Mortality Trends among Older Patients Admitted to the Geriatric Centre, University College Hospital, Ibadan, Nigeria, 2013-2017.

BACKGROUND: Attaining successful clinical outcomes in the management of hospitalised older patients in the overburdened healthcare services in Nigeria constitutes a major challenge against the backdrop of dearth of data on the predictors of mortality among them. OBJECTIVES: To describe the mortality trends and associated factors among older patients (>60 years) at the Geriatric Centre, University College Hospital, Ibadan between January 2013 and December 2017. METHODS: Hospital records of older patients admitted were analysed. Data extracted included socio-demographic, diagnoses, length of stay from date of admission to discharge or death. Results of vital signs, anthropometric measurements and laboratory tests carried out at admission were also obtained. RESULTS: The mean age of the 1,091 older patients admitted was 73.6±8.6 years. The overall crude proportion of in-hospital deaths was 9.0% (males=11.3% > females=7.2%, p=0.024) and it increased from 4.1% in 2013 to 12.1% in 2017. The overall unadjusted 30-day mortality rate per 1000 patient-days was 28.9 deaths (95% CI 23.5-35.3). The predictors of mortality were increased length of stay on admission OR=1.061 (95% CI 1.005-1.119), being retired OR=1.672 (95% CI 1.011-2.778), stroke OR=4.019 (95% CI 2.258- 7.138), heart failure OR=3.435 (95% CI 1.455-8.100), Sepsis OR=2.176 (95% CI 1.294-3.654), Anaemia OR=2.820 (95% CI 1.320-6.017), Dementia OR=3.701 (95% CI 1.433-9.549) and malignancies OR=2.658 (95% CI 1.181-5.979). CONCLUSION: There was a temporal increase in mortality among older patients. Similarly, staying longer on admission and chronic medical conditions with their complications were the most significant contributors to mortality.

A descriptive study of the morbidity pattern of older persons presenting at a Geriatric Centre in Southwestern Nigeria.

CONTEXT: Rapid population ageing is a demographic reality in most countries of the world. Old age is associated with changes which may culminate in health problems, necessitating provision of appropriate preventive, curative, and rehabilitative services. However, reports from many low- and middle-income countries have shown lack of preparedness to cater for the healthcare needs of older persons. AIM: This study described the morbidity profile and its determinants among persons aged 60 years and above who presented at an established geriatric centre in southwestern Nigeria. MATERIALS AND METHODS: Data were obtained from electronic health records of 4886 patients aged ≥60 years who visited the facility between 1st January 2013 and 31st December 2014. Data were analyzed using Stata version 13 (Texas, USA). Frequency distributions were used for descriptive analysis, and chi-square test was used to test associations. RESULTS: More than a half, 2919 (59.7%), of the respondents were females and almost three quarters 3501 (71.7%) were aged between 60 and 74 years. Mean number of morbidities was 1.81 ± 0.9, and less than half, 1097 (42.0%), presented with only one morbidity, most commonly, hypertension. There were significant age-related differences for musculoskeletal (P = 0.001), endocrine (P = 0.01), and psychological problems (P = 0.01). In addition, gender differences were observed as a significantly higher proportion of females presented with general symptoms (P = 0.02) and musculoskeletal problems (P = 0.0001) than men. CONCLUSION: The most common presenting morbidities at this geriatric health centre were mostly noncommunicable diseases. Information obtained will be useful in the design of similar facilities in other parts of the country and region at large.

Bone Scintigraphy in Breast Cancer Patients in Ibadan, Nigeria.

BACKGROUND: The bone is the commonest site of metastases from breast carcinoma. Radionuclide isotope scanning is a sensitive scanning procedure for the demonstration of bone pathology. In May 2006, a gamma camera was introduced into clinical use for skeletal scintigraphy at the University College Hospital, Ibadan, Nigeria. OBJECTIVE: To review the first five years findings of skeletal scintigraphy in our breast cancer patients. METHODS: We retrospectively reviewed the clinical data and scintigraphic bone studies of patients with histology proven breast carcinoma managed in the Surgical Oncology Division, University College Hospital, Ibadan, Nigeria between May 2006 and April 2011. RESULTS: Within the period, a total of 597 breast cancer patients had skeletal scintigraphy (SS). Of the 594 (99.5%) SS reports available for review, scintigraphic evidence of bone metastases was found in 232 (39.1%) patients. Correlation of bone involvement and clinical stage showed that a large majority of the patients had stage IV (83.3%) and III (15.7%) disease. Most patients (71.6%) had multiple bone lesions. The bone lesions were osteoblastic in 88.9% of the patients; only 1.8% had purely osteolytic lesions with the remainder being a mix of both. CONCLUSION: There was scintigraphic evidence of bone metastasis in most of our patients with stage four breast cancer and in some with locally advanced disease. Multiple bone lesions were found in many of them and almost all the lesions were osteoblastic. Moreover, both the truncal and axial skeletal bones were involved in similar proportions.

Plasma homocysteine, B vitamins and bone mineral density in osteoporosis: a possible risk for bone fracture.

BACKGROUND: Changes in plasma total homocysteine (tHcy) folic acid, vitamins B12 and B6 in individuals with osteoporosis are reported to impair collagen cross-linking and contribute to low bone mineral density (BMD). There is paucity of information on these associations in osteoporotic patients at risk of bone fractures in Nigeria. The study evaluated plasma tHcy, folic acid, vitamins B12 and B6, in relation to BMD in individuals with osteoporosis. METHODS: Fifty osteoporotic patients age 57.05 +/- 1.9 years were selected and fifty non osteoporotic volunteer's age 54.8 +/- 0.9 years were included as controls. The osteoporotic group consisted of 11 males and 39 females (1:3.5) while the controls consisted of 13 males and 37 females (1:2.8) respectively. Bone mineral density, anthropometric indices plasma tHcy, folic acid, vitamins B12 and B6, were determined using standard procedures. RESULTS: The results showed remarkably significant increase in plasma tHcy (p < 0.001) (180%) compared with the control value. Striking significant decreases were observed in folic acid (62%), vitamins B12 (42%), B6 (59%) and BMI p < 0.001) compared with control values. Positive correlation was obtained between vitamin B12 and BMD (r = 0.311, p < 0.05). CONCLUSION: Significant increase in tHcy with corresponding decreases in folic acid, vitamins B12 and B6 are related to decrease in BMD in osteoporotic patients. These changes could be important risk factors for bone fracture in osteoporotic Nigerians. Supplementation with the B vitamins may be beneficial to the patients.

Removal of orthopaedic implants from patients at the University College Hospital, Ibadan.

BACKGROUND: Removal of orthopaedic implants is often done after complete healing of fractures. Orthopaedic implants are removed for a variety of reasons such as patients' request after fracture union, implant failure and other complications arising from the use of implants. AIMS AND OBJECTIVES: To determine the indications and complications of removal of orthopaedic implants in our hospital. METHODS: A retrospective study of medical records of all patients who underwent removal of orthopaedic implants used for fracture fixation at a Nigeria teaching hospital during the five year period between 2007 and 2011. Information about age, sex, indications for fracture fixation, indications for removal of implant, types of implants removed, complications of implant removal and its treatment were studied. RESULTS: Thirty patients whose orthopaedic implants had been in place for a mean duration of 12 months before removal were included in the study. 80% of the implants were removed from the femur. Implant failure is the commonest indication for implant removal accounting for 60% of cases. CONCLUSION: Healed fractures and implant failure are the commonest indications for removal of orthopaedic implants in our centre. Implant removal should be advocated when they have failed or become symptomatic. However, appropriate patient selection and adequate surgical technique should be employed to achieve satisfactory outcome.

Socio demographic and clinical correlates of knee pain in adult women attending a primary care clinic.

AIMS AND OBJECTIVES: The objectives of the study were to determine the socio demographic and clinical correlates of knee pain in women in a primary care clinic. PATIENTS AND METHODS: The study was a cross-sectional survey of 400 women attending the General Outpatients' clinic of the University College Hospital (U.C.H.), Ibadan, Nigeria using the systematic random sampling technique. RESULTS: The prevalence of knee pain was 42.0% (95% CI 40.0- 41.0). The radiographic findings in the knees showed mostly osteophytes in 24 out of the 28(85.7%) respondents who had radiographs done. The highest prevalence of knee pain was found in caterers and traders, 62.5% and 51.6%, respectively (p= 0.001). Multivariate analysis done using logistic regression with a backward selection showed that the odds of developing knee pain increases with age (Odds Ratio=1.585, 95% CI 1.321-1.903, p=0.000), and body mass index (Odds Ratio 1.587, 95% CI 1.295-1.946, p=0.000). CONCLUSION: The prevalence of knee pain in women seen at the primary care clinic is high. Preventive measures for knee pain need to be instituted.

Tooth loss: are the patients prepared?

BACKGROUND AND AIM: Tooth loss is associated with esthetic, functional, psychological, and social impacts on the life of individuals. This study was designed to find out how Nigerians feel about losing their teeth and what effects, if any, this has on their lives. Most of the problems presented to the dentist as difficult denture tolerance could be as a result of the emotional effects of tooth loss rather than problems from the denture itself. MATERIALS AND METHODS: The study was carried using a self-administered questionnaire to consenting adult patients undergoing tooth extraction at the Oral and Maxillofacial Clinic, University College Hospital, Ibadan, Nigeria. The data collected were analyzed using SPSS, version 15.5. RESULTS: A total of 90 respondents completed the questionnaires; 35 (27.6%) were males while 55 (43.3%) were females. The respondents were aged 0-70 years. Immediate acceptance of tooth loss was noted in 88 (69.3%) cases, but 6 (47%) accepted the loss only after 1 year, while 8 (6.3%) of the cases found it difficult to accept losing their teeth and incidentally, all of them were 30 years and above. Only 52 (40.9%) of the patients were prepared for the emotional effect of losing their teeth. A feeling of relief immediately following tooth extraction was expressed by 75 (43.9%) cases and of these 32 (47.8%) were females. The emotional effects following teeth loss were sadness 22 (12.9%) cases, depression in 11 (6.4%), feeling of losing body part in 24 (14%), feeling of aging in 4 (2.3%), while 13 (7.6%) respondents felt unconcerned. CONCLUSION: We observed that emotional effects of tooth loss are also experienced among our patients with a range of emotions quite similar to those observed by previous authors from the developed world. The significant number of patients that failed to come to terms with their tooth loss indicates that the effect of tooth loss on self-esteem and self-image is not short lived as it has been assumed.

Intra-tumoral ligation and the injection of sclerosant in the treatment of lingual cavernous haemangioma.

INTRODUCTION: Haemangiomas are developmental vascular abnormalities and more than 50% of these lesions occur in the head and neck region, with the tongue, buccal mucosa, lips and palate most commonly involve. They are considered as harmatomas rather than true neoplasms Factors such as patient's age, size and site of lesion and the proximity of lesion to vital structure are paramount in the determination of the therapeutic approach 7 surgical excision, cryotherapy, injection of feeder vessels with sclerosants and embolization of the blood vessels. CASE REPORT: We report the management of cavernous haemangioma of the tongue in a 38 year old man using intra-tumoral ligation (The Popescu Procedure) and injection of sclerosant under general anaesthesia. RESULT: The efficacy of this method lies in the fact that it obstructs the vascular channels to and from the entire tumour mass leading to progressive atrophy of the vascular endothelia, fibrous hyperplasia and the substitution of the angiomatous tissues by a fibroconnective tissue mass which initially appears excessive but remodels and produces an acceptable appearance which can be further improved by plastic surgery. CONCLUSION: The procedure was well tolerated and the patient made excellent recovery. It is recommended in our centre where facilities for technologically demanding methods are not available.

Management of mandibular chronic osteomyelitis using Belfast technique.

Chronic osteomyelitis is still common in developing countries like Nigeria due to the fact that conditions associated with the lowering of resistance to infections like malnutrition, malaria, anaemia, and acute eruptive fever are still prevalent in our society. Various operative techniques have been described for the treatment of chronic osteomyelitis with various outcomes. A case of chronic osteomyelitis of the mandible managed using the Belfast technique is presented. The Patient was followed up for 2 years with no evidence of recurrence of infection and a repeat radiograph at the end of follow-up revealed new bone formation. The Belfast technique is effective in the treatment of chronic osteomyelitis of the mandible and is recommended in the management of this condition.

Predisposing factors and outcome of treatment of non-union of long-bone fractures in Ibadan, Nigeria.

AIMS AND OBJECTIVES: This study was done to find out factors that contribute to development of Non-union of long bone fractures in this environment and the outcome of operative intervention. This is a prospective hospital based study. PATIENTS AND METHODS: All patients with Non-union of long bone fracture that presented in the hospital since January 1997 were recruited into the study. The data included causative factors, treatment given before presenting in the hospital, type of surgical procedure and result of treatment. The study was completed in December, 2005. RESULTS: 78 patients presented with 87 Non-union of long bones. A male, female ratio of 1.6:1 was encountered while 69.2 per cent of the patients were below the age 55years. Road Traffic Accident accounted for 68 fractures (78.2 per cent) while duration of injury before presentation varies from 6 months to 22 months. Atrophic non-union occurred in 60 cases (69.0 per cent) and hypertrophic non-union in 21 cases. Non-union of the femur occurred in 33 cases (37.9 per cent) humerus in 24 cases (27.6 per cent), tibia in 16 cases (18.4 per cent), radius and ulna in 14 cases (16.1 per cent). The initial treatments of the fresh fracture in the 78 patients with nonunion were by the traditional bonesetters in 51 patients (65.4 per cent) while the remaining fractures were treated by plaster of paris in hospital. Open reduction and internal fixation using plate and screws with bone grafting was the most common procedure for treating the non-union in most cases. Union was achieved in the entire patients following surgical intervention. CONCLUSION: Important factor that appears to contribute to non-union of long bone in this environment is soft tissue interposition between the fracture ends of the bone, which is found in all fractures with more than one diameter displacement. Another factor is interference with periosteal blood supply from disruption of soft tissue envelope as a result of high energy injuries which is also responsible for the displacements that were observed in these fractures. The treatment by traditional bone setters which entails daily massage of the fracture creating a macro movement at the fracture site is also an important contributing factor.

Pattern of the cases seen in the accident and emergency department in a Nigerian Tertiary Hospital over a period of twelve months.

INTRODUCTION: There is a dearth of information on emergency medical services in Nigeria. This study was conducted to determine the age, sex distribution and the pattern of patient presentation in the Accident and Emergency Department of a Nigeria teaching hospital. METHODS: A retrospective study of all cases seen at the accident and emergency department of the University College Hospital in 2003 was carried out. The information extracted from the records includes age, sex, and diagnosis, department to which the patient was referred, the month of presentation and the outcome within the first twenty four hours of presentation. RESULTS: A total of 4674 patients attended the casualty, with a male: female ratio of 1.2:1. The third decade was the peak age distribution. There was a predominance of surgical cases (61%). In the treatment outcome, 52.1% were referred to other departments while there were ten (0.2%) mortalities. Trauma related cases constituted 45.1%. Road traffic accidents were the commonest cause of trauma. CONCLUSION: The largest proportion of patient were in the active third decade of life. Trauma is the commonest cause of presentation in the Accident and Emergency Department. A significant proportion of patients do not require admission. The doctor in the Accident and Emergency Department must be skilled in basic trauma care.

The use of thromboembolic prophylaxis by surgeons: A multicentre Nigerian study.

BACKGROUND: Despite the well known contributions of deep vein thrombosis and pulmonary embolism to perioperative deaths, these major causes of morbidity and mortality appear not to be given adequate attention by surgeons in our environment. OBJECTIVE: To study the practice of thromboembolic prophylaxis among surgeons in some sub-specialties in three Nigerian tertiary institutions. MATERIALS AND METHODS: A structured questionnaire was used to collect information from consultants in the surgical sub-specialties on the use of thromboembolic prophylaxis in their practice. RESULTS: Fifty nine adequately completed questionnaires were returned. Of this, only 28 (47.5%) used prophylaxis routinely in major surgeries. Use was most frequent in orthopaedics and least in ophthalmology and otorhinolaringology. Subcutaneous heparin was the most commonly employed agent and the most important indication for prophylaxis was a previous history of thromboembolism. CONCLUSION: The results obtained suggest low use of prophylaxis. Evidenced-based guidelines are available on antithrombotic and thrombolytic therapy with the benefits outweighing risks, burdens and costs. Therefore greater attention should be paid to antithrombotic measures by all the surgical sub-specialties and patients stratified according to risk.

Pattern of congenital orthopaedic malformations in an African teaching hospital.

BACKGROUND: Congenital Orthopaedic malformations are common malformations that are usually unacceptable to the common populace in the West African sub-region. There is paucity of knowledge about the common types of Orthopaedic congenital malformations in our environment This study was undertaken to determine the pattern of congenital Orthopaedic malformations in a Teaching Hospital. STUDY DESIGN: This was a prospective study of all the Orthopaedic congenital malformations seen in our surgical outpatient departments and the inpatient referrals from the wards between January 1995 and December 2003. RESULT: There were 284 patients in total with a male to female ratio of 2:1 and age range between two days to nine years. Clubfoot (CTEV) accounted for 52.8% of all the malformations while Congenital knee dislocation (CDK) and calcaneovalgus deformity accounted for 8%. Congenital hip dislocation (CDH) accounted for only 2.2% of all the cases. CONCLUSION: Congenital talipes equinovarus deformity is the most common congenital orthopaedic malformation in this environment while congenital hip dislocation (CDH) is rare when compared with the Caucasians.

Double blind clinical trial comparing the safety and efficacy of nimesulide (100mg) and diclofenac in osteoarthrosis of the hip and knee joints.

BACKGROUND: Osteoarthritis of the hip or knees is a very disabling condition in both Caucasians and Africans. A lot of medical drugs have been in use with their corresponding side effects, hence the search for newer drugs with fewer side effects. STUDY DESIGN: A double blind clinical trial comparing the safety and efficacy of nimesulide and diclofenac was carried out in the University College Hospital Ibadan. All patients referred to the outpatients department of the orthopaedic division with osteoarthritis of the hips and knees who met the criteria for inclusion in the study were used for the study. RESULTS: There were a total number of sixty-seven (67) patients. 70.6% of the nimesulide patients had only mild pain in the involved joint on completion of the eight weeks trial compared to 50% of the diclofenac group. A significant proportion of the patients in the diclofenac group (50% vs 17.6%) had break through pain that warranted the use of at least two tablets of 500mg of paracetamol per week in contrast to the nimesulide group. There was a statistically significant difference in the frequency of side effects between the patients in the diclofenac group and the nimesulide group (p<0.05). CONCLUSION: Nimesulide was found to be more effective in relieving pain in osteoarthritis of the hip and knees and with less side effects than diclofenac.

The ultrastructure of the peri-articular osteophytes - an evaluation by scanning electron microscopy.

OBJECTIVE: Osteophytes are intra-articular osteochondral tissues, which are usually found at the margins of degenerating synovial joints. The aetiology or pathogenesis of this tissue has been a subject of protracted debate. The aim of this study was to offer a possible aetiology and or pathogenesis of this expendable yet important osteochondral tissue using the scanning electron microscopy to evaluate the structure of the cartilage mantle of osteophytes and the relationship of this mantle with that of the adjoining normal articular cartilage. METHODS: Sections of periarticular osteophytes and osteophyte-normal articular cartilage composite tissues were obtained during total knee replacement for osteoarthritis (OA). These sections were routinely processed and examined using the scanning electron microscope with emphasis on the osteophytic cartilage mantle and the merger of the osteophyte and the adjoining normal articular cartilage. RESULTS: The cartilage mantle of osteophytes was found to be thinner but continuous with that of the adjoining normal articular cartilage. However, a longitudinal bar of acellular tissue was found to separate the subchondral bones of both tissues. The cellular (chondrocyte) arrangement in the osteophytic cartilage was similar to that of the adjoining normal articular cartilage. In addition, in the superficial layer, there was looping of collagen fibres between the normal articular cartilage mantle and that of the osteophytic tissues. CONCLUSION: The continuity between the cartilage mantle of osteophytes and the adjoining normal articular cartilage may suggest that in the formation of osteophytes, the chondrocytes from the adjoining normal articular cartilage greatly influence the mesenchymal tissue precursor of osteophyte to differentiate along a chondrocytic pathway initially. With subsequent vascular invasion probably from the periosteum, the neocartilage develops a bony core with a completely separate blood supply from that of the adjoining subchondral bone.

Further characterization of storage-related alterations in immunoreactivity of archival tissue sections and its implications for collaborative multicenter immunohistochemical studies.

Storage of unstained paraffin slides may lead to the deterioration of specimens and failure to detect cellular proteins immunohistochemically. Although the implication of age-induced alterations on multicenter immunohistochemical studies would be considerable, they have not been investigated previously. The current study was undertaken to examine the effect of this factor further and to explore new ways of overcoming the resultant shortcomings. The authors now report on the immunodetection of a host of antigens in similarly preserved unstained serial paraffin slides obtained from three centers using a panel of eight antibodies. Staining of recently prepared sections from the authors' centers resulted in similar strong patterns in seven of eight antibodies, with one antibody demonstrating variable immunoreactivity. However, storage of unstained paraffin sections at room temperature resulted in a variable but progressive decrease in expression of several tissue antigens. Although the loss in antigenicity was proportional to the length of storage, the effect was reversible if super antibody concentrations were used. The authors conclude that recently prepared paraffin sections from centers with similar fixation protocols have similar immunoreactivity and are suitable for use in comparative multicenter studies. However, in view of the delays that may attend tissue transportation during these projects, the authors suggest that test systems should be checked for age-induced antigen degradation by incubating sections with higher antibody concentrations.

Report on the 2nd symposium of the International Cartilage Repair Society.

The articular cartilage is a unique tissue and a functional articular cartilage is critical to proper joint function. The inability of the articular cartilage to heal traumatic defects with a similar quality tissue has been appreciated since the time of hippocrates. Although a variety of surgical procedures have been developed over the past 50 years in attempt to overcome this treatment challenge, none has been successful in achieving regeneration of normal articular cartilage. It is these treatment challenges that form the reasoning behind the formation of the International Cartilage Repair Society (ICRS) and her 2nd annual symposium is presented.

Acute calcific tendinitis simulating tendon sheath infection.

Tendon sheath infection has catastrophic consequences if not diagnosed. We present acute calcific tendinitis, a simulator of tendon sheath infection with a good prognosis in a 14 year old athletic tennis player.

Quadriceps tendon rupture in an adolescent.

Quadriceps tendon rupture is said to be rare in patients younger than 40 years of age. We report a case of quadriceps tendon rupture in a 13 year old athletic boy.

Congenital dislocation of the knee in Ibadan, Nigeria.

Between January 1996 and December 2001, 41 congenital dislocations of the knee joints (30 patients) were reduced with closed methods by immediate reduction without anaesthesia and serial casting in plaster of Paris immobilization for a period of six to eight weeks. The patients' age ranged from the age of one week to four weeks with a male to female ratio of 1.5:1. The right knee was involved in 46.65% the left in 16.6% and bilateral involvement in 36.65% of patients. Routine check of the hip did not reveal any patient with hip instability. All the patients followed up after 2 years showed excellent results. We conclude that congenital knee dislocation when discovered early and without any other congenital malformation can be managed conservatively with excellent results.