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Background: Breast cancer is the second leading cause of death from cancer in women in sub-Saharan Africa, yet there are few well characterised large-scale survival studies with complete follow-up data. We aimed to provide robust survival estimates in women in this setting and apportion the survival gaps. Methods: The African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort study was done at eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, South Africa, Uganda, and Zambia). We prospectively recruited women (aged ≥18 years) who attended these hospitals with suspected breast cancer. Women were actively followed up by use of a telephone call once every 3 months, and a mobile health application was used to keep a dynamic record of follow-up calls due. We collected detailed sociodemographic, clinical, and treatment data. The primary outcome was 3-year overall survival, analysed by use of flexible proportional mortality models, and we predicted survival under scenarios of modified distributions of risk factors. Findings: Between Sept 8, 2014, and Dec 31, 2017, 2313 women were recruited from these eight hospitals, of whom 85 did not have breast cancer. Of the remaining 2228 women with breast cancer, 58 women with previous treatment or recurrence, and 14 women from small racial groups (white and Asian women in South Africa), were excluded. Of the 2156 women analysed, 1840 (85%) were histologically confirmed, 129 (6%) were cytologically confirmed, and 187 (9%) were clinically confirmed to have breast cancer. 2156 (97%) women were followed up for up to 3 years or up to Jan 1, 2019, whichever was earlier. Up to this date, 879 (41%) of these women had died, 1118 (52%) were alive, and 159 (7%) were censored early. 3-year overall survival was 50% (95% CI 48–53), but we observed variations in 3-year survival between different races in Namibia (from 90% in white women to 56% in Black women) and in South Africa (from 76% in mixed-race women to 59% in Black women), and between different countries (44–47% in Uganda and Zambia vs 36% in Nigeria). 215 (10%) of all women had died within 6 months of diagnosis, but 3-year overall survival remained low in women who survived to this timepoint (58%). Among survival determinants, improvements in early diagnosis and treatment were predicted to contribute to the largest increases in survival, with a combined absolute increase in survival of up to 22% in Nigeria, Zambia, and Uganda, when compared with the contributions of other factors (such as HIV or aggressive subtypes). Interpretation: Large variations in breast cancer survival in sub-Saharan African countries indicate that improvements are possible. At least a third of the projected 416 000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable downstaging and improvements in treatment. Improving survival in socially disadvantaged women warrants special attention. Funding: Susan G Komen and the International Agency for Research on Cancer.

Background: Makerere University introduced a new policy1 on the minimum qualification for appointment to a lecturer teaching position and eligibility for subsequent promotions. The highlight of the policy is a requirement for a PhD or equivalent as the minimum qualification necessary for appointment to a lecturer position and above.As a result of this policy fewer and fewer members have shown interest or indeed joined the Faculty of Medicine teaching staff roll.Objectives: This study set out to investigate the perception of the faculty and the impact of the policy on staffing.Methods: Literature review, oral and a questionnaire interviews were used to gather data. Participants included current members of teaching staff (of biomedical sciences and clinical disciplines) postgraduate students and visiting overseas academic staff and adjunct staff employed by the Ministry of Health at teaching hospitals.Data collected was analyzed and summarized in tabular form.Results: A PhD or equivalent is required as a minimum qualification to join academic positions at lecturer level and above at Faculty of Medicine and subsequent promotion to higher positions. There was a significant lag in promotions and recruitment in the Faculty of Medicine compared to counterparts employed by the Uganda Ministry of Health at the teaching hospitals. Participants expressed strong views that a PhD or equivalent should not be a minimum requirement nor should it be a prerequisite for promotions though it should be encouraged. Policy documents from other universities did not require a PhD or equivalent qualifications as a minimum requirement for appointment to the academic ranks of those institutions.Conclusion: Whereas it is desirable for the academic staff to acquire a PhD, it should not be a mandatory requirement. The policy was not in the best interest of the Faculty of Medicine and may not be for other medical schools to impose that requirement for appointment or promotion.University policy makers should consider schools of medicine as an exception to the policy requiring a PhD or equivalent as minimum requirement for teaching at a Medical School.

Background: The Makerere University Faculty of Medicine started the implementation of the Problem Based Learning/Community Based Education and Service curriculum for incoming students in the academic year 2003/2004. It undertook an intense preparatory period of 2 years before implementation, which included sensitizing, and training tutors to take their new role. Objectives: To evaluate student and tutor perception of the New PBL Curriculum at the Faculty of Medicine and to evaluate tutors perception of how well the students were doing.Methods: The study was at the end of the first semester, after seventeen weeks of the new curricula implementation. A 19-item questionnaire was self-administered by the students. An open discussion led by one of the investigators followed that questionnaire filling session. A 5-point likert scale was used to rate the different aspects. A different questionnaire was administered to the 35 academic staff that had tutored the twenty tutorial groups of eight to ten students each. The data collected from the two questionnaires was analyzed using SSPS software. The Faculty Research Committee approved the study.Results: Out of 180 students, 135 students filled in the questionnaire. In addition 25 tutors out of 35 filled in their questionnaire. The tutors’ facilitation of the tutorials was rated highly by the students. Students’ rated their (students’) participation in the tutorial process as excellent. The students rated access to learning resources as inadequate and they were anxious as to whether they were learning enough. On the other hand the tutors were satisfied with the depth and scope of the discussions by the students. The majority of the tutors thought it was the right move to introduce PBL. They were however concerned about sustainability of the novel educational reform (PBL).Conclusion: The students perceived the new method as acceptable. They expressed anxiety and uncertainly as to whether they were learning enough. And whereas the students were not sure they were learning enough, the tutors were satisfied with the depth of knowledge exhibited by the students. To sustain the reform tutors’ concerns and fears ought to be addressed.

Background: Injury and deaths due to road traffic crashes are a major public health problem in developing countries. Boda bodas (motorcycles) are a practical and a sought after economic activity in Uganda’s capital and cities. The injuries related to boda bodas contribute significantly to the number road traffic injuries seen at Mulago hospitals, taking out significant resources including consumables and the health worker time. This study investigated the pattern of injuries, mortality and estimate cost of care.Methods: A prospective descriptive observational study over a 9 months period was carried out at Mulago Hospital and Complex, Accident and Emergency wards. The Study population was patients involved in Boda Boda related road traffic crushes. Consecutive patients presenting on every 3rd day were selected. Research Ethics committee approval was sought before the study was commenced.Results: A total of 124 patients presented with injuries that warranted at least an overnight stay at the Accident and Emergency ward. Out of the just over 2000 admissions, the majority were males (sex ratio F: M 1:3.5) There was one fatality. Injuries were in 7 categories namely Head, chest, abdominal, pelvic, spinal and soft tissues and extremity fractures. Helmet use in this study was 22%, an improvement from previous nearly zero percent. The estimated cost of care per injured patient was USD 300.Conclusion: Boda Bodas continue to be a major cause or agent of road traffic injuries and a significant economic burden. The morbidity and mortality can be mitigated by encouraging use of protective gear like helmets and encouraging enforcement of traffic laws.

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Background: Most studies on thyroid dysfunction have been on patients refereed for treatment, little is known about the prevalence in the general populations. The importance of knowing such prevalence data lies in that fact that subclinical thyroid dysfunction is an important risk on development of heart disease, osteoporosis, hypercholesterolemia and mental illness. This study set out to determine thyroid dysfunction prevalence in a health young adult population.Methods: A cross sectional study carried out at the College of Health Sciences, Makerere University enrolled 100 Undergraduate medical students by invitations through notices and announcements. Informed consent was sought after approval from research ethics committee.Results: Of the 100 students enrolled and the samples drawn; 83 tests for TSH and 82 tests for FT4 were successfully run. Three results were abnormal making a prevalence of 3.6% for thyroid dysfunction; a high TSH (5.71) with a normal fT4 (19.2), a normal TSH (1.67) with a high fT4 (22.31) and one with a low TSH (0.03). The mean age of participants was 23 years, there were slightly more males 1.3:1.Conclusion: The prevalence of thyroid dysfunction in this cohort was low but falls in the range found elsewhere. These findings could inform the criteria of screening asymptomatic otherwise young health adults.

In Uganda most cancers to the exception of bladder and penis are increasing in incidence. The incidence of cancer of stomach is 5.6/100,000 from 0.8/100,000 in the 1960s a seven fold increase.The purpose of this guideline document is to highlight the salient points in gastric cancer diagnosis and treatment in the Ugandan context. It doesn’t only outline what is practical and efficacious but also our aspirations of practice as resources committed to the whole area of Oncological care services improve in the country. The primary and secondary prevention strategies are outlined. The multistage process of gastric oncogenesis is discussed in relation to the scientific basis of diagnostic and screening procedures. The treatment modalities including surgery radiotherapy and chemotherapy are discussed. A prognostication scale is included. Traditionally gastric cancer presents late and with a poor prognosis. The greatest strategy we have for management is in primary and secondary prevention. However a better understanding of how it arises (risk factors) will be important in informing prevention and treatment strategies. The Uganda cancer-working group intends that this information is disseminated to wider readership in the region as part of the strategy of improving Oncological care service in the region.

Background: Breast cancer is the most common cancer among women in many parts of Africa. Facilities for screening and early detection are extremely limited yet early diagnosis improves survival. This study explored the practice of Breast Self Examination among female university students as a means of screening and early detection in a low resources environment.Subjects and Methods: A cross sectional descriptive study at a Sub Saharan university. A call for volunteers to the study was made; a pretested standardised questionnaire was used for data collection. The process was limited to an interview and a physical examination. IRB approval was granted before the study began.Results: A total of 320 participants volunteered, 314 were recruited. The majority were aged between 21 and 25. The range was between 19 to 31 years. There was a high awareness of Breast self Examination (BSE) of 81.5%, 30% had ever performed a BSE, 14% performed it regularly, 8% knew the correct monthly timing, the technique was accurately demonstrated by 1% of participants. 4.8 were found to have breast lumps.Conclusion: There is a likelihood of most young women in the country practicing BSE inadequately. There is a need for widespread BSE campaigns emphasizing the correct technique and a need to evaluate BSE efficacy. The prevalence of breast lumps among young women attending this university was comparable to other community prevalence studies in this age group.

Background: The surgical work output in Uganda is qualitatively and quantitatively inadequate. The number of surgeons is estimated at 100 for a population of over 26 million Ugandans. Thispaper reports on how to improve recruitment of surgical trainees and training of surgeons in Uganda, focusing on perceptions of potential trainees, trainers, and medical administrators.Methods: This was cross sectional, descriptive study sampled at least 50% of each of the relevant category of interviewees. Self-administered questionnaire and focus group discussions were used tocollect data, which was analyzed manually using a master sheet. It was approved by the Ethics and Research Committee.Results: Paediatrics and Public Health were rated as the disciplines of choice for postgraduate training in Uganda. The reasons why potential trainees would shy away from specialized surgical training were excessive workload, risk of catching HIV/AIDS, low financial returns and a poorlearning environment. The major bottlenecks in surgical training, which were cited, included inadequate number of scholarships, inadequate supervision by trainers, inadequate facilities and poor work conditions for trainers.Conclusion: The remedies to this complex problem revolve round providing more resources, (human, materials, money), improving supervision by the trainers, advocacy for an evidence basedcurriculum content and availing more funding into the Medical Education sector to improve Human Resource for Health development.

Background: The breast cancer landscape in Uganda is characterized by late disease and poor outcomes. Even though receptor status is an important prognostic factor, it is not routinely conducted in the country. This study was set to describe the oestrogen receptors (ER) status and associated clinico-histopathological features of breast cancer among women in Uganda. Method: A cross sectional descriptive study, carried out among women with histologically confirmed breast cancer, recruited at the Mulago Hospital breast clinic and determined their receptor status determined by immunohistochemistry (IHC), which was preceded by H&E staining. Results: In total 114 women were enrolled over a 5 months period. Mean age was 47 years (13-87), half (50%) of the women had advanced disease (T4 tumours), 48/114 (42%) presented more than 12 months after onset of symptoms and most had poorly differentiated (grade III) invasive ductal carcinomas, 61/114 (53%) and 50/114 (44%) were ER- negative tumours. Conclusion: Breast cancer is common among young African premenopausal women, it presents mostly as T4 tumours and close to half are ER negative. This is an over representation of ER negative tumours.Key Words: Breast cancer, Advanced stage, Hormonal receptor status, Triple negative breast cancer

Background: There is a severe shortage of health workers in sub-Saharan Africa yet this subcontinent experiences a significant proportion of the world’s disease burden. This shortage is further reflected in the lack of personnel for surgical sub specialities such as orthopaedics, paediatrics, neurology and urology to mention but a few.Objective: This review therefore sought to summarize the current literature on the state of surgical training in sub Saharan Africa, discuss the challenges faced and the possible ways to overcome these challengesMethods: We performed online searches of electronic databases i.e. PUBMED, MEDLINE and African Journals online that feature many African Journals not index by the ‘regular’ databases.Results: The searches returned 88 articles and 24 of which were included in the review, we present results focused on; training capacity and methods, scope of practice, technology and surgery, and low research capacity and output.Conclusion: The future of surgical training in Africa will depend on the ability of the leadership to create or and adopt innovative educational technologies, recruit and retain trainers and attract trainees on one hand and on the other, the growth of demand for quality surgical care in the great lakes regions. For those that have excelled in training need to build on those successes and share their stories.Keywords: Surgical Training, challenges, sub- Saharan Africa

Background: Mammography is an established screening tool for breastcancer in high-income countries but may not be feasible for most resourcepoor nations. Alternative modalities are needed to mitigate the impact of the increasing incidence and mortality due to breast cancer. This may require the development of new technologies or reevaluation of old technologies applicable to resource limited settings.Objective: To determine the sensitivity and specificity of breast transillumination as compared to mammography and to describe featuresof benign and malignant breast lesions as seen with breast transillumination.Methods: A single group descriptive analytical study was conductedover a six month period (2011) in the breast unit of Mulago Nationalhospital. Eligible participants were consecutively sampled. Participantsunderwent Clinical Breast Examination (CBE), breast transillumination(BT), mammography (MG) and histopathological analysis of identifiedbreast lumps. Sensitivity, specificity and predictive values werecalculated. Features of the masses detected by transillumination werethen described.Results: The number of participants recruited was 201 (mean age 42years, range 30-80 years). The average palpable lump size was 3.8cm (range 0.5 to 10 cm). BT had a sensitivity of 63.2% (PPV 86.8%) anda specificity of 89.5% (NPV 61.2%) with mammography as the referencestandard. Also, 73.3% of breast lumps with irregular margins and 88.5%with dense opacity at transillumination turn out to be malignant athistopathology examination.Conclusion: The Breast transillumination technique had a moderatesensitivity of 63.2%. This warrants a large scale population-basedevaluation of BT as a screening tool. This technique may not substitutemammography but to be considered an option where mammographyaccess is limited.

Background: The incidence of breast cancer in Uganda has nearly tripled in three decades, the reasons not wholly understood. Country specific evidence is needed to better understand associated risk factors. Breast density is a strong predictor of breast cancer risk in Caucasian populations. The aim of this study was to establish whether increased breast density is a contributory risk factor for breast cancer amongst black African women.Methods: A case control study carried out at the National Referral and teaching Hospital, Mulago in Kampala Uganda over a 6 months period. All patients who presented for breast cancer screening and underwent a mammography breast examination during the study period had their breast densities measured using the BI-RADS classification were eligible. Those diagnosed with breast cancer during the period formed the cases and those who had a normal breast examination formed the controls. Mulago receives patients from all over the country but more so from the central part, owing to its location (proximity). Prevalence of high breast density between the two groups was compared using cross tabulations and an association between high breast density and breast cancer was defined. Prior ethical approval was obtained.Results: The prevalence of high breast density (Grade III & IV) among this cohort of East African women was 39% (52/135) overall; with a distribution of 51% (26/46) among the cases and 29% (26/89) among the controls There was a positive association between HBD and breast cancer with odds ratio of 3.15.Conclusion: High breast density seems to be associated with breast cancer among this group of East African black women. Although prevalence of high breast density was comparable to some of the studies done in Caucasian populations, there was an unexpected inverse relationship between HBD, high parity and early age of first pregnancy.

Introduction: Spina Bifi da is one of the most serious developmental disability of the infant. The prevalence of Spina Bifi da varies across time, region, race and ethnicity. Worldwide, it accounts for as many as 4.7 in 10,000 live births. Although Spina bifi da in its entirely is commonly seen in neurosurgical practice there is sparse literature on this disabling congenital anomaly in the Ugandan context. This study therefore aimed at describing the clinical features and early post operative outcomes.Methods: A prospective descriptive study recruited children with Spina Bifi da Cystica admitted to Neurosurgical ward over a period of 11 months from May 2010 to March 2011, at Uganda’s National Referral Hospital. Clinical presentations of these patients were obtained by performing a general and neurological examination and using a standardized questionnaire. The patients were followed up for two weeks to establish early outcomes.Result: A total of 51 patients with Spina Bifi da Cystica were studied, representing 3.9% of all patients admitted on the unit that period. Out of those 54.9% were males and 45.1% were females. The mean age of their mothers was 23.8 years and the second birth rank was the mostly affected. Family history of Spina Bifi da was present in 7.8%. Nearly all patients (98%) had myelomeningocele with a most common site being lumbosacral (47.1%). Hydrocephalus was noted in 72.5% of patients before surgery and talipes equinovarus was the other most associated congenital anomaly. Forty three patients were operated on. The rest 8 patients died before surgery. The mean preoperative hospital stay was 17.6 days.Conclusion: Patients had long pre operative lapse before the definitive management was offered and all the deaths occurred during this period. Exploration of factors responsible for this delay may enhance opportunities for timely intervention. Keywords: Spina Bifi da Cystica, surgery, early outcomes

East and Central African Journal of Surgery. 2011 Nov/ December;16 (3)

Introduction: There is uncertainty as to the exact interaction between HIV and Breast Cancer. Available studies are inconclusive about any relation whether causal or protective and the number of patients in these studies small. Objective: To determine the prevalence of HIV among confirmed incident breast cancer cases and to describe the associated clinico-pathological features. Design: Analytical cross sectional study Methods: Over a period of 6 months consecutively eligible patients were recruited from the Mulago Hospital breast clinic. Breast lesions were biopsied and blood withdrawn for HIV sero-survey. Collected data was double entered into Epidata version v 3.1.1, exported to STATA 10.0 for analysis. Results: Sixty two breast cancer patients consented to participate in the study and of these, 22(35.48%) were positive for HIV compared to HIV prevalence in the general population of 6-7%. All the participants were female. The mean age of HIV negative subjects was 45 years (range: 21-80 years) and for HIV positive subjects was 32.4 years (range 18-52 years). There was a significant association between HIV status and age, BMI and CD4 Counts as well as for histological grade and stage (P< 0.024). Conclusion: The prevalence of HIV among the studied breast cancer group was significantly higher than that in the general population. HIV was associated with poor prognostic factors. A high index of suspicion of the co-existence of these two diseases in a context of high HIV preva-lence is warranted. Future studies should explore for a causal association.

Introduction: Reference values may vary significantly among populations and cultures for which dietary intakes may be different. Each laboratory is expected to investigate the transferability of the expected values to its own patient population and if necessary determine its own reference ranges. This study sought to establish Folic acid and Vitamin B12 referencevalues for young Ugandan adults, which reference values could be used as baseline information for future research, especially related to their role in breast cancer prevention.Methods: A cross sectional study in which 200 undergraduate student volunteers were enrolled. The minimum sample size was 126 using the Open Epi version 2. Relevant demographics and physical examination parameters were taken as well as blood samples for laboratory tests. Prior ethical approval was granted.Results: The levels of folic acid were 4.17 – 20ng/ml and remained constant over the age cohorts. The vitamin B12 range was 117-1158pg/ml. Both ranges were comparable to ranges seen in other populations.Conclusion: In as much as the dietary intake for this study population is presumed different from populations in the western countries, the ranges for these two vitamins were similar.

Background: Where as the first Laparoscopic cholecystectomy was performed more than three decades ago in Europe. In Uganda interventional laparoscopic procedures like cholecystectomy and appendicectomy commenced only recently. This paper in three parts describes the first 178 procedures done at a hospital in Kampala, a cost saving technique for Laparoscopic appendicectomy as well as highlighting a practical skills transfer model. Method: Multiple designs; a descriptive retrospective design for part one, a prospective single cohort for part two and a qualitative description for part three. The data was collected from the operating room logs operative notes and follow-up visits notes for the first part. For the second part a prospective single cohort design, every consecutive patient who presented with features of acute appendicitis and consented was included in the study. A low cost extra corporeal appendiceal stump ligation technique is described. For part three, the notes, materials and schedules used for skills transfer session were reviewed. Sata was manually analysed using a spreadsheet. Institutional Review Board (IRB) approval was secured. Results: Of the 178 procedures 64 (36%) were appendicectomy, 30 (17%) were cholecystectomy and 75 (42%) were diagnostic. Male: Female ratio was 1:3. Major complications occurred in 1.7% of the study group. Two appendicectomy and two cholecystectomy were converted. A cost containment extracorporeal ligation technique for appendiceal stump ligation was performed for 50 appendicectomy with no wound sepsis recorded, in the follow up period. Conclusion: The complication rates were comparable to work done elsewhere. The appendicectomy extracorporeal technique was safe and low cost. Short but repetitive hands-on training sessions are appropriate for training qualified surgeons on site. Interventimal Laparoscopic surgery is feasible in resource limited settings.

Background: Nodular goitre remains a problem of enormous magnitude with an estimated prevalence of 19 to 35% worldwide. Of all thyroid nodules 5-10% are cancerous and require surgery. By identifying the benign ones unnecessary surgery, the associated morbidity and associated costs could be avoided. Fine needle cytology is recommended as the initial evaluation of thyroid nodules. Its main limitations are inadequate cellular harvest and indeterminate results. Aspiration (FNA) and non-aspiration (FNNA) techniques were evaluated in this study for purposes of judging which technique is better for cellular harvest. In providing the standard amount of follicular cells for cytodiagnosis (SAFC). Methods: In a cross-sectional comparative descriptive study, 100 thyroid nodules were categorized by their widest diameter into 4cm. Both FNA and FNNA were performed on each nodule (randomly assigned). After Papanicolaou and Diff-Quik staining, the follicular cells harvested were quantitatively analyzed for the SAFC by a cytopathologist blinded to the biopsy technique used and compared using Wilcoxon signed Ranks test and McNamara’s test statistic. Ethical approval was secured. Results: The patients’ age range was 19 to 70 yrs (mean 43yrs) and 95.5% were females. Regarding the provision of the SAFC: FNNA had a higher mean cell count than FNA (108 Vs 63), p= 0.001; FNNA was superior to FNA, OR= 6.5, p4 cm and 1-4 cm, using FNNA or FNA. Conclusion: The findings suggest that with regard to the provision of the standard amount of follicular cells for cytodiagnosis of thyroid nodules, FNNA is superior to FNA technique. There is no statistically significant association with the diameter of the thyroid nodule biopsied. FNNA technique is less technically challenging and does not require a syringe holder.

Introduction: Mesenteric venous thrombosis is a rare but lethal form of mesenteric ischemia. Diagnosis before frank thrombosis and gangrene is a challenge. Documented experience in the East African region is scanty. This short series suggest renal dysfunction as a consequence of delayed diagnosis, intussusception as a differential and highlights the challenges of management with limited investigative capacity. Methods: The design was a descriptive retrospective review of 5 patient data files using pre-determined parameters. The analysis was done manually using a spreadsheet. Results: Five patients were reported on over a 2-year period. Two died within the First 10 weeks. One was lost to follow up. Two were surviving with complications of short bowel syndrome. Conclusion: These reports were typically characterized by delayed diagnosis. Renal dysfunction was a consistent feature. Intussusception was a definite differential. For the clinician, heightened index of suspicion is necessary to interpret less than a typical acute abdomen presentation in absence of full range investigative capacity.African Health Sciences 2009; 9(4): 284 - 289