Non-trauma surgical emergencies in adults: Spectrum, challenges and outcome of care.

INTRODUCTION: Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. METHODS: A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. RESULTS: Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. CONCLUSION: Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital.

Examination malpractice in our medical schools: prevalence and import on tomorrow's doctors.

UNLABELLED: AIMS AND OBJECTIVES. The objective of this paper is to estimate the prevalence of examination malpractice among medical students; its import on medical education and future doctors. MATERIALS AND METHODS: Structured questionnaires were administered to consenting medical students of participating four medical colleges in Nigeria. Data was collated and analysed using SPSS version 11. RESULTS: Three hundred and eighty two students responded. There were 210 males and 172 females (M: F-1.2:1); age range 19-45 years, mean 24.86 ± SD. Majority 304(79.6%) were in the 5th and final years. At secondary and tertiary levels, 67(18.1%) and 79(22.2%) were respectively involved in cheating. Mode of cheating included seeking examination materials, 10(2.6%); copying answers between examination rooms, 18(4.8%); copying assignments, 290(77.7%) and copying laboratory results 206(56.6%). Clinical examinations not performed were described as "normal" by 206(56.6%). Motivation for cheating included previous failures and escape punishment in 6(3.3%) and 31(10.4%) respectively. While 46(12.8%) tried to induce lecturers to change grades, 97(25.8%) would not inform the authority if they suspected that examination leaked. CONCLUSION: Examination malpractice in High schools and Tertiary institutions also includes the medical students. Educating pupils from the elementary schools on effects of cheating, inclusion of this practice in the medical curriculum as part of Medical Ethics and Institutional culture of Integrity among doctors are recommended. Stiffer punishment for offenders would reduce the practice among the students.

Penile fracture at LAUTECH Teaching Hospital, Osogbo.

BACKGROUND/OBJECTIVE: We have seen three cases of penile fracture presenting in diverse ways in our teaching hospital. We want to highlight the difficulties of management when patients present late. PATIENTS AND METHODS: Three case reports of young men whose ages range between 22-32 years and who presented at 1 year 6 months, four weeks, and 3 hours respectively, following penile fracture. RESULTS: The patient that presented within 3 hours had immediate exploration and primary repair with good results while the one that presented after four weeks is still being followed up. The patient that presented very late has been lost to follow up after he was told that he would require surgery. CONCLUSION: Early surgical intervention in penile trauma still gives the best result and is hereby advocated. Decision to operate or not should also be based on the empirical finding of size of tear if there is no associated urethra injury.

Rotational rural surgery for the poor in developing countries.

Radio and television announcements advised patients with surgical problems in the rural areas of Osun State, Nigeria, to report at any of the nine zonal headquarters of the state which were closest to their homes in order to receive free treatment. Over 1000 patients reported and 801 received operations on a rotational basis within nine weeks. We studied 719 of these patients, ages between 4 months and 87 years, who had detailed follow-up records. There were 14 different procedures ranging from a hernia repair to the separation of syndactyly. Complications included postoperative pain, haematoma and late superficial wound infection. We concluded that rotational free surgery can help the poor in the third-world countries to receive treatment that they would otherwise not be able to afford.

Mirizzi syndrome caused by a bile pseudocyst.

BACKGROUND: Mirizzi syndrome caused by bile pseudo cyst presents diagnostic and management challenges to the surgeon. OBJECTIVE: To emphasize to clinicians the need to always recognize and correct associated liver derangements before surgery so as to prevent the usual accompanying high morbidity/mortality associated with Mirizzi syndrome. CASE REPORT: We report an unusual and previously unreported pathology of post-cholecystectomy Mirizzi syndrome in a 35 year old female who developed a bile pseudo-cyst and which may possibly qualify for Mirizzi syndrome type 5--highlighting the need for maximum pre, -intra, and post-operative challenges for improved prognosis. The patient was lost from reactionary haemorrhage due to limited facilities. CONCLUSION: There is a crying need in developing countries to have Critical Care centers and for Clinicians to recognize the necessity for adequate pre, intra and post-operative care of these high risk patients.

Pattern and outcome of emergency surgery in a new Nigerian Teaching Hospital--The LAUTECH Osogbo experience.

AIMS AND OBJECTIVES: To present a 5 years experience on the pattern and outcome of emergency operations in a new teaching hospital. MATERIALS AND METHODS: A retrospective study carried out between April 1998 and March 2003 with appropriate data extracted from the available case notes. RESULTS: Two thousand and seventy operations were performed within the period of study. Seven hundred and twenty six of them were done as emergency. Obstetrics' and Gynaecology cases were 66.6% while 33.4% (including six cases of perforated uterus and gangrenous bowel from unsafe abortion) belong to the general surgery and specialty emergencies. Waiting time, mean of which was 39.5+/-2.7 hours, was unduly prolonged. Mortality was 10.3%. CONCLUSION: The high morbidity and mortality as reflected in this study could be reduced through prompt surgical interventions, education on contraceptive awareness and legistilation against unsafe abortion.

Knowledge, attitudes and practices of the educated and non-educated women to cancer of the breast in semi-urban and rural areas of SouthWest, Nigeria.

OBJECTIVES: That women with cancer of the breast seek medical help late is a common occurrence in developing countries. We decided to see if education and environment play any role in this and in cancer screening. A semi-structured questionnaire was drawn to inquire about knowledge, attitude (beliefs) and practices of women to breast cancer and available cancer screening methods in their environment- particularly Self and Clinical Breast Examination. PATIENTS AND METHODS: The questionnaires, prepared in English and vernacular, were given to women and women relations seen in the surgical clinics and wards of Ladoke Akintola University Teaching Hospital, Osogbo and some primary health centers, for various ailments. Traders in market places and rural communities were included. RESULTS: Analysis was by SPSS, chi-square, percentage frequency and tested at probability level of 0.05. Eight hundred and thirty two respondents were collected. Six hundred and twenty five (72.2%) were from Semi-urban while 207(27.8%) were from the rural regions. The age range was between 15 and 72 years with a mean age of 30.89+/-11.58. The educational level showed that 304(36.4%) had tertiary education. Six hundred and four (72.6%) have previous knowledge of cancer of the breast, 149(17.4%) offered possible aetiological reasons, and 341(41.1%) have some knowledge of associated symptoms. Available screening methods of Self and Clinical breast examination was practised by 393(47.2%) of the respondents. One hundred and fifty five (32.3%) would give consent to mastectomy while as many as 619(74.4%) have deep fear of the disease. CONCLUSION: Despite a relatively high literate level in the study group, knowledge of aetiological causes of breast cancer, including risk factors is abysmally low; so is knowledge and attitude to symptoms. Because of this poor/inadequate knowledge, as well as available screening methods, efforts should be made to upgrade the knowledge of our women through Information, Education and Communication (I.E.C) on cancer of the Breast and the consequences of late presentation.

Medical problems in geriatric surgical patients.

Age is often a marker for co-morbid illness that may complicate attempts at surgery, hence careful preoperative assessment and vigorous treatment of the pre-operative medical condition with adequate post-operative supports are needed for safe surgery. In our series, a fifteen months study period, six hundred and Ninety five patients were operated upon out of which forty four patients were 65 years old and above (6.3% ); Age ranged between 65 years and 80 years (mean age of 70 years). The patients with medical problems were sixteen (36.4% ) out of which urinary tract infection was the most common (43.8% ). The most common anaesthetic technique was spinal anaesthesia in 45.5%, the most common operative procedure was herniorrhaphy (36.4% ); followed by prostatectomy (26.5% ). Three of the patients presented with wound infection; mortality was 2.3%, which occurred in a patient who died of multiple organ failure.

Cryptorchidism in a local population in Nigeria.

OBJECTIVE: To screen for undescended testis, retractile testis and other anomaly of the external genitalia in randomly selected Nursery/Primary schools in Osogbo, Nigeria. DESIGN: A prospective study involving seven different Nursery/Primary schools with 1615 male pupils ages 2-10 years were screened. SETTING: Five private Nursery/Primary schools and two government owned primary school in Osogbo. METHODOLOGY: Permission was sought from the schools' Headmasters through the proprietors of the private schools, Local inspector of Education of government primary schools, and the ethical committees of the University and the Teaching Hospital Male pupils were examined by three groups made up of a consultant and a resident in each group. RESULTS: A total of 1615 male pupils were examined out of which 40 pupils (2.5%) were found to have undescended testis, five of these (12.5%) had bilateral cryptorchidism. Eighteen had right undescended testis (45.0%) while seventeen (42.5%) presented with left undescended testis. Four pupils had retractile testis two on each side and another four had a co-existing hydrocoele with their undescended testis. CONCLUSION: Prevalence of Cryptorchidism in the age group in this study is significant. There is need to screen male children so that early detection and correction may be effected.

The pattern of gunshot injuries in a communal clash as seen in two Nigerian teaching hospitals.

BACKGROUND: The pattern of gunshot injury in the Ife-Modakeke communal clash between March 3 and May 23, 1999 was analyzed in this study. METHODS: The history was recorded for each patient presenting at the hospital with gunshot injuries from the clash. Each was examined and followed up through subsequent treatment in the wards and clinics. RESULTS: The study included 185 patients. The male-to-female ratio was 22.1 to 1, and 45.9% of the patients ranged in age from 21 to 30 years. The mean age was 28.3 +/- 11.2 years, and the mortality rate was 8.6%. There were 120 warriors and 65 noncombatants. Government workers and students made up most of the noncombatants (42.5%), whereas drivers and farmers constituted the vast majority of the warriors (23.3%). Injury to the lower limbs was the most commonly seen injury (54.6%). Sustained fractures and femoral fractures were the most common fracture (n = 100, 54.1%). Head and colonic injuries were the greatest cause of mortality. CONCLUSION: For civilian gunshot injuries, morbidity and mortality rates are high in the less developed countries because of inadequate prehospital and hospital care. Efforts should be made to improve these facilities.

Ureteric injuries following pelvic operations.

BACKGROUND: Iatrogenic injuries to the ureter are hazardous complications of pelvic operations, causing severe morbidity and even mortality. OBJECTIVE: To present our 10 years experience in the management of such ureteric injuries. DESIGN: A retrospective study carried out between January 1990 and December 1999. SETTING: Two busy health institutions, namely Ife State hospital and Wesley Guild Hospital, both of the Obafemi Awolowo University (OAU) Teaching Hospitals Complex, Ile-Ife, Nigeria. RESULTS: The incidence of iatrogenic injury was 0.4%. Ureteral transection was the commonest lesion (58%). Ureteroneocystostomy was performed in 70% of the operated cases. Those diagnosed at the time of injury and treated with end-to-end anastomosis had the best results. CONCLUSION: The proper identification and, when necessary, isolation of the ureter during operations in which there is a risk is crucial in reducing the incidence of ureteral injuries.