Determinants of anemia among pregnant women attending a tertiary hospital, Mogadishu, Somalia: unmatched case-control study.

OBJECTIVE: The objective of this study was to identify the factors associated with anemia among pregnant women attending a tertiary referral hospital in Mogadishu, Somalia. METHODS: An unmatched case-control study was conducted on pregnant women who visited the antenatal clinics of a tertiary referral hospital between March and July 2021. The study recruited pregnant women who had a hemoglobin level of <11 g/dL into the anemic group, while those with hemoglobin levels ≥11 g/dL were included in the non-anemic group. Demographics, clinical, obstetrics, nutrition-related, hygiene- and sanitation-related, and parasitic infection-related data were collected. RESULTS: A total of 449 pregnant women (399 anemic and 50 non-anemic) participated in the study. A total of 224 (56.7%) in the anemic group and 31 (62.0%) in the non-anemic group did not consume any dark green, leafy vegetables such as spinach, bukurey, cagaar, and koomboow (p=0.040). Notably, 255 (63.9%) in the anemic group and 21 (42.0%) in the non-anemic group had a middle-upper arm circumference <23 cm. More than half of anemic [335 (84%)] and non-anemic [46 (92.0%)] were classified under low dietary diversity score. Majority of the study participants, 288 (72.4%) of the anemic and 39 (78%) of the non-anemic groups, used pit toilets in dwellings, and 70.2% (134/191) of the anemic and 64.4% (246/382) of the non-anemic groups disposed of solid waste in open fields. CONCLUSION: This study demonstrated that women who consumed green vegetables such as spinach, bukurey, cagaar, and koomboow in their diet had middle-upper arm circumference less than 23 cm, and those with low dietary diversity significantly developed anemia during pregnancy.

Evolution in liver trauma management: a single centre experience.

OBJECTIVES: Liver trauma is common and can be treated non-operatively, through radiological embolisation, or surgically. Non-operative management (NOM) is preferred when possible, but specific criteria remain unclear. This retrospective study at a level I trauma centre assessed the evolution and outcomes of liver injury management over more than 20 years. METHODS: Data from January 1996 to June 2020 were analysed for liver trauma cases. Variables were evaluated, including the type of injury, diagnostic modalities, liver injury grade, transfer from other hospitals, treatment type, and length of hospital stay. Outcomes were assessed using soft (hospitalisation time and intensive care unit stay) and hard (mortality) endpoints. RESULTS: In total 406 patients were analysed, of which 375 (92.4%) had a blunt and 31 (7.6%) a penetrating liver trauma. Approximately one-third (31.2%) were hemodynamically unstable, although 78.8% had low-grade liver lesions. The initial treatment was non-operative in 72.9% of the patients (68.5% conservative, 4.4% interventional radiology). Blunt trauma was treated by surgery in 23.2% of the patients, while 74.2% in case of penetrating trauma. Overall mortality was 11.1% including death caused by associated lesions. The 24-h mortality was 5.7%. Indication for surgical treatment was determined by hemodynamic instability, high grade liver lesion, penetrating trauma, and associated lesions. CONCLUSIONS: Although the role of surgery in liver trauma management has strongly diminished over recent decades, hemodynamically unstable patients, high-grade lesions, penetrating trauma, and severe associated lesions are the main indications for surgery. In other situations, NOM by full conservative therapy or radiological embolisation seems effective.

Impact of 18FFDG-PET/CT and Laparoscopy in Staging of Locally Advanced Gastric Cancer: A Cost Analysis in the Prospective Multicenter PLASTIC-Study.

BACKGROUND: Unnecessary D2-gastrectomy and associated costs can be prevented after detecting non-curable gastric cancer, but impact of staging on treatment costs is unclear. This study determined the cost impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FFDG-PET/CT) and staging laparoscopy (SL) in gastric cancer staging. MATERIALS AND METHODS: In this cost analysis, four staging strategies were modeled in a decision tree: (1) 18FFDG-PET/CT first, then SL, (2) SL only, (3) 18FFDG-PET/CT only, and (4) neither SL nor 18FFDG-PET/CT. Costs were assessed on the basis of the prospective PLASTIC-study, which evaluated adding 18FFDG-PET/CT and SL to staging advanced gastric cancer (cT3-4 and/or cN+) in 18 Dutch hospitals. The Dutch Healthcare Authority provided 18FFDG-PET/CT unit costs. SL unit costs were calculated bottom-up. Gastrectomy-associated costs were collected with hospital claim data until 30 days postoperatively. Uncertainty was assessed in a probabilistic sensitivity analysis (1000 iterations). RESULTS: 18FFDG-PET/CT costs were €1104 including biopsy/cytology. Bottom-up calculations totaled €1537 per SL. D2-gastrectomy costs were €19,308. Total costs per patient were €18,137 for strategy 1, €17,079 for strategy 2, and €19,805 for strategy 3. If all patients undergo gastrectomy, total costs were €18,959 per patient (strategy 4). Performing SL only reduced costs by €1880 per patient. Adding 18FFDG-PET/CT to SL increased costs by €1058 per patient; IQR €870-1253 in the sensitivity analysis. CONCLUSIONS: For advanced gastric cancer, performing SL resulted in substantial cost savings by reducing unnecessary gastrectomies. In contrast, routine 18FFDG-PET/CT increased costs without substantially reducing unnecessary gastrectomies, and is not recommended due to limited impact with major costs. TRIAL REGISTRATION: NCT03208621. This trial was registered prospectively on 30-06-2017.

Effects of Ultrafine Fly Ash against Sulphate Reaction in Concrete Structures.

In this study, Afsin Elbistan C-type fly ash (FA) was used, which protects against the sulphate reaction that damages concrete. The detrimental effects of post-reaction decrease with increasing fly ash fineness. The study used 10%, 30%, and 50% weight substitutes of cement. The fly ash was ground in a ball mill for 0, 10, 20, 30, 45, and 60 min, and Blaine fineness values of 1555, 1632, 2347, 2589, 2766, and 3433 cm2/g were obtained, respectively. The effect of the samples on the sulphate resistance was investigated by exposing the samples to 5% or 10% added sulphate solutions, and the compressive strength and ultrasonic pulse velocity of the concrete were tested. The compressive strength values obtained decreased with the increase in sulphate content, and the increase in the grinding time and the amount of substituted FA increased the compressive strength values. It was observed that weight loss increased with increasing sulphate content and decreased with the addition of FA with a high Blaine fineness. It was determined that as the Blaine fineness value increased, the sulphate content, FA substitution amount, and ultrasonic pulse speed decreased. This study was carried out to determine the effects of fly ash used at different fineness and replacement ratios on the performance and strength of concrete after exposure to external influences such as sulphate. The use of fly ash instead of cement will reduce the use of waste materials and natural resources and prevent environmental pollution. The cost of cement and concrete will be reduced.

Vitamin D levels in patients attending a tertiary care hospital in Mogadishu, Somalia: a retrospective review of 28,125 cases.

OBJECTIVE: The objective of this study was to identify the prevalence and risk factors for vitamin D deficiency among patients attending a tertiary hospital in Mogadishu, Somalia. METHODS: This retrospective study examined the results of serum 25-hydroxy-vitamin D tests of 28,125 patients admitted to Somalia Mogadishu-Turkey Training and Research Hospital between January 2017 and December 2021. Vitamin D insufficiency is defined as 20-30 ng/mL, deficiency as 10-19 ng/mL, and severe deficiency as <10 ng/mL. RESULTS: A total of 28,125 patients with a mean age of 44.27±20.4 years were included in the study. The majority of patients were in the age group of 19-40 years. The mean serum level of 25-hydroxy-vitamin D was 28.42±15.34 ng/mL. Of the patients included in the study, 5.8% (1,618/28,125) had vitamin D sufficiency, 6.5% (1,826/28,125) had vitamin D insufficiency, 41.8% (11,761/28,125) had vitamin D deficiency, and 45.9% (12,920/28,125) had severe vitamin D deficiency. The mean serum 25-hydroxy-vitamin D levels were lower in females than in males (p<0.001). CONCLUSION: The study indicated a high prevalence of vitamin deficiency among patients attending the largest tertiary care hospital, particularly female patients and older people. It is recommended to develop educational and awareness programs, and campaigns to reduce vitamin D deficiency in the population, especially those at high risk.

Determinants of anemia among pregnant women attending a tertiary hospital, Mogadishu, Somalia: unmatched case-control study

SUMMARY OBJECTIVE: The objective of this study was to identify the factors associated with anemia among pregnant women attending a tertiary referral hospital in Mogadishu, Somalia. METHODS: An unmatched case-control study was conducted on pregnant women who visited the antenatal clinics of a tertiary referral hospital between March and July 2021. The study recruited pregnant women who had a hemoglobin level of <11 g/dL into the anemic group, while those with hemoglobin levels ≥11 g/dL were included in the non-anemic group. Demographics, clinical, obstetrics, nutrition-related, hygiene- and sanitation-related, and parasitic infection-related data were collected. RESULTS: A total of 449 pregnant women (399 anemic and 50 non-anemic) participated in the study. A total of 224 (56.7%) in the anemic group and 31 (62.0%) in the non-anemic group did not consume any dark green, leafy vegetables such as spinach, bukurey, cagaar, and koomboow (p=0.040). Notably, 255 (63.9%) in the anemic group and 21 (42.0%) in the non-anemic group had a middle-upper arm circumference <23 cm. More than half of anemic [335 (84%)] and non-anemic [46 (92.0%)] were classified under low dietary diversity score. Majority of the study participants, 288 (72.4%) of the anemic and 39 (78%) of the non-anemic groups, used pit toilets in dwellings, and 70.2% (134/191) of the anemic and 64.4% (246/382) of the non-anemic groups disposed of solid waste in open fields. CONCLUSION: This study demonstrated that women who consumed green vegetables such as spinach, bukurey, cagaar, and koomboow in their diet had middle-upper arm circumference less than 23 cm, and those with low dietary diversity significantly developed anemia during pregnancy.

Postpartum depressive symptoms in women with female genital mutilation in Somalia.

OBJECTIVES: This study aimed to identify associated factors for postpartum depression (PPD) among women with female genital mutilation (FGM) in Somalia. METHODS: This was a cross-sectional study conducted between February and May 2021 in Somalia Mogadishu-Turkey Recep Tayyip Erdogan Training and Research Hospital, Mogadishu, Somalia. Mothers with any known chronic disease, or psychiatric disorders and who refused to participate were excluded from the study. The cutoff point for depression was defined as ≥13 points according to the Edinburgh Postnatal Depression Scale. RESULTS: Out of 446 postpartum mothers, 267 (59.9%) had increased depressive symptoms in the early postpartum period. PPD scale scores of mothers who were very poor were significantly higher depression scores than their counterparts (p = .002). Education level, place of residence, occupational status, number of children, type of FGM, and the presence of perineal tear did not differ significantly between depressed and non-depressed groups. CONCLUSIONS: Women with FGM had increased depressive symptoms in the early postpartum period in Somalia. In addition, women who had lower income had higher PPD scores than their counterparts. Further studies are needed to develop a deeper understanding of the relationships between FGM and PPD and its causes.

Do Attitude, Awareness and Intention to Perform Female Genital Mutilation or Cutting for Their Daughters of Women Healthcare Providers Differ from Mothers in Somalia?

Aim: This study aimed to determine whether there were differences in attitude, awareness, and intention to perform female genital mutilation or cutting for their daughters in the future between female healthcare providers and mothers. Methods: A comparative cross-sectional study design was used. Results: A total of 508 women were included in the study. Of the participants, 68.7% (n = 349) were mothers (Group I) who visited the hospital and 31.3% (n = 159) were women healthcare professionals (Group II) [27% (n = 137) nurses and 4.3% (n = 22) doctors]. It was found that 8 (1.6%) of the participants did not have FGM/C and the FGM/C ratio was lower in group II (95%) than in group I (100%) (p < 0.001). In group I, 99.7% (n = 299) of the participants and 30.6% (n = 19) of those in group II reported intending to perform FGM for their daughters in the future (p < 0.001). The reasons for FGM/C most cited by participants were a traditional rite of passage into womanhood (78%), religious requirement (69.3%), and preservation of their virginity until marriage (59.3%). "Stop FGM" was given as a message on FGM/C by 60% of the participants (n = 79) who answered (n = 127, 100%) to open-ended questions. Conclusion: The results of this study show that female health professionals with higher education and monthly income had less positive perception of their FGM/C and less intention to allow their daughters to undergo FGM/C.

Effect of COVID-19 pandemic on female sexual function in women with female genital mutilation.

We aimed to evaluate the impact of the COVID-19 pandemic on female sexual function in women with female genital mutilation (FGM) in Somalia. This cross-sectional study was conducted on women with FGM attending the gynaecologic outpatient clinic of our hospital, between March and June 2021, using a validated Female Sexual Function Index (FSFI) questionnaire with a physical examination based on FGM typing. Those women who refused to participate, those with mental illness, uncontrolled systemic disease, drug, alcohol, or khat addiction, pregnant, genital prolapse, gynaecological or urological cancer, previous pelvic surgery, premature ovarian failure, genital skin diseases, drug use that affects sexual function and those with or suspected of having COVID-19 infection were excluded. A total of 201 sexually active women enrolled, with a mean age of 29 (14-55) years. Comparison of FSFI scores and the COVID-19 pandemic, a statistically significant worsening in the mean FSFI scores and all its domains (p<.001, for each). All of the domains of the FSFI were determined higher before and during the pandemic except pain. There is a decline in female sexual functioning during the COVID-19 outbreak in women with FGM. FGM is a major public health concern necessitating urgent response in Somalia.Impact statementWhat is already known on this subject? As it stands, there is a body of research on sexual behaviour during COVID-19 pandemic, but a lack of conclusive evidence. However, our knowledge of the sexual function of women with FGM during the COVID-19 pandemic is largely based on very limited data.What do the results of this study add? There is a decline in female sexual functioning during COVID-19 pandemic in women with female genital mutilation in Somalia.What are the implications of these findings for clinical practice and/or further research? FGM is a major public health problem necessitating urgent response worldwide. There is an urgent need to implement FGM prevention programmes and raise public awareness in order to eradicate this harmful practice.

Clinical Characteristics of Patients with Hepatocellular Carcinoma: A Single-Center 3-Year Experience from Somalia.

Background: To evaluate the relationship between prognosticators representing tumor aggressiveness and socio-demographic, laboratory, and imaging findings in patients with hepatocellular carcinoma (HCC). Methods: We retrospectively searched patients with HCC between January 2017 and December 2019 in our tertiary referral hospital. The tumor-related factors and liver damage indicators and their relationship to indicate the value of prognosis were analyzed. Results: A total of 268 HCC patients, with a male-to-female ratio of 2.8 : 1. The mean age was 52.6 years. The patient with portal vein thrombosis (PVT) was older, had higher liver laboratory parameters (AST, ALT, total bilirubin, and direct bilirubin), and had larger tumor size. Patients with the larger tumor size had a higher AFP level, had more tumor multifocality. The majority of patients were in Child's A (73.6%) and B (17.2%) classes. The laboratory parameters of HCC patients were increased in Child's C compared to other groups of Child-Pugh classification. Conclusions: The presence of PVT and large-sized tumor in patients with HCC indicated a poorer prognosis than non-PVT group and small tumor sizes.

Nationwide oncological networks for resection of colorectal liver metastases in the Netherlands: Differences and postoperative outcomes.

INTRODUCTION: Widespread differences in patient demographics and disease burden between hospitals for resection of colorectal liver metastases (CRLM) have been described. In the Netherlands, networks consisting of at least one tertiary referral centre and several regional hospitals have been established to optimize treatment and outcomes. The aim of this study was to assess variation in case-mix, and outcomes between these networks. METHODS: This was a population-based study including all patients who underwent CRLM resection in the Netherlands between 2014 and 2019. Variation in case-mix and outcomes between seven networks covering the whole country was evaluated. Differences in case-mix, expected 30-day major morbidity (Clavien-Dindo ≥3a) and 30-day mortality between networks were assessed. RESULTS: In total 5383 patients were included. Thirty-day major morbidity was 5.7% and 30-day mortality was 1.5%. Significant differences between networks were observed for Charlson Comorbidity Index, ASA 3+, previous liver resection, liver disease, preoperative MRI, preoperative chemotherapy, ≥3 CRLM, diameter of largest CRLM ≥55 mm, major resection, combined resection and ablation, rectal primary tumour, bilobar and extrahepatic disease. Uncorrected 30-day major morbidity ranged between 3.3% and 13.1% for hospitals, 30-day mortality ranged between 0.0% and 4.5%. Uncorrected 30-day major morbidity ranged between 4.4% and 6.0% for networks, 30-day mortality ranged between 0.0% and 2.5%. No negative outliers were observed after case-mix correction. CONCLUSION: Variation in case-mix and outcomes are considerably smaller on a network level as compared to a hospital level. Therefore, auditing is more meaningful at a network level and collaboration of hospitals within networks should be pursued.

Determinants of Disagreement with Female Genital Mutilation Among Mothers.

Aim: Female genital mutilation (FGM) is widely practiced in Somalia. Limited data are available on the attitude of the Somalia community regarding FGM. The present study aimed to explore the attitude of mothers toward the practice of FGM. Methods: A cross-sectional study was conducted from March to July 2021 among mothers attending outpatient clinics at a tertiary referral hospital in Mogadishu, Somalia. Results: A total of 247 participants were included, 65.2% of whom believed this practice should be continued. The most cited reason reported regarding FGM was a requirement for religion (90.7%). About 73.9% of mothers stated that the most cited reason reported regarding the abandonment of FGM was health complications. About 59.8% of the study participants thought that FGM could be stopped through education. The results revealed that women who graduated from primary school (OR: 2.21; 95% CI: 1.090-4.51), who had no social media account (OR: 2.305; 95% CI: 1.147-4.633), and women who were circumcised by a traditional birth attendant (OR: 4.55; 95% CI: 1.57-13.22) were more likely to think that FGM should be continued compare with their counterparts. Conclusions: We found that mothers who were less educated, had no social account and those circumcised by a traditional birth attendant had more positive attitudes toward FGM.

18F-Fludeoxyglucose-Positron Emission Tomography/Computed Tomography and Laparoscopy for Staging of Locally Advanced Gastric Cancer: A Multicenter Prospective Dutch Cohort Study (PLASTIC).

Importance: The optimal staging for gastric cancer remains a matter of debate. Objective: To evaluate the value of 18F-fludeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) in addition to initial staging by means of gastroscopy and CT in patients with locally advanced gastric cancer. Design, Setting, and Participants: This multicenter prospective, observational cohort study included 394 patients with locally advanced, clinically curable gastric adenocarcinoma (≥cT3 and/or N+, M0 category based on CT) between August 1, 2017, and February 1, 2020. Exposures: All patients underwent an FDG-PET/CT and/or SL in addition to initial staging. Main Outcomes and Measures: The primary outcome was the number of patients in whom the intent of treatment changed based on the results of these 2 investigations. Secondary outcomes included diagnostic performance, number of incidental findings on FDG-PET/CT, morbidity and mortality after SL, and diagnostic delay. Results: Of the 394 patients included, 256 (65%) were men and mean (SD) age was 67.6 (10.7) years. A total of 382 patients underwent FDG-PET/CT and 357 underwent SL. Treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 patients (3%), and SL detected peritoneal or locally nonresectable disease in 73 patients (19%), with an overlap of 7 patients (2%). FDG-PET/CT had a sensitivity of 33% (95% CI, 17%-53%) and specificity of 97% (95% CI, 94%-99%) in detecting distant metastases. Secondary findings on FDG/PET were found in 83 of 382 patients (22%), which led to additional examinations in 65 of 394 patients (16%). Staging laparoscopy resulted in a complication requiring reintervention in 3 patients (0.8%) without postoperative mortality. The mean (SD) diagnostic delay was 19 (14) days. Conclusions and Relevance: This study's findings suggest an apparently limited additional value of FDG-PET/CT; however, SL added considerably to the staging process of locally advanced gastric cancer by detection of peritoneal and nonresectable disease. Therefore, it may be useful to include SL in guidelines for staging advanced gastric cancer, but not FDG-PET/CT.

Objectively measured preoperative physical activity is associated with time to functional recovery after hepato-pancreato-biliary cancer surgery: a pilot study.

BACKGROUND: Surgical resection is currently the cornerstone of hepato-pancreato-biliary (HPB) cancer treatment. A low preoperative aerobic fitness level has been identified as a modifiable risk factor associated with complications after major abdominal surgery. A person's aerobic fitness is influenced by performing moderate to vigorous physical activity (MVPA). This study aims to determine the activity monitor measured levels of MVPA performed among patients on the waiting list for HPB cancer surgery and their association with postoperative outcomes. METHODS: A prospective, observational multi-center cohort pilot study was conducted. Patients enlisted for resection surgery on suspicion of HPB (pre)malignancy were enrolled. Performed MVPA was measured by an Actigraph wGT3X-BT. Additionally, aerobic fitness was measured via the Incremental Shuttle Walk Test, and (post)operative variables were collected from the electronic patient files. The association between MVPA and the pre- and postoperative variables was determined by univariate and multivariable (logistic) robust regression. RESULTS: A total of 38 participants, median age 66.0 (IQR 58.25-74.75) years, were enrolled. The median daily MVPA was 10.7 (IQR 6.9-18.0) min; only 8 participants met the Dutch MVPA guidelines. Participant's age and aerobic fitness were associated with MVPA by multivariable statistical analysis. Time to functional recovery was 8 (IQR 5-12) days and was associated with MVPA and type of surgery (major/minor) in multivariable analysis. CONCLUSION: Seventy-six percent of patients enlisted for resection of HPB (pre)malignancy performed insufficient MVPA. A higher level of MVPA was associated with a shorter time to functional recovery.

Clinical characteristics of acute liver failure associated with hepatitis A infection in children in Mogadishu, Somalia: a hospital-based retrospective study.

BACKGROUND: Hepatitis A is one of the most common infectious causes of acute hepatitis, and currently, a neglected global public health problem necessitating an urgent response in Somalia. Hepatitis A infection and its rare complication of acute liver failure in children are largely based on very limited data. The aim of the study was therefore to investigate the Hepatitis A infection and its rare complication of acute liver failure in children in Somalia. METHODS: This retrospective study was conducted on children aged 0-18 years who were admitted to the pediatric departments of the Somalia Mogadishu-Turkey Training and Research Hospital, Somali, from June 2019 and December 2019. Patients who were tested for hepatitis A infection during the study period and had complete data were included. Children with chronic disease, primary or secondary immunodeficiency, blood transfusion history, and missing data were excluded. Abstracted data including patients' demographics, clinical presentation, laboratory results, ultrasonographic findings, length of hospital stay, clinical course and outcome were retrieved from the hospital database system. RESULTS: Of the 13,047 children, 219 were analyzed. Of the 219 Hepatitis A cases, 25 (11%) were diagnosed with pediatric acute liver failure (PALF). The mean age of children with Hepatitis A was 6.7 years. The majority of cases were reported in the 5-9 (39.7%) year age range. Hepatic encephalopathy, length of hospital stay, levels of albumin, and values of PT, aPPT, and INR were significantly higher in children with acute live failure. The presence of cholecystitis and cholecystitis with ascites in the sonographic evaluation were poor prognostic markers for acute liver failure. CONCLUSIONS: This study revealed hepatitis A virus infection and its related acute liver failure among hospitalized children in Somalia of which 11% had PALF. Hence, the introduction of Hepatitis A vaccination, which is the main public health tool, into the national immunization program, the improvement of hygiene conditions, raising awareness of the disease, and increasing health literacy are necessary to prevent the consequence of the Hepatitis A virus in children.

Spectrum and Prevalence of Thyroid Diseases at a Tertiary Referral Hospital in Mogadishu, Somalia: A Retrospective Study of 976 Cases.

BACKGROUND: Thyroid disorder is one of the most common noncommunicable diseases worldwide and neglected public health issues in Somalia. The aim of the study thus was to investigate the thyroid disorders in patients attending to the largest tertiary referral hospital in Somalia. METHODS: This retrospective study was conducted on patients admitted to the internal department of Somalia Mogadishu-Turkey Education and Research Hospital, Somali, between January 2017 and December 2019. Patients who were tested for thyroid function tests and had complete data were included. Patients with incomplete data and currently treated for any thyroid disorder were excluded from the study. Abstracted data including patients' sociodemographic characteristics, thyroid function tests, and histopathological findings were retrieved from the hospital database system. RESULTS: A total of 976 patients with thyroid disorders were enrolled, of whom 66.6% (n = 650) were female and 33.4% (n = 326) were male. The mean age of the patients was 47 ± 18.5 years. The majority of the patients were reported in the 31-50 (35.9%) age range. The most reported thyroid function disorders were 58.8% euthyroid sick syndrome followed by 15.4% hypothyroidism, 12.5% subclinical hypothyroidism, 7.6% hyperthyroidism, and 5.7% subclinical hyperthyroidism. The distribution of comorbidity indicated that 13.4% had diabetes mellitus, 10.4% had HIV, 4.9% had malaria, and 4.5% had HIV and malaria coinfection. Thyroid malignancies were detached in 22 (2.2%) patients including eleven papillary thyroid cancer, nine patients had follicular thyroid cancer, and two patients had differentiated thyroid cancer. CONCLUSIONS: Euthyroid sick syndrome was the most common type of thyroid disease in our setup. Hypothyroidism is the second most common, followed by subclinical hypothyroidism. Papillary thyroid cancer was the predominant histology among thyroid malignancies, followed by follicular thyroid cancer. This study revealed that thyroid diseases emerge as an important endocrine disorder encountered in Somali, necessitating a major public health response.

Case-mix adjustment to compare nationwide hospital performances after resection of colorectal liver metastases.

BACKGROUND: Differences in patient demographics and disease burden can influence comparison of hospital performances. This study aimed to provide a case-mix model to compare short-term postoperative outcomes for patients undergoing liver resection for colorectal liver metastases (CRLM). METHODS: This retrospective, population-based study included all patients who underwent liver resection for CRLM between 2014 and 2018 in the Netherlands. Variation in case-mix variables between hospitals and influence on postoperative outcomes was assessed using multivariable logistic regression. Primary outcomes were 30-day major morbidity and 30-day mortality. Validation of results was performed on the data from 2019. RESULTS: In total, 4639 patients were included in 28 hospitals. Major morbidity was 6.2% and mortality was 1.4%. Uncorrected major morbidity ranged from 3.3% to 13.7% and mortality ranged from 0.0% to 5.0%. between hospitals. Significant differences between hospitals were observed for age higher than 80 (0.0%-17.1%, p < 0.001), ASA 3 or higher (3.3%-36.3%, p < 0.001), histopathological parenchymal liver disease (0.0%-47.1%, p < 0.001), history of liver resection (8.1%-36.3%, p < 0.001), major liver resection (6.7%-38.0%, p < 0.001) and synchronous metastases (35.5%-62.1%, p < 0.001). Expected 30-day major morbidity between hospitals ranged from 6.4% to 11.9% and expected 30-day mortality ranged from 0.6% to 2.9%. After case-mix correction no significant outliers concerning major morbidity and mortality remained. Validation on patients who underwent liver resection for CRLM in 2019 affirmed these outcomes. CONCLUSION: Case-mix adjustment is a prerequisite to allow for institutional comparison of short-term postoperative outcomes after liver resection for CRLM.

Resectability and Ablatability Criteria for the Treatment of Liver Only Colorectal Metastases: Multidisciplinary Consensus Document from the COLLISION Trial Group.

The guidelines for metastatic colorectal cancer crudely state that the best local treatment should be selected from a 'toolbox' of techniques according to patient- and treatment-related factors. We created an interdisciplinary, consensus-based algorithm with specific resectability and ablatability criteria for the treatment of colorectal liver metastases (CRLM). To pursue consensus, members of the multidisciplinary COLLISION and COLDFIRE trial expert panel employed the RAND appropriateness method (RAM). Statements regarding patient, disease, tumor and treatment characteristics were categorized as appropriate, equipoise or inappropriate. Patients with ECOG≤2, ASA≤3 and Charlson comorbidity index ≤8 should be considered fit for curative-intent local therapy. When easily resectable and/or ablatable (stage IVa), (neo)adjuvant systemic therapy is not indicated. When requiring major hepatectomy (stage IVb), neo-adjuvant systemic therapy is appropriate for early metachronous disease and to reduce procedural risk. To downstage patients (stage IVc), downsizing induction systemic therapy and/or future remnant augmentation is advised. Disease can only be deemed permanently unsuitable for local therapy if downstaging failed (stage IVd). Liver resection remains the gold standard. Thermal ablation is reserved for unresectable CRLM, deep-seated resectable CRLM and can be considered when patients are in poor health. Irreversible electroporation and stereotactic body radiotherapy can be considered for unresectable perihilar and perivascular CRLM 0-5cm. This consensus document provides per-patient and per-tumor resectability and ablatability criteria for the treatment of CRLM. These criteria are intended to aid tumor board discussions, improve consistency when designing prospective trials and advance intersociety communications. Areas where consensus is lacking warrant future comparative studies.

[A boy with a spontaneous rupture of the spleen; a complication of infectious mononucleosis]. / Een jongen met een spontane miltruptuur.

BACKGROUND: Spontaneous rupture of the spleen occurs in 0.1-0.2% of patients with infectious mononucleosis and is associated with a high mortality (9-13%). Rupture is not normally preceded by a trauma. CASE DESCRIPTION: A previously healthy 17- year-old boy presented at the Emergency Department with acute onset of pain in his left upper abdomen and left shoulder. Initially he showed no signs of shock, but he did have signs of an acute abdomen. In addition, spots of pus were seen on both pharyngeal arches. Urgent ultrasound showed free fluid in his abdomen, and CT scan revealed active bleeding from the spleen. The patient underwent embolisation of the splenic artery. Serological investigations were positive for a recent infection with the Epstein-Barr virus. CONCLUSION: In young patients with signs of acute abdomen and pharyngitis, in the absence of prior trauma, spontaneous rupture of the spleen should be considered. The severity of a rupture of the spleen may initially be underestimated as haemodynamic instability and signs of shock occur only at a late stage.

Clinical Outcomes After Unilateral Adrenalectomy for Primary Aldosteronism.

Importance: In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of antihypertensive medications with a subsequent decreased risk of cardiovascular and/or cerebrovascular morbidity and drug-induced adverse effects. Objective: To evaluate the change in BP and use of antihypertensive medications within an international cohort of patients who recently underwent surgery for primary aldosteronism. Design, Setting, and Participants: A cohort study was conducted across 16 referral medical centers in Europe, the United States, Canada, and Australia. Patients who underwent unilateral adrenalectomy for primary aldosteronism between January 2010 and December 2016 were included. Data analysis was performed from August 2017 to June 2018. Unilateral disease was confirmed using computed tomography, magnetic resonance imaging, and/or adrenal venous sampling. Patients with missing or incomplete preoperative or follow-up data regarding BP or corresponding number of antihypertensive medications were excluded. Main Outcomes and Measures: Clinical success was defined based on postoperative BP and number of antihypertensive medications. Cure was defined as normotension without antihypertensive medications, and clear improvement as normotension with lower or equal use of antihypertensive medications. In patients with preoperative normotensivity, improvement was defined as postoperative normotension with lower antihypertensive use. All other patients were stratified as no clear success because the benefits of surgery were less obvious, mainly owing to postoperative, persistent hypertension. Clinical outcomes were assessed at follow-up closest to 6 months after surgery. Results: On the basis of inclusion and exclusion criteria, a total of 435 patients (84.6%) from a cohort of 514 patients who underwent unilateral adrenalectomy were eligible. Of these patients, 186 (42.3%) were women; mean (SD) age at the time of surgery was 50.7 (11.4) years. Cure was achieved in 118 patients (27.1%), clear improvement in 135 (31.0%), and no clear success in 182 (41.8%). In the subgroup classified as no clear success, 166 patients (91.2%) had postoperative hypertension. However, within this subgroup, the mean (SD) systolic and diastolic BP decreased significantly by 9 (22) mm Hg (P < .001) and 3 (15) mm Hg (P = .04), respectively. Also, the number of antihypertensive medications used decreased from 3 (range, 0-7) to 2 (range, 0-6) (P < .001). Moreover, in 75 of 182 patients (41.2%) within this subgroup, the decrease in systolic BP was 10 mm Hg or greater. Conclusions and Relevance: In this study, for most patients, adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. Furthermore, a significant proportion of patients with postoperative, persistent hypertension may benefit from adrenalectomy given the observed clinically relevant and significant reduction of BP and antihypertensive medications.