, Ethiopia in April 2012 using a self-administered questionnaire. Data were analyzed using computer based statistical software IBM SPSS data editor version 20.0. In addition to descriptive statistics difference in proportions was compared using Chi-square test

RESULTS

Of the 161 students, 101 (62.7%) were male. The mean age of respondents was 24.1 years (SD 2.02, ranging from 21 to 35). Majority, 138 (85.7) wanted to pursue their specialty training in the near future, their first career of choice being surgery for, 50 (31.1%), followed by internal medicine for, 44 (27.3%) and Obstetrics and Gynaecology for, 29 (18.0%]), However 18 (11.2%) did not specify their career of choice. The basic science fields such as anesthesiology, and oncology were the least favored choices by the students. The main reasons that influenced the students' decisions to opt for a particular specialty were inspiration during their clinical practicein 67 (41.6%). Financial reward (24.2%), dedication to the field (19.2%) possession of competency needed for the speciality (18.6%) and Influence of teacher (16.1%) were also factors that influenced future choice of speciality of the students.

CONCLUSION

The majority of medical students preferred to pursue their specialty training. As the number and interest in certain specialties is huge, training centers must be ready to cater for the interests shown by the students. The lack of interest towards certain specialists such as basic sciences, anesthesiology, and oncology requires a special attention by policy makers.

Attitudes toward neurosurgery in a low-income country: a qualitative study

OBJECTIVE

To adapt a study exploring the needs of neurosurgery patients in a tertiary care hospital in Canada to examine, for the first time, the perspectives of neurosurgery patients in a low-income country with limited health care resources.

METHODS

Semistructured interviews were conducted with 25 neurosurgery patients at Tikur Anbessa Specialized Teaching Hospital in Addis Ababa, Ethiopia. Interviews were conducted in Amharic or Oromo, translated into English, and subjected to modified thematic analysis.

RESULTS

The following 5 themes emerged: 1) With limited resources, many patients did not seek information outside of that obtained during the clinical encounter. 2) Patients valued direct verbal communication and deferred to the surgeon's authority. 3) Religion played an instrumental role in patient attitudes toward surgery. 4) Most patients did not feel anxious about surgery. 5) A few patients did not inform family members about their medical condition.

CONCLUSIONS

Qualitative research methodology in neurosurgery can be successfully adapted from resource-abundant to resource-poor contexts. In low-income countries, patients are faced with limited options for self-education and self-empowerment, and fatalistic and paternalistic attitudes may be prevalent. Local cultural values and expectations can influence practice differently than they do in resource-rich countries.

Microscopic transphneoidal surgery experence from christian Medical Center Addis Abeba Ethiopia

BACKGROUND

The transphneoidal approach to the pituitary gland using the microscope has undergone continuous modification since its introduction by Hardy over 50 years ago. It is one of the most effective and safest of major neurosurgical procedures with excellent outcomes and low complication rates.

OBJECTIVE

To describe the experience of Endonasal microscopic transsphenoidal surgery at Myungsung Christian Medical Center during three-years period.

PATIENTS AND METHODS

This is a hospital based retrospective review of patients with pituitary tumor for whom microscopic transsphenoidal surgery was done in Myungsung Christian Medical Center, Addis Ababa, Ethiopia in the period between September 2010 and August 2014. Patients' demographic data, type of symptoms, hormonal profile, imaging modality, complications and outcomes were recorded in apre-formed questionnaire. Frequencies and means were computed for description of the various variables and presented in prose form and graphs. The association between categorical variables was calculated using Chi-square test.

RESULTS

sixteen (53.3%) patients were males, 14 (46.7%) females. The mean age was 33.77, ± 10.85 years (rang 14 - 53). The most common presentation were headache in 28 (93.3%) patients and visual disturbances in 26 (86.7%), while 18 (60%) had bitemporal hemianopia. prolactin levels were elevated in 4 (13.3%) of them having hyperprolactinemia, cortisol levels revealed hypercortisolemia with clinical evidence Cushing disease in 5 (16.7%). Three ((10%) had elevated growth hormone levels with acromegalic features. All patients included in the study had a MRI; tumors were with suprasellar extension in all (100%) patients, involvement of floor ofsella in 18 (60%), extension to sphenoid sinus in 8 (26.7%) and with parasellar extension in 5 (16.7%). Twenty-seven (90%) were done through direct transnasal, 2 (6.7%) transseptal transphneoidal approach; in one patient the approach was translabial. Early complication and mortality rate was 18 (60%) and 2 (6.7%) respectively. At one-year follow-up period, 22 (73.3%) patients had good functional outcome, while 6 (20% 0 were in the same status as in the preoperative period, 2(6.7%) had residual/recurrent tumor.

CONCLUSION

Our patients were relatively advanced cases with suprasellar and parasellar extensions. Direct transnasal approach, is straightforward, quick and does not require dissection of nasal mucosa or removal of septal cartilage and that the procedure can be done by neurosurgeon with some experience in the procedure without an increased risk of complications. High early complication rate was tolerable and manageable. Acceptable mortality and good functional outcome during follow up period is encouraging and compares favorably with African and other similar studies.

Review of morbidity and mortality among patients adimitted to the Surgical Intensive Care Unit at Tikur Anbessa Specialized Teaching Hospital, Ethiopia

BACKGROUND

Caring for the critically ill is a challenge in developing country including Ethiopia, where heath needs often outstrip available resources. There is scarce data available on morbidity and mortality of surgical intensive care unit patients in Ethiopia.

OBJECTIVE

To describe mortality, morbidity and outcomes of patients under the care of surgical intensive care unit team between September 2010 and August 2011.

PATIENTS AND METHODS

This is a hospital based retrospective review of morbidity and mortality among surgical patients admitted to Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia in the period between September 2010 and August 2011.

RESULTS

The study reviewed 441 surgical intensive care unit admissions over one- year period Age ranged from 10 to 90 years mean 37.55 ± 16.56 years. Mortality was high in 21-30 years age group, 9.1%. The highest admission was from cardiothoracic surgery unit, 37.4%, the average length of hospital stay was 4.52 days (range 1 to 87 days). Significant number 52 (33.3%) of patients who died under surgical ICU care belongs to General surgery unit. Two Hundred eighty (63.5%) patients had an uneventful course, while 156 (35.4%) and 161 (36.5%) died and developed complications respectively. Age of the patient at the time of admission, mode of admission, and post admission complications were significantly and positively associated with mortality (p = 0.0001) while gender did not show any association with mortality at SICU (p = 0.528).CCONCLUSION:The highest admission was from department of cardiothoracic surgery, while mortality rate was high-st from general surgery side. There are significant and positive associations ofa ge, urgency ofa dmission, and complications with mortality while gender did not show any association.

Concentric craniotomy: removal of tumor involving the skull and the intracranial space

BACKGROUND

Removal of a tumor involving both the intracranial space and the skull presents technical challenges. This is especially so if there is a potential for significant hemorrhage due to a hemangioma or a significant attachment to the brain as with a meningioma.

CASE DESCRIPTION

We describe a technique where the tumor attached to the skull is left undisturbed and a second wider concentric craniotomy exposes normal dura. The entire tumor, both intracranial and that involving the skull and dura, can then be removed as one specimen.

CONCLUSION

The technique we describe, a concentric craniotomy, transforms a difficult operation with the potential for significant hemorrhage into a more standard removal of a convexity tumor.

Laparascopic cholecstectomy at Myungsung Christian Medical Center, Ethiopia: a five-years experience

BACKGROUND

Laparoscopic cholecystectomy is a recent entry in the treatment of gall bladder disease in Ethiopia mainly in private hospitals of the capital city, Addis Ababa, and is slowly gaining acceptance. Like all new techniques, it has generated considerable controversy and debate on its merits over the traditional open operation.

OBJECTIVE

The aim of this study was to review our experience of laparoscopic cholecystectomy at Myungsung Christian Medical in, Ethiopia

MATERIAL AND METHODS

A hospital based retrospective cross sectional analysis was conducted in Myungsung Christian Medical Center, Addis Ababa, Ethiopia. Patients' medical records and operation theater registers of 681 patients for whom laparoscopic cholecystectomy were done for symptomatic and complicated cholelithiasis, between January 2005 and December 2009 were analyzed using computer based statistical software SPSS version 11.0. Difference in proportions were examined using Chi-square test with its conventional criterion for statistical significance (p < 0.05).

RESULTS

The female to male ratio was 6.6:1 with mean age of 44.4 [Standard Deviation, 0.53] years. Of the six hundred eighty-one patients admitted and planned for laparoscopic cholecystectomy, 661 (97.1%) patients completed the procedure successfully (p < 0.0001) and the procedure was converted to open surgery in 20 (2.9%) for various reasons. Mean duration of operation and hospital stay were 58.9 +/- 18.2 [SD] minutes and 36.9 +/- 10.9 [SD] hours respectively. Postoperative mortality and complication rate were 0.15% and 2.94% respectively.

CONCLUSION

LC is safe and effective procedure even in difficult cholelithasis (p < 0.0001), in addition the merit of laparoscopic cholecstectomy include fast recovery, minimal tissue trauma, less postoperative hospital stay (p < 0.0001). Hence, LC could be practiced by general surgeons working in third world countries.

Review of lumbar disc diseases at Tikur Anbessa Hospital

BACKGROUND

Disc degeneration is common, the pattern and prevalence of various signs of disc degeneration is unclear. Neither hospital nor population-based data or study is available on lumbar disc diseases in Ethiopia. The sequelae of disk degeneration are among the leading causes of functional incapacity in both sexes and are a common source of chronic disability in the working years. Lumbar disc disease refers to a collection of degenerative disorders that can lead to low back pain as people age.

OBJECTIVE

Review the pattern, clinical manifestation, diagnostic method and management decision of patients with degenerative lumbar disc disease at the neurosurgical referral clinic of Tikur Anbessa Hospital during the fiscal year 2009.

PATIENTS AND METHODS

This is a hospital based cross sectional study of patterns of patients with lumbar disc diseases seen at the neurosurgical referral clinic, Tikur Anbessa Specialized Teaching Hospital (TASTH), Department of Surgery, Addis Ababa, Ethiopia in the period between January and December 2009 (12 months). Data taken while clerking patients and patents' medical record at referral clinic were main source of information. Standardized and structured questionnaire prepared for this purpose were used to analyze the sociodemographic, clinical manifestation, diagnostic modalities such as lumbar myelography, CT and MRI, patterns of disc disease in lumbar spine at NSRC with reference to age, severity and level distribution were reviewed. Difference in proportions were examined using Chi-square test.

RESULTS

The study reviews 364 patients with lumbar disc diseases at the neurosurgical referral clinic, TASH over the one-year period (2009), their age ranged from 20 to 82 years (median, 44.0). Pain, numbness and neurologic claudication were the three most common presenting symptoms, occurring in 337(92.5%), 232 (63.7.6%) and 111 (30.5%) respectively. Lumbar MRI was the statistically significant investigation modality of choice (p < 0.0001). Two hundred thirty-five (70.1%) patients had disc prolaps (P < 0.0001), 18.5% had disc bulge. Lumbar degenerative disc disease was most frequently seen at L4-L5 level in 309 (54.5%) patients (P < 0.0001). both L4-L5 and L5-S1 accounted for 79.1% of the disc displacements. On MRI, disc displacements, were central in 61.2%, lateral in 9.3% and posterolateral in 15.8%.

Evaluation of standards of informed consent formats in research proposals approved by Faculty of Medicine, Addis Ababa University

BACKGROUND

Medical research involves the voluntary participation of human subjects. Potential participants need information upon which they can make their decision. This review aims to evaluate standard of informed consent and information to human participants in researches conducted at Faculty of Medicine (FoM), Addis Ababa University (AAU).

DESIGN AND METHODS

A retrospective cross sectional analysis was conducted to evaluate the medical research protocols submitted and approved by the Faculty Research Review Committee between 2000 and 2007 at the Faculty of Medicine, Addis Ababa University. The data were analyzed using computer based statistical software SPSS version 11.0.

RESULTS

Of 105 research protocols submitted and approved by the Faculty Research Review Committee, 40 (38.1%) were epidemiological and 28 (26.7%) clinical types of studies by design. The remaining 21 (20%) and 16 (15.2%) belong to behavioral and biomedical categories respectively. Informed consent sheets (ICS), 56 (53.3%) were written, and 15 (14.3%) verbal. The proportion of written ICS sheet was significantly higher than verbal type (p<0.0001). ICS and Study Information Sheet (SIS) were included in the research protocols in 71 (74.7%) and 57 (60.0%) of the cases respectively. Inclusion of statements describing potential risks in 45 (63.4%) protocols was significantly lower (p<0.0001) compared to benefits to the subjects in 58 (81.7%). Statements describing extent of confidentiality and voluntary participation were stated in 55 (77.9%) and 63 (88.7%) of the protocols, respectively, whereas, disclosure of refusal to participate without penalty and consent was found in 42 (45.9%).

CONCLUSION

During the initial years, the proportion of written ICS as well as complete ICS and SIS were very low. Nevertheless, the research protocols evaluated in this study had shown encouraging improvement in the proportion of written ICS (p<0. 0001) and completeness of ICS as well as SIS over time.

In-patient surgical mortality in Tikur Anbessa Hospital: a five-year review

BACKGROUND

To our knowledge neither hospital nor population-based data is available about mortality patterns in Ethiopia.

OBJECTIVE

This review summarizes the patterns of deaths that occurred in hospital under the care of surgical team, during the 5-year period.

PATIENTS AND METHODS

This is a hospital based retrospective cross sectional analysis of mortality among surgical patients admitted to Tikur Anbessa Specialized Teaching Hospital (TASTH), Department of Surgery, Addis Ababa, Ethiopia in the period between January 2002 and December 2006. The monthly activity reports, death registry sheets and death certificate of deceased patients from all surgical wards were analyzed using computer based statistical software SPSS version 11.0. Difference in proportions were examined using Chi-square test with its conventional criterion for statistical significance (p < 0.05).

RESULTS

The study reviews 694 deaths from 9991 surgical admissions, and 9860 procedures at TASTH over the 5-year period. There were 6.9% overall deaths among the admissions and 7.0% per procedure. The postoperative mortality rate was 4.5% (443/9860). The male-to-female ratio was 2.9:1. The mean age was 41 [Standard Deviation, 17.38] years. Four hundred fifty-two (15.7%) patients admitted on emergency basis and 242 (3.4%) of elective admissions died while in hospital surgical care (p < 0.0001). About 56% of deaths resulted from non-traumatic causes whilst 44% from traumatic causes. Similarly operative deaths were observed in 443 (63.8%) while nonoperative mortality in 252 (32.2%). Among patients with trauma, isolated head injury (59.2%) was major cause of death (p < 0.0001), while, of the non-traumatic admissions, malignancy accounted for 164 (42.1%) of the deaths, When specialties are compared, significant number, 234 (34.4%) of the deaths belong to neurosurgery unit (p < 0.0001) followed by general surgery.

CONCLUSION

In conclusion, more men died than women did, more patients admitted on emergency basis died than patients admitted on elective basis (p < 0.0001). Although, the overall mortality rate of 7% and postoperative death rate of 4.5% is acceptable, it could have been reduced significantly had there been appropriate setting to manage trauma cases. Trauma and Neurosurgical cares are yet to develop and need special attention.

Surgically treated pulmonary tuberculosis: report on cases from Tikur Anbessa Hospital, Addis Ababa, Ethiopia

BACKGROUND

The treatment of pulmonary tuberculosis has evolved through multiples of treatment modalities including pulmonary surgery. In Ethiopia, though the disease is very common, there is no information regarding the patterns of surgically treated pulmonary tuberculosis and its outcome.

OBJECTIVE AND STUDY DESIGN

A retrospective clinical study was conducted to investigate the patterns and outcomes of surgically treated cases of pulmonary tuberculosis. Data was collected from the clinical records of all patients operated at the chest surgery unit with a confirmed diagnosis of pulmonary tuberculosis at the Tikur Anbessa teaching specialized referral hospital (26).

RESULT

Twenty-six patients were admitted for surgery, 80.8% of these patients were males. The mean duration of illness before presenting to the hospital was 27.6 months. Cough and hemoptysis were the two most common presenting symptoms, occurring in 26 (100%) and 24 (92.3%). The most common feature seen in chest x-rays was a completely destroyed lung tissue in 10 (38.5%). The parts of the lung commonly involved were the left side in 16 (61.5%) and the upper lobes in 14 (53.8%). The Sputum examination for acid-fast tubercle bacilli tested positive for 24 (92.3%) of the patients. The most frequent indications for surgery were severe hemoptysis for 12 (46.2%), radiographic evidence of destroyed lung for 5 (19.2%) and strong evidence for Aspergilloma for 3 (11.5%). The most frequently performed procedure were left upper lobectomy in 10 (38%), left pneumonectomy in 7 (26.7%) and right pneumonectomy in 7 (26.7%). Nine significant (34.6%) complications occurred in the postoperative period, the commonest being postoperative pneumonia in 4 (15.4%). Two (7.7%) of the patients died. During the follow-up period six patients developed significant late postoperative complications.

CONCLUSION

In the Ethiopian setting, though anti-tuberculous chemotherapy is the standard treatment for pulmonary tuberculosis in a majority of patients, there are still definite indications in which surgical management plays a vital role.

Surgical management of 234 patients with hydatid disease: the Tikur Anbessa Hospital experience

OBJECTIVE

The aim of this study was to evaluate the pattern and surgical management of hydatid disease.

METHODS

A hospital based retrospective cross sectional analysis was conducted in Tikur Anbessa Hospital, department of surgery, Addis Ababa, Ethiopia. Patients' medical records and operation theater registers of 234 patients operated upon for hydatid disease between September 1995 and August 2005 were analyzed

RESULTS

One hundred and twenty three patients were male and 111 female. Their age ranged from 13-69 years, with median and peak age of incidence of 30 and 21-30 years respectively. Hundred forty five (62.0%) patients were from rural population. Significant number of patients (40.6%) came from Oromiya regional state (p < 0.004). The most common presenting symptoms were pain in 206/234 (88.0%) patients with hydatidosis, mass or organomegally in 106/141(75.2%) patients with intraabdominal hydatid diseases, cough in 91.2% and expectoration in 83.3% of cases of thoracic hydatidosis. Liver and lung (79.6%) are the most commonly affected organs. More than one organ involvement was seen in 13.7% of cases. Ultrasonography and chest roentgenography were the main modalities of investigation of abdominal and thoracic hydatidosis respectively. Surgical techniques employed for removal of cysts was evacuation in 181 (67.3%). capitonnage in 167 (62.1%) and pericystectomy in 47 (17.5%) organs. In 191 (81.6%) patients the postoperative course was uneventful while 15.8% developed postoperative complications. There were six deaths. The follow up period ranged from 1 month to 3 years (mean 5.6 months).

CONCLUSION

Hydatidosis is not uncommon in rural communities of Ethiopia particularly in Oromiya. Complete excision of the disease processes with maximum preservation of tissue is safe and ideal for most patients with hydatidosis.

Surgical treatment of achalasia cardia in Tikur Anbessa Hospital, Ethiopia

OBJECTIVE

This review aims to evaluate 61 patients with achalasia cardia treated with Heller's cardiomyotomy in Tikur Anbessa Hospital (TAH).

METHODS

A hospital based cross sectional analysis was conducted in TAH, Department of Surgery, Addis Ababa, Ethiopia between January 1996 and December 2005. Medical records and operation theater registers of 61 patients operated upon for achalasia cardia were analyzed retrospectively.

RESULTS

Thirty-four were male and twenty-seven female with mean age of 25 years (range 9-58). All had dysphagia to solid foods. Thirty-one (50.8%) patients had weight loss. The diagnosis of achalasia cardia was confirmed in 60 (98.4%) patients by barium swallow; in 23/25 (92.0%) by esophagoscopy. Cardiomyotomy was performed through transabdominal (83.6%) and transthoracic (16.4%) approaches. Immediate postoperative course was uneventful in 52 (85.2%) patients, while 9 (14.8%) patients developed immediate postoperative complication. There was no in-hospital mortality. Median operation time and hospital stay were 60 minutes and 7 days respectively. Late complications occurred in 7/52 (13.5%) patients, Gastroesophageal Reflux Disease (GERD) (9.6%) being the most common. A very good palliation of dysphagia was achieved in 88.5% of cases (p < 0.0001).

CONCLUSION

Significant improvement in dysphagia of patients with achalasia cardia following modified Heller's myotomy alone is possible in majority of the patients.

Intramedullary cavernous haemangioma of spinal cord: a case report and literature review

A 27-year-old female patient with progressive paraparesis and incontinence of urine of 9 months duration was managed at Tikur Anbessa Hospital, Neurosurgery unit, Department Of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa. Thoracic myelography showed an intramedullary mass at T3-T5 levels of the spinal cord. Histopathology revealed cavernous haemangioma. Near total surgical removal of the haemangioma was done. and the patient put on intensive physiotherap. Cavernous haemangioma should be suspected in the differential diagnosis of patients with progressive deterioration of spinal cord function. Total surgical excision of the lesion is the current treatment modality.

Experience of surgical therapy in 72 patients with thoracic hydatidosis over a 10-year period

OBJECTIVE

This review aims to evaluate retrospectively 72 patients diagnosed to have thoracic hydatid disease and treated surgically in Tikur Anbessa Hospital between December 1993 and November 2003.

DESIGN

Retrospective Analysis hospital records.

SETTINGS

Tikur Anbessa Hospital, Department of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa, Ethiopia.

PATIENTS AND METHODS

Medical records and Operation theater registers of seventy-two Patients operated on for Thoracic hydatidosis were evaluated retrospectively. Chest Roentgenogram was the main diagnostic tool used Main surgical techniques employed were evacuation in 44 (52.4%) cysts, cystotomy in 30 (35.7%) cysts, and enucleation in 10 (12%) cysts. Additional palliative procedures (such as pericystectomy and Capitonnage) and radical procedures (such as resection of the lung) were also employed.

RESULTS

forty of the patients were male and thirty-two female with a mean age of 31.4 years. The most Common presenting symptoms were cough in 60 (83.3%) patients, expectoration in 47 (65.3%) patients and chest pain in 38 (52.8%) patients. Chest radiography revealed a round opacity or shadow in 58 (80.6%) patients. All patients were treated surgically. The mean hospital stay was 38.3 days. Major postoperative Complications occurred in 12 (16.9%) patients; pneumonia, pleural effusion and prolonged air leak were the complications in order of their frequency. There was one postoperative death and one recurrence at 6-months follow-up period.

CONCLUSION

Surgical excision of pulmonary hydatidosis with maximum preservation of lung parenchyma is possible in the majority of patients and should remain the mainstay of surgical treatment.