Hydrothorax and air fluid levels in the right chest - a diagnostic dilemma.

SUMMARY: A diaphragmatic defect that permits abdominal contents to herniate into the right side of the chest is rare. In adults with right-sided diaphragmatic hernias, few occur without a history of trauma, and even fewer are symptomatic. This case report illustrates such a case and the rare entity of an anterolaterally located hernia. Although uncommon and easily missed, consequences of diaphragmatic hernias can be disastrous. The importance of a combination of high clinical suspicion and the use of computed tomography (CT) to aid diagnosis, and the dangers of a surgical condition being incorrectly assessed and admitted to a non-surgical specialty are highlighted in this case.

The effect of COVID-19 on essential surgical admissions in South Africa: A retrospective observational analysis of admissions before and during lockdown at a tertiary healthcare complex.

BACKGROUND: With COVID-19 having spread across the globe, it has become standard to implement infection control strategies (colloquially known as lockdown) with the intention of reducing the magnitude and delaying the peak of the epidemiological curve. Personal infection mitigation strategies coupled with lockdown have caused a change in healthcare-seeking behaviour, with individuals not attending to their ill health as they previously did. OBJECTIVES: To determine whether admissions for urgent and emergency surgical pathologies have declined during the COVID-19 lockdown period, and the magnitude of the decline. METHODS: A retrospective analysis was conducted, comparing pre-lockdown (3 February - 26 March 2020) and lockdown (27 March - 30 April 2020) admission incidences for surgical pathologies at a tertiary healthcare complex in North West Province, South Africa. Poisson regression models were created to determine admission incidence rate ratios (IRRs). RESULTS: Of 769 surgical admissions included in the analysis, 49.7% were male and 67.2% were unemployed. There was a 44% reduction in the incidence of non-trauma admissions during lockdown (IRR 0.56; 95% confidence interval (CI) 0.47 - 0.68; p<0.001) and a 53% reduction in the incidence of trauma-related admissions (IRR 0.47; 95% CI 0.34 - 0.66; p<0.001). CONCLUSIONS: Even when the prevalence of SARS-CoV-2 infection was minimal, COVID-19 lockdown in North West was associated with a significant reduction in surgical admissions. In order to ensure an overall benefit to public health, a balance between maintaining the integrity of COVID-19 control mechanisms and access to healthcare services is essential.

Flexible fiberoptic bronchoscopy in respiratory care: Diagnostic yield, complications, and challenges in a Nigerian Tertiary Center.

INTRODUCTION: Flexible fiberoptic bronchoscopy (FOB) is a key diagnostic and therapeutic procedure in pulmonology. Experience with fiberoptic bronchoscopy is scanty in most developing countries. OBJECTIVES: The goal of this study was to report our experience and clinical utility of fiberoptic bronchoscopy. METHODS: A review of bronchoscopy requests, services, and reports performed over a 5-year period was performed. Demographic characteristics were extracted. Indications for the procedures, type of bronchoscopic sampling done, final diagnosis, and complications were reported. Sensitivities, specificities, and overall diagnostic yield of the procedures were determined. RESULTS: About 163 diagnostic bronchoscopies were performed during the study. Ninety-nine patients with complete data were analyzed. Mean age was 54.8 ± 19.2 years, with males constituting the majority, 56.6%. Suspected bronchial cancer and pleural effusion were the main indications for bronchoscopy (33% and 19.1%, respectively). A total of 80, 39, and 99 bronchial washings, brushings, and bronchial biopsies were performed, respectively. Bronchial cancer was confirmed in 51.5% and was diagnostic in 57% of suspected pleural effusion. Pulmonary tuberculosis was confirmed in 50% of suspected cases and additional 8 cases were diagnosed. The overall diagnostic yield of bronchoscopy was 62%. Specificities of bronchial brushing and washing cytology for excluding bronchial cancer were 90.9 and 83%, respectively, and sensitivities of detecting bronchial cancer were 64.3% and 59%, respectively, P< 0.05 each. Serious complication occurred in about 1%. There was no mortality. CONCLUSIONS: These results show that FOB is a useful and safe procedure with a low complication rate in our setting.

Haemodynamic Changes during Awake Fibreoptic Bronchoscopy in Nigeria.

INTRODUCTION: There are no reports on haemodynamic changes on West African patients undergoing fibreoptic bronchoscopy (FOB). The aim of this study was to document these changes in West African patients undergoing awake FOB. MATERIALS AND METHODS: All consenting patients considered for awake FOB had their pulse rates, blood pressures and oxygen saturations documented at various phases of FOB, during procedures and up to 30 minutes after FOB to monitor any changes from pre-procedure levels. The values were analysed using SPSS version 16. RESULTS: One hundred and sixty FOB were performed on 145 patients. In non- sedated patients, the maximum oxygen saturation fall was 6% at the level of the vocal cord while the pulse rate rose as high as 13% at the carina. Bronchial washings exerted the most changes in sedated patients (SPO2 fell by 4.9%, and pulse rate rose by 11.9%). The mean arterial pressure increased occurred during bronchial washing for both groups (18.7% for non-sedated and 15.7% for sedated patients) CONCLUSION: Tachycardia, elevations in blood pressure and hypoxaemia are more pronounced and occur earlier during FOB in non-sedated patients. Traversing the vocal cords and bronchial washing evoke the most cardivascular changes during FOB.

The impact of psychological illness on outcome of corrosive esophageal injury.

PURPOSE OF STUDY: Esophageal stricture is a debilitating condition with significant morbidity and mortality, occurring often as a complication of the ingestion of corrosives. In the adult, majority of cases are intentional whilst being accidental in the pediatric population. We therefore sought to describe the circumstances of intentional corrosive ingestion and determine the presence and impact of psychiatric illness on the outcome of management. MATERIALS AND METHODS: A retrospective analysis of case folders of patients managed with this condition over a ten-year period (2000-2009) was done by comparing sociodemographics and outcome of management in patients with and without psychiatric disorders. RESULTS: Twenty seven cases were reviewed. Mean age was 30.7 (SD =16.01), with a M:F ratio of 1.25:1.86.2% had a diagnosable psychiatric condition, the most common being depression in 55.6% of the patients. Caustic soda (55.6%) was the most common corrosive ingested. There was a significant difference in mean duration before presentation in patients with (1.7 days) and without (6.6 days) previous psychiatric illness (P = 0.01). A significant positive association was also found between surgical outcome and previous history of psychiatric disorder (P = 0.02). CONCLUSION: Early recognition of psychosocial distress is important to prevent deliberate self-harm. Counter-intuitively, a previous history of psychopathology limits esophageal injury by early presentation and therefore improve chances of a good surgical outcome.

Oxygen supplementation during awake fibreoptic bronchoscopy in a Nigerian tertiary hospital.

BACKGROUND: Examination of the airway is necessary in a wide variety of conditions. This study was carried out to determine the need for oxygen supplementation during the conduct of flexible fibreoptic bronchoscopy on the awake patient. STUDY DESIGN: A prospective study of consecutive consenting patients requiring awake flexible bronchoscopy between January 2010 and December 2011 using a fibreoptic bronchoscope in the study centre was conducted. With the aid of transcutaneous pulse oximetry, baseline oxygen saturation values were recorded as well as at the various stages of the procedure as well as during brush cytology, washings, biopsy, transbronchial biopsies and transbronchial needle aspirations and 5, 15 and 30 minutes post-procedure. Data was analysed using SPSS 16 and significant values were taken at pd"0.05. RESULTS: Sixty-seven awake fibreoptic bronchoscopies were performed on 61 patients comprising 38 males and 29 females and a mean age of 51.9 ± 18.9 years. The lowest mean SPO2 of 91.2% was attained during brush cytology. Thirty- four patients (50.7%) had the procedure without oxygen supplementation. Supplemental oxygen was required in all seven patients with a baseline SPO2 of d"92% while it was required in 63.2% of patients with baseline SPO2 of 93- 96%. Baseline oxygen saturation was the most important predictor of the need for oxygen supplementation (p= 0.005). CONCLUSION: Routine oxygen supplementation is not mandatory for the safe conduct of flexible bronchoscopy. The baseline oxygen saturation value accurately predicts the need for oxygen administration.

Pancreatic pseudocyst in Ile-Ife revisited: 5 more cases.

BACKGROUND: Pancreatic pseudocyst is a major health problem in the developed countries and its incidence is noted to be getting higher among the Caucasians as a result of better diagnostic techniques. This retrospective study was done to review the cases of pancreatic pseudocyst seen between 1991 and 1999 at the Obafemi Awolowo University Teaching Hospitals, Ile-Ife, Nigeria. The 5 cases seen over this period of study were used to illustrate its rarity. METHOD: The case notes of the patients managed for pancreatic pseudocyst during the period under review were studied and analysed to evaluate the different modes of presentation, investigations done and the modes of treatment. RESULTS: The age range of the patients varied between 23 and 70 years with three of them being male while two were female. The most common presenting symptom and sign were abdominal pain and abdominal mass. Abdominal ultrasonography, chest X-ray, upper gastrointestinal endoscopy and laboratory blood tests were the investigative procedures carried out. The treatment modalities were either conservative or surgical (operative). One patient had spontaneous resolution of the pseudocyst, 2 had external drainage while the remaining 2 had cystogastrostomy. Two of the patients responded well to treatment and were being followed up in the Surgical Out Patient Clinic, one died within 24 hours of surgery while the other developed diabetes mellitus 3 months post surgery and was referred to the physicians for follow-up. CONCLUSION: Though pancreatic pseudocyst remains uncommon in Nigeria, ultrasonography can play an essential role in assisting diagnosis while successful management of this condition is still possible in the absence of current endoscopic techniques of drainage.