Use of methylene blue dye for lymphatic basin mapping and sentinel lymph node biopsy in breast cancer patients in Enugu, Nigeria.

Background: Sentinel lymph node biopsy is the current standard of care for axillary staging and further treatment planning in patients with clinical axillary node-negative breast cancer. Sentinel node (SN) biopsy was designed to accurately stage the axilla and minimize the side effects of conventional axillary-lymph-node dissection without sacrificing oncologic outcomes. Sentinel lymph node biopsy is normally performed with nuclear scan and patent blue violet or isosulfan blue. These are expensive and not commonly available in resource-poor regions such as West Africa. Methylene blue dye is a commonly used agent in a wide range of clinical diagnostic procedures and has been used by other investigators to perform this procedure. This study was designed to demonstrate the feasibility and effectiveness of SN biopsy in the management of axillary node-negative breast cancer in resource-limited populations using methylene blue dye. Aim: To determine the efficacy of methylene blue dye as a single tracer in lymphatic basin mapping and sentinel lymph node biopsy in patients with clinical axillary node-negative breast cancer. Methods: This was a prospective, case-controlled study involving 28 consecutively presenting female patients with clinical axillary node-negative breast cancer at the University of Nigeria Teaching Hospital, Enugu. Each of the patients had lymphatic basin mapping and sentinel lymph node biopsy with a sub-areola-subdermal injection of methylene blue dye. The SN (s) were then removed using the dye as the marker. Each patient then had a mastectomy or wide local excision as appropriately planned and conventional levels I and II axillary dissection was performed in the same sitting. The SNs and other axillary nodes were reviewed independently by our institution's pathologist. Each patient's axillary dissection specimen acted as her control for the study. Results: The SNs were identified in 24 (85.7%) patients. There was a demonstrable learning curve with an improvement in identification rate in the later half of the cases (92.9%) compared to the earlier half of the cases (78.6%). A range of 1-3 nodes and a mean of 1.78 nodes were obtained. A sensitivity of 90.9%, specificity of 79.6%, false-positive rate of 28.6%, false-negative rate of 9.1%, and accuracy of 95.8% were obtained. There was no incidence of allergic/hypersensitivity reaction. Conclusion: Sentinel lymph node biopsy with methylene blue dye can be applied with high accuracy within resource-limited environments. However, there is a definite short learning curve that must be overcome and the procedure validated before clinical application in decision-making.

Evaluation of content and cost of traditional eye medication in a resource-poor country - Implications for eye care practice and policy.

BACKGROUND: Cataract, glaucoma, and conjunctivitis are common causes of ocular morbidity in Nigeria. A major obstacle in reducing the burden of ocular morbidity in rural areas is access to eye care services. Up to 80% of the population in developing countries use traditional medications for their primary healthcare needs because they are accessible, available, and affordable. The aim of this study is to evaluate the content and cost of commercialized traditional medications used in the treatment of common eye conditions in Nigeria. PATIENTS AND METHODS: All the registered traditional healers (THs) at an International Trade Fair in Enugu who treated eye problems were identified. Data on their location and scope of their practice were collected by the researchers. Proxy patients consulted THs in the trade fair with simulated cataract, glaucoma, and bacterial conjunctivitis, and treatment was sought. Medication for the treatment of the simulated disorders was paid for and procured. The mode of administration and the cost of the drugs were recorded by proxy patients. Each medication was labeled with a code and sent to the laboratories of the National Agency for Drug Administration and Control for analysis. Data were entered into a database on Microsoft Access and transferred to STATA V12.1 (StataCorp) for analysis. RESULTS: Cataract was treated by 87.5% of all the traditional eye healers interviewed. A total of 32 samples were collected and analyzed. These comprised mainly oral (53.1%) and topical traditional medications (43.8%). The pH of the topical samples ranged from 3.5 to 10, while the mean microbiological load per topical solution was 3.3 × 104 cfu/mL ± 0.96. The cost of treatment of cataract ranged from 4 to 70 USD. CONCLUSION: The content of the majority of the samples of traditional eye medications in this study had high extremes of pH and/or had a high microbial content. The practice of THs should be regulated.

Experiences and desired nursing assistance of women on out-patient breast cancer chemotherapy in Southeastern Nigeria.

OBJECTIVE: This study explored the experiences and nursing support needs of women undergoing out-patient breast cancer chemotherapy in two teaching hospitals in Southeastern Nigeria. METHODS: Using a qualitative descriptive design, based on grounded theory approach and focus group discussion (FGD) methodology, 20 histological confirmed breast cancer patients at different stages of combination chemotherapy (cyclophosphamide, doxorubicin, and fluorouracil ) were purposively selected and engaged in FGDs at two surgical oncology clinics. Data saturation was reached at the fourth FGD. The audio-taped and transcribed data were content analyzed using thematic approach. RESULTS: Participants were all christians of the Igbo-speaking ethnic group, and aged between 36 and 66 years. Most were married and had at least primary education. Five themes emerged from the FGDs: inadequate preparation for chemotherapy; chemotherapy scary, distressful, and financially demanding; hope, faith and courage sustained treatment; self-care actions initiated to 'weather the storm'; and nursing assistance desired to foster hope and enhance patients' acceptance of, adjustment and adherence to breast cancer chemotherapy in Nigeria. Culture influenced their chemotherapy perspectives and coping. CONCLUSION: Women with breast cancer in southeastern Nigeria desired but were inadequately prepared to cope with chemotherapy distress they experienced. Nurses could help patients to accept and navigate through chemotherapy by initiating and supporting effective and efficient self-care actions that are culturally congruent.Copyright © 2015 John Wiley & Sons, Ltd.

Ethics of physiotherapy practice in terminally ill patients in a developing country, Nigeria.

Physiotherapy has been widely defined as a healthcare profession that assesses, diagnoses, treats, and works to prevent disease and disability through physical means. The World Confederation for Physical Therapy describes physiotherapy as providing services to people and populations to develop, maintain, and restore maximum movement and functional ability throughout the lifespan. Physiotherapists working with terminally ill patients face a myriad of ethical issues which have not been substantially discussed in bioethics especially in the African perspective. In the face of resource limitation in developing countries, physiotherapy seems to be a cost-effective means of alleviating pain and distressing symptoms at the end-of-life, ensuring a more dignified passage from life to death, yet referrals to physiotherapy are not timely. Following extensive literature search using appropriate keywords, six core ethical themes related to physiotherapy in terminally ill patients were identified and using the four principles of bioethics (patient's autonomy, beneficence, nonmaleficence, and justice), an ethical analysis of these themes was done to highlight the ethical challenges of physiotherapists working in a typical African setting such as Nigeria.

Comparability, diagnostic validity and completeness of Nigerian cancer registries.

BACKGROUND: Like many countries in Africa, Nigeria is improving the quality and coverage of its cancer surveillance. This work is essential to address this growing category of chronic diseases, but is made difficult by economic, geographic and other challenges. PURPOSE: To evaluate the completeness, comparability and diagnostic validity of Nigeria's cancer registries. METHODS: Completeness was measured using children's age-specific incidence (ASI) and an established metric based on a modified Poisson distribution with regional comparisons. We used a registry questionnaire as well as percentages of death-certificate-only cases, morphologically verified cases, and case registration errors to examine comparability and diagnostic validity. RESULTS: Among the children's results, we found that over half of all cancers were non-Hodgkin lymphoma. There was also evidence of incompleteness. Considering the regional completeness comparisons, we found potential evidence of cancer-specific general incompleteness as well as what appears to be incompleteness due to inability to diagnose specific cancers. We found that registration was generally comparable, with some exceptions. Since autopsies are not common across Nigeria, coding for both them and death-certificate-only cases was also rare. With one exception, registries in our study had high rates of morphological verification of female breast, cervical and prostate cancers. CONCLUSIONS: Nigeria's registration procedures were generally comparable to each other and to international standards, and we found high rates of morphological verification, suggesting high diagnostic validity. There was, however, evidence of incompleteness.

FACTORS DETERMINING THE RESULTS OF THE EXAMINATION OF THE WEST AFRICAN COLLEGE OF SURGEONS IN GENERAL SURGERY.

BACKGROUND: The general surgery results of the West African College of Surgeons (WACS) post-graduate fellowship examination could not be regarded as satisfactory when compared with the results of similar post-graduate examinations in some developed countries. For example the pass rate of the West African College of Surgeons examination was usually under 40% whereas the pass rate in oral examination in a similar post-graduate examination, the American Board of Surgery was 84% in 2006, 73% in 2012. The first time pass rate in general surgery of final year general surgery residents at the American Board of Surgery qualifying and certifying examinations were 74% - 78% between 2000 and 2007. AIM & OBJECTIVES: To identify the factors responsible for the high failure rate at the general surgery fellowship examinations of the West African College of Surgeons. STUDY DESIGN: Descriptive study .We studied and analyzed the West African College of Surgeons examination results for April 2012, October 2012, April 2013 and October 2013 with emphasis on the results, the conduct of the examination and the opinion from fellows about the examiners. Well structured questionnaires were sent to fellows who had passed all the various fellowship examinations of the West African College of Surgeons in general surgery to indicate their opinion about the examination, and the examiners. SETTING: University College Hospital, Ibadan, and Jos University Teaching Hospital, Jos, Nigeria. METHODOLOGY: The first part of the study dealt with an analysis of each section of the examination prospectively studied over a 2-year period. This consisted of four sets of examination results. The second part was a questionnaire-based study administered to Fellows who had passed the WACS final fellowship examination in general surgery. The questionnaire had three sections: primary, part 1 and part 2 and included basic demographics, date at attempts in each grade of the examinations and the outcome. It also included the views of the respondents on the conduct of the examination and outcome. The data were analyzed using Microsoft Excel. RESULTS: A total of 720 candidates with age range of 28 - 39 years and a mean of 33.2 years sat for the Part 1 Fellowship examinations in 2012 and 2013 with an average of 180 candidate per examination. At the Part 2 fellowship examination, 84 candidates with the age range of 31 - 42 year and a mean of 36.5 years sat the Part 2 Fellowship examination with an average of 21 candidates for each Part 2 examination in general surgery during the same period. The examinations held in April and October of each year. While an average of 28.8% of the candidates passed, an average of 71.2% of the candidates failed the Part 1 Fellowship examinations in 2012 and 2013. The aggregate clinical score was responsible for failure in 59.5% of the candidates. In the Part 2 Fellowship examination in general surgery during the same period, 31.5% of the candidates passed while an average of 68.5% of the candidates failed per examination. The aggregate clinical score was responsible for 53.3% of the candidates who failed the Part 2 examination. Furthermore, 60 - 69.7% of the candidates had a favourable opinion about the conduct of the examination, 54.5 - 63.6% rated the professionalism of the examiners high, even though the pass rate at the first attempts of the various grades of the examination by the respondents was about 50 percent. CONCLUSION: The clinical part of the examination is a major factor responsible for the high failure rate in the general surgery fellowship examinations of the West African College of Surgeons. In order to mitigate this, residents in training should be exposed to the clinical management of a wide range of cases in the discipline with majority of the operations performed by them under the direct supervision of their consultants.

Attitudes of cancer patients in a university teaching hospital in southeast Nigeria on disclosure of cancer information.

OBJECTIVE: The attitudes of cancer patients from southeast Nigeria on disclosure of cancer information were studied to ascertain their information needs and what information was disclosed to them by their physicians. METHODS: Structured questionnaires were administered on all consenting cancer patients that were managed at the University of Nigeria Teaching Hospital Enugu between July and October 2011. The data collected were analysed with Statistical Package for Social Sciences version 18. RESULTS: Two hundred and forty-four patients participated in the study. Ninety-five per cent of the participants wanted to know the nature of their diagnosis, but 76.7% admitted to being informed of the diagnosis by their doctors. Nearly 54% of participants will like to be informed of a bad prognosis, but only 1.8% was informed. The word cancer was used to disclose the diagnosis to 69.4% of the patients, but 108 (44.3%) patients did not have any idea what cancer meant, 39.8% knew it as an incurable disease whereas 8.6% described it as a tumour or abnormal growth. Patient factors that significantly improved the disclosure of diagnostic information were education (p = 0.044) and site of the cancer (p = 0.043). CONCLUSIONS: Most of the surveyed cancer patients in University of Nigeria Teaching Hospital Enugu desire to know the truth about the diagnosis of their disease, and more than 50% of them desire to know when the disease becomes terminal and death is imminent. Physicians in southeast Nigeria should consider the information needs of the individual patients and tailor their disclosure practices to meet these individual needs.

Contents and readability of currently used surgical/procedure informed consent forms in Nigerian tertiary health institutions.

BACKGROUND: Surgical informed consent forms should have evidence that their use will enhance a shared decision-making which is the fundamental objective of informed consent in clinical practice. In the absence of any guideline in Nigeria on the content and language of informed consent forms, we sort to examine the surgical and procedure consent forms used by Federal tertiary health institutions in Nigeria, to know whether they fulfill the basic elements of informed consent. MATERIALS AND METHODS: The surgical and procedure informed consent forms of 33 tertiary health institutions in Nigeria were assessed for their readability and contents. Adequacy of their content was evaluated based on provision for 28 content items identified as necessary information to be provided in a good consent form. The potential of the forms to be comprehended were assessed with Flesch readability formula. RESULTS: The contents of majority of the forms were scant. None of the forms made provision for documentation of the patient's permission for blood transfusion, tissue disposal, awareness of the risks of not undergoing the prescribed treatment, and the risk of anesthesia. Risk disclosures were only mentioned in specific terms in 11.4% of the forms. Less than 10% of the forms made provisions for an interpreter, signature of anesthetists, alternative to the procedure to be mentioned, and answering of the patient's questions. The Flesch reading ease scores of the forms ranged from 34.1 (Difficult) to 67.5 (Standard), with a mean score of 55.2 (Fairly difficult level). Field evaluation of the forms show that they shall be partly understood by 13- to 15-year-old patients with basic education but are best understood by literate adult patients. CONCLUSION: The content of majority of the informed consent forms used in Nigerian tertiary health institutions are poor and their readability scores are not better than those used in developed parts of the world. Health Institutions in Nigeria should revise their informed consent forms to improve their contents and do a usability trial on the sample forms before deployment in order to ensure that they are comprehensible for their patient population.

Gastrointestinal stromal tumours at the University of Nigeria Teaching Hospital Enugu, Nigeria: an immunohistochemical study of GIT mesenchymal tumours.

Mesenchymal tumours of the gastrointestinal tract (GIT) are uncommon. Recent progress in the understanding of the biology and origin of these tumours has led to their reclassification. A new subclass designated Gastrointestinal Stromal Tumours (GIST) is diagnosed based on the presence of a mutational over expression of c-kit protein that is thought to be critical in the pathogenesis of these tumours. This new class oftumours may form the majority of gastrointestinal mesenchymal tumours. Even though the diagnosis of GIST is mainly based on positive staining with CD117, a minority of tumours with histological characteristics of GIST are CD117 negative and are classified as CD117 negative GIST. In this first review of mesenchymal GIT tumours from Nigeria, we present 11 cases ofmesenchymal tumours of the gastrointestinal tract seen within a six-year period at our centre. Immunohistochemistry was performed on 7 of them in which histological appearances suggested GIST. Only two cases had all the criteria defined in the consensus conference on the diagnosis of GIST. Our findings, albeit in a very small sample, contrasts with what obtains in developed countries in the proportion of GIT mesenchymal tumours that are truly GIST. This raises a question to be answered on the true nature and proportion of gastrointestinal strumal tumours among GIT tumours in Nigerian patients.

Delays in presentation and treatment of breast cancer in Enugu, Nigeria.

OBJECTIVE: To assess the delays and define the causes of delay in presentation and treatment of breast cancer patients in Enugu, Nigeria. DESIGN: A cross-sectional survey of breast cancer patients using a semi structured questionnaire. SETTING: Surgical Oncology unit, University of Nigeria Teaching Hospital Enugu, (UNTH-E), Nigeria. SUBJECTS: 164 consecutively presenting breast cancer patients seen between June 1999 and May 2005. RESULTS: Most of the patients (82.3%) reported for initial evaluation at a modern health facility while 17.5% reported first to alternative practitioners. Forty six patients (26.4%) presented within a month of noticing the symptoms while 72 (45.3%) delayed more than 3 months. In contrast, 18 (17%) were seen at the site of definitive treatment within one month of seeking help at the initial hospital while 73.4% had a delay of more than 3 months after the initial hospital contact. Institutional or physician induced delays were present in 46.2% of the cases while patient related delays were present in 79.2% of cases. Only use of alternative practitioners for initial treatment was significantly related to delays of more than three months before presentation (p = 0.017). CONCLUSION: For breast cancer prevention programs in Nigeria to succeed, they must in addition to breast awareness and screening programs, address the institutional bottlenecks, the dearth of knowledge among primary care physicians and improve referrals from alternative practitioners and prayer houses.

Challenges in the repair of large abdominal wall hernias in Nigeria: review of available options in resource limited environments.

OBJECTIVE: To evaluate the challenges and outcome of management of large abdominal wall hernias in a resource limited environment and highlight the options available to surgeons in similar conditions. DESIGN: A review of prospectively collected data on large abdominal wall hernias managed between 2003 and 2009. SETTING: University of Nigeria Teaching Hospital, Enugu, Nigeria and surrounding hospitals. SUBJECTS: Patients with hernias more than 4 cm in their largest diameter, patients with closely sited multiple hernias or failed previous repairs and in whom the surgeon considers direct repair inappropriate. OUTCOME MEASURES: Demographics of patients with large hernias, methods of hernia repair, recurrences, early and late complications following the repair. RESULTS: There were 41 patients, comprising 28 females and 13 males with ages 14 - 73 years. Most (53.7%) were incisional hernias. Gynecological surgeries (66.7%) were the most common initiating surgeries. Fifteen of the patients (36.6%) have had failed previous repairs, 41.5% were obese, five patients presented with intestinal obstruction. Thirty nine of the hernias were repaired with prolene mesh, one with composite mesh and one by danning technique. Most of the patients had extra peritoneal mesh placement. Three patients needed ventilator support. After a mean follow up of 18.6 months, there was a single failed repair. Two post op deaths were related to respiratory distress. There were 12 wound infection and 8 superficial wound dehiscence, all of which except one resolved with dressing. One reoperation was done following mesh infection and extrusion. CONCLUSION: Large abdominal wall hernia repair in resource limited environments present several challenges with wound infection and respiratory distress being the most notable. Surgeons who embark on it in these environments must be prepared t o secure the proper tissue replacement materials and have adequate ventilation support.

Gastrointestinal Stromal Tumours at the University of NigeriaTeaching Hospital Enugu; Nigeria: an Immunohistochemical Study of GITMesenchymal Tumours

Mesenchymal tumours of the gastrointestinal tract (GIT) are uncommon. Recent progress in the understanding of the biology and origin of these tumours has led to their reclassification. A new subclass designated Gastrointestinal Stromal Tumours (GIST) is diagnosed based on the presence of a mutational over expression of c-kit protein that is thought to be critical in the pathogenesis of these tumours.This newclass of tumoursmay form the majority of gastrointestinal mesenchymal tumours. Even though the diagnosis of GIST is mainly based on positive staining with CD117; a minority of tumours with histological characteristics of GIST are CD117 negative and are classified asCD117 negativeGIST. In this first reviewof mesenchymalGITtumours fromNigeria;we present 11 cases ofmesenchymal tumours of the gastrointestinal tract seen within a six-year period at our centre. Immunohistochemistry was performed on 7 of themin which histological appearances suggested GIST. Only two cases had all the criteria defined in the consensus conference on the diagnosis ofGIST. Our findings; albeit in a very small sample; contrastswith what obtains in developed countries in the proportion of GIT mesenchymal tumours that are truly GIST. This raises a question to be answered on the true nature and proportion of gastrointestinal strumal tumours among GITtumours inNigerian patients

Delays in Presentation and Treatment of Breast Cancer in Enugu; Nigeria

To assess the delays and define the causes of delay in presentation and treatment of breast cancer patients inEnugu;Nigeria. Across-sectional survey of breast cancer patients using a semi structured questionnaire. SurgicalOncology unit;University ofNigeriaTeachingHospitalEnugu; (UNTH-E);Nigeria. 164 consecutively presenting breast cancer patients seen between June 1999 andMay 2005. Most of the patients (82.3) reported for initial evaluation at a modern health facility while 17.5reported first toAlternative practitioners. Forty six patients (26.4) presented within a month of noticing the symptoms while 72 (45.3) delayed more than 3 months. In contrast; 18 (17) were seen at the site of definitive treatment within one month of seeking help at the initial hospital while 73.4had a delay of more than 3months after the initial hospital contact. Institutional or physician induced delayswere present in 46.2of the caseswhile patient related delayswere present in 79.2of cases.Only use of alternative practitioners for initial treatmentwas significantly related to delays ofmore than threemonths before presentation (p= 0.017). For breast cancer prevention programs in Nigeria to succeed; they must in addition to breast awareness and screening programs; address the institutional bottlenecks; the dearth of knowledge among primary care physicians and improve referrals fromalternative practitioners and prayer houses

Surgical training in resource-limited countries: moving from the body to the bench--experiences from the basic surgical skills workshop in Enugu, Nigeria.

Increasingly, many institutions and surgical groups are resorting to laboratory simulations when teaching surgical skills. The Association of Surgeons of Great Britain and Ireland partnered with the West African College of Surgeons and Johnson and Johnson Corporation to introduce basic surgical skills (BSS) training into West Africa. The local faculty at the University of Nigeria Teaching Hospital, Enugu, was able to use the opportunity of this partnership to establish a regular basic surgical skills training programme. The achievement in Enugu shows that, with a dedicated team of local faculties, giving the local medical trainers a short introduction to the practicalities of organizing and conducting BSS is enough to jump start the programme in resource-poor countries. The Enugu example is a model that should be emulated by centres in other resource-poor countries to make the course a regular feature of their surgical training.

Closed suction drainage versus closed simple drainage in the management of modified radical mastectomy wounds.

OBJECTIVE: To compare the outcomes of modified radical mastectomy wounds managed by closed wound drainage with suction and without suction. METHOD: A prospective randomised trial was conducted at the University College Hospital in Ibadan, and the University of Nigeria Teaching Hospital in Enugu. Fifty women who required modified radical mastectomy for breast cancer were randomised to have closed wound drainage with suction (26 patients) and closed wound drainage without suction (24 patients). RESULTS: There was no significant difference in the intraoperative and postoperative variables. Suction drainage drained less volume of fluid and stayed for a shorter time in the wound, but the differences were not significant. There was no difference in the length of hospital stay, time to stitch removal, and number of dressing changes. More haematomas and wound infections occurred in the simple drain group while more seromas occurred in the suction drain group, but these were not significant. The suction drain was more difficult to manage and the cost was 15 times higher than the simple drainage system. CONCLUSION: Closed simple drains are not inferior to suction drains in mastectomy wounds and, considering the cost saving and simplicity of postoperative care, they are preferable to suction drains.

Bilateral benign phyllodes tumour in a nulliparous woman: a case report and review of literature.

Cystosarcoma Phyllodes is an uncommon disease of the breast with variable clinical behaviour. Its incidence is reported as 1% of all breast tumours. The occurrence of bilateral disease is very rare. In this communication, we present a case of metachronous bilateral benign cystosarcoma phyllodes presenting in a 24year old nulliparous lady. She had right breast mastectomy after two recurrences following local excision. The left breast lesion developed one year after the treatment of the right lesion, again she had to be treated with mastectomy after 2 recurrences. This case unlike most reported cases of bilateral Phyllodes tumour occurred in a nulliparous lady. The problems of diagnosis, clinical behaviour and management are discussed.

Osteogenic sarcoma in the breast--case report of a diagnostic dilemma.

Breast cancer is the leading cancer in females worldwide, the vast majority being carcinomas, and only 0.2-0.3% being sarcomas. Of the mammary sarcomas, extra-osseous osteogenic sarcomas constitute a small heterogeneous group. This communication reports a case of primary extra-osseous osteogenic sarcoma occurring in the breast of a48-year-old female, and presents a literature review of this condition. A pre-requisite for the diagnosis of primary mammary osteogenic sarcoma is the exclusion of an osteogenic sarcoma arising from the underlying ribs or sternum. Like all other osteogenic sarcomas in general, these neoplasms are characterized by the direct formation of osteoid matrix by the tumour cells. Primary osteogenic sarcoma of the breast may arise from metaplastic sarcomatous transformation of neoplastic cells in a primary breast carcinoma, fibroadenoma, malignant phyllodes tumour, or may exceptionally represent a nonphyllodes sarcoma of the breast arising from the soft tissues of an otherwise normal or previously irradiated breast.

Changing clinicopathological profile of intussusception in Nigeria--a 20-year review.

BACKGROUND/AIMS: Intussuception was a common cause of intestinal obstruction at the University College Hospital, Ibadan. A peculiar type characterized by being ceco-colic, and found most commonly in adults, was the commonest variety found, but over the last few years this type of intussusception appears to have reduced in incidence. The aim of the study is to define the relative incidence of intussusception and the contribution of the various types of the overall incidence as seen at the University College Hospital, Ibadan, Nigeria. METHODOLOGY: Review of case notes and the surgical pathology records of all cases of Intussusception seen at the University College Hospital, Ibadan between 1975 and 1994 was done. RESULTS: There was a 48.1% decline in the absolute number of cases seen during the period of the study, and this decline was more among adult cases than infantile intussusception. The mean age of presentation of infantile intussusception was 8 months, while it was 42 years for adults. The classical triad of vomiting, pain and bloody stool was seen in only 15% of cases. Morbidity and mortality rates were high at 18 and 8.5% respectively and this was related to delayed presentation. CONCLUSIONS: The incidence of intussusception has fallen in the community studied and this decline has affected the adult age group and the ceco-colic type of intussusception more. Late presentation is a feature of most cases and is related to the high mortality and morbidity rates seen.

Job stress associated with surgical training in Nigeria.

Surgical residency training is acknowledged as being stressful, however the degree of stress, factors causing it, methods of coping with it, and the incidence of substance abuse has not been previously studied in our environment. We therefore used a self-administered questionnaire to survey 100 Nigerian Surgical Residents of whom 72 responded in September 1995. Our result shows that our residents spend 39.8, 36.8 and 23.3 percent of their time on patient care, educational activities and ancillary care, respectively. Eighty-nine percent of them considered their work to be stressful mainly because of lack of facilities and the unstructured nature of the program. Physical exhaustion, irresponsible behavior and sleep disorders were some of the abnormalities suffered as a result of this. In all, 5.6% rated the stress as severe, while 69.4% considered it moderate. Examinations produced the most stress, followed by operating sessions and patient care. Overall, substance abuse was uncommon with 16.7% claiming to have used alcohol in the one month preceding the study, but 8.3% claimed to need alcohol in order to function. Tobacco, benzodiazepine and barbiturates are some of the substances that our respondents have abused. There was no reported abuse of cannabis, heroin, cocaine, LSD or other psychotropic drugs. We conclude that though stress is inevitable during surgical training, some of the causes can be ameliorated. There is need to reduce the amount of time residents spend on ancillary care, while the current methods of examinations should be reconsidered to incorporate current adult learning theories. Residents should get adequate time for rest and recreation while exposure to modern surgical training in better-endowed centers should be incorporated into the training programme.

Normal pattern of pubertal changes in Nigerian boys.

To find out the mean age of onset of puberty among Nigerians boys and the correlation between the various physical features of puberty, a randomised community based survey was done. Biographical data were obtained from 162 urban school boys and 304 rural school boys using questionnaire and physical examination. The sexual maturation of the subjects were staged using the standard criteria/photoplates developed by Tanner1 for the pubic hair and external genitalia. Sexual maturation of Nigerian boys was observed to start between 9 to 15 years of age. Most often there is a close concordance between stages of genitalia maturation and pubic hair stages at each age but stages of both features can be entirely discordant. Genitalia maturation is always ahead of pubic hair stages. Maturation starts at the same age in both urban and rural boys but urban boys complete maturation faster than rural boys. By 19 years of age most rural and urban boys have fully matured. Compared with works done by previous authors on boys from developed countries, this data will suggest that Nigerian boys start their sexual development later than boys from developed countries.