AUDIT OF THE PRACTICE OF DAY CASE SURGERY IN THE DIVISION OF PAEDIATRIC SURGERY, UNIVERSITY COLLEGE HOSPITAL, IBADAN.

Background: Paediatric day case surgery refers to planned procedures on patients on a non-resident basis but requires some facilities and time for recovery before discharge home on the day of surgery. This study was conducted to audit paediatric day case surgery practice at our centre, and to determine the outcome of day case surgeries. Patients and Methods: This is a retrospective study of cases seen over a period of 12 years, 2010 to 2022. These patients' data were assessed from their case notes and information obtained for each of the patients included age, gender, diagnosis, type of operation, type of anesthesia and post operative complications. The data were analyzed using SPSS version 22.0 for windows. Results: A total of 1,211 patients were recruited, with a M: F; 6: 1. The age of patients ranged from one week to 15 years with a median age of two years. A higher proportion of case load involved infants and toddlers compared to the other paediatric age groups. In this review, the largest volume of cases was seen in the last five years with the peak in 2018 (202). The right groin for an isolated diagnosis was operated in 381 (59 %) patients compared to the left 265 (41 %). The mean duration of surgery time was 40 minutes. Most of the patients had General Anesthesia (GA) with endotracheal tube, face mask, and laryngeal mask airway (LMA) using isoflurane, halothane and propofol at different times as anesthetic agents. There were no re admissions or mortality, however two of our patients had recurrence necessitating a re-do surgery. Conclusion: Groin hernias are the most common day cases in children in our facility. Day case paediatric surgery is safe, and outcome is generally good, when well managed.

PREFERENCES OF CHOICE OF FUTURE SPECIALTY: INSIGHTS FROM FINAL YEAR MEDICAL STUDENTS IN IBADAN, NIGERIA.

Background: The choice of specialty by medical students and early career doctors affects health workforce distribution in any country. In addressing healthcare needs of the populace, appropriate distribution of manpower across board is essential. Several factors come into play in making these choices. This study assessed factors affecting the career choices of final year medical students and how curricular changes may have influenced these. Methods: This was a cross-sectional study conducted among 236 final year medical students of the University of Ibadan by convenience sampling using self-administered semi-structured questionnaires. Questions were on sociodemographic characteristics, career counselling, preferred future career, and factors affecting these choices. Data were analyzed using SPSS version 21 software. Results: A total of 236 medical students participated in the study. The mean age of participants was 23.6(±1.9) years. Only 112(47.5%) respondents had received any form of career counseling/guidance in the course of their medical training. The commonest first choice specialties were obstetrics and gynecology 54(22.9%), surgery 44(18.6%), and psychiatry 18(7.6%). Personal interest most often (185, 78.4%) influenced career choice overall, showing significance in obstetrics and gynecology (p=0.02), family medicine (p=0.02), and public health (p<0.001). Conclusion: The predominant choices of future specialty among final year medical students were obstetrics and gynecology, surgery and psychiatry. The change in curriculum for medical students may have affected the pattern of their choices with more interest shown in previously neglected areas.

Awareness and Knowledge of Birth Defects among Antenatal Clinic Attendees at the University College Hospital, Ibadan, South-West, Nigeria.

BACKGROUND: The burden of birth defects is disproportionately higher in developing countries. OBJECTIVES: This study assessed the knowledge of risk factors and prevention of birth defects among ante-natal clinic attendees at the University College Hospital, Ibadan, Oyo State, Nigeria. METHODS: This was a cross-sectional study among 415 mothers who presented at the antenatal clinic. A semi-structured questionnaire was used to obtain information on respondents' socio-demographic profile, pregnancy, birth history, knowledge on prevention and risk factors for birth defects. Descriptive statistics was used to present results, independent t-test and ANOVA were used to determine the factors associated with mean of overall knowledge of birth defects. Test statistics was done at a 5% level of statistical significance. RESULTS: The mean age of the women was 31.7 ± 4.8 years. Overall, 93 (22.4%) of the women were above 35 years, 118 (29.9%) were skilled workers and 343 (84.9%) had tertiary education. More than half (219, 52.8%) of the respondents had good knowledge of birth defects (56.4% had good knowledge of prevention and 66.0% had good knowledge of risk factors). Antenatal clinic attendees in their first trimester had higher mean overall knowledge score (8.3 ± 4.9) compared to those in second (7.9 ± 4.5) and third (7.9 ± 4.9) trimesters but this was not statistically significant (p=0.873). However, respondents in skilled/ semi-skilled occupation (8.62) had a significantly higher mean knowledge score compared with those in unskilled occupation/ unemployed (7.33) (p=0.005). CONCLUSION: Knowledge of birth defects is relatively low among women. To reduce the occurrence and severity of birth defects, there is a need to educate mothers on the knowledge, prevention and importance of screening for birth defects.

CONTEXTE: Le fardeau des malformations congénitales est disproportionnellement plus élevé dans les pays en développement. OBJECTIFS: Cette étude a évalué les connaissances sur les facteurs de risque et la prévention des malformations congénitales chez les patientes des consultations prénatales de l'University College Hospital, Ibadan, État d'Oyo, Nigéria. MÉTHODES: Il s'agissait d'une étude transversale auprès de 415 mères qui se sont présentées à la clinique prénatale. Un questionnaire semi-structuré a été utilisé pour obtenir des informations sur le profil sociodémographique des répondantes, la grossesse, l'histoire de la naissance, les connaissances sur la prévention et les facteurs de risque de malformations congénitales. Des statistiques descriptives ont été utilisées pour présenter les résultats, un test indépendant et une ANOVA ont été utilisés pour déterminer les facteurs associés à la moyenne de la connaissance globale des malformations congénitales. Les statistiques du test ont été effectuées à un niveau de signification statistique de 5 %. Soins prénatals, Santé de l'enfant, Connaissances. RÉSULTATS: L'âge moyen des femmes était de 31,7 ± 4,8 ans. Dans l'ensemble, 93 (22,4%) des femmes avaient plus de 35 ans, 118 (29,9%) étaient des travailleurs qualifiés et 343 (84,9%) avaient un diplôme de l'enseignement supérieur. Plus de la moitié (219, 52,8%) des répondants avaient une bonne connaissance des malformations congénitales (56,4% avaient une bonne connaissance de la prévention et 66,0% avaient une bonne connaissance des facteurs de risque). Les patientes en consultation prénatale au cours de leur premier trimestre avaient un score de connaissance global moyen plus élevé (8,3 ± 4,9) par rapport à celles des deuxième (7,9 ± 4,5) et troisième (7,9 ± 4,9) trimestres, mais cela n'était pas statistiquement significatif (p = 0,873). Cependant, les répondants exerçant une profession qualifiée/semi-spécialisée (8,62) avaient un score moyen de connaissances significativement plus élevé que ceux exerçant une profession non qualifiée/chômeur (7,33) (p=0,005). CONCLUSION: La connaissance des malformations congénitales est relativement faible chez les femmes. Pour réduire l'occurrence et la gravité des malformations congénitales, il est nécessaire d'éduquer les mères sur les connaissances, la prévention et l'importance du dépistage des malformations congénitales. MOTS-CLÉS: Malformations congénitales.

Childhood intussusception: a multicentre study in a middle-income country.

BACKGROUND: The outcome in infants and young children of intestinal obstruction due to intussusception is well documented in high-income countries. Our aim was to investigate the current pattern of presentation, management and outcome of childhood intussusception in a middle-income country using a multicentre approach. METHODS: Records of children managed for intussusception in three centres in South West Nigeria were retrospectively reviewed and analysed. RESULTS: One hundred and ninety children managed for intussusception were analysed. The male-to-female ratio was 1.8:1. The median age was 7 months with a peak age incidence of 3-6 months. Peak incidence was recorded during the dry season. Passage of bloody stool, vomiting, abdominal pain and fever were the most common presenting features. Seventy-three (38.4%) of the patients presented with the classic triad. The median duration of symptoms was three days and only 19 (10.1%) patients presented in less than 24 hours. Ileocolic intussusception was the most common anatomic type, occurring in 166 (87.4%) patients, and was significantly associated with age. Twenty-two (56.4%) had successful hydrostatic reduction, while 165 (88.2%) required surgery. Forty (21.1%) patients suffered postoperative complications. Eleven (5.8%) of the patients died. The median duration of hospital stay was six days, and this correlated with the duration of symptoms and the length of hospital stay. CONCLUSION: Delayed presentation is a persisting challenge in the management of childhood intussusception in Nigeria. Prompt referral to a paediatric surgeon may reduce the surgery rate, associated morbidity and the length of hospital stay.

LATE THIRD TRIMESTER ULTRASOUND DIAGNOSIS OF DUODENAL ATRESIA - THE IMPORTANCE OF DETAILED PRENATAL ULTRASOUND SCREENING.

Duodenal atresia (DA) is the commonest type of congenital small bowel obstruction usually presenting in the neonatal period. About half of fetuses with duodenal atresia have other associated anomalies, and these associations often contribute to morbidity and mortality. DA can be fatal unless promptly diagnosed and treated surgically. In experienced hands and in countries where prenatal ultrasound screening for anomalies is routine, DA can be confidently diagnosed prenatally, which can help in reducing the perinatal morbidity and mortality associated with diagnosis after delivery. We report a case of DA diagnosed by ultrasonography at 36 weeks gestation in a 34 year old multiparous woman in a hospital where targeted prenatal ultrasound screening for fetal anomalies was recently introduced, and reviewed relevant literature.

Disclosure of cardiac variants of uncertain significance results in an exome cohort.

This study examined the impact of disclosing subclassifications of genetic variants of uncertain significance (VUS) on behavioral intentions. We studied return of VUS results to 79 individuals with a cardiomyopathy-associated VUS, subclassified into VUS-high or VUS-low. Primary outcomes were perceived risk (absolute and comparative), perceived severity, perceived value of information, self-efficacy, decision regret, and behavioral intentions to share results and change behaviors. There was no significant difference between the 2 subclasses in overall behavioral intentions (t = 0.023, P = .982) and each of the individual items on the behavioral intentions scale; absolute (t = -1.138, P = .259) or comparative (t = -0.463, P = .645) risk perceptions; perceived value of information (t = 0.582, P = .563) and self-efficacy (t = -0.733, P = .466). Decision regret was significantly different (t = 2.148, P = .035), with VUS-low (mean = 17.24, SD = 16.08) reporting greater regret. Combining the subclasses, perceived value of information was the strongest predictor of behavioral intentions (ß = 0.524, P < .001). Participants generally understood the meaning of a genetic VUS result classification and reported satisfaction with result disclosure. No differences in behavioral intentions were found, but differences in decision regret suggest participants distinguish subclasses of VUS results. The perceived value of VUS may motivate recipients to pursue health-related behaviors.

BOWEL RESECTION IN CHILDREN IN IBADAN, NIGERIA.

BACKGROUND: Acquired, and largely, preventable conditions are the predominant reasons for bowel resection in children in developing countries. This is in contrast to known indications in developed countries, where congenital conditions predominate. It is however, unknown, if the situation has changed with recent public health awareness initiatives. AIM: To examine the current indications, pattern and outcome of bowel resection in children in our center. METHODOLOGY: This was a retrospective review of the records of children 14 years and below who had had bowel resection procedures within a 90-month period at the University College Hospital, Ibadan. Patients who had colonic resections for Hirschsprung's disease were excluded from this study. RESULTS: A total of 91 children (57 boys, 34 girls) aged 6 hours to 14 years with a median of 7 months had bowel resections during the study period. There were 10 (11%) neonates, 51 (56%) infants and 30 (30.9%) children > 1 year. Common indications for bowel resection were intestinal atresia in neonates, intussusception in older infants and typhoid intestinal perforation/adhesive intestinal obstruction in children > 1 year. Overall, intussusception was the commonest indication in 54 (59.3%) followed by typhoid intestinal perforation in 9 (9.9%). The resection types were right hemicolectomy in 56 (61.5%), segmental small bowel resection in 31 (34.1%) and colonic resection in 4 (4.4%) patients. Thirty-seven (40.7%) patients developed post-operative complications, mostly surgical site infection in 25 (27.5%) and 17 (18.7%) developed long-term complications such as incisional hernia in 9 (9.9%). The mortality rate was 5.5% (5 patients). CONCLUSION: Intussusception and typhoid ileal perforation accounted for the majority of bowel resections in children in this study; late presentation was common and associated with high morbidity. Early presentation with prompt and effective management would improve outcome.

A CASE OF COMPOUND INTUSSUSCEPTIONS IN A NIGERIAN CHILD - A RARE FINDING IN A COMMON DISEASE.

Intussusception is the most common, non-congenital, cause of intestinal obstruction in infants. There are various patterns of intussusception seen in children with the most common being ileo-colic variety. Compound intussusception in which intussusception involves more than one non-adjacent segment is a rare finding in the literature and it can be associated with worse morbidity than typically occurs, especially in a region where delayed presentation is a major contributor to morbidity and mortality in the treatment of intestinal obstruction. We report the first documented case of double compound intussusception in an African child and reviewed relevant literature.

Measurement of Testicular Volume in healthy Nigerian newborns AT IBADAN, NIGERIA using THE PRADER Orchidometer.

BACKGROUND: Determining the normal testicular volume in the newborn at birth is essential in the assessment of the degree of virilization of the external genitalia since abnormal development of the genitalia is closely related to the testicular volume in the male newborns. OBJECTIVES: To establish a standard testicular volume (TV) for male newborn Nigerians using the Prader Orchidometer and determine the relationship between the testicular volume in the newborn and the age of the newborns at birth, the birth weight, the maternal age at delivery and the maternal parity. METHODS: Prospective cross-sectional study of all term male neonates within 72 hours of birth from April 2013 to March 2014 in the three largest obstetric centres (University College Hospital, Adeoyo Maternity Hospital and Our Lady of Apostles Catholic Hospital) in Ibadan, Nigeria. They underwent clinical examination of the external genitalia and the testicular volumes were measured using the Prader orchidometer. RESULTS: A total of 867 male neonates were recruited into the study with a mean age of 2.89±6.21 days. The testicular volume ranged from 1 - 3 ml on both sides with a mean right testicular volume of 1.14±0.38 ml. There was a significant correlation between gestational age as well as birth weight and the testicular volume (r = 0.146, p = 0.03). CONCLUSION: This study has determined a normative value for testicular volume measured by Prader Orchidometer in newborns in a typical African population which could be used as a reference when evaluating neonates with patients with testicular abnormalities.

Routine prenatal ultrasound anomaly screening program in a Nigerian university hospital: Redefining obstetrics practice in a developing African country.

BACKGROUND: Congenital anomalies are among the leading causes of fetal and infant morbidity and mortality worldwide. Prenatal ultrasound (US) screening has become an essential part of antenatal care in the developed world. Such practice is just evolving in the developing countries such as Nigeria. The aim of this article is to present our initial experience and demonstrate the effectiveness of a prenatal US screening program in detecting congenital malformation in a developing country. MATERIALS AND METHODS: This was a prospective evaluation of the prenatal US screenings conducted at a major referral hospital in Southwestern Nigeria. All pregnant women referred to the antenatal clinic for mid-trimester screening during the period of study were assessed. RESULTS: Two hundred and eighty-seven pregnant women (5 with twin gestations) were presented for fetal anomaly scan during the study period. Twenty-nine anomalies (9.9%) were detected among the scanned population. Sixteen of the anomalies were followed to delivery/termination with a specificity of 93.5%. The commonest malformations were demonstrated in the genitourinary tract (34.5%) followed by malformations within the central nervous system (27.6%). Six (20.6%) of the anomalies were lethal. Five of the anomalies were surgically correctable. CONCLUSION: Institutions and hospitals across Nigeria and other low- and middle-income countries need to develop policies and programs that would incorporate a standardized routine screening prenatal US in order to improve feto-maternal well-being and reduce the high perinatal mortality and morbidity in developing nations.

OBSTRUCTED INGUINAL HERNIA IN CHILDREN: CASE-CONTROLLED APPROACH TO EVALUATE THE INFLUENCE OF SOCIO-DEMOGRAPHIC VARIABLES.

BACKGROUND: Obstructed inguinal hernia in children is associated with high morbidity in developing countries due to delay in accessing care. Attempts made to reduce waiting time to herniotomy are not backed by a predictive model of disease occurrence and modeling obstructed inguinal hernia implies knowledge of factors associated with this complication. AIM & OBJECTIVES: To determine the relationship between socio-demographic variables and obstructed inguinal hernia in children. DESIGN: Case controlled. SETTING: Paediatric surgery unit of a tertiary hospital. MATERIALS AND METHODS: The study was prospective - all children presenting with obstructed inguinal hernia at University College Hospital, Ibadan, Nigeria between May 2009 and April 2014 were studied. For each case, two children with non-obstructed inguinal hernia were recruited consecutively as controls. Their demographics, clinical features, management and outcomes were obtained including the socio-demographic attributes of the parents. The data obtained were computed using SPSS; the p-value for significance was set at < 0.05. RESULTS: A total of 81 consecutive patients (27 with obstructed inguinal hernia and 54 with non-obstructed inguinal hernia) were studied; they were aged between 2 weeks and 13 years with a mean of 25.9 ± 3.8 months. There were no differences between cases and controls based on gender, parents' religion, tribe, social status and side affected (p > 0.05). The mean age at presentation was 13.7 ± 5.6 months in the obstructed inguinal hernia vs. 32.0 ± 4.8 months in the non-obstructed inguinal hernia groups (p = 0.016). The duration of groin swelling before presentation was not significantly different (30.0 ± 7.7 vs. 28.3 ± 6.4 months, p = 0.893). Infants were three times more likely than older children to develop obstruction (OR = 3.33, CI: 1.20, 9.09, p = 0.020). CONCLUSION: The age at presentation is the significant socio-demographic variable in this study that could predict obstruction in healthy children with inguinal hernia delivered at term.

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.

Anorectal malformation in an adult: a case report.

BACKGROUND: Anorectal malformations (ARM) are usually diagnosed at birth, although, some patients have presented in the hospital beyond the newborn period without recognition of the anomaly. Late presentation in adulthood has also been reported. We report a case of adult ARM whose mother was instructed not to present in the hospital until she was old enough. METHOD: An adult female patient was evaluated and investigated preoperatively for high ARM with rectovestibular fistula. She had an initial colostomy which was followed by a primary posterior sagittal anorectoplasty (PSARP). Post-operatively, continent level was assessed using the Kelly continent score. RESULTS: She had good post-operative recovery with an episode of faecal soilage. The Kelly continent score was 3 which later improved to 5. CONCLUSION: Although the sphincteric tone may be weak in the adult patient with ARM with reduced continent level at the initial stage, overall outcome of management of ARM with primary PSARP is good and comparable to outcome in children.

The problematic Duhamel pouch in Hirschsprung's disease: manifestations and treatment.

PURPOSE: The Duhamel operation is commonly employed to treat Hirschsprung's disease (HD). We have seen a number of patients referred to our center with problems following a Duhamel procedure performed elsewhere, and have analyzed our experience with these children. METHODS: We reviewed 17 patients with Hirschsprung's disease who underwent a Duhamel procedure elsewhere, in whom we performed a redo pull-through for persistent symptoms of constipation, impaction, and enterocolitis. RESULTS: All patients (n=17) had constipation/impaction or enterocolitis, 9 of whom were soiling due to overflow incontinence. Biopsies of the pulled-through bowel found 6 patients with persistent aganglionic bowel and 2 patients with ganglion cells present but hypertrophic nerves, a finding we interpreted as "transition zone bowel". The remaining 9 patients without a pathological indication for reoperation had a mega Duhamel pouch. All patients underwent a redo operation: 8 via a posterior sagittal approach (7 with a laparotomy, 1 without) and 9 by a transanal, Swenson-type resection with a laparotomy. The posterior sagittal approach was used in cases with severe pelvic fibrosis considered unsuitable for a trans-anal operation. 15 patients were followed up postoperatively for longer than 2 months, 13 of whom now have voluntary bowel movements, including 8 who need a small dose of laxatives. 2 patients are still diverted. CONCLUSION: Although perhaps successful for many patients around the world, the Duhamel pull-through can leave patients with significant symptoms, including impaction and overflow incontinence. It is unclear why some patients with a Duhamel pouch do not empty well. Clearly, those patients with a mega Duhamel pouch suffer from impaction. These patients need to be detected, because reoperation with resection of the Duhamel pouch can dramatically improve their quality of life.

Spontaneous neonatal pneumomediastinum: the "spinnaker sail" sign.

Spontaneous pneumomediastinum is a rare condition in the newborn, not associated with identifiable trauma or mechanical ventilation. It is diagnosed by a combination of physical examination and confirmatory chest radiograph, with various recognized signs identifiable in this condition. We report the case of a male neonate, who had pneumomediastinum confirmed by the presence of a wind blown spinnaker sail sign and was managed conservatively. We also reviewed the literature.

Pattern and outcome of childhood intestinal obstruction at a tertiary hospital in Nigeria.

BACKGROUND: Intestinal obstruction is a common cause of pediatric surgical emergency with a high morbidity and mortality in Africa. METHODS: A retrospective review of cases managed from January 1996 to December 2005 at a teaching hospital in Southwestern, Nigeria was done to examine the pattern of causes of intestinal obstruction in children and the management outcome. RESULTS: One hundred and thirty cases were seen over the study period with an age range of 2 hours to 14 years. Majority (61.24%) were infants, while 18.46% were neonates. Fifty-five cases (42.31%) were due to congenital causes while the rest were of acquired causes. The major causes of intestinal obstruction in the study were intussusception (29.23%), anorectal malformations (22.31%), obstructed inguinoscrotal hernia (16.92%) and Hirschsprung's disease (13.85%). Surgical site infection and sepsis were the commonest complications observed with an overall complication rate of 60.78%. The mortality rate was 3.08% and most (75%) occurred in neonates. CONCLUSION: While mortality as an outcome of management is low, the morbidity was very high in this study.