Evaluation of postgraduate educational environment in a Nigerian teaching hospital.

BACKGROUND: Congenial educational environment (EE) is paramount to effective impartation of knowledge as required in residency training. In this study EE for residency training is evaluated using Postgraduate Hospital Educational Environment Measure (PHEEM). OBJECTIVES: To assess the postgraduate educational environment at the University of Nigeria Teaching Hospital (UNTH), South-East Nigeria, using PHEEM and to determine if there are significant differences in PHEEM scores amongst various sub-groups of resident doctors. METHODS: A cross-sectional study, employing a census survey, involving the administration of validated PHEEM questionnaires to residents in the Departments of Internal Medicine, Obstetrics/Gynaecology, Pediatrics and Surgery in the year 2018. Data entry and analysis were done using SPSS. ANOVA assessed significance of total scores and sub-scale scores. Cronbach's alpha was calculated. RESULTS: A total of 114 Males and 46 females; 93 registrars and 67 senior registrars responded giving 71% response rate. Overall PHEEM score was 85.82; Role autonomy (29.27), Perception of teaching (34.80), Perception of social support (21.55). Males scored more than females in total PHEEM score (p = 0.000, F = 148.235), perception of teaching (P = 0.000, F = 420), and perception of social support (p = 0.000, F = 162.95), but not in role autonomy (p = 0.748, F = 0.104). Registrars scored more than senior registrars in total PHEEM (p = 0.000, F = 67.159), role autonomy (p = 0.000, F = 25.123), Perception of teaching (p = 0.000, F = 18.042) but not in perception of social support (p = 0.31, F = 1.045). There were significant differences in total and subscale scores amongst the specialties. Cronbach's alpha was 0.915. CONCLUSIONS: Postgraduate educational environment in UNTH has more positives than negatives but with room for improvement. There are significant differences in PHEEM scores among various groups of resident doctors.

Effects of Clarithromycin Administration on Gastric Acid Secretion and Cytoprotection in Wistar Rats.

The incidence of peptic ulcer disease in Nigeria is 28% (Ndububa and Adeyemi, 2008). Clarithromycin (CLX) is used in the treatment of peptic ulcer owing to its antibacterial effect. Whether CLX has effects on other gastrointestinal parameters that reduce peptic ulcer has not been previously investigated. Therefore the effects of CLX on gastric acid secretion, mucus secretion and gastric ulcer scores in rats were investigated. A total of 30 albino wistar rats were used for the study. Out of this number, 10 rats each were used for gastric acid secretion, mucus secretion and ulcer scores respectively. In each of these sub groups, 5 rats served as test and were treated with CLX orally and 5 rats served as control. Standard methods were used for the estimation of these parameters of gastric function. The results showed that basal gastric acid, peak acid output following histamine stimulation and mucus secretion were significantly increased (p<0.001) in CLX-treated (test) rats than in their control. Furthermore, ulcer scores were significantly reduced (p<0.001) in the CLX-treated rats than control. In conclusion, Clarithromycin administration reduced gastric ulcers in rats. This may be attributable to not only its antibiotic property but also its ability to increase gastric mucus which counteracts the aggressive effect of the acid.

Evaluation of the educational environment of a new medical school in southeast Nigeria.

BACKGROUND: Educational environment (EE) affects transfer/acquisition of knowledge and skills needed in training medical students. Evaluation of EE by students is paramount to rating the EE of a medical school as well as evaluate effects of interventions. Assessing EE of medical schools is a current global trend. OBJECTIVES: : To evaluate EE at the new medical school of the Chukwuemeka Odumegwu Ojukwu University Teaching Hospital Awka, Anambra State, Nigeria; calculate the total and subscale (Dundee Ready Educational Environment Measure) DREEM scores and assess differences in these scores amongst the different classes, age groups, and sexes. METHODOLOGY: This was a descriptive cross-sectional study using census survey. We administered DREEM questionnaire to 4th, 5th, and 6th year medical students in the 2018/2019 academic session after ethical approval from Health Research and Ethics Committee (HREC). Data entry and analysis done using SPSS. ANOVA was used for association between level of study, age group, and total DREEM/Subscale scores. Test for association between sex and mean subscale/total score was done using independent sample t-test. P value <0.05 was adjudged significant. Cronbach's alpha for internal consistency was calculated. RESULTS: Of 206 students, 185 filled in the questionnaire. Total DREEM score was 119.66, Students' perception of teachers 26.74, Students' academic self Perception 21.94, Students' Perception of Learning 30.75, Students' Social Self Perception 15.04, Students' Perception of Atmosphere 25.26. Three items scored above 3 while 11 items scored ≤2. Fourth year students significantly scored higher than others for all subscale and total DREEM score. No significant associations between age or gender and subscale or total DREEM scores. Cronbach's alpha for all scores was 0.91. CONCLUSIONS: The EE was not excellent but "more positive than negative." Improvements are necessary in all domains of DREEM to ensure better quality of the educational environment.

Practice patterns of preoperative hormonal stimulation in pediatric penile surgeries-A survey of Nigerian pediatric surgeons.

BACKGROUND: Variable practice patterns exist in the use of Preoperative Hormonal Stimulation (PHS) prior to penile surgeries and there seems to be no generally agreed standards. OBJECTIVE: To assess the current practice patterns of PHS before penile surgeries among Nigerian pediatric surgeons and compare with literature. MATERIALS AND METHODS: Self-administered questionnaires were distributed amongst consultants and senior registrars in Pediatric surgery during the 2019 Association of Pediatric Surgeons of Nigeria (APSON) national conference. SPSS version 20 was used for data entry and analysis and results presented as ranges, percentages, tables. Test for association was done using chi square test and a p-value of <0.05 was deemed significant. RESULTS: All fifty respondents comprising 43 males, 7 females; 31 consultants and 19 senior registrars have managed hypospadias, with eighty-six percent managing less than 50 per year. Seventy-six percent practice PHS and more proportion of males use PHS than females (p = 0.027).Only 15.8% and 7.9% respectively estimated serum testosterone before and after PHS. Majority (92.1%) gave PHS because of small-appearing penis and 86.8% have used it in proximal hypospadias. Most commonly used form of PHS was intramuscular testosterone (76.3%) while 2 mg/kg testosterone was commonest dose (65.7%). Ninety-one percent give intramuscular testosterone at 2-4 weeks intervals; ninety-four percent give 2-3 doses of intramuscular testosterone preoperatively with last dose given 2-4 weeks before surgery in 57.9%. Ninety-two percent thought PHS will not increase postoperative complications and pubic hair was most common complication of PHS (63%). DISCUSSION: There is diversity in PHS practices among Nigerian pediatric surgeons. Though mainly low-volume surgeons, majority use PHS before penile surgeries especially in proximal hypospadias and small-appearing penis. Males tend to practice PHS more than females and most commonly used form of PHS is 2-3 doses of 2 mg/kg intramuscular testosterone at 2-4 weekly intervals with last dose given 2-4 weeks before surgery. This study may be limited by bias inherent in self-reported practices and outcomes as seen in surveys, though surveys help to evaluate practices of professionals. CONCLUSIONS: Majority of Pediatric surgeons in Nigeria use PHS in form of intramuscular testosterone mainly for small appearing penis and proximal hypospadias. Most common dosing is 2 mg/kg at 2-4 weeks intervals and 2-3 doses preoperatively with the last dose 2-4 weeks preoperatively. Serum testosterone estimation is not common before PHS. Many believe that PHS does not increase complications following penile surgeries. Current diversity in practice suggests the need for further studies to encourage standardization or guidelines for practice in Nigeria.

Indications, Types and Outcomes of Resections for Acquired Intestinal Conditions in Children.

BACKGROUND: Variable intestinal segments of children may need resection due to congenital or acquired conditions. Resection is done when these intestinal segments are nonviable or dysfunctional. In HICs most resections are for congenital conditions while in LMICs acquired and largely preventable conditions predominate.The spectrum of acquired intestinal conditions leading to bowel resection may also vary between HICs and LMICs. OBJECTIVES: To determine the indications, types and outcomes of intestinal resection for acquired conditions in children. METHODS: A retrospective review of pediatric bowel resections from acquired anomalies over a 10-year period in a tertiary hospital. Data entry and analysis done using SPSS. Fisher's exact test was used to assess level of significance for categorical variables and p-value of <0.05 was adjudged significant. Results are presented as means±SD, ratios, percentages and tables. RESULTS: Fifty-nine males and thirty-three females with a median age of 8 months were recruited. Complicated intussusceptions and right hemicolectomy were the most common indication and procedure respectively. Proportion of right hemicolectomies was more in infants than older children (p=0.0103) while ileal resection was higher in older children (p<0.001). Post-operative complications were seen in 35.8% and mortality rate was 8.7%. CONCLUSION: Complicated intussusception is the main acquired indication for intestinal resection. Right hemicolectomies and ileal resections were done mainly during infancy and beyond infancy respectively.

Assessment of the effect of urethral plate width on outcome of hypospadias repair.

BACKGROUND: The paradigm for hypospadias repair is a straight penis with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the parents of the patient. OBJECTIVE: To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate. PATIENTS AND METHODS: This study was a prospective evaluation of patients operated for hypospadias. The urethral plate width (UPW) of the patients were measured preoperatively using vernier calipers. The patients were categorized into groups A and B. Group A patients have a UPW <8 mm, whereas group B patients have a UPW ≥8 mm. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair. RESULTS: Overall, 47 patients had their hypospadias repaired during the study period. But, only 42 patients who had their distal hypospadias repaired using tubularized incised plate urethroplasty were evaluated. There were 20 patients (47.6%) in group A and 22 patients (52.4%) in group B, with a mean urethral plate of 7.3 mm ± 0.50 SD. The mean UPW in group A was 5.6 mm ± 1.22 SD and the mean UPW in group B was 8.8 mm ± 0.88 SD. Overall, mean HOPE score was 40.0 ± 6.83 SD. Group A patients had a mean HOPE score of 38.7 ± 7.49 SD, whereas Group B patients had a mean HOPE score of 41.2 ± 6.08 SD. P-value was 0.725, which is not statistically significant. Relating good urinary stream (15 in group A and 20 in group B) with the width of the urethral plate statistically (using Spearman correlation technique) gave a P-value of 0.03 (P < 0.05), which is statistically significant. CONCLUSION: Our findings indicate that the cosmetic outcome of hypospadias repair may not be determined by UPW, but the functional outcome may be predicted by the width of the urethral plate.

Outcome of feminizing genital reconstruction in female sex assigned disorder of sex development in a low-income country.

BACKGROUND: In patients with disorders of sex development (DSD), surgical/medical treatments are undertaken after sex assignment to ensure congruent bodily appearance and function. Genital reconstruction in these patients can be daunting with varied outcome. Understanding these outcomes is imperative, more especially in a developing country where added challenges exist. OBJECTIVE: This study evaluates the outcome of genital surgery in patients with DSD assigned female sex. METHODS: A retrospective analysis of 25 cases of female sex assigned DSD managed in two tertiary centers in southeast Nigeria was performed. Data of these cases were collected from the case notes, discharge summaries, and theater records. IBM SPSS Statistics Data Editor, version 21, was used for data entry and analysis. RESULTS: The patients presented at median age of 12 months (range 2 days-30 years), with 15 (60%) cases reared as female and 10 (40%) reared as male before presentation. The predominant phenotype was phallus with empty fused/unfused labioscrotum and urethra opening in the labioscrotum or perineum in 21 (84%) patients. Evaluation revealed features suggestive of 46XX DSD in 21 (84%) patients, ovotesticular DSD in two (8%), and androgen insensitivity in two (8%). A total of 10 cases required sex reassignment after evaluation. Overall, 24 of the 25 cases had feminizing genital procedures. After a median follow-up period of 2 years (range 2 months-8 years), six (25%) cases developed procedure-related complications, three (12.5%) had social maladjustment, and two (8.3%) patients reported features of gender dysphoria. DISCUSSION: The procedures of feminizing genitoplasty in this study did not differ from the established procedure. However, as a result of challenges of delayed presentation, inadequate early management, sociocultural factors, and a lack of facilities for full evaluation, some cases may require sex reassignment and more daunting reconstructive procedures. This may give rise to less than optimal outcome. The study was limited by the retrospective nature, small number of cases, and the short duration of follow-up of the cases. CONCLUSION: Feminizing genital procedures for DSD in our setting may be associated with procedure-related complications and non-surgical complications. Improving surgical technique and addressing the challenges of delayed presentation and fixation on male gender may improve overall outcome.

Outcomes of surgical management of intestinal atresias.

BACKGROUND: Outcome of managing intestinal atresias has improved in many developed countries, but most reports from low and middle income countries (LMICs) still show high morbidity and mortality. OBJECTIVE: The objective of the following study is to evaluate the outcome of surgically managed intestinal atresias in our health resource-limited setting. PATIENTS AND METHODS: All cases of intestinal atresias managed surgically from July 2007 to July 2012 were retrospectively analyzed. RESULTS: There were 23 patients comprised of 11 males and 12 females; 10 duodenal atresias (DA), 13 jejunoileal atresias (JIA) and no colonic atresias. The mean age at presentation to the surgeon was 10.3 days (range 2-43 days) for JIA and 10.6 days (range 1-35 days) for DA. Average weight at presentation was 2.2 kg for JIA and 2.4 kg for DA. Mean duration from presentation to surgery was 3.4 days for JIA and 4.8 days DA. All the JIA had primary repair; type 1 DA had duodenotomy and web excision while others had diamond duodenoduodenostomy. However one DA had duodenojejunostomy. 7 out of 10 DA patients (70%) had at least one associated anomaly, the most common being annular pancreas. There were 4 re-operations in JIA and none in DA (17.4% reoperation rate for 3 anastomotic leaks, 1 anastomotic stricture). Average hospital stay was 23 days for JIA and 12.3 days for DA. Overall, 5 (5) patients died (2 JIA and 3 DA) giving a mortality rate of 21.7%. Mortality rate for DA is 30% while for JIA is 15.4%. Causes of death were: Sepsis with disseminated intravascular coagulation (1), sepsis from anastomotic leakage (1), septic shock (1), anesthesia-related (1), undetermined (1). Two of the mortalities (40%) had re-operation for anastomotic leak. CONCLUSIONS: Short-term survival of neonates with intestinal atresias in our unit is still poor when compared with statistics from developed countries. Late presentation is common in this series, but does not appear to have negatively affected outcome. A high proportion of the mortalities had reoperation for anastomotic leak.

Irreducible inguinal hernias in the paediatric age group.

BACKGROUND: An inguinal hernia is said to be irreducible when the content fails to return into the peritoneal cavity without surgical intervention. Irreducibility is an ever present risk in untreated inguinal hernias and its management remains an important part of pediatric surgery practice. When a hernia is irreducible, morbidity and mortality increase This risk of irreducibility is more in some patient groups. METHODS: A retrospective analysis of all irreducible inguinal hernias in children of both sexes from neonatal age to 15 years who presented at the University of Nigeria Teaching Hospital from January 2000 to June 2010 and needed emergency groin exploration when reduction failed on conservative management. RESULTS: There were 25 irreducible inguinal hernias requiring emergency groin exploration. This represents 10.2% of all inguinal hernias managed within the period, with a male:female ratio of 11.5:1. Nineteen (76%) were on the right while six (24%) were on the left. Forty percent (40%) of the irreducible hernias were in older infants. Sixty-seven (67%) of the neonatal hernias presented as irreducible. There were 3 bowel resections (12% bowel resection rate), 2 testicular losses (8% testicular loss rate) and one death (4% mortality). CONCLUSION: There is a high rate of irreducibility of inguinal hernias in neonates, and in right-sided hernias Identification of risk factors in and risk stratification of patients with uncomplicated inguinal hernias will help reduce the rate of irreducible inguinal hernias and their attendant morbidities.

Profile of paediatric umbilical hernias managed at Federal Medical Centre Umuahia.

BACKGROUND: Umbilical hernias are common in children but many resolve spontaneously within the first five years of life. Most umbilical herniorrhaphies in our environment are due to symptomatic hernias which constitute a small percentage of all umbilical hernias. PATIENTS AND METHODS: A retrospective review of all pediatric patients with UH treated at Federal Medical Centre Umuahia, Abia State from February 2001 to February 2011. RESULTS: There were 22 patients but only 20 of the folders were found and analyzed. They were made up of 11 males and 9 females with a mean age of 6.19 +/- 0.83 years and median age of 6 years. Nine(7 males and 2 females) had acute incarcerations, nine (3 males and 6 females) had recurrent umbilical pains without incarceration and two (1 male and 1 female) had recurrent incarcerations. Age range for acute incarceration was 2-8 years (mean: 4.69 years, median: 4 years); recurrent umbilical pains was 4 months -15 years (mean: 7.7 years, median: 8 years) and for recurrent incarceration 2-10 years (mean: 6 years). All had standard umbilical hernia repairs except one whose parents declined surgery after reduction of acute incarceration. One patient with acute incarceration had gangrenous bowel with hernia sac abscess and was offered bowel resection with end-to-end anastomosis. On short-term follow-up, the symptoms resolved in all the patients following surgery. Five patients had six complications: 1 exuberant granulation tissue, 2 stitch reactions, 2 superficial wound dehiscence and one superficial wound infection. There were no mortalities and no recurrence on short-term follow-up. Only one patient (5%) registered under the National Health Insurance Scheme (NHIS). CONCLUSIONS: Active observation of all umbilical hernias at all ages will ensure early detection of complications and prompt treatment. Elective repair of umbilical hernias in patientsabove five years with fascia defect greater than 1.5cm is encouraged. Comprehensive NHIS will ensure early presentation and reduced complications.

Intensive care unit admissions in Federal Medical Centre Umuahia south east Nigeria.

BACKGROUND: The Federal Medical Centre Umuahia (FMCU) is a tertiary referral centre in Abia state, southeast Nigeria serving a catchment area made of Abia state and environs. An intensive care unit (ICU) was established in the hospital in December 2009 to improve healthcare delivery to critically ill patients. OBJECTIVE: To determine the admission patterns and report the initial experience in the intensive care of patients in the FMCU. METHODS: This is a retrospective study ofthepatients admitted into the ICU of FMCU from December 2009 to March 2011. Data retrieved from the patients ICU records included demographics, indication for admission, length of stay in ICU, and outcome of stay The cost of ICU care was extracted from the financial records of the patient following discharge or demise. Data acquisition and analysis was performed using the statistical package for social sciences (SPSS) version 15. RESULTS: A total of 87 patients were studied consisting of 59 males and 28 females. The ages ranged from 2 days to 87 years with a mean age of 41 +/- 2.34 years. There were 11 patients within the pediatric age range (12.6%). Post-operative surgical patients (51) accounted for the majority of the admissions (58.6%). There were also 21 non-operated trauma cases (24.1%), 7 medical cases (8.1%), 8 obstetrics and gynecological cases (9.2%). Post-operative admissions were mainly emergencies--39 cases (76.5%) cases while 12 (23.5%) were elective. Most post-operative ICU admissions followed abdominal surgery -31 cases (58.8%) while neurological trauma accounted for most non-operated trauma 17cases (81%). The cost of stay per patient ranged from N2745.65 to N238123.4 ($82.23 to $1536.28) with an average cost per day of N19506.75 ($125.85). The cost per day for mortality cases was N28598, 74 ($184.51). The modal length of ICU stay was 2 days with a mean of 3.63 +/- 0.34 days and a range of one to sixteen days. About 68.4% of the patients spent = 3 days (38.3% of total ICU days), while 31.6% spent > 3 days (61.7% of total ICU days). Of the 87 patients, 57 (65.5%) were discharged from ICU to the wards, 28 (32.2%) died in ICU while 2 (2.3%) were referred to bigger centers. Twelve mortalities (42.8%) were among the emergency postoperative patients and 10 (35.8%) non-operated trauma patients (80% of which are neurological trauma). CONCLUSION: From our study, most ICU admissions and is comparable to other studies in Africa. The cost of stay is very high when compared with annual per capita income in Nigeria of $1190.

Spontaneous scrotal enterocutaneous fistula: a case report and review of literature.

BACKGROUND: Spontaneous scrotal enterocutaneous fistula (SSECF) is a rare entity both in our local and international literature. No report of such has emanated from south eastern Nigeria. METHOD: The case note of the patient was retrieved and relevant data extracted and summarized. An extensive pubmed search was done and results reviewed and compared with the present case. RESULT: The case report of the successful surgical management of a 7 week male who developed right hemiscrotal SSECF as a result of neglected, irreducible right inguinoscrotal hernia is outlined. A review current literature is also highlighted. CONCLUSION: Spontaneous scrotal enterocutaneous stula is a very rare complication of neglected, educible, strangulated inguinoscrotal hernia. Treatment is invariably inguinal exploration, excision of iseased bowel with end to end anastomosis. Early detection and early repair policy will prevent this.

Management of sexual assault-related large rectovaginal fistula in an eight-year-old.

Rectovaginal fistula may be a complication sexual assault in children. Management of these cases could be daunting with possibilities of significant psychological and physical morbidity. An eight-year-old girl presented with vulvar fecal leakage from a large rectovaginal fistula two weeks after sexual assault. The child was managed by initial diverting colostomy and the fistula repair was carried out via a posterior sagittal approach. This report highlights significance of initial thorough evaluation in cases with suspected traumatic rectovaginal fistula, and demonstrates benefits of posterior sagittal approach in the definitive treatment of large-sized fistula.

Profile of pediatric abdominal surgical emergencies in a developing country.

We aim to determine the profile and determinants of outcome of pediatric abdominal surgical emergencies in southeastern Nigeria. We prospectively analyzed 115 children with abdominal surgical emergencies managed at the University of Nigeria Teaching Hospital, Enugu, Nigeria, from January 2008 to June 2009. The emergencies were typhoid intestinal perforation (TIP) 22 (19.1%), intussusception 20 (17.4%), obstructed hernia 17 (14.8%), neonatal intestinal obstruction 11 (9.6%), appendicitis 11 (9.6%), trauma 8 (6.9%), ruptured omphalocele/gastroschisis 8 (6.9%), Hirschsprung's disease 7 (6.1%), adhesive bowel obstruction 7 (6.1%), and malrotation 4 (3.5%). The mean time to diagnosis was 3.5 days (range, 4 hours to 12 days). Ninety-three cases had an emergency operation, while 22 were managed nonoperatively. After a mean hospital stay of 10.8 days (range, 2-38 days), 35 (37.6%) of the operated patients had one or more postoperative complications. There were 10 (8.7%) deaths. Overall, TIP had a higher postoperative complication rate (P < 0.001), while neonates had a higher mortality (P < 0.001). Delayed presentation and lack of neonatal and pediatric intensive care facilities were daunting challenges. A pediatric abdominal surgical emergency in our setting has high morbidity and mortality. Efforts geared towards improvement in time to diagnosis and perioperative care may result in better outcomes.

Trends in neonatal intestinal obstruction in a developing country, 1996-2005.

BACKGROUND: Despite the advances in neonatal surgery, the outcome of neonatal intestinal obstruction (NIO) in many developing countries has been reported to be poor. This study describes the trends in NIO, including the contributory factors in southeast Nigeria. METHODS: We performed a comparative analysis of 128 consecutive NIO managed from January 1996 to December 2005 at the University of Nigeria Teaching Hospital, Enugu, in southeast Nigeria. RESULTS: Fifty-five (43.0%) neonates were managed in the first 5 years (group A) and 73 (57.0%) in the last 5 years (group B). Etiology of obstruction did not vary significantly in the two groups. Average duration of symptoms before presentation fell from 5.9 days (group A) to 4.7 days (group B). With exception of Hirschsprung's disease (HD), all other cases required operative treatment. In HD, colostomy rate declined from 44.4% (group A) to 26.7% (group B). More neonates in group B were managed with general anesthesia and perioperative third-generation cephalosporin antibiotics (p < 0.01). While complication rate did not vary significantly in the two groups (group A, 42%; group B, 40.3%), survival improved (group A, 61.8%; group B, 72.6%). Earlier presentation, improved manpower, and use of potent antibiotics may have contributed to the improved outcome. Challenges in the form of lack of neonatal intensive care facilities and dearth of qualified personnel persist. CONCLUSION: There is a trend toward earlier presentation and increased survival of babies with NIO in our setting. Improving the existing facilities and trained manpower, and establishing collaboration with centers that have excellent results may further encourage the trend.