A Fifteen Year Experience of Total Thyroidectomy for the Management of Simple Multinodular Goitres in a Low Medium Income Country.

INTRODUCTION: Total thyroidectomy as a treatment for simple multinodular goitre is not well recognised in most centres in low middle income countries. METHOD: This paper is a retrospective review of outcomes of total thyroidectomy for simple multinodular goitres in the last fifteen years in a tertiary hospital in Nigeria. RESULTS: A total of 652 thyroidectomies were done from January 2001 to December 2015. Simple multinodular goitres were indication for a total thyroidectomy in 447 patients (68.6%) with a male to female ratio of 1:6. Postoperative complications were hypocalcaemia in 22 (4.9%), unilateral recurrent laryngeal nerve palsy in 13 (2.8%) and haemorrhage in 2 patients. Others were seroma and cellulitis. Tracheostomy was required in 35 (5.8%) patients but none was permanent. CONCLUSION: Total thyroidectomy is a relatively safe treatment option for patients who have simple multinodular goitre. It provides a permanent cure with a low postoperative morbidity risk. The burden of replacement l-thyroxine needs to be discussed with the patients.

Diagnostic accuracy of tru-cut biopsy of breast lumps at University College Hospital, Ibadan.

BACKGROUND: Tru-cut needle biopsies form an integral part of Triple assessment of breast cancer and include clinical assessment, mammography and core needle biopsy. No study has been done to evaluate the validity of the procedure in our environment. This study was done to evaluate the validity of core needle biopsies in our centre. METHOD: A retrospective study of patients with tru-cut needle biopsies of breast lumps and follow-up excisional biopsy or mastectomy done in the Department of Surgery, University College Hospital, Ibadan over a ten year period was done. Fifty one patients who fulfilled the inclusion criteria had their records obtained from the Department of Pathology. The diagnosis was classified into benign and malignant with the excisional biopsy or mastectomy diagnosis used as the gold standard. The sensitivity, specificity and accuracy were calculated and kappa was also done to evaluate the degree of agreement. RESULTS: A total of 51 cases were included in this study. The average age of the patients was 47 ± 13 years with a range from 19 to 81 years. Thirty of the biopsies (59%) had a definitive diagnosis of malignancy while twenty one (41%) were benign. The overall sensitivity, specificity and accuracy were 86%, 71% and 80.4% respectively. The specificity of malignant biopsies was 68% while benign was 35%. The level of agreement for malignant biopsies was higher than benign biopsies with a kappa of 0.39 for malignant diagnosis as against 0.29 for benign. CONCLUSION: Tru-cut needle biopsies have a comparable sensitivity and specificity to excisional biopsies. Diagnostic accuracy can be further enhanced with the adoption of image guided biopsies.

Mirizzi syndrome: report of a case and the challenge of management in our environment.

BACKGROUND: Mirizzi Syndrome is a rare complication of cholelithiasis reported to occur in 1% of all patients with gall stones and an incidence of 0.7-1.4% in all cholecystectomies. It is characterized by an impaction of a large calculus in the Hartman's pouch of the gall bladder (GB) or in the cystic duct, causing an extrinsic obstruction of the common hepatic duct. This can, with time, result in varying degrees of fistula formation between the duct and the GB. Types I, IIa, b and c have been described depending on the circumference of the duct involved in the cholecysto-choledochal fistula. This syndrome presents clinically as surgical jaundice. The preoperative diagnosis is difficult as well as the surgical management of the type II subtypes. The aim of this paper is to draw attention to this clinicopathological entity as it occurs with the same frequency in our environment as in the environment with high incidence of cholelithiasis. METHOD: We report a case in our practice (Mirizzi Type IIa) and discuss the difficulties encountered in pre-operative diagnosis and subsequent management. The literature is also reviewed RESULTS: The diagnosis of Type IIa Syndrome was made on the operating table. The on-table cholangiogram was inconclusive. A choledochoplasty was performed over a T-tube and this was removed after 12 weeks. Patient has done well thereafter. CONCLUSION: The local surgeon is advised to have a high index of suspicion about this condition so as not to be caught unawares.

A RANDOMISED CONTROLLED TRIAL ON CLINICAL EFFICACY OF SODIUM PERBORATE MIXED WITH DISTILLED WATER AND 30% HYDROGEN PEROXIDE IN THE LIGHTENING OF NON-VITAL DISCOLOURED ANTERIOR TEETH.

Objective: To compare the effectiveness of sodium perborate mixed with distilled water and sodium perborate mixed with 30% hydrogen peroxide as non-vital bleaching agent of anterior discolored teeth. Materials and methods: A randomized controlled trial was undertaken among 61 patients who presented with 70 discolored anterior teeth at the Conservative and Family Dentistry Clinics of the University College Hospital, Ibadan, Nigeria. The 70 teeth were randomly allocated into two groups of treatments. In Group A, the test group, the coronal part of endodontically treated teeth was further treated with sodium perborate mixed with distilled water while group B, the control group, the coronal part of endodontically treated teeth were also further treated with sodium perborate mixed with 30% hydrogen peroxide. Information on study participants biodata and satisfaction with treatment were obtained. Tooth shade assessment was done using shade guide units of the vitapan shade guide at baseline and during recall visits on days 7, 14, and 21. Frequencies, means, and standard deviations were generated. The Chi-squared test was used to determine the association between two categorical variables at p < 0.05. Results: In the control group, the mean ± SD tooth shade was 12.5 ± 3.2, 8.7 ± 3.8, 4.9 ± 2.8, and 3.1 ± 2.2 at baseline, Day 7, Day 14, and Day 21, respectively. In the test group, the corresponding values were 12.8 ± 3.2, 9.6 ± 3.9, 5.6 ± 3.0, and 4.0 ± 2.9. The mean ± SD tooth shade scores of the control and test groups were 12.5 ± 3.2 and 12.8 ± 3.2, respectively (p = 0.15). Twenty-two (62.9%) and 19 (54.3%) of the study participants in the control and test groups, respectively, reported that they were extremely satisfied (p = 0.60). Conclusion: The effectiveness of sodium perborate mixed with distilled water and sodium perborate mixed with 30% hydrogen peroxide in lightening the coronal part of endodontically treated non-vital discolored anterior teeth was similar. Both bleaching agents demonstrated similar patient satisfaction.

Stitch abscess masquerading as recurrent thyroid cancer.

Recurrent thyroid cancer after remnant ablation is a known entity in follow up of differentiated thyroid cancer. It is however unusual for a stitch abscess to present as a recurrent thyroid cancer. We highlight the diagnostic dilemma of a stitch abscess masquerading as a recurrent thyroid cancer in a young female adult in the setting of financial constraint.

Correlation of cag-A serological status with histological parameters of chronic gastritis among dyspeptic patients in south western Nigeria.

BACKGROUND: The aim of this study was to determine the sero-prevalence of Cag-A strains of Helicobacter pylori in both dyspeptic and non-dyspeptic individuals and also correlate the serological status of Gag-A strain of H. pylori with the various graded histological variables of chronic gastritis in the dyspeptic patients. METHODS: Using helicobacter p120 Cag-A enzyme linked immunosorbent assay, Cag-A serology test was carried out on 65 dyspeptic patients and 65 age and sex matched non-dyspeptic controls. The gastric biopsies of the patients were also histologically examined to ascertain the presence, nature and degree of the following histological variables of gastritis: colonisation by H. pylori; inflammation, intestinal metaplasia and mucosal atrophy. The CagA serological status was then correlated with the graded variables. RESULTS: A prevalence of 46.2% and 58.8% seropositivity for Cag-A strain of H. pylori was found among dyspeptic patients and control individuals respectively. Cag-A seropositive patients accounted for nine(81.8%) of the 11 cases with moderate to severe activity and 75% of both cases with mucosal atrophy and cases with intestinal metaplasia. CONCLUSION: Infection with Cag-A positive Helicobacter pylori was equally prevalent among both dyspeptic patients and control subjects studied. CagA seropositivity, however, appeared to be associated with higher inflammatory activity in the mucosa of patients with chronic gastritis and may be associated with intestinal metaplasia and mucosal atrophy in H. pylori-induced chronic gastritis.

The impact of non-closure of the platysma muscle layer on the cosmesis of thyroidectomy scar - a randomised double-blind controlled trial.

BACKGROUND: The relevance of closing the platysma muscle layer after open thyroidectomy has received little interest in terms of research. The objective was to determine whether non-closure of the platysma muscle layer after open thyroidectomy impacts significantly on the cosmetic outcome of the resulting collar scar. METHODS: In this prospective randomised controlled clinical trial, patients were assigned randomly to have the platysma muscle layer closed or not closed. The primary endpoint was the cosmesis of the collar scar six weeks after surgery assessed using the patient and observer scar assessment scale (POSAS). Additional endpoints included operation time and early postoperative wound complications. RESULTS: Ninety-two patients were recruited, with 46 randomised to each group. The patient scar assessment subscale(PSAS) of the POSAS showed no significant difference in the scar cosmesis between the two groups six weeks after surgery (median PSAS: 16.5 vs 17.5; p = 0.514). The observer scar assessment subscale (OSAS) showed that the platysma muscle layer closure group had marginally better scars (median OSAS: 15 vs 17; p = 0.045). The size of the goitre did not make any significant difference in the scar cosmesis. There was no significant difference in the incidence of early postoperative wound complications as well as the median operation time. CONCLUSION: Not closing the platysma muscle layer had no significant impact on the scar cosmesis six weeks after open thyroidectomy, with no significant difference in the incidence of early postoperative wound complications and the operation time.

Self-medication profile of dental patients in Ondo State, Nigeria.

BACKGROUND: The practice of self medication has been extensively researched but there is dearth of information about its modality among dental patients in developing countries. Hence, this study was designed to determine the proportion of dental patients who practice, medications employed and the reasons for resorting to self medication in general dental populations in Ondo State, Nigeria and to make appropriate recommendations. METHODS: This study was conducted between June 2007 and June 2008 at the Federal Medical Centre, Owo and State Specialist Hospital, Akure, Ondo State, Nigeria. Five hundred and thirty six consenting respondents were selected by multistage sampling technique and interviewed with the aid of semi structured questionnaire. RESULTS: Almost half of the respondents (42% or n=225) admitted to self medication while the majority (58%) did not practice it. Drugs utilized are usually singly (56.4%) rather than in combination (43.6%), commonly analgesics (50.1%) and antibiotics (30.4%), with the majority (45.8%) using the medications for at least one week. The reasons cited by respondents for self medication were their perception that they know what to do and it saves time and money. CONCLUSION: A sizable majority of the respondents admitted to self-medication usually with analgesics. Adequate health education of the populace on the use and misuse of analgesics needs to be mounted, while dental services should be made readily available and affordable so that self medication among dental patients can be reduced to the barest minimum.

Intussusception and volvulus secondary to jejunal adenocarcinoma in an adult Nigerian male: a case report.

A 31 year-old Nigerian man with jejuno-jejunal intussusception with the lead point being an adenocarcinoma complicated by small intestinal volvulus is presented. The subtle clinical features of an underlying small bowel malignancy were masked by the overwhelming clinical and radiological features of intussusception. rare case is reported to remind clinicians to have an increased index of suspicion of malignancy in patients who present with the usual features of chronic anemia, weight loss and loss of appetite with an intra-abdominal mass. The presentation of acute intestinal obstruction, with mesenteric vein thrombosis probably due to intussusception or volvulus should not however lower the suspicion. Histological evaluation of surgical biopsies is of immense importance.

Review of fine needle aspiration cytology in the management of goitres in Ibadan, Nigeria.

OBJECTIVE: The use of Fine Needle Aspiration Cytology (FNAC) in the investigation of goitres was introduced into our practice more than a decade ago. This is a review of its diagnostic accuracy for thyroid carcinoma seven years after the first evaluation and following the establishment of the 'FNAC Clinic'. METHOD: This is a retrospective study of patients who had FNAC of goitres and the histopathology of their thyroidectomy specimens between 1995 and 2004. The accuracy of the cytology reports were evaluated against the histology reports. The turnaround time of the patients for surgery was also determined. RESULTS: There were 130 females and 21 males with an age range of 7-86 years. The diagnostic accuracy of the procedure for carcinoma was 89% with a sensitivity of 35%, specificity of 97%, positive predictive value of 64%, and a negative predictive value of 91%. The average turnaround time for surgery was 178.7 +/- 248.7 days with a range of five days to three and a half years. CONCLUSION: The diagnostic accuracy of FNAC of goitre for carcinoma improved in the period under review. However, the long surgery turnaround time may reduce the usefulness of the procedure. The accuracy may be improved further by a protocol of ultrasound guidance, capillary collection with no-aspiration technique, on-site review of slides with a repeat of FNA as necessary.

Nonsteroidal gastropathy in dentistry--issues and controversies in patient's management.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) provide excellent analgesia for mild to moderate pain and are therefore commonly prescribed in dental practice. However, they are not without side effects, most notably upper gastrointestinal toxicity. This article reviews the issues and controversies in managing dental patients especially those who present with acute pain in the light of introduction of preventive strategies to reduce such gastrointestinal complications. METHODOLOGY: This review is primarily based on articles selected from Medline between 1997-2006 concerning upper gastrointestinal toxicity following NSAID use and introduction of preventive strategies to reduce them with particular reference to dental practice and developing countries. RESULTS: Selective COX-2 inhibitors (coxibs) cause fewer gastrointestinal events than do non selective NSAIDs. However, they should be used with caution in the light of recent evidence linking them with adverse cardiovascular events. CONCLUSION: Dental Practitioners need to be aware of notable side effects and the role of preventive strategies when prescribing NSAIDs.

SELF-MEDICATION PROFILE OF DENTAL PATIENTS ATTENDING A NORTH EASTERN TERTIARY HOSPITAL IN NIGERIA.

BACKGROUND: Self-medication is widely practiced worldwide. Literatures abound on its use for medical ailments but there is paucity of information for dental complaints especially in Northeastern Nigeria. Hence, this study was designed to determine the prevalence of self-medication for dental problems before dental consultation and its associated factors among patients attending Federal Teaching Hospital (FTH), Dental and Maxillofacial Outpatient Clinic, Gombe, Gombe State, Nigeria. MATERIALS AND METHODS: A descriptive cross-sectional study based on a structured pretested close-ended interviewer-administered questionnaire was distributed among adults visiting FTH outpatient dental clinic, Gombe, Nigeria for a period of 8 months. The questionnaire was composed of two main sections: demographic characteristics and questions assessing the behaviour of self-medication. The non-probability convenient sampling technique was used and data was stored and analysed using IBM-Statistical Package for Social Sciences (SPSS) version 23.0. RESULTS: The results showed that the prevalence of self-medication was found to be 41.5% (194/468), with a higher prevalence among females (55.1% or 107/194) than males (44.9% or 87/194). The majority (52% or101/194) of the patients were in the 2-4th decades of life. Educational status was significantly associated with self-medication. Analgesics accounted for the greatest percentage (98/164 or 59.8%) of orthodox drugs used followed by antibiotics (62/164 or 37.8%). However, with respect to individual medication consumed, paracetamol accounted for the majority (28.7%). A greater number (55/194 or 28.4%) could not remember the name of the orthodox drugs they took before consultations. Street hawkers were the main source of these medicaments (36.6 or 71/194%). Fear of dental treatment (20.1% 39/194), ailment is simple and the need not to see a dentist (20.1% 39/194) were claimed to be the main reason for practicing self-medication with periodontitis (53.1% or 103/194), pulpitis (13.9% or 27/194) and pericoronitis (10.8% or 21/194) the main predictors. CONCLUSION: The prevalence of self-medications to dental problems in this study was discovered to be high with the use of both orthodox and unidentified traditional drugs. National Health Insurance Scheme should be made to cover all social group of Nigerians in order to encourage easy accessibilities of all people to wide range of medical and dental consultations, thereby discouraging the practice of self-medication.

Factors influencing the pattern of self-medication in an adult Nigerian population.

BACKGROUND: Despite the growing research interest in self-medication, little information has been available about its major determinants especially in developing countries. This informed the conduct of this study to determine the major factors that influence the pattern of self medication in a population of market women in Ifako-Ijaiye area of Lagos, Nigeria. METHODS: Interviewer administered pretested semistructured questionnaire was used to collect data from 205 market women selected by multistage sampling technique. RESULTS: The patent medicine dealers were the commonest source of information on medications (31.4%) and where they were obtained (52.2%). The exceptions were the educated (62.5%) respondents who obtained theirs from hospitals and pharmacies. Trade and generic names (61.1%) were common means of drug recognition especially among the educated respondents (P<.05). Education of the respondents was the major factor influencing the practice of self-medication though the pattern was descriptively associated with the marital status and educational level of the respondents (P<.05). Benefits of the practice includes in the order: curing of ailments (58.0%), saving time and money (32.0%) and independence of care (7.0%). CONCLUSION: Literacy and public health education were the major factors influencing the pattern of self-medication among market women. Recommendations on the role of education of market women, patent medicine dealers and the importance of community pharmacy were suggested.

Bilateral transverse facial cleft as an isolated deformity: case report.

Transverse facial clefts are rare deformities, these mostly occur as part of syndromes such as facial dysostosis and branchial arch syndrome. This is a report of a case of isolated, asyndromic bilateral facial cleft seen at a semi-urban specialist hospital. Congenital facial defects remain sources of mental and social stress to the families. Infanticide, perhaps a thing of the past in the developed world may still be practiced in cases of congenital deformities in the developing countries, hence the need for early involvement of social workers and clinical psychologist in management.

HIV/AIDS and the surgeon.

Human Immunodeficiency Virus and Acquired Immunodeficiency Disease (HIV/AIDS) are one of the most difficult challenges facing practicing surgeons worldwide. The challenge is more acute in sub-Saharan Africa as it currently has the highest prevalence of HIV infection in the world. Surgeons are at risk of occupationally acquired infection as a result of intimate contact with the blood and other body fluids of HIV patients requiring surgery. Patients also risk being infected by surgeons and other health care workers during surgical or dental procedures. The seropositive status of the majority of HIV positive patients may be unsuspected by the attending medical personnel who may not practice universal precautions against infection. The non-availability of relevant devices is however the most important factor militating against the use of universal precautions, especially in developing countries. There is therefore a need to increase the awareness about universal precautions and to provide the necessary devices to promote constant adherence to these procedures in order to reduce the risk of nosocomial HIV infection.

EXPERIENCE WITH MANAGING RETROSTERNAL GOITRES IN IBADAN, NIGERIA.

BACKGROUND: There is no general consensus on the definition of retrosternal goitre (RSG) however thyroidectomy remains the gold standard of treatment with or without a sternotomy. AIM: To review the outcome of surgical management of retrosternal goitres. METHODOLOGY: Retrospective review of records of patients who had thyroidectomy for RSG over a 15-year period. RESULTS: Out of a total of 45 patients, 34(76%) were females and 11(24%) were males with a male/female ratio of 3:1; while their age ranged between 28 and 72years with a mean of 57+15SD. All the patients were euthyroid and a quarter did not have symptoms apart from a neck mass. In all, 15% of the patients had recurrent goitre. CT scan of neck and chest was done in 31 (72%) patients; while 44 (98%) patients had cervical retrosternal goitres, 1(2%) patient had ectopic retrosternal goitre. A cervical incision was sufficient in 28 (62%) patients while 17 (38%) patients required additional sternotomy. Total thyroidectomy was done in all the patients. There were post-operative complications in 19 (42%) patients. Histopathology showed that 3(6.6%) patients had papillary thyroid carcinoma while 42(93.4%) had benign pathology findings. CONCLUSION: Surgical removal is the treatment of choice. Most retrosternal goitres can be resected through a collar stud incision; however the possibility of a need for a sternotomy should always be planned. The simultaneous occurrence of cervical and ectopic retrosternal goitre should always be ruled out with a CT scan.

Bile duct stricture -- a sign of things to come?

OBJECTIVE: The aim of the report is to highlight this difficult to-treat condition hitherto uncommon in our environment and warn of the likelihood of more to come with the rising incidence of gallstone in our sub region. PATIENT AND METHOD: A case report of an 18-year-old male undergraduate patient. RESULT: A successful management with clinical, biochemical and radiological evidence (OTC and tubograms) despite inadequate investigative tool. PRINCIPAL CONCLUSION: With the rising incidence of gall stones in our environment, it is imperative that the Trainee Surgeon must be schooled in common biliary surgery and help prevent this dreaded complication (bile duct stricture) and other sequelae of gall bladder surgery. A plea is also made for the provision of essential investigative tool to facilitate management of such cases in recognised centers.

Familial thyrotoxicocis in five Nigerians.

We describe the occurrence of thyrotoxicosis in four Nigerian families. Hitherto. the descriptions of familial thyrotoxicosis have been confined to the Caucasian population and only recently in a Chinese family. This is the first description of familial thyrotoxicosis in the Nigerian population. The mutation analysis of the genomic DNA of the TSH receptor of these patients is required to define the genetic mutations that caused the disease. We recommend that a high index of suspicion for familial thyrotoxicosis should be exercised in the clinical evaluation of patients who present with hyperthyroidism.

Recurrent leg ulcers in a 16-year old Nigerian girl.

This is a report of a 16-year old Nigerian girl who presented with recurrent leg ulcers associated with gastrointestinal symptoms. The management of this patient, who has ulcerative colitis manifesting with pyoderma gangrenosum, underlines the need for thorough evaluation of cutaneous ulcers in the tropics. The medical treatment of ulcerative colitis in childhood, with reservation of bowel resection for complications is preferred.

Factors influencing the choice of surgery as a career by pre-registration interns.

BACKGROUND: The dwindling interest in surgery and surgical specialties raises the fears that the surgical man-power requirements of the society may not be met adequately in coming years. There is a need to explore ways of stimulating interest in surgery in order to forestall this. OBJECTIVE: To identify factors that influence or predict the choice of surgery as a career by interns. METHODS: A descriptive cross-sectional study of 271 interns was conducted using structured self administered questionnaires. The data obtained included demographic details, details of internship rotations, choice of specialty, reasons for nonconsideration of surgery and if the interns had role models, staff advisers and first degree relatives who were surgeons. Data were analysed using descriptive and inferential statistics (SPSS software) with the level of significance at p < 0.05. RESULTS: There were 163 (60.1%) males and 108 (39.9%) females with a mean age of 25.8 years. The majority (97%) wished to commence residency training soon after internship; surgery (37.6%), and internal medicine (22.4%) were the most popular choices. Reasons for non-consideration of surgery included: stressful (46.1%), future family plans (41.3%) and difficult training (18.1%). Males were more likely to choose surgery than females (52.1% vs. 13.0%, p < 0.001). Married interns were less likely to choose surgery compared to their single colleagues (0% vs. 37.5%, p = 0.042). Having surgeons as role models, staff advisers or first degree relatives were significantly associated with selecting a career in surgery. CONCLUSION: Gender, marital status, having surgeons as role models, staff advisers or first degree relatives in medical school are significant factors influencing the choice of a career in surgery.