Anatomical variations of the sternal angle and anomalies of adult human sterna from the Galloway osteological collection at Makerere University Anatomy Department.

BACKGROUND: Anatomical variations of the sternal angle and anomalies of the sternum are unique happenings of major clinical significance. It is known that misplaced sternal angles may lead to inaccurate counting of ribs and create challenges with intercostal nerve blocks and needle thoracostomies. Sternal foramina may pose a great hazard during sternal puncture, due to inadvertent cardiac or great vessel injury. These sternal variations and anomalies are rarely reported among Africans. The aim of this study was to determine the anatomical variations of the sternal angle and anomalies of the sternum among adult dry human sterna at the Galloway osteological collection, Makerere University, Uganda. MATERIALS AND METHODS: This was a descriptive cross sectional study in which quantitative and qualitative data were collected. The study examined 85 adult human sterna at the Department of Anatomy, Makerere University. Univariate and bivariate analyses were done using SPSS 21.0 for Windows. RESULTS: Over 40% (36/85) of the specimens had variations in size, location and fusion of the sternal angle. There was no significant difference in the mean size of the sternal angle in males at 163.4 ± 6.7o compared with 165.0 ± 6.4o in females (p = 0.481). Of the 85 specimens examined, only 21 (24.7%) had a xiphoid process. The most frequent sternal anomalies were bifid xiphoid process 42.9% (9/21) and sternal foramen 12.9% (11/85). CONCLUSIONS: Sternal variations and anomalies are prevalent in the Galloway osteological collection and there is need for increased awareness of these findings as they may determine the accuracy of clinical and other procedures in the thoracic region.

Cost-effectiveness of groin hernia repair from a randomized clinical trial comparing commercial versus low-cost mesh in a low-income country.

BACKGROUND: Over 200 million people worldwide live with groin hernia and 20 million are operated on each year. In resource-scarce settings, the superior surgical technique using a synthetic mesh is not affordable. A low-cost alternative is needed. The objective of this study was to calculate and compare costs and cost-effectiveness of inguinal hernia mesh repair using a low-cost versus a commercial mesh in a rural setting in Uganda. METHODS: This is a cost-effectiveness analysis of a double-blinded RCT comparing outcomes from groin hernia mesh repair using a low-cost mesh and a commercially available mesh. Cost-effectiveness was expressed in US dollars (with euros in parentheses, exchange rate 30 December 2016) per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained. RESULTS: The cost difference resulting from the choice of mesh was $124·7 (€118·1). In the low-cost mesh group, the cost per DALY averted and QALY gained were $16·8 (€15·9) and $7·6 (€7·2) respectively. The corresponding costs were $58·2 (€55·1) and $33·3 (€31·5) in the commercial mesh group. A sensitivity analysis was undertaken including cost variations and different health outcome scenarios. The maximum costs per DALY averted and QALY gained were $148·4 (€140·5) and $84·7 (€80·2) respectively. CONCLUSION: Repair using both meshes was highly cost-effective in the study setting. A potential cost reduction of over $120 (nearly €120) per operation with use of the low-cost mesh is important if the mesh technique is to be made available to the many millions of patients in countries with limited resources. TRIAL REGISTRATION NUMBER: ISRCTN20596933 (http://www.controlled-trials.com).

Prevalence of treated and untreated groin hernia in eastern Uganda.

BACKGROUND: Hernia repair is the most commonly performed general surgical procedure worldwide. The prevalence is poorly described in many areas, and access to surgery may not be met in low- and middle-income countries. The objectives of this study were to investigate the prevalence of groin hernia and the surgical repair rate in a defined sub-Saharan region of Africa. METHODS: A two-part study on hernia prevalence was carried out in eastern Uganda. The first was a population-based prevalence study with 900 randomly selected men in a Health and Demographic Surveillance Site. The second was a prospective facility-based study of all surgical procedures performed in the two hospitals providing surgical care in the region. RESULTS: The overall prevalence of groin hernia (current hernia or scar after groin hernia surgery) in men was 9.4 per cent. Less than one-third of men with a hernia had been operated on. More than half had no pain symptoms. The youngest age group had an overall prevalence of 2.4 per cent, which increased to 7.9 per cent in the age range 35-54 years, and to 37 per cent among those aged 55 years and above. The groin hernia surgery rate at the hospitals investigated was 17 per 100,000 population per year, which corresponds to a surgical correction rate of less than 1 per cent per year. Based on hospital records, a considerable number of patients having surgery for groin hernia were women (20 of 84 patients, 24 per cent). CONCLUSION: Groin hernia is a common condition in men in this east Ugandan cohort and the annual surgical correction rate is low. Investment is needed to increase surgical capacity in this healthcare system.

Chronic osteomyelitis in a Ugandan rural setting.

OBJECTIVE: To determine the incidence pattern and outcome of chronic osteomyelitis in a rural setting. DESIGN: A prospective descriptive study where a proforma was drafted to study all consecutive patients with features of chronic osteomyelitis over a period of six years, Clinical findings on presentation, treatment, duration of symptoms, initial treatment sought, operative treatment, post operative outcome and demographic data were all documented. SETTING: Mityana hospital, a rural 120 hospital bed, located in Mubende District. It serves Mubende district and the neighbouring districts of Mpigi, Sembabule, Kyenjojo, Kibale and Kiboga. The majority of the population in these districts are mainly peasants involved in cattle keeping and agriculture. PATIENTS: One hundred and twenty patients with chronic osteomyelitis were treated between June 1996 - June 2001. RESULTS: One hundred and twenty patients with chronic osteomyelitis seen in a period of six years, involving various bones of the body. Forty five percent were females, the highest incidence occurred in the age range of 10 - 19 years. The commonest a etiological history was by pricks. The bones most frequently affected were phalanges (43.3%) followed by the tibia (21.6%). Forty four percent of these patients first used local herbs before going to hospital. Fifty five percent of the patients were found to have a big spleen of not less than 12cm below the costal margin and the best treatment option was sequestrectomy and curretage with imperical administration of antibiotics. Complications observed on follow up were: cosmetically bad fingers where curretage and sequestrectomy were done. Distortion of the foot arches where the matarsals were disarticulated and persistent discharging sinuses. CONCLUSION: Chronic osteomyelitis is a debilitating dirty disease endemic in the peasantry communities. It persists because of delay in seeking medical treatment because the first line of treatment is mainly herbs where the terminal phalanges were involved. Sequestrectomy and curettage were a better option to disarticulation because the function of the finger is not interfered with. The biggest number of cases seen involved the phalanges (45.3%) followed by the tibia 21.6% because of the nature of occupation of the rural communities.

Management of cancer of the stomach in Mulago Hospital Kampala, Uganda.

OBJECTIVE: To determine the clinical presentation, mode of investigation and management of gastric cancer at New Mulago Hospital. DESIGN: Prospective descriptive study. SETTINGS: Three general surgical wards, Department of Surgery, New Mulago Hospital. SUBJECTS: Thirty five patients were studied within 12 months. RESULTS: Gastric cancer was found to be prevalent in tribes inhabiting volcanic areas of south western Uganda especially the Banyankole (25%). The commonest mode of clinical presentation was epigastric pain, weight loss, constipation, epigastric tenderness, palpable epigastric mass and anaemia. The most accurate mode of investigation was by endoscopy followed by barium meal. The commonest locality was the pyloric atrium (40%) histologically adenocarcinoma (95.5%) predominated. Gastric cancer was found to be more common in patients with blood group O+ve. All patients had been subjected to some kind of medical treatment especially with antiacids, H2 receptor antagonists which contributed to the delay in presentation. The majority of patients (94.5%) presented with advanced disease and no curative surgery was possible. CONCLUSIONS: These results show that early diagnosis of gastric cancer is still a dream at Mulago hospital since most patients present with advanced disease. To address this problem, all health workers should be sensitised on symptoms and signs for early aggressive investigation or an early referral to enable early diagnosis of gastric cancer. The investigatory capacity of rural hospitals should be boosted to enable early detection of gastric cancer.

Long-term complications of inguinal hernia repair.

OBJECTIVE: To assess the pattern of long term complications of inguinal hernia repair. DESIGN: A prospective, descriptive study. PATIENTS: Eighty six consecutive patients who presented with symptoms and signs of long-term complications of inguinal hernia repair. SETTING: Out patient clinic of a rural hospital at Mityana in Uganda. RESULTS: A number of long term complications of inguinal hernia repair were discovered. The most frequent was recurrence of hernia (42%) followed by stitch absesses/sinuses (24.2%). Others included intestinal obstruction, faecal/urine fistulae, painful scars/neuromas, unilateral/bilateral testicular atrophy, impotence, hydrocele, multiple incision scars on same side and hypertrophic scars. Complications were more prevalent between 50-70 years. In children the majority of repairs were done below 10 years. CONCLUSION: Majority of these complications could be avoided by first investigating for the aetiology of the hernia in elective cases, use of better surgical techniques and expertise. Good follow up is essential to avert distressing complications like testicular atrophy, faecal and urine fistulae.