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It was on my watch that the surgical residency program at Meharry Medical College had its accreditation withdrawn in 1990. Thus, the consequences of losing minority training programs have always been particularly difficult for me. I recall a session of senior black surgical leaders—both private practitioners and academicians—at the National Medical Association (NMA) annual meeting in New Orleans in 1986, when the status of the Meharry surgical residency program arose. I had never been to Meharry but knew many alumni who were in practice around the country and, therefore, by inference, the quality of its products. Dr. Louis Bernard was en route to the dean’s office, and the chair of surgery position was soon to be vacant. Working with the Meharry surgical faculty from 1987-1990, we put the finishing touches on an outstanding group of young men and women recruited by Dr. Louis Bernard and his faculty to produce a cadre of black surgeons who are providing superb surgical care in communities all across America today, including academia and private practice. The Obstetrics/ Gynecology and Pediatrics Programs at Meharry were lost in 1991, a year after surgery was decertified—the common denominator for all three being the paucity and lack of diversity of clinical material. During roughly the same era, Harlem Hospital also lost programs in orthopedic surgery, ophthalmology, and otolaryngology. We are in the twilight of an important part of our history as many African-American physicians who were products of these famed and now-defunct historically black training programs in St. Louis, Kansas City, Philadelphia,

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DISCUSSION AND LITERATURE REVIEW

Whereas the frequently benign juvenile melanoma is not an unusual lesion in children, MM has remained a rare affliction of infants and young children of all races. In indigenous black African children, MM is probably even rarer still. The 22 cases (all Caucasians), reported by Scalzo et al. over a 33-year period in a temperate setting were aged mostly 12—15 years, while a female gender skewing was identified in an earlier Australian series. The current case of MM in an indigenous Nigerian African is remarkable not only for the unusual age of two-and-a-half years but also for the black racial background. Indeed, we are not aware of an earlier case of primary MM in our tertiary health facility (since inception some 22 years ago), or one emanating from an indigenous African child of the Negro stock. Although Chamlin and Williams had earlier linked the occurrence of melanoma to sun sensitivity, the abundance of solar rays in the tropical setting would make the rarity of primary MM (and indeed, other skin malignancies), a counterintuitive reality. It is our view that the abundance of melanin pigment in the heavily pigmented skin of most black Africans may indeed be protective against solar radiation-induced skin damage. That the latter is a common antecedent event in the evolution of MM is well recognized.

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Pathologic Findings

A fine-needle aspirate of the axillary mass was done. This was reportedly consistent with a malignant lymph node infiltration showing “very cellular” smears with large pleomorphic cells and hyperchro-matic nuclei. A pathologic diagnosis of axillary lymph node metastasis was made, with a strong suggestion of a subsequent biopsy of the adjoining skin lesion for further diagnostic clarification and identification of the tissue of origin. An excision (skin) biopsy of the adjoining lesion over the garment nevus was eventually carried out after some inevitable delay, processed, examined, and reported separately by two consultant histopathologists (EAOA and KAA). Their individual findings were subsequently reconciled at a joint clinicopathological review. As shown in Figure 4, findings included melanin pigments in the superficial dermis, along with nests and alveolar patterns of proliferating melanocytes arranged around blood vessels in reticular dermis. The morphology of the melanocytes was reported as “biphasic.” While some of the cells were polygonal or epithelioid with prominent nucleoli, others were spindle-shaped with ovoid nuclei. These findings and those from an earlier fine-needle aspirate of the axillary mass were considered consistent with a diagnosis of MM with axillary nodal metastasis.

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A.O., a female Nigerian of black racial parentage was two-and-a-half years old at presentation. Follow­ ing an earlier referral from a private health institution, consultation was sought at the Emergency Pediatric Unit of the University of llorin Teaching Hospital, llorin (UITH), a tertiary care facility located in north central Nigeria. The presenting features included the appearance of multiple swellings at the upper back and the left axilla in the preceding five months. Preceding the (sudden) appearance of these swellings were several black/hyperpigmented areas on the trunk and extremities, including the palms and soles. Some of these hyperpigmented lesions had been present since birth, with a few of these developing noticeable hair growth as early as when the child was about 12 months. Significant events and “therapeutic” interventions in the two months preceding her presentation at UITH included a fairly rapid increase in the sizes and number of the aforementioned swellings, the local application of topical home remedies (including shea butter and palm oil), an earlier misdiagnosis of the axillary swelling as a “giant boil” (furuncle), and consequently an incision followed by antimicrobial therapy. Subsequently, there was purulent discharge from the same lesion, as well as noticeable spontaneous ulceration and bleeding in some of the other masses. Systemic symptoms at the time of referral included some weight loss and a progressive loss of appetite. The possibility of a superficial lymphadenitis of tuberculous etiology was considered remote, especially on account of a satisfactory immunization record (BCG inclusive), the significant absence of preceding respiratory symptoms, and indeed, the emphatic denial of a positive history of contact. Also, neither the only eight-year-old sibling nor the parents had similar skin lesions.

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INTRODUCTION

Whereas the overall incidence of malignant melanoma (MM) has surged by 150% in the last 30 years, the pediatric morbidity burden remains low with 4.2 cases per million in persons younger than 20 years. Most cases occur in whites, and only 0.3-0.5% of cases are diagnosed before the age of 13 years. Indeed, MM accounts for only 1-3% of all pediatric malignancies. Whereas a recognizable congenital nevocellular nevus (NCN) constitutes an important predisposing lesion for malignant transformation in infancy and early childhood, a potential precursor of MM in adolescents is the BK mole syndrome, or dysplastic melanocyte nevus (DMN). The average number of acquired pigmented nevi, or moles per person, is comparatively fewer in black Africans compared with that of whites, and this may partly explain the correspondingly rarer incidence of primary MM in black Africans. Against the background of the scorching tropical sunshine of sub-Saharan Africa, the local rarity of MM and other cutaneous malignancies may well be due to a relative immunity of the pigmented skin of black Africans to the noxious effects of solar “inducers” of malignant transformation. Because of their distinct rarity, a low index of clinical suspicion, as well as the paucity of investigative tools, previous reports on MMs in the African child hardly existed in accessible literature. Besides a recent report of three Nigerian siblings in whom MM understandably coexisted with a pre-existing xeroderma pigmentosum, the present report to the best of our knowledge, is probably the first of a primary MM in an indigenous black African child. Continue Reading »

The observation that less than 15% of the hypertensive population received no formal education in spite of Nigeria being a developing country suggests that there should be a high awareness of factors that will affect hypertension. The high education rate observed in this study may be because it was conducted in Lagos the economic capital of Nigeria. Despite this, it was observed that a fairly high percentage had serious misconceptions about hypertension, and the patients who displayed some knowledge appeared to be in denial of the disease. Our observation that over 60% of our patents irrespective of the educational background believe that psychosocial stress was the main cause of hypertension and that they will achieve a permanent cure for hypertension is a gross misconception that needs to be addressed. This is in agreement with the finding of Al-Sowielem et al. in Saudi Arabia. It is, however, comforting to note that the majority were aware of some complications and entertained reasonable fears to ensure compliance with medication. This is contrary to the studies of Hale et al. in South Africa who found that only 20% of patients who suffered from a stroke associated stroke with hypertension. It is disheartening to note that a sizable proportion still consider the possibility of achieving cure by homeopaths, native doctors, and faith healers, even though our experience is that many abandon the hospital clinics and are eventually brought back after having developed serious complications. The role that traditional healers play in medical care delivery in the country remains controversial, as 60-70% of the hypertensive populace still consult them at one time or the other.

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Out of 2,000 distributed questionnaires, data from 1,365 (68.3%) that were returned fully completed were analyzed.

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