Resection Rates and Predictors of Resectability of Pancreatic Tumors at Mulago Hospital: A Retrospective Cross-Sectional Study.

Objective To explore the radical (RO) resection rate and surgical outcome for the carcinoma of body and tail of the pancreas.Methods The clinical and operative data and follow-up Results of 214 patients with the carcinoma of body and tail of the pancreas were analyzed retrospectively.Results One hundred and twenty of the 214 patients with the carcinoma of body and tail of the pancreas underwent surgical treatment,the overall resection rate was 59.2% (71/120),and the R0 resection rate was 40.8% (49/120).Compared with other treatments,the patients receiving R0 resection had smaller size,lower lymph node involvement and peri-pancrcatic organ involvement.The radical resection rates for TNM stage Ⅰ ,Ⅱ and Ⅲ patients were 100%,100% and 87.5%,respectively,which were significantly higher than those in stage IV A (29% ) and IVB(0% ) (P＜ 0.01 ).Moreover,the overall 1,3 and 5-year survival rates in the total resection of the carcinoma of body and tail of the pancreas were 14.5%(31/214),7.0%(15/214) and 2.4%(5/214),respectively,which were significantly better than those in the palliative resection group (9.1%,0 and 0),bypass operarion and laparotomy group (12.2%,0 and 0) and non-surgical group (1.20%,0 and 0)(P＜0.01).Conclusions The early diagnosis of the carcinoma of body and tail of the pancreas is crucial for increase in radical resection rate.The radical resection plays an important role in the improvement of surgical treatment. Key words: Pancreatic neoplasm; Body and tail of the pancreas; Radical resection; Resection rate; Survival rates

Objective To summarize and analyze data of solid pseudopapillary tumor of pancreas (SPTP) in China,and investigate its epidemiology,clinical features,diagnosis and treatment.Methods Retrieval of Chinese Medical Current Contents and China Biology Medicine disc by the key words of solid pseudopapillary tumor of the pancreas,papillary cystic tumor of the pancreas,pancreatic papillary epithelial tumor,cystic solid tumor of pancreas and Frantz tumor were performed,and relevant literatures were included.Results A total of 1180 SPTP patients from 117 articles were involved.There were 1054 women and 126 men and the ratio of male to female was 1:8.37.The average age was 29 years old (range 9 ～83 years).Detailed clinical information was available for 1172 cases,and the main clinical manifestations included abdominal discomfort (n=526,44.88％),medical check-up (n=464,39.59％),abdominal mass (n=131,11.18％).Laboratory and imaging tests were non-specific.The tumors size was 1.3～ 30 cm with a mean value of 7.84 cm.Four handreds and seven (36.8％) cases were located in pancreatic head,96 (8.7％)were in pancreas neck and 587 (53.1％) were in the body and tail of pancreas.Eleven handreds and sixteen patients received treatment,and the resection rate was 99.2％ (n =1107).Pathological examination showed that 628(57.0％) cases were benign and 306 (27.8％) were presented as malignant behavior,mainly as infiltrative growth and invasion of the surrounding organs,vessels.Nine handreds and seventy-seven cases were followed up (ranging from 1 month to 13 years),and re-occurrence or metastasis were detected in 42 cases (4.3％) and 24 patients died.Conclusions Solid pseudopapillary tumor of pancreas is a rare pancreatic tumor with low-grade malignant potential,and part of this tumor may present as malignant behavior and it primarily affects young females.No characteristics in clinical manifestations,laboratory and imaging tests are found.Pathological examination can confirm the diagnosis.Surgical resection is the therapy of choice and the prognosis is good. Key words: Pancreatic neoplasms; Solid pseudopapillary tumors of pancreas; Disease attributes; Therapy ; Retrospective studies

Objective To investigate the imaging features in CT/MR of pancreatic neuroendocrine tumors(PNETs)with multiple lesions and further deepen the understanding of this disease. Methods A retrospective review of 12 PNETs patients' radiological data with pancreatic tumors' numbers ≥2 and confirmed by surgery or fine needle aspiration biopsy in Changhai Hospital were conducted. Five cases underwent pancreatic CT plain and enhanced scan, 2 cases underwent MRI plain and enhanced scan, and 5 cases underwent both CT and MRI scan. Results There were totally 46 lesions in 12 patients. There were 29(63.0%) lesions located in the pancreatic head and neck, and 17(37.0%) lesions located in body and tail of pancreas. The sizes of the lesions ranged from 0.8 to 9.5 cm, and the median size was 2.9 cm. Forty-four(95.7%) of the tumors was round or oval, and 2(4.3%) was lobulated; 44(95.7%) mass solid and 2(4.3%) was cystic. CT plain scan detected punctate, crescent or nodular calcification in 8(17.4%) lesions; enhanced scan found 42 lesions(91.4%) were markedly enhanced in the arterial phase, 2 lesions (4.3%) were markedly enhanced in the pancreatic phase; 2 lesions (4.3%) were slightly enhanced and the degree of enhancement was lower than that of the normal pancreas. Four cases (33.3%) had dilatation of pancreatic duct and/or the bile duct, 4 cases (33.3%) had distant organ metastasis, 2 cases (16.7%) had lymph node metastasis, and 3 cases (25.0%) had vascular invasion. Conclusions PNETs can be multiple and vary in the size. Most of the lesions are round or oval solid lesions and the malignant signs for organ metastasis can be found occasionally. In dynamic enhanced scanning, the obvious enhancement of the solid portion in the tumor and the higher enhancement degree than that of normal pancreas is the main characteristic. Key words: Pancreas; Neuroendocrine tumors; Tomography, X-ray; Magnetic resonance imaging

ObjectiveThe endoscopic endonasal transsphenoidal approach is a widely-used method for the surgical treatment of pituitary adenomas. We aimed to evaluate the results of endoscopic surgery by comparing preoperative classification methods and investigating their relationship with postoperative resection and remission rates and complications.MethodsWe retrospectively reviewed the medical records of 236 patients (118 males) who underwent surgery for pituitary adenomas. Preoperative Knosp classification, tumor size (TS), suprasellar extension (SSE), postoperative resection and remission rates, and complications were evaluated.ResultsThe follow-up period was 3 months to 6 years. The patients’ ages ranged between 16 and 84 years. Endocrinologically, 114 patients (48.3%) had functional adenoma (FA), and 122 patients (51.7%) had non-functional adenoma (NFA). Among the FA group, 92 (80.7%) showed remission. A statistically significant difference was found between patients with and without remission in terms of the Knosp, TS, and SSE classifications (p<0.01). Knosp, TS, and SSE classification grades were found to be correlated with the resection rates (p<0.01). Meningitis was seen in seven patients (3.0%), diabetes insipidus in 16 (6.9%; permanently in two [0.9%]), and rhinorrhea in 19 (8.1%). Thirty-six patients (15.3%) developed pituitary insufficiency and received hormone replacement therapy.ConclusionThe resection categories and remission rates of FAs were directly proportional to the adenoma sizes and Knosp grades, while the degree of suprasellar growth further complicated resection and remission rates. Adenoma sizes less than 2 cm and SSEs less than 1 cm are associated with favorable remission and resection rates.

Therapeutic hypothermia for birth asphyxia in low-resource settings: a pilot randomised controlled trial

BackgroundQuality of intrapartum care is an important intervention towards increasing clients’ utilization of skilled attendance at birth and accelerating improvements in newborn’s and maternal survival and wellbeing. Ensuring quality of care is one of the key challenges facing maternal and neonatal services in Uganda. The study assessed quality of intrapartum care services in the general labor ward of the Mulago national referral and teaching hospital in Uganda from clients’ perspective.MethodsA cross sectional study was conducted using face to face interviews at discharge with 384 systematically selected clients, who delivered in general labor ward at Mulago hospital during May, 2012. Data analysis was done using STATA Version (10) software. Means and median general index scores for quality of intrapartum care services were calculated. Linear regression models were used to determine factors associated with quality of care.ResultsOverall, quality of intrapartum care mean index score was 49.4 (standard deviation (sd) 15.46, and the median (interquartile range (IQR)) was 49.1 (37.5–58.9). Median index scores (IQR) per selected quality of care indicators were; dignity and respect 75 (50–87.5); relief of pain and suffering 71.4 (42.8-85.7); information 42.1 (31.6-55.3); privacy and confidentiality 33.3 (1–66.7); and involvement in decision making 16.7 (1–33.3). On average, higher educational level (college/university) (β: 6.81, 95% CI: 0.85-15.46) and rural residence of clients (β: 5.67, 95% CI: 0.95-10.3) were statistically associated with higher quality scores.ConclusionThis study has revealed that quality of intrapartum care services from clients’ perspective was low. Improvements should be focused on involving clients in decision making, provision of information about their conditions and care, and provision of privacy and confidentiality. There is also need to improve the number and availability of health care providers in the labor ward.

BackgroundThere is a scarcity of data on the burden of depression among Ugandans with rheumatoid arthritis (RA) patients. We aimed to screen for symptoms of depression, their severity and associated factors among patients with RA in Uganda.Patients and MethodsA descriptive, cross-sectional study was conducted between September and December 2020 at Mulago National Referral Hospital (MNRH) and Nsambya Hospital. Patients with RA were enrolled consecutively. Data on demographics, disease course and comorbidities and depression symptomatology were collected through an interviewer administered questionnaire. Symptoms of depression were screened for using the depression/anxiety dimension of the EuroQoL questionnaire.ResultsForty-eight patients with a median age of 52 (IQR: 43.5–60.5) years were recruited in the study. The majority of the patients were female (91.7%, n=44). Twenty-nine patients (60.4%) had comorbidities with a median Charlson comorbidity score of 3 (IQR: 2–4). Overall, 70.8% (n=34) had depressive symptoms. Patients attending MNRH were more likely to have depressive symptoms (p=0.025). Significantly, patients with depressive symptoms were younger (p=0.027), had lower health index value (p<0.001), and lower overall self-reported health status (p=0.013). At binary logistic regression, patients at MNRH (crude odds ratio (COR): 4.32, 95% confidence interval (CI): 1.16–16.15, P=0.030), patients aged <52 years (COR: 5.24, 95% CI: 1.23–22.28, P=0.025) and those with mild RA (COR: 5.71, 95% CI: 1.15–28.35, P=0.033) were significantly more likely to have depressive symptoms. Increase in age (COR: 0.94, 95% CI: 0.89–0.99, P=0.025), and high visual analogue score (COR: 0.94, 95% CI: 0.89–0.99, P=0.013) were protective.ConclusionDepressive symptoms were common among RA patients in Uganda. Routine screening, diagnosis and management of depression is recommended among young patients to improve quality of life and patient outcomes.

INTRODUCTION Traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). In these low-resource settings, accurate patient prognostication is both difficult and essential. Deep learning-a branch of machine learning using neural networks with multiple hidden layers-has the potential to predict outcomes better than other machine learning algorithms and capture complex non-linear patterns. METHODS Data from TBI patients of all ages were prospectively collected at Mulago National Referral Hospital in Kampala, Uganda, from 2016 to 2020. We designed the 3 aforementioned models to predict good versus poor outcome at hospital discharge. The DNN included four hidden layers. Predictors included 13 clinical variables easily acquired on admission-spanning demographics, physical exam, presence of polytrauma or seizures, and mechanism of injury-and whether or not the patient received surgery. Model performance was assessed using 5-fold cross-validation. We calibrated the model using Platt scaling. RESULTS Ultimately, 2164 patients were included for model training and a subset of 1677 for model testing, of which 12% had poor outcomes. The mean age was 28 -± 15 years and 85% were male. The mean admission Glasgow Coma Score (GCS) was 12.4 ± 2.9. Twenty-eight percent of patients received surgical intervention. The DNN demonstrated the highest area under the receiver operating characteristic curve (AUC) at 93.2% with an F1 score of 0.70, followed by the SNN at 92.7% and 0.68, and finally the LRnet at 92.1% and 0.64, respectively. CONCLUSION We present one of the first uses of deep learning to predict outcomes after TBI in the LMIC setting. The model slightly outperforms both SNN and LRnet on composite metrics. All models performed well. Before implementation, the model should be externally validated on other LMIC data. Future studies should continue optimization of DNN model architecture and illuminate the individual treatment effect associated with surgery in these predictions, with the ultimate aim of enhancing surgical decision making in the low-resource setting.

IntroductionPonseti technique is the treatment of choice for idiopathic congential talipes equino varus (ICTEV) since 1950s with excellent treatment outcomes reported worldwide. However, despite the popularity of this technique, Uganda adapted it as a treatment modality for ICTEV in May 2005. Since then, the effectiveness of delivered Ponseti care to children with this very common orthopaedic deformity under the supervision of an orthopaedic surgeon was unknown. The implication of this undertaking was that, satisfactory outcomes would then support the Ministry of Health (MOH)-Uganda´s decision to embrace this mode of treatment and if the outcomes were unsatisfactory, MOH would then consider a policy revision in this regard. To assess the midterm treatment outcomes of children with ICTEV who had been enrolled for treatment at Mulago National Referral Hospital in the period of 2006-2009.Methodsin November/December 2013, a cross-sectional study was conducted to assess the treatment outcomes of 68 feet of 45 children using the designed questionnaire and the PBS score; a pilot study of 10 neonates was performed prior to research. A good treatment outcome meant having a foot or feet that did not require any major or minor surgery.Resultsforty-five (45) children with 68 ICTEV feet were evaluated; males 29 (64.4%) and 16 (35.6%) females with a mean age of 73.22 months (SD 11.364, range 48-96 months). Among the feet assessed, 46 (68%) had good to excellent outcomes while 22 (32%) had a relapse of moderate and severe deformity. Good functionality was seen in 61.8% out of which, 69% and 55.9% had no limitation in walking or running respectively.ConclusionPonseti treatment technique in children with ICTEV under the care of predominantly orthopaedic officers with some supervision from orthopaedic surgeons had fair to good midterm outcomes even in low resource settings like Uganda. Public health approach should be embraced in the management of clubfoot in Uganda by enhancing adequate comprehensive support supervision and establishment of reliable institutionalized systems for patient follow up which will lead to early detection and treatment of relapsed ICTEV cases or neglected clubfeet in the communities.

Safe and Effective Escalation of Evidence-Based Chemotherapy for Mature B Cell Non-Hodgkin's Lymphoma in a Low Resource Setting

Distribution and Characteristics of Severe Traumatic Brain Injury at Mulago National Referral Hospital in Uganda

IntroductionSexually transmitted diseases (STDs) are a major cause of long-term disability. Urethral discharge syndrome (UDS), abnormal vaginal discharge (AVD) and genital ulcer disease (GUD) are very common in low-income and...

Robotic distal pancreaticosplenectomy for large complex oncocytic pancreatic neuroendocrine tumors: a rare pancreatic neoplastic variant

INTRODUCTION Traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). In these low-resource settings, effective triage of TBI patients-including the decision of whether or not to perform neurosurgery-is critical in optimizing both patient outcomes and healthcare resource utilization. METHODS Data from TBI patients of all ages were prospectively collected at Mulago National Referral Hospital in Kampala, Uganda, from 2016 to 2019. Seven different machine learning models (based on 1 linear and 6 non-linear algorithms) designed to predict good vs poor outcome near hospital discharge were developed and internally validated using 5-fold cross-validation. Predictors included clinical variables easily acquired on admission-demographics, physical exam, and mechanism of injury-and whether or not the patient received surgery. Using the elastic-net regularized logistic regression model (GLMnet), the probability of poor outcome was calculated for each patient both with and without surgery (quantifying the “treatment benefit”). A relative treatment benefit was then calculated, equaling this benefit of surgery divided by the probability of bad outcome with no surgery. Predictions were calibrated using Platt scaling. RESULTS Ultimately, 1766 patients were included. Areas under the receiver operating characteristic curve (AUCs) ranged from 81.7% (k-nearest neighbors) to 88.0% (random forest). The GLMnet had the second-best AUC at 87.7%. For the entire cohort, the median relative treatment benefit was 37.6% (IQR, 31.0% to 46.0%); similarly, in just those receiving surgery, it was 38.0% (IQR, 31.4% to 47.0%). The top four variables promoting good outcomes in the GLMnet model were high GCS, being fully alert, having both pupils reactive, and receiving surgery. CONCLUSION We provide the first deployable machine learning-based model to predict TBI outcomes with and without surgery in LMICs, thus enabling more effective surgical decision making in the resource-limited setting. Currently, patients are not being optimally chosen for neurosurgical intervention. Future studies should externally validate the model, improve model performance by combining data across countries, and explore use of more advanced algorithms.

Objective To investigate the clinical application of binding pancreaticogastrostomy (BPG) in the central pancreatectomy (CP). Methods The clinical data of 62 patients with benign and low-grade malignant lesions in the neck and body of pancreas who received CP combined with BPG from January 2010 to October 2014 were retrospectively analyzed. Fifty-six patients with space-occupying lesions of the head and neck of pancreas were confirmed by postoperative pathological examinations, including 21 solid pseudopapillary tumors of pancreas (SPTPs), 19 pancreatic neuroendocrine neoplasms (PNENs) (13 non-functional islet cell tumors), 16 pancreatic cystic tumors (12 serous cystadenomas and 4 mucinous cystadenomas) and 6 ruptures in the head and neck of pancreas. CP combined with BPG was performed. The central pancreas was resected via upper and anterior approaches after surgical exploration, and digestive tract reconstruction was applied using BPG. The operation time, volume of intraoperative blood loss, time of postoperative gastrointestinal function recovery, drainage tube removed time, duration of hospital stay and postoperative complications were recorded. Patients were followed up by outpatient examination and telephone interview up to January 2015, and follow-up included the level of blood glucose, conditions of pancreatic exocrine function and with or without pancreatic pseudocyst. Results All the patients underwent successful operation without perioperative death. The average operation time, average volume of intraoperative blood loss, average time of postoperative gastrointestinal function recovery, average drainage tube removal time and average duration of postoperative hospital stay were 155 minutes (range, 125-230 minutes), 300 mL (range, 210-425 mL), 3.0 days (range, 2.0-5.0 days), 6.0 days (range, 4.0-10.0 days) and 10.5 days (range, 9.0-21.0 days), respectively. Seven patients with delayed gastric emptying were cured by non-surgical treatment. Of 6 patients complicated with pancreatic fistula, 4 patients (Grade A) had healed pancreatic fistulas during hospitalization, 2 patients (Grade B) with drainage tubes were discharged from hospital and then drainage tubes were removed after confirming healed pancreatic fistula by imaging examination. Of 2 patients with intraperitoneal hemorrhage, 1 underwent under gastroscope cauterisation for hemostasis and 1 underwent open reoperation for hemostasis. All the patients were followed up for 3-36 months with a median time of 25 months and without high blood glucose, pancreatic exocrine function insufficiency and pancreatic pseudocyst. Conclusions CP with the advantages of minimal invasion and quick recovery can be used as a priority surgical method for benign or low-grade malignant tumors and injures in the neck and body of pancreas. BPG is safe and feasible as well as reduce the incidence of pancreatic fistula after CP, and it is an ideal reconstruction. Key words: Pancreatic neoplasms; Pancreatic trauma; Central pancreatectomy; Binding pancreatico-gastrostomy; Pancreatic fistula