Evaluation of evidence-based medicine adoption among Nigerian surgeons: competence, knowledge, attitudes, practices, and barriers.

AIM: To determine the competence, knowledge, attitude, and barriers to evidence-based medicine (EBM) among surgeons in southwest Nigeria. METHODS: Between April 1 and June 30, 2019, a composite questionnaire consisting of the McAllister knowledge and attitude questionnaire, the Zwolsman barrier questionnaire, and 5 questions from the Berlin Questionnaire (BQ) on competence in EBM was administered to 185 surgeons and trainees in five hospitals in southwest Nigeria. RESULTS: The study involved 169 respondents (57 surgeons and 112 trainees). A total of 122 (72.1%) participants reported to always/often use EBM in their practice and 47 (27.9%) to rarely/never use EBM. The majority of both groups still relied on traditional sources of information in their clinical practice. Even though self-identified EBM-users (28% points) scored significantly higher on the BQ than non-users (23.8% points), there was no difference in their performance on the McAllister and Zwolsman questionnaires. Paradoxically, those with prior training in EBM were not more likely to use EBM than those without training, and there were no significant differences in their BQ scores. CONCLUSIONS: Surgeons in Nigeria have a high level of awareness and use of EBM, as indicated by the 72% awareness rate found in our study, but their knowledge and confidence in its application are low. Our findings indicate that the quality of EBM training in the region needs to be reevaluated.

Patients' satisfaction with emergency care services in a University Teaching Hospital in South-West, Nigeria.

BACKGROUND: Patient satisfaction is a measure of the extent to which patients are contented with the health care they received from their health care provider. OBJECTIVE: The goal of this study was to measure the satisfaction of patients admitted to the Emergency Centre and to determine the factors affecting the satisfaction. METHOD: A cross-sectional study was conducted over four months among patients admitted into the Emergency Centre of the hospital. Systematic sampling method was used by trained personnel who collected the data from the participants using a pre-tested structured questionnaire. RESULT: Out of 199 patients that participated, 51.3% rated the reception at the Emergency Centre as very good while the speed of pain control was rated as excellent by only 9.0% of the participants. The time to surgical intervention was rated very good and excellent by 57.3% and 9.5% respectively. Comparable value was obtained by both nurses and doctors on the overall attitude across the 5 scoring domains. Overall, 90.5% of participants were satisfied with the services and experiences at the Emergency Centre of the hospital, however, suggested areas of improvement include employment of more staff by 51.8%, provision of more equipment by 41.2%, and 27.6% requested for availability of more facilities. CONCLUSION: A high percentage of the patients were satisfied with the overall service in our Emergency Centre while some other areas require improvement.

Awareness and Use of Surgical Checklist among Theatre Users at Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria.

BACKGROUND: Surgical checklist was introduced by the World Health Organization to reduce the number of surgical deaths and complications. During a surgical conference on "safety in surgical practice," it was noticed that the awareness and the use of surgical checklist are poor in Nigerian hospitals. This study was aimed at determining the awareness and use of surgical checklist among the theater users in our hospital, factors militating against its implementation, and make recommendations. METHODS: This is a prospective study at Ekiti State University Teaching Hospital, Ado-Ekiti; questionnaires were distributed to three groups of theater users - surgeons, anesthetists, and perioperative nurses. The responses were collated by the lead researcher, entered into Microsoft Excel spreadsheet, exported, and analyzed with SPSS. RESULTS: Eighty-five questionnaires were distributed, 70 were returned, and 4 were discarded due to poor filling. The studied 66 comprised 40, 12, and 14 surgeons, anesthetists, and perioperative nurses, respectively. Fifty-five (83.3%) of the responders indicated awareness of the checklist but only 12 (21.8%) correctly stated that the main objective is for patients' safety and for safe surgery. Major barriers to its use include lack of training 58.2%, lack of assertiveness of staff 58.2%, and that its delays operation list 47.2%. CONCLUSION: The study demonstrated high level of awareness of surgical checklist in our hospital; however, this awareness is based on wrong premises as it is not reflected in the true aim of the checklist. Majority of the responders would want to be trained on the use of checklist despite the highlighted barriers.

Self-discharge against medical advice from tertiary health institution: A call for concern.

BACKGROUND: Self-discharge by patients without completing their treatment is a problematic issue in healthcare and is strongly associated with readmission and poor treatment outcome. PATIENTS AND METHODS: A descriptive study of the rate and reasons why patients with limb injuries took self-discharge against medical advice (DAMA) from our facility, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria, a tertiary health institution between May 2011 and April 2014. RESULTS: One hundred and thirty-one (16.2%) patients took DAMA out of 810 patients seen with limb injuries. Age ranges from 3 to 95 years with a mean of 36.31 ± 19.34 years. Road traffic crash accounted for 110 (84%) of the injuries. One hundred and sixteen (88.5%) had fractures and 9 (6.9%) had soft tissue injuries. Fifty-eight (44.3%) of the patients were referred cases, 128 (97.7%) signed DAMA form while 3 (2.3%) absconded from the hospital. Reasons for DAMA were mainly; belief more in traditional bone setters (TBSs) (36.6%); pressure from relations (22.9%) and high cost of hospital care (19.8%). One hundred and one (77.1%) of the patients volunteered that they were going to TBS for continued care. CONCLUSION: High percentage of patients DAMA from our facility and majority of them were in favour of unorthodox form of treatment.

Results of surgical treatment of nonunion of humeral shaft fracture with dynamic compression plate and cancellous bone grafting.

OBJECTIVE: We evaluated the treatment of nonunion of humeral shaft fracture with dynamic compression plate from January 2002 to December 2009. METHODS: Twenty-two patients were treated over the study period. Trauma was the predominant cause of injury in 86.4% of the patients. RESULTS: Nonunion was atrophic in 81.8% and hypertrophic in 18.2% of the individuals. There was a primary injury of the radial nerve in 27.3% of the patients. All the participants had closed fracture at presentation, and 81.2% had received previous treatment from traditional bone setters and 18.8% had failure of the conservative cast management. The average time to healing was 16 weeks. Previous treatment from traditional bone setters significantly affected the time to fracture healing (p<0.05). All fractures had successful union. CONCLUSION: It was concluded that dynamic compression plating remains an effective treatment option for nonunion of humeral shaft fracture. Level of Evidence III, Retrospective study.

Resultados de tratamento cirúrgico da pseudoartrose de fratura diafisária do úmero com placa de compressão dinâmica e enxerto de osso esponjoso / Results of surgical treatment of nonunion of humeral shaft fracture with dynamic compression plate and cancellous bone grafting

OBJETIVO: Avaliamos o tratamento da pseudoartrose de fratura diafisária do úmero com placa de compressão dinâmica de janeiro de 2002 a dezembro de 2009. MÉTODOS: Vinte e dois pacientes foram tratados durante o período do estudo. O trauma foi a causa predominante de lesão em 86,4% dos pacientes. RESULTADOS: A pseudoartrose foi atrófica em 81,8% e hipertrófica em 18,2% dos indivíduos. Havia lesão primária do nervo radial nervo em 27,3% dos pacientes. Todos os participantes tinham fratura fechada à apresentação e 81,2% deles tinham recebido tratamento anterior de traditional bone setters (pessoa que faz a redução de ossos quebrados ou deslocados, geralmente sem ser médico licenciado) e 18,8% tinham falha do tratamento conservador com gesso. O tempo médio até a união foi 16 semanas. O tratamento anterior com traditional bone setters afetou significantemente o tempo de consolidação da fratura (p < 0,05). Todas as fraturas tiveram consolidação bem-sucedida. CONCLUSÃO: Concluímos que o uso de placa de compressão dinâmica continua a ser uma opção eficaz de tratamento da pseudoartrose de fratura diafisária do úmero. Nível de evidência III, Estudo retrospectivo.

OBJECTIVE: We evaluated the treatment of nonunion of humeral shaft fracture with dynamic compression plate from January 2002 to December 2009. METHODS: Twenty two patients were treated over the study period. Trauma was the predominant cause of injury in 86,4% of the patients. RESULTS: Nonunion was atrophic in 81,8% and hypertrophic in 18,2% of the individuals. There was a primary injury of the radial nerve in 27,3% of the patients. All the participants had closed fracture at presentation, and 81,2% had received previous treatment from traditional bone setters and 18,8% had failure of the conservative cast management.The average time to healing was 16 weeks. Previous treatment from traditional bone setters significantly affected the time to fracture healing (p<0,05). All fractures had successful union. CONCLUSION: It was concluded that dynamic compression plating remains an effective treatment option for nonunion of humeral shaft fracture. Level of Evidence III, Retrospective study.

Interlocking nailing without imaging: the challenges of locating distal slots and how to overcome them in SIGN intramedullary nailing.

Placement of the distal interlocking screw is the most difficult part in all intramedullary nail interlocking screw systems and the Surgical Implant Generation Network (SIGN) interlocking system is not an exception. SIGN nails are interlocking implants designed with a precision instrumentation set for use in treatment of long bone fractures without an image intensifier. Locating the distal slots of SIGN nails could be challenging for young SIGN surgeons when treating very complex comminuted fractures and in obese patients. This study was stimulated by a patient who presented one year after surgery with knee pain due to a migrating nail because of missed distal screws. A total of 48 patients divided into two groups of 24 were studied retrospectively and prospectively. The retrospective studies revealed that failure to locate distal locking slots in ten antegrade nailing procedures was due to wrong entry point and comminution of the fracture. The challenges encountered led us to innovating methods to overcome the difficulties of placement of distal screws in a prospective study. Application of methods A and B made location of the distal slots easier in the prospective study even though there were more complex comminuted fractures. The methods also reduced the antegrade operation time by 1 hour 11 minutes. We concluded that SIGN nailing could be challenging and frustrating at the early learning stage. Application of the two innovative methods will make distal slot location easier. They will also make SIGN interlocking nailing less difficult for young SIGN surgeons as they journey through the learning curves.

Acquired boneless forearm as a complication of traditional bone setting.

An 8-year-old girl sustained closed fracture of the right ulna 10 weeks prior to presentation. She was taken to a traditional bone setter who applied a tight splint. The patient reported pain, but the splint was not removed. A week after application of the splint, a foul odor was detected and removal of the splint showed extensive exposure of the forearm bones. Above elbow amputation was rejected by the patient's parents when she was taken to hospital, where she was admitted for 8 weeks by a second traditional bone setter. A trained nurse applied herbal concoctions and dressed the wound daily in anticipation that the skin would cover the exposed bone fragments. She was brought to our hospital for wound dressing so that the skin would cover the exposed bones fragments. Examination revealed a grossly shortened right forearm--by 7 cm compared with her left--extensive exposure of both radius and ulna at the anterior aspect of the forearm, and loss of sensation and movement of the fingers. Radiographs showed sequestrated radius and ulna with involucrum around the olecranon process. Above elbow amputation was offered to the patient but the parents again declined. The forearm bones detached while scrubbing the wound for review and removal of the sequestrated bone. The wound healed within one and a half weeks of dressing, resulting in an acquired boneless forearm.

Achieving interlocking nails without using an image intensifier.

Interlocking nails are commonly performed using an image intensifier. These are expensive and are not readily available in most resource-poor countries of the world. The aim of this study was to achieve interlocking nailing without the use of an image intensifier. This is a prospective descriptive analysis of 40 consecutive cases seen with shaft fractures of the humerus, femur, and tibia. Fracture fixation was done using Surgical Implant Generation Network (SIGN) nails. Forty limbs in 34 patients were studied. There were 12 females and 22 males, giving a ratio of 1:2. The mean age (years) was 35.75+/-13.16 and the range was 17-70 years. The studied bones were: humerus 10%, femur 65%, and tibia 25%. The fracture lines were: transverse 40%, oblique 15%, and communited 45%. Fracture grades were: closed 90%, grade I, 5%, grade II, 2.5%, and grade IIIA, 2.5%. Surgical approaches were: antegrade 62.5% and retrograde 37.5%. Indications for fixation were: recent fracture 92.5%, non-union 5%, and malunion 3%. Methods of reductions were: open 85% and closed 15%. The mean follow-up period (years) was 1.50+/-0.78. The union time averaged 3 months. Complication was mainly screw loosening due to severe osteoporoses in one case. It is, therefore, concluded that, with the aid of external jigs and slot finders, interlocking can be achieved without an image intensifier.

Septic arthritis in a Nigerian tertiary hospital.

BACKGROUND: Septic arthritis is a disabling disease that requires early diagnosis and prompt management for optimal outcome. Late presentations with deformities were noticed in our clinic. The aim of this study was to determine the pattern of septic arthritis in our environment. METHODS: This was an 18-month prospective study in a Nigerian teaching hospital. Thirty-nine consecutive patients with 45 incidences of septic arthritis were studied. Joint aspirates were taken for microbiologic investigation. RESULTS: Patient ages ranged between 0.5-60 years and the mean age was 7.4 years. The male to female ratio was 2.9:1, and the knee was the most commonly affected joint. The duration of symptoms before presentation ranged between 4-17 days with a mean of 11.1 +/- 3.6 days. Twenty-five (64.1%) of the patients were on inadequate antibiotics before presentation. Seventy-three percent of septic arthritis involving the upper limb joints occurred below the age of one year and 92.3% of the involved lower limb joints occurred after one year of age. CONCLUSION: The upper limb joints were significantly affected below one year of age and the joints of the lower limb were more involved after one year of age (p = 0.001). Improper prescription of antibiotics before presentation to the hospital was noticed in 64.1% and should be discouraged.

DAREJD simple technique of draining acute paronychia.

The severe deformities of the fingers seen in poorly treated or late presenting cases of paronychia stimulated this prospective study. The aim was to make early diagnosis and to find a simple method of draining the pus in the paronychia. This was a prospective hospital based study at the Wesley Guild Hospital (WGH) Ilesa for 9 months. Using simple materials like 23G or 21G needle, cotton wool, chlorohexidine solution, methlylated spirit and zinc oxide plaster, abscess in acute paronychia was drained by lifting the nail fold with the tip of the needle. Ten cases of paronychia in 8 patients were drained with the method. Combination of the early drainage and antibiotics showed that all the patients were relieved of pain and could use their fingers normally within 2 days. There was no need of anesthesia and daily dressing. The drainage technique is simple and effective. The early drainage prevents the occurrence of any form of complication.

Normal leg compartment pressures in adult Nigerians using the Whitesides method.

In Caucasians, the range of normal intracompartmental pressure of the leg is from 0 mmHg to 15 mmHg. In the literature, such measurements have not been done in Africa to identify normal leg intracompartmental pressures. We have sought to identify the normal range of pressures in such a population of Nigerians, and to demonstrate the reproducibility of the Whitesides injection technique with materials that are easily available in most hospitals so that compartment syndromes could be identified promptly and inexpensively in developing countries. We performed a 16-month hospital-based prospective study at Wesley Guild Hospital in Ilesa, Osun State, Nigeria, to measure the intracompartmental pressures in the anterior and deep posterior compartments of 49 contralateral uninjured legs of patients with closed contralateral tibial fractures, measured at presentation. The Whitesides infusion technique was used with the aim of determining the normal range of compartmental pressure in Nigerians. The anterior compartment pressures ranged from 3 mmHg to 18 mmHg with a mean 7.6 +/- 2.6 mmHg. The pressure in the deep posterior compartment ranged from 3 mmHg to 14 mmHg with mean of 7.4 +/- 2.7 mmHg. The values are similar to those reported in the literature. There was no statistically significant difference between the pressures in the two compartments (p = 0.668).

Compartmental pressure in adults with tibial fracture.

Acute compartment syndrome is associated with tibial fractures and failure to diagnose it leads to grave consequences. This study was conceived with the aim of determining the intra-compartmental pressure in adults with closed tibial fractures and intended to provide early diagnosis of acute compartment syndrome. The Whitesides injection method was used, using hospital [corrected] available materials. The intra-compartmental pressure in the anterior and deep posterior compartments of 52 patients with closed tibial fractures was measured at presentation and 4 hourly for 24 h. In three patients, the pressure was very high, and the differential pressure (i.e. the difference between the diastolic blood pressure and the intra-compartmental pressure) was less than or equal to [corrected] 30 mmHg, which was diagnostic of acute compartment syndrome. They were all treated by fasciotomy. It is concluded that Whitesides' [corrected] method can be used to diagnose acute compartment syndrome. The apparatus is easy to set up, cheap [corrected] and therefore ideal for use in our environment where sophisticated devices of tissue pressure measurement are not available.