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.

Effect of warm intravenous and irrigating fluids on body temperature during transurethral resection of the prostate gland.

BACKGROUND: Transurethral resection of the prostate gland with irrigation fluid at room temperature leads to perioperative hypothermia which could give rise to adverse cardiovascular events in the perioperative period. The use of isothermic irrigation fluid reduces but does not eliminate this risk. Routine use of warm intravenous fluids along with isothermic irrigation had not been documented. This study set out to investigate the effect of the use of warm intravenous fluid together with isothermic irrigation fluid on the body temperature in patients undergoing transurethral resection of the prostate gland. METHODS: One hundred and twenty consented patients with obstructing benign prostatic hyperplasia were randomly assigned to one of 3 groups. Group 1 received irrigation and intravenous fluids at room temperature, group 2 received warmed irrigation fluid at 38 degrees C along with intravenous fluid at room temperature while group 3 patients received warmed irrigation fluid and warmed intravenous fluids at 38 degrees C. Their perioperative body temperature changes were monitored, analyzed and compared. RESULTS: The mean decrease in body temperature at the end of the procedure was significantly greater in group 1 (0.98 +/- 0.56 degrees C) than in group 2 (0.42 +/- .21 degrees C) (p < 0.001). Significantly more patients in group 1 also experienced shivering. However, in group 3, there was no significant change in the mean body temperature (p > 0.05) and none of them felt cold or shivered. CONCLUSION: It is concluded that the use of isothermic irrigation fluid together with warm intravenous fluids during TURP prevents the occurrence of perioperative hypothermia.

A variant epidermal growth factor receptor protein is similarly expressed in benign hyperplastic and carcinomatous prostatic tissues in black and white men.

BACKGROUND AND OBJECTIVE: Anti-epidermal growth factor receptor strategies are now established in cancer treatment We have recently described the presence of EGFRvIII (a variant EGFR) in prostatic tumours from UK white men and this is now a target for anti-prostate cancer treatments. However, there has been no report on the expression of this abnormal protein in black men. MATERIALS AND METHODS: We determined EGFRvIII expression in sections of normal, benign hyperplastic (BPH) and carcinomatous (CaP) prostatic archival tissues from Nigerian men and UK white men using streptavidin immunohistochemical techniques. The EGFRvIII immunoreactivity was scored visually using a semi-quantitative method and the results compared statistically. RESULTS: EGFRvIII expression increased with increasing malignancy in both study populations (CaP > BPH > Normal p, <0.0001). Furthermore, EGFRvIII expression was similar in both BPH and CaP tissues in black and white men (p, 0.86 and 0.31 respectively). CONCLUSION: These results demonstrate that EGFRvIII immunoreactivity in prostatic tumours in black men is similar to that in white men. Anti-cancer treatments directed at the EGFRvIII should be equally effective in men from both subpopulations.

Anti-PSA immunoreactivity in primary prostatic tissues from black African men.

Prostatic specific antigen (PSA) immunoreactivity is the most commonly used histological marker to identify epithelial cells of prostate origin. Unlike tissues from white men in which grade-related variability has been reported, the pattern of PSA immunoreactivity in prostatic tissues from black African men is presently unknown. This study was done to evaluate the pattern of PSA staining in sections of normal, benign hyperplastic and malignant prostatic glands from men from this sub-population. PSA immunostaining was done on 4-microm serial sections from archival specimens of benign prostatic hyperplasia (BPH) and carcinoma of the prostate (CaP) obtained from black African men using standard immunoperoxidase techniques. The intensity of PSA immunoreactivity of the glands was scored using a semi-quantitative method. PSA expression decreased with increasing de-differentiation of the tissue histotype with poorly differentiated tumours staining least. PSA immunoreactivity was strong in 100% of normal glands and 84% of BPH glands and moderate in the rest. In contrast, PSA immunopositivity was strong in 32% of CaP glands, moderate in 26%, weak in 34% and absent in 8%. Statistical comparison revealed that PSA expression was significantly higher in benign tissues (normal/ atrophic and BPH) than in CaP glands [p = < 0.0001]. Our findings show that PSA immunoreactivity is grade-related in prostatic tissues from black men and this has implications for clinical diagnosis and research. It also confirms the limitations of PSA-testing in diagnosing CaP, and indicates that newer immunohistochemical tests for malignant prostatic cells should be acquired by Sub-Saharan laboratories.

EXPERIENCE WITH MANAGING CHILDHOOD URETHROCUTANEOUS FISTULA AT IBADAN.

BACKGROUND: Urethrocutaneous fistula could be a distressing condition to the child and parents alike. Its management could be challenging and requires adequate expertise. AIM: To review the characteristics and aetiology of urethrocutaneous fistula managed in our division over a ten-year period. METHODOLOGY: All children with urethrocutaneous fistulae from July 2006 to June 2015 were subject of this review. The demography, aetiology, type of fistula, operation performed and the outcome were retrieved from the division operation book and case notes of the patients. The data was analyzed using SPSS Inc. version 20 and odd ratio. RESULTS: Thirty-five children were managed over a period of ten tears. The age ranged from 6 months to 13 years with a mean of 4±1.9years. Seventy one percent of urethrocutaneous fistulae resulted from complication of childhood male circumcision procedures performed in private hospitals and by nurses. One child (3%) had isolated perineal urethrocutaneous fistula while 26% complicated hypospadias repair at these locations: glandular in 1% case, subcoronal in 3% cases, penile in 2% cases, and penoscrotal in 3% cases. Ten (29%) children with abnormal haemoglobin AC was noted in 3 (9%) patients and haemoglobin AS in 7 (20%) patients. The odd ratio between abnormal haemoglobin and normal haemoglobin was 3.8. The surgical repair of post-circumcision urethrocutaneous fistulae and post-hypospadias had a recurrent fistulae in 4 (16%) and 3 (33%) respectively. Majority of the fistulae were repaired by simple closure in 80% post-circumcision and in 44% post-hypospadias repair. in the more difficult cases, penile degloving with urethral mobilization was done in 16% post-circumcision fistula and 22% post-hypospadias fistula with no recurrence. CONCLUSION: in this study, post-circumcision urethrocutaneous fistula was the commonest cause of childhood urethrocutaneous fistula, the severe ones could require penile degloving to achieve repair without tension; recurrence was a major complication.

Multiple malignant lesions involving the orofacial region: a case report.

We describe a rare finding in a 38 year old patient with previously undiagnosed prostate cancer who presented with multiple facial swellings, mental nerve neuropathy and paraplegia. While the co-existence of paraplegia and mental nerve neuropathy is a possible feature of metastatic prostate cancer involving the spine and mandible, the concomitant occurrence of multiple facial swellings involving the anterior mandible with its related gingival and lip mucosa, frontal bone and parotid glands is a rare finding. This raised a suspicion of two histologically different malignancies co-existing in this patient. Fine needle aspiration cytology (FNAC) of the parotid lesion and incisional biopsy of the gingival lesion were reported as Lymphoblastic lymphoma and Non Hodgkin's Lymphoma respectively. A Transrectal biopsy of the prostate gland confirmed adenocarcinoma of the prostate gland. The patient however died due to a number of intercurrent illnesses and rapid deterioration consequent on his disease condition. Unfortunately, all efforts to carry out an autopsy were unsuccessful due to strong objection of the relatives on religious grounds. Problem associated with the diagnosis and management of such a rare case in a developing economy was highlighted.

HISTOPATHOLOGIC PATTERN OF BLADDER CANCERS IN IBADAN SOUTHWEST NIGERIA: AN UPDATE.

BACKGROUND: A study from the University College Hospital, Ibadan, Southwest, Nigeria on bladder cancers had described an increase in the frequency of urothelial carcinoma compared to the earlier reported preponderance of squamous-cell carcinoma. AIM: To provide an update on the histopathologic pattern of bladder cancers in our community and to explore its implications for future health system policies. METHODS: The records of the Ibadan Cancer Registry from January 1997 to December 2014 were reviewed and the data analyzed for the histologic subtypes of bladder cancers diagnosed in the hospital. RESULTS: Two hundred and sixteen bladder tumours were recorded during this period with a male to female ratio of 3.2:1. Complete information was available in 195 cases of which 181 (96.8%) were bladder carcinomas whilst 14 were sarcomas. Of the bladder carcinomas, 68.5%, 19.9% and 11.6% were urothelial carcinomas, squamous cell carcinomas, and adenocarcinomas (AC) respectively. Urothelial carcinoma was more common in all age groups and its peak age of occurrence was in the 51-60 year age group. The peak age for squamous cell carcinoma was in the 41-50 year age group. Mean and median age of occurrence was significantly lower in females in the urothelial and squamous cell carcinomas, but lowest in squamous cell carcinoma [P = < 0.0001]. CONCLUSION: This population study has confirmed urothelial carcinoma as the predominant histotype of bladder cancer in Ibadan, Southwest Nigeria currently and that both urothelial and squamous cell carcinomas occur earlier in women.

Grinding machine injury of the hand: a preliminary report.

Case notes of 20 patients who presented with grinding machine injury to the hand from April 1984 to March 1990 were analysed for pattern of injury, method of management and outcome of treatment. Thirteen cases were seen in the last three years of this period (the SAP era) compared to seven cases in first three years of the period (the pre-SAP era). Children from low socio-economic class were the commonest victims. The right hand was commonly involved alone. Most injuries were multiple but the skin of the dorsum of the hand and ring finger were most commonly injured. Associated fractures of the metacarpals, carpals, joint dislocations in the hand and injuries to other parts of the body were uncommon. Thorough washing of the wound with soap and water, careful, limited initial debridement, elevation of the hand, antibiotics, antitetanus prophylaxis and early intensive hand physiotherapy yielded good to excellent results in seventeen patients. Eventhough the viability of the crushed skin on the dorsum of the hand may be questionable at initial presentation most of it will 'take' and we advocate that as much of this skin as is possible should be spared.

Day case transurethral prostatectomy in Nigeria.

BACKGROUND: Caudal block regional anaesthesia has been used over the years for out-patient procedures, and in transurethral resection of the prostate gland in Nigeria since 1995. In a preliminary study involving 10 selected patients undergoing TURP, spontaneous voiding resumed on the operative day, and their discharge on the same day did not in any way lead to any adverse events. This larger series further confirms the safety of transurethral resection of the prostate gland as a day case procedure. METHOD: One hundred and eighty patients with obstructing benign prostatic enlargement on urethral catheter drainage with prostate glands weighing 60g or less on ultrasound assessment, were subjected to transurethral resection of the prostate gland (TURP) as day-cases under caudal block regional anesthesia using 2% xylocaine with 1 in 80,000 adrenaline. Hemostasis was secured until effluent of the irrigation fluid from the bladder was totally free of any visible trace of blood. A catheter was not inserted postoperatively. The patients were discharged on the same day after they had satisfactorily voided. RESULTS: These patients resumed spontaneous voiding postoperatively before discharge on the operative day. Their discharge on the same day did not in any way lead to any adverse events. CONCLUSIONS: With a better understanding of the anatomy of the innervations and blood supply of the prostate gland, and proper patient selection, this larger series has confirmed that day-case TURP without postoperative catheterization can now be safely added to the list of day case procedures.

Soap induced urethral pain in boys.

OBJECTIVE: To describe the cause, possible pathogenesis and management of "idiopathic" urethral pain in boys. PATIENTS AND METHOD: Eighteen boys presenting with distal urethral pains over a period of 12 years were reviewed and their responses to the application of bland petroleum jelly to the external urethral meatus before each soap bath was noted. RESULTS: The symptoms started suddenly while bathing with soap. Penile erections at onset occurred in 14 (78%). Two (11%) had purulent urethral discharge and 1 (5.5%) had meatal stenosis. Application of bland petroleum jelly to the external urethral meatus before each soap bath satisfactorily controlled the urethral pains. CONCLUSION: "Idiopathic urethral pain in boys" may be due to soap induced chemical urethritis and responds well to application of bland petroleum jelly to the external urethral meatus before each soap bath with appropriate antibiotics when there is associated purulent urethral discharge.

Experience with caudal block regional anesthesia for transurethral resection of the prostate gland.

Ninety five consecutive patients with obstructing prostatic enlargement requiring surgery underwent caudal anesthesia for transurethral resection of the prostate gland (TURP). Their mean age was 73 +/- 7.8 years, the mean preoperative volume of the prostate gland was 160cc and the mean resection time was 97.3 +/- 30 minutes. The anesthesia was satisfactory with a mean pain score of 0.3 +/- 0.6 on the 0-10 pain rating scale. No complication of the anesthetic procedure occurred. Ten patients were discharged free of catheter on the same day while all the remaining 85 patients were discharged within 48 hours of surgery. It is concluded that caudal anesthesia with 2% xylocaine with 1 in 80,000 adrenaline gives adequate anesthesia for transurethral resection of the prostate gland.

Delayed primary realignment of posterior urethral rupture.

The treatment of acute posterior urethral rupture is controversial. Twelve patients who presented with acute posterior urethral rupture over a five-year period were treated by delayed primary realignment of the injury. The technique of this procedure and the outcome are the subject of this presentation. Eight patients had successful realignment without strictures. Two patients with strictures responded to simple dilatations with bougies and the other two had formal urethroplasty.

Fournier's gangrene in Ibadan.

Twenty six patients with Fourniers gangrene seen over an 8 year period at the University College Hospital Ibadan are presented. Their ages ranged from 34 years to 70 years with a mean of 52.5 years. Possible predisposing conditions were present in 17 (65%) patients. The anterior scrotal skin alone was most commonly involved. They were treated with systemic antibiotics, wound debridement and sitz baths. While the wound healed spontaneously on this regimen in 6 (23%) patients, 19 (73%) patients required suture closure of their clean granulating wounds. None required rotational skin flap scrotoplasty and no deaths occured. It is stressed that because of the independent arterial supply and venous drainage of the testes, even when the entire scrotum has sloughed, orchidectomy should never be considered a management option.

Crush injuries of the hand.

A retrospective review of 58 patients presenting with crush injuries of the hand within the 6 year period April 1984 to March 1990 was undertaken. The male-female ratio was 3:1, with a mean age of 25.13 +/- 15.1 years. The peak incidence was in the 3rd decade of life. Machines (55.17%) were the commonest cause with the pepper grinder featuring most prominently. The dorsum (60.3%), little (55.1%) and ring (53.5%) fingers of the right hand were the most commonly involved. Most of the injuries were multiple. Management was mainly conservative and entailed initial limited debridement, thorough washing with soap and water under adequate anaesthesia, bulky boxing glove dressing, elevation, antibiotics and early hand physiotherapy with late reconstruction. Results were excellent in 13 (22.41%), good in 19 (32.76%) poor in 23 (39.66%) and unknown in 3 (5.17%) who were lost to follow-up. Our poor result is perhaps the warning signal that we should abandon our extreme conservative stance and be more aggressive in our attitude to these injuries.

Experience with 5-fluoro-uracil and levamisole in the management of advanced rectal carcinoma.

Eleven cases of bulky rectal carcinoma occupying the whole of the pelvis are presented. We refer to this advanced rectal carcinoma as "frozen" pelvis. Management of these cases includes performing a divided stoma colostomy, intravenous administration of 5-fluoro-uracil, intraperitoneal instillation of 5-fluoro-uracil when ascites is present, intra-rectal perfusion with 5-fluoro-uracil, administration of levamisole, and radiotherapy. We think this regimen improves, to some extent, the quality of life and probably prolongs survival period, although disturbing tenesmus does not disappear completely. This will buttress the argument that abdomino-perineal resection is justified when possible, even if only as a palliative measure to prevent disturbing tenesmus.

Surgery of toxic goitre in non-euthyroid patients: a preliminary report.

In recent years, the cost of medical care has skyrocketed and since medical treatment is not free, some drugs are now beyond the reach of some patients. One of such drugs is the antithyroid drug, carbimazole, which has been priced beyond the reach of our thyrotoxic patients. We have therefore been forced to operate on these patients whenever they present, even while thyrotoxic. The principle of our management is to anticipate the development of thyroid crises and to prevent its occurrence post-operatively by using saturated solution of potassium iodide (SSKI) or Lugol's iodine, propranolol, diazepam, and hydrocortisone. This is a preliminary report of the first twelve consecutive patients so treated.

Caudal block anesthesia for transrectal prostate biopsy.

OBJECTIVE: Transrectal prostate biopsy is a potentially painful procedure. Our service has significant experience with caudal anesthesia for perianal procedures. This study is aimed to determine the effectiveness of caudal anesthesia for transrectal prostate biopsy. PATIENTS AND METHODS: Seventy consecutive patients undergoing transrectal prostate biopsy were entered into the study. The patients were requested to complete a questionnaire structured to assess the pain felt during the procedure using the visual analog score (VAS). The effectiveness of the caudal anesthesia was determined by the anesthesia of the perineum and the laxity of the anal sphincter. Complications from the procedures were recorded. RESULTS: All the patients completed and returned the questionnaire. The average age of the respondents is 65.8 years. Among the 34 patients with caudal block, effective anesthesia was achieved in 28 patients and ineffective in six patients. However, the mean VAS for the pain from transrectal prostate biopsy was 1.49 +/- 1.93 SD (range 0-6.0) for the patients with effective caudal anesthesia and 8.02 +/- 1.79 SD (range 5.0-10.0) for patients with no caudal anesthesia. There was a reduced requirement for analgesics after prostate biopsy for patients with effective caudal anesthesia. Three patients (8.8%) had minor complications (transient dizziness) following the injection of the anesthetic into the caudal epidural space. CONCLUSION: Satisfactory analgesia for transrectal prostate biopsy can be achieved with the use of CA and it results in better cooperation of the patient during the procedure.

Female urethral and bladder neck injury after rape: an appraisal of the surgical management.

The aim of this study was to discuss the surgical management of urethral and bladder neck injury after urethral coitus during rape. A 21-year-old lady presented with total urinary incontinence of 1-year duration after being raped. On examination, she had urethral laceration and a patulous urethra and bladder neck suggesting urethral coitus during the rape. Her introitus and vagina were however normal. She had repair of her urethral laceration and plication of her urethra and bladder neck via a vaginal approach. She regained her continence and voids without any residual urine. Urethral coitus is rare. Urethral coitus in the presence of a normal introitus and vagina is very rare. The urethral and bladder neck injury resulting from this can be satisfactorily corrected by urethral and bladder neck plication via a vaginal approach with the vaginal incisions positioned to forestall suture line apposition, which may lead to wound failure.

The retained urinary catheter.

Retention of urinary catheters is an increasing complication in our practice. We have reported 18 patients seen over a 6-month period during which 528 catheterizations were done, representing an incidence of 3.4%. Various forms of management were offered and blind percutaneous suprapubic puncture (BPSP) was found to be simple and effective. One out of 13 patients, however, undergoing BPSP developed transient haematuria. The high incidence of malfunctioning catheter balloon mechanisms may be due to poor quality equipment or lack of appropriate storage facilities.