Post-operative recurrence in mycetoma after adequate medical and surgical treatment is common and a serious problem. It has health, socio-economic and psychological detrimental effects on patients and families. It is with this in mind, we set out to determine the predictors of post-operative recurrence in mycetoma. The study included 1013 patients with Madurella mycetomatis causing eumycetoma who underwent surgical excision at the Mycetoma Research Centre, Khartoum, Sudan in the period 1991–2015. The clinical records of these patients were reviewed and relevant information was collected using a pre-designed data collection sheet. The study showed, 276 patients (27. 2%) of the studied population developed post-operative recurrence, 217 were males (78. 6%) and 59 were females (21. 4%). Their age ranged between 5 to 70 years with a mean of 32 years. The disease duration at presentation ranged between 2 months and 17 years. The majority of the patients 118 (42. 8%) had mycetoma of 1 year duration. In this study, students were the most affected; 105 (38%) followed by workers 70 (25. 4%), then farmers 48 (17. 3%). The majority of the patients were from the Central Sudan 207 (75%), Western Sudan 53 (19. 2%) while 11 patients (4%) were from the Northern part. Past history of surgical intervention performed elsewhere was reported in 196 patients (71. 1%). Family history of mycetoma was reported in 50 patients (18. 1%). The foot was the most affected site, 245 (88. 7%), followed by the hand seen in 19 (6. 8%) patients and 44 (4. 5%) had different sites involvement. Most of the patients 258 (93. 5%) had wide local surgical excisions while 18 had major amputation. The model predicted that the certain groups have a high risk of recurrence, and these include patients with disease duration greater than 10 years and extra-pedal mycetoma. Patients with disease duration between [5–10] years, with pedal mycetoma, who had previous surgery, with positive family history and underwent wide local surgical excision. Patients with disease duration [5–10] years, with pedal mycetoma, had previous surgery, with no family history but presented with a disease size (> 10 cm), were non- farmers and underwent wide local surgical excision. Other groups are patients with disease duration (≤5 years), with pedal mycetoma, age <59 years, living in the Western /Eastern / Southern regions of the Sudan and with positive family history and had wide local surgical excision. Also included patients with disease duration (≤5 years), with pedal mycetoma, aged <59 years, living in the northern or central region, with no family history but presented with a disease size >10 cm, working as farmers or students and underwent wide local surgical excision. In conclusion, these groups of patients need special care to reduce the incidence of post-operative recurrence with its morbidity and detrimental consequences. In depth studies for the other predisposing factors for post-operative recurrence such as genetic, immunological and environmental factors are needed.
Eumycetoma is a chronic granulomatous destructive and mutilating subcutaneous fungal infection [1,2]. The disease is endemic in many tropical and subtropical regions in what is known as the Mycetoma Belt [3,4]. It has many medical, health, socio-economic detrimental bearings on the affected patients and communities [5,6]. Currently there are no accurate data on its prevalence and incidence globally, likewise the infection route, susceptibility or resistance [7,8]. The patient usually presents with small painless subcutaneous mass which gradually increases in size and spreads along the different tissue planes which eventually causes massive damage, destruction and loss of function of the affected body parts [9,10]. The extremities are affected most but any site can be affected [11,12]. Effective management of mycetoma depends mainly on accurate diagnosis. This in turn depends on identification of the type of mycetoma and extent of the disease through a meticulous clinical interview, clinical examinations and a battery of investigations. The later includes various imaging techniques, organism identification using grains culture, phenotypic morphological identification, molecular techniques and cyto-histopathological identification [13,14,15,16]. The management usually involves a combination of surgery and prolonged antifungal therapy [17]. The surgical treatment ranges from wide local surgical excision (WLE), repeated debridement and amputation. Early small lesions are amenable to cure with good prognosis. However, the majority of patients present late with advanced disease and such patients are difficult to cure and frequently relapse after apparently adequate treatment with a high morbidly [18,19,20]. Post-operative recurrence in mycetoma is a frequent problem and its explanation is an enigma. It has many impacts on the patients and health authorities in endemic areas. With this background, this study was conducted to understand the clinical predictors of post-operative recurrence of eumycetoma. It also aims to identify the interactions between the different predictive factors in an attempt to develop a predictive model for eumycetoma post-operative recurrence based on the most important clinical factors identified. However, this study is presented with some limitation such as the retrospective and the single-center experience nature.
The association between clinical factors and mycetoma post-operative recurrence as a target/ outcome variable was investigated. Clinical predictive factors were selected and reformatted using the available domain knowledge provided by expertise in the field of mycetoma. These factors were: age, gender, residence, disease site and duration in years, occupation, family history, previous surgery and type of surgery. These characteristics are shown in Table 1. In this study, missing data were small and arbitrary (less than 5%). Therefore, the Markov chain Monte Carlo (MCMC) method was used assuming a multivariate normality [21]. In this study, machine learning algorithms; Decision Tree (DT) and Random Forest (RF) were utilized for predicting mycetoma post-operative recurrence assuming unknown data mechanism [22]. Data was partitioned as 70% for training the algorithms with the remaining 30% of the data kept for the validation purpose. Models were trained with 5-fold cross-validation to avoid model over fitting and to ensure model stability [23]. Model performance was evaluated using model accuracy, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and Area under the Receiver Characteristic Curve (AUC) [24]. AUC measures the discrimination ability of the model on predicting the class levels of target variable based on the predictive factors. It is a single scalar value that represents the excepted performance of receiver operating characteristic (ROC) curve.
The study included 1013 patients with Madurella mycetomatis caused eumycetoma patients who underwent surgical treatment at the Mycetoma Research Centre, Khartoum, Sudan in the period 1991–2015. The study documented that, 276 patients (27. 2%) developed post-operative recurrence, [Table 1]. The study population were 727 males (71. 8%) and 286 females (28. 2%). Their age ranged between 5 and 70 years with a median of 23 years. Most of the patients, 625 (61. 7%) were in the age group 18–39 years, 199 (18. 6%) in the age group 31–59 years and 169 (16. 7%) were less than 18 years old at presentation. The disease duration at presentation ranged between 2 months and 17 years. The majority of patients, 839 (82. 8%) had mycetoma of less than five years duration, 171 (14. 3%) had mycetoma with a duration ranged between 5 to 10 years and 29 (3%) had mycetoma for more than 10 years. In this study, students were affected most; 398 (39%) followed by farmers 156 (15. 4%). The majority of the patients were from the Central Sudan 817 (80. 7%), Western Sudan 117 (11. 5%) while 48 patients (4. 7%) were from the Northern part. The history of previous surgical treatment performed elsewhere was reported in 566 patients (56%). Family history of mycetoma was reported in 132 patients (13%). The foot 868 (85. 7%) was the most affected site followed by the hand seen in 84 patients (8. 3) and 61 patients (6%) had mycetoma at different parts. Most of the patients, 962 (95%) had wide local surgical excisions while 51 patients (5%) had major amputation. The amputation included above and below knee, below elbow and Syem’s amputations. The study showed that, 276 patients (27. 2%) developed post-operative recurrence of whom 217 were males (78. 6%) and 59 were females (21. 4%). Their age ranged between 5 year and 70 years with a mean of 32 years [Table 1]. The disease duration at presentation ranged between 4 months and 19 years. The majority of the patients 118 (42. 8%) had mycetoma of 1 year duration. In this study, students were affected most; 105 (38%), followed by workers 70 (25. 4%), then farmers 48 (17. 3%). The majority of the patients were from the Central Sudan 207 (75%), Western Sudan 53 (19. 2%) while 11 patients (4%) were from the Northern part. Past history of surgical intervention performed elsewhere was reported in 196 patients (71. 1%). Family history of mycetoma was reported in 50 patients (18. 1%). The foot was the most affected site 245 (88. 7%) followed by the hand seen in 19 (6. 8%) patients and 12 (4. 5%) had mycetoma at different parts. 258 (93. 5%) of the patients had wide local surgical excisions while the rest of patients had major amputation. Amputation included above and below knee, below elbow and Syem’s amputations.
Ethical clearance was obtained from Soba Hospital Ethical Committee. Patients’ informed consents proved to be unnecessary in this study.
Post-operative recurrence in mycetoma is a thoughtful problem. It has numerous undesirable medical, health, socio-economic and psychological impacts on the affected patients and their families, communities and health authorities in endemic regions. It is an important motive for patients to drop out follow up and treatment incompliance and hence the inclination of patients for traditional medical treatment. The factors predicating this phenomenon were not studied previously. However, patients’ characteristics and clinical presentation can partially offer an explanation. Thus the present study was set out to understand the predictive ability of some clinical factors on predicting the post-operative recurrence of eumycetoma. The present study had showed young farmers with small sized pedal mycetoma, with short disease duration, who are residing in endemic areas, with no family history and who underwent wide local excision are most likely to remain disease free. We can also concluded that, adequate surgical treatment conditions are obligatory to achieve good outcome and to reduce recurrence. Appropriate health education programmes to encourage early presentation to medical care are essential to reduce the postoperative recurrence rate with its detrimental impacts.
medicine and health sciences
pathology and laboratory medicine
mycetoma
engineering and technology
tropical diseases
geographical locations
sudan
surgical and invasive medical procedures
health care
decision analysis
signs and symptoms
management engineering
neglected tropical diseases
fungal diseases
africa
research and analysis methods
public and occupational health
infectious diseases
decision trees
lesions
people and places
socioeconomic aspects of health
diagnostic medicine
surgical excision
health education and awareness
Predictors of Post-operative Mycetoma Recurrence Using Machine-Learning Algorithms: The Mycetoma Research Center Experience