Trauma death in a resource constrained setting: mechanisms and contributory factors, the result of analysing 147 cases.

AIMS AND OBJECTIVES: The objective of the following study is to analyze the trauma type (causes), injury pattern and factors that may have contributed to death within 72 h of admission into our emergency department (E.D). MATERIALS AND METHODS: An 18 month prospective observational study, done from April 2009 to September 2010. All the patients were that admitted for 72 h following a full assessment by the attending clinician were enlisted for the study. The demographic data of each patient, time of arrival at the E.D, type of injury sustained, time of incident, previous care at any peripheral hospital, clinical state of the patient, Glasgow coma scale (GCS), Injury severity score (ISS) and treatment offered before death were entered into a Proforma. DATA ANALYSIS: This was done using EPI-Info statistical programme version 3.4.3 of 2007(by CDC Atlanta Georgia , USA). RESULTS: A total of 4011 patients were seen in the E.D during the period. 1943 (48.4%), were trauma emergencies, with a (147; 41.4%) mortality. Their ages ranged from 4 to 87 years, with an average of 34.5 years. The male:female ratio was 7:1. The assessed GCS ranged from 6 to 15, with an average of 9.1, the ISS ranged from 9 to 75 with an average of 31.3. Road traffic accidents (RTAs) accounted for 118 (80.3%) of the deaths, assaults 14.3%, falls from height 4.0% and gunshot injuries 1.4%. The overall mortality was 17.1%. CONCLUSION: The major source of trauma death was RTA; The most frequently injured part of the body was head, with death resulting clinically hemorrhage. The 17.1% mortality is multifactorial: The late presentation (in some cases occasioned by interference by persons not knowledgeable in the basics of trauma care) lack of trained personnel and the systemic deficiencies.

Letter: Skin cancer in albinos at the University of Calabar Teaching Hospital, Calabar, Nigeria.

We evaluated all the albinos with a histologic diagnosis of skin cancer seen in the University of Calabar Teaching Hospital, Calabar, Nigeria, during the 7-year period, (January 2001 to December 2007). The ages, sex, clinical presentation/site(s), number of lesions per patient, type of skin cancer, treatment, outcome and follow up were analyzed. This was compared with the total number of skin cancers. Of the skin cancers diagnosed, 11 percent were in patients with albinism.

Cutaneous squamous cell carcinoma in Calabar, southern Nigeria.

BACKGROUND: Several studies have shown that in Africa squamous cell carcinoma (SCC) is commoner than other skin malignancies. The risk factors are grouped generally into solar and nonsolar factors and their contributions vary with race, geographical region and site of lesion. This study attempted to identify risk factors and outcome of management of this problem in our region of southern Nigeria. METHODS: All patients with histological diagnosis of SCC presenting to the University of Calabar Teaching Hospital during the period January 2005 to December 2006 were evaluated. RESULTS: In total, 10 patients (6 male, 4 female, mean age 39.3 years, range 16-62) were seen. There were six patients (60%) with Marjolin's ulcer (MU) of the leg, with a male:female ratio of 5:1 and a latency period of 14.7 years, with trauma as the leading cause of injury. The other four patients (40%) had non-MU SCC. Two of these four patients (one man, one woman) were albino, and had lesions that involved the head. The other two patients were both women, and had vulval lesions. All 10 patients had delayed hospital admission, after poor results with topical herbal treatment. After hospital treatment, the results were satisfactory in three patients (two with MU and the male albino patient). The other seven patients had generally poor results from treatment, which comprised various combinations of excision, adjuvant chemotherapy and radiation. CONCLUSION: Ignorance and sociocultural factors were underlying issues in delaying treatment. Education highlighting the risk associated with chronic wounds and albinism, and the need for prevention, prompt treatment and proper surgical management, would improve prognosis with a reduction in the healthcare cost of this problem.

Salivary gland tumour of the lip: report of two cases and literature review.

BACKGROUND: Salivary gland tumours (SGT'S) are uncommon. The minor glands are dispersed throughout the upper aerodigestive submucosa including the lip. OBJECTIVE: To present two case reports of salivary gland tumour of the upper lip and highlight its diagnostic and therapeutic challenges. CASE REPORTS: A 50-year-old female farmer presented with a two year history of swelling of the upper lip and the histology revealed a pleomorphic adenoma of the minor salivary gland. She was offered a wide excision which resulted in a huge upper lip defect managed by a two staged lip switch ABBE flap. The second patient, a 40-year-old female teacher presented with a 10 year history of a left sided upper lip swelling. Histology revealed pleomorphic adenoma. She was offered an excision with no evidence of recurrence after 26 months of follow up. CONCLUSION: Salivary gland tumours should be considered as a differential diagnosis of tumours of the lip: Early presentation is advocated as late presentation with advanced tumour presents diagnostic and therapeutic challenges.

High voltage electrical injuries in the University of Calabar Teaching Hospital.

BACKGROUND: Burn injuries are a common presentation in Nigerian hospitals and result from a variety of causes. Recently, many have resulted from Petroleum related fire incidents. High voltage electrical injuries are relatively rare; lightning strikes even rarer. In traditional societies where Traditional medicine practitioners are usually the first to be contacted and where late presentation to hospitals is the rule, complications such as the wet gangrene necessitating amputation are common. Even when patients present relatively early and are resuscitated and treated, complete prosthetic rehabilitation is difficult because of poverty and lack of social support systems. CASE REPORT: This review presents three cases of high voltage electrical burns resulting from typical 11KVA burns as well as lightning strike. It also highlights the role of prompt presentation in a health facility with appropriate resuscitation in determining good treatment outcomes.

Closed drainage of liver abscesses: the 'UNICAL' drain as an efficient and cost saving device in a tropical setting.

INTRODUCTION: Liver abscesses occur in both the developed and developing countries. Up to the time of this study lever abscesses in our centre were drained with open laparotomy, because of the lack of standard equipment for percutaneous drainage. We present a preliminary report of six cases of liver abscesses drained percutaneously using the 'UNICAL' closed drainage system. METHODOLOGY: Six patients all males aged 23 54 years were treated for liver abscesses using the 'UNICAL' drain (a locally devised active drain system), under ultrasound guidance. Five of the patients had amoebic abscesses, all located in the right hepatic lobe. The sixth patient had multiple pyogenic abscesses involving both hepatic lobes. The six patients had pre and post-drainage antimicrobial therapy for a total of two weeks. RESULTS: One patient, who was a diabetic, had a recollection of pus within a week after the initial drainage. He was redrained with the same device with complete cure. Full blood count and liver function tests showed anaemia (haemoglobin < 10 g/dl), leucocytosis and hyperbilirubinaemia in five patients. CONCLUSION: We conclude that the 'UNICAL' drain is an effective and cheap device for percutaneous drainage of liver abscess under ultrasound guidance in a'resource poor environment'.

Kaposi sarcoma: changing trend in Calabar, south eastern Nigeria.

BACKGROUND/OBJECTIVE: Kaposi sarcoma (KS) is now the most frequently reported malignant skin tumour in some areas of Africa and was endemic in Africa before the advent of the human immunodeficiency virus (HIV) infection. The prevalence has increased with the emergence of HIV infection. The objective of this report is to describe the frequency, current clinical pattern, and anatomic distribution of KS in Calabar, south-eastern Nigeria and compare this with total malignant skin tumour. METHOD: All the patients with histologic diagnosis of KS presenting to the University of Calabar Teaching Hospital from January 2005 and December 2006 were analyzed as part of the wider study of malignant skin tumorus. Diagnosis of HIV was based upon enzyme linked immunosorbent assay. RESULTS: In our study, there were 11 patients (7 males and 4 females), with a male: female ratio of 1.75:1. This was the commonest malignant skin tumor (38%) followed by squamous cell carcinoma (SCC) (34.5%) and the age ranged from 21-60 years (mean 42.9 years). Nine patients (81.8%) were HIV positive including the 4 females (age ranged from 21-45 years) and 2 (18.2%) HIV negative, aged 59 and 60 years. The lower limb was the commonest site (50%). Atypical lesions involved the eyelids/nose and penis. CONCLUSION: KS is now the commonest malignant skin tumour in our region with the HIV related KS as the commonest clinical type. Successful prevention and treatment of HIV infection would reduce the prevalence of this tumour.

Cholecystectomy: indications at University of Calabar Teaching Hospital, Calabar, Nigeria.

BACKGROUND/OBJECTIVE: The relative rarity of gallbladder disease has been documented in various parts of Africa. Recently the incidence has been reported as rising in some African countries. We undertook this study to evaluate the indications for cholecystectomy in our center and compare with others. METHODS: This is a retrospective study of 18 open cholecystectomies in 10 years. RESULTS: The ages ranged from 13 and 65 years (mean 39.2 years). There were 15 females and 3 males (F:M? = ?ratio 5:1). Calculous cholecystitis 9 (50%) in patients, acalculous cholecystitis 8 (44.4%) and a patient with carcinoma of the gallbladder were offered cholecystectomy. The commonest stone was mixed multiple stones. CONCLUSION: The numbers of cholecystectomies attest to the rarity of gallbladder disease in this environment. This may be due to the high fiber and low cholesterol diet predominant in this costal population in southern Nigeria.

Lightning burns and traditional medical treatment: a case report.

BACKGROUND: Lightning strikes are relatively uncommon. In our culture where superstitions are strong and natural events often linked to evil forces, the traditional bonesetter/healer is often consulted first. Patients then seek orthodox care when complications develop. Patients also have difficulty accepting ablative treatment when indicated. OBJECTIVE: To present an usual case of bilateral upper limb burns caused by lightning and complicated by refusal to receive orthodox treatment. CASE REPORT: A 22 year old woman was struck by lightning while asleep. Instead of going to hospital, she was taken to a traditional healer where she spent two months before presenting with gangrenous upper limbs to hospital. Patient refused amputation and abandoned hospital against medical advice. CONCLUSION: This case report of bilateral upper limb burns resulting from lightning is rare. Importantly, the case highlights the role of ignorance, superstition and the disastrous results of traditional medical practice in our healthcare delivery.

Dermatofibrosarcoma protuberance: case reports.

BACKGROUND: Dermatofibrosarcoma protuberance (DFSP) is a relatively uncommon soft tissue neoplasm with intermediate to low grade malignancy, rarely metastasizing to regional lymph node or distant site but with proclivity for local recurrence due to inadequate resection. METHODS: We evaluated the clinical histories and treatment outcomes of five consecutive patients who had histologic diagnosis of DFSP in the University of Calabar Teaching Hospital between 2000 and 2004. RESULTS: The five cases reported had histologic diagnosis, sought for after excision. The male:female ratio was 2:3 with an age range of 17-35 years (mean, 26.6 years). Two of the lesions involved the neck and the other three sites involved were the anterior chest wall, groin and proximal thigh. Three of the lesions were recurrent. CONCLUSION: DFSP is an uncommon tumour, painless, cutaneous and multilobulated lesions should arouse the suspicion of this tumour. Early presentation, pre-operative histologic diagnosis and postoperative evaluation of resection margins would enhance the goal of ensuring adequate excision for improved outcome.

High tension electricity burns: a case report.

BACKGROUND: Recently in some areas there has been an upsurge in rural electrification. Though electricity is desirable, it is one of the most potentially dangerous commodities in the society. OBJECTIVE: We present this report highlighting the need for prevention as high tension electricity injury though uncommon is reputed for significant morbidity and mortality. METHOD: A case report of a 30 year old female trader with high tension electricity burns in a rural community seen in the University of Calabar Teaching Hospital, Calabar. RESULT: Successful management of 10% burn involving multiple sites. Patient's husband was electrocuted in the incident. CONCLUSION: High tension burns are reputed for significant morbidity and mortality hence the need for prevention. Strategies recommended should include safety of electrical installations, protective apparels for electricity workers as well as health education for consumers.

Neurofibrosarcoma - complicating neurofibromatosis-I: case report and review of relevant literature.

SUMMARY: Neurofibromatosis I is a multi systemic genetic and progressive disorder. Malignancy is one of the several complications and frequency of neurofibrosarcoma is significantly higher in NF-I patients. Neurofibromatosis was noted at 2 years after birth and overtime became malignant for which a below the knee amputation was done at the age of 29 years. Malignant transformation probably occurred prior to excision of the tumour at 26 years. Recurrence within 18 months is suggestive of inadequate excision and of a slow growing tumour. Diagnosis was missed despite previous presentation to other hospitals. This case presentation and review of literature highlights the need for early diagnosis and follow up, education of the patients and their families and the need for histological diagnosis for lesion removed to achieve overall improvement in morbidity and mortality. KEYWORDS: neurofibromatosis I, neurofibrosarcoma.

HLA class I phenotype and gene frequencies in parts of southern Nigeria.

HLA-A, B and C antigens were determined in 101 healthy subjects from two major and several minor ethnic groups in some parts of Southern Nigeria. Compared to earlier data based on a panel of expatriate Nigerians, significant differences were observed in antigen phenotype and gene frequencies particularly at the HLA-A locus. At least three antigenic specificities not previously observed in the expatriate Nigerians were detected in the present study. These included HLA-B8. B14 and CW1. These antigens however occurred at low frequencies. The antigens A23 and B7 were in positive linkage disequilibrium along with others which involved CW4 with B53 or B35. It is concluded from our findings that HLA polymorphisms in Nigerians may not be completely reflected in major population group studies alone. It is possible that more specificities may be detected by continued testing of the minor ethnic groups. The importance of this could be immense in disease association studies involving HLA genes as well as in anthropology.

Clinical and bacteriological study on childhood empyema in south eastern Nigeria.

Forty-eight children with empyema thoracis were seen over a seven-year period (December, 1982 to November 1989) in the University of Calabar Teaching Hospital, Calabar, Nigeria. This number accounted for 0.2% of all paediatric admissions during the period. The peak age incidence was 2 years and under. Pneumonia was the antecedent illness in about all cases, but surprisingly, measles played an insignificant role. Late consultation and severe morbidity were constant feature with anaemia and cardiac failure as frequent complications of the disease. Staphylococcus aureus, the predominant causative organism was resistant to penicillin and ampicillin but sensitive to gentamicin, cloxacillin and erythromycin. The initial use of the parenteral gentamicin or cloxacillin in treating children with empyema is therefore recommended. This study demonstrates the rarity and low fatality (6%) of childhood empyema in Calabar, but protracted hospitalisation and exorbitant medication involved make it an important disease. Perhaps, it can be completely eliminated if parents are educated enough to avoid late reporting of childhood respiratory disease.

PIP: Physicians analyzed December 1982-November 1989 data on 48 2-60 month old children with empyema thoracis at the University of Calabar Teaching Hospital in southeastern Nigeria to determine the incidence and etiology of empyema thoracis in this region. The incidence rate stood at 2/1000 pediatric admissions. 3 children died (6.3%), all of heart failure. 47 children suffered from fever, cough, and breathlessness, the symptoms for pneumonia. Even though bronchopneumonia is a common complication of measles which occurs frequently in Calabar, only 3 children (6.25%) also had measles. The most frequent complication of this accumulation of pus in the thoracic cavity was congestive heart failure (16 cases). 47 patients suffered from anemia (hemoglobin levels 11 gm/dl). Hemoglobin levels of 54% of all patients decreased over time to 8 gm/dl. In fact, 2 children had hemoglobin levels of 4.4 gm/dl and they experienced cardiac failure. Laboratory personnel were only able to examine pleural aspirates from 37 patients. They did not detect any organisms in 27% of these aspirates. This may have been due to parent's widespread practice of giving medication to all the children before coming to the hospital. 45.9% of the aspirates only grew Staphylococcus aureus while another 8.1% grew it and other pathogens. About 90% of the pathogens were resistant to ampicillin and penicillin and almost 90% were sensitive to cloxacillin, gentamicin, and erythromycin. Cloxacillin was very expensive and parenteral erythromycin was unavailable. Nevertheless the pediatricians used parenteral gentamicin and cloxacillin. The parents were responsible for buying the antibiotics which tended to be costly. All the patients required emergency closed tube thoracostomy drainage within 24 hours of admission. 83.3% remained in the hospital for 2 weeks and 33.3% for 1 month. Despite the rarity of empyema, long hospitalization and expensive drugs make it an important disease in Calabar.

Epidemiology of death in the emergency department of a tertiary health centre south-south of Nigeria.

BACKGROUND: The emergency department (E.D) of any hospital is an important entry point of critically ill patients. The initial management of these patients is often challenging, and for valuable lives to be saved, the in fracture and manpower should be up to date. OBJECTIVE: To analyze the epidemiology of death in our Emergency Department within 72hours after admission, the death rate, and to establish any contributory factors. METHOD: Demographic data, time of arrival at the ED, physical finding, the Glasgow coma scale(GCS), the injury severity score(ISS), the diagnosis, investigations done, treatment offered, the time of death and the autopsy report, were entered into a Proforma. These data was analyzed using EPI-Info statistical programme version 3.4.3 of 2007. RESULTS: Four thousand and eleven (4,011) patients were seen in the E.D during the period. A total of three hundred and fifty five (355) mortalities were recorded. Their ages ranged from 4-87years, with an average of 34.5years. The male: female ratio was 2.1:1. The overall mortality in the hospital during the period was 859: the E.D mortality figure representing 41.3%. Fifteen patients were brought in dead. The 355 deaths fell into two categories: trauma and non-trauma. One hundred and forty-seven (41.4%) persons died from trauma; road traffic accidents (RTAs) accounting for 118 (80.3%). Two hundred and eight (58.6%) persons died from nontrauma related causes, with chronic cardiovascular disorders been the most frequent cause of death 52[25.0]. Majority of the mortalities were between 26-50 years age range. 86.2% of the mortalities presented late, greater than 6hours after the incidence. Within the 72 hours period, only 129(36.3%) were able to do the requested tests. Out of the 355 deaths, only 4[1.1%] were autopsied. An in-hospital 72hours death rate of 8.6 was recorded. CONCLUSION: Road traffic accidents and cardiovascular disorders are the common causes of emergency death in UCTH. A recorded death rate of 8.6% is high, suspected contributory factors include systemic deficiencies such as the lack of a trauma system, prehospital care; late presentation, the role of chemist operators, traditional healers, and delayed referral systems.

Squamous cell carcinoma in South-Eastern equatorial rain forest in calabar, Nigeria.

BACKGROUND: In North America and Europe, 80% of invasive skin cancers are basal cell carcinoma while 20% are squamous cell carcinoma (SCC). In contrast, African studies reveal a preponderance of SCC. Risk factors are grouped into solar and nonsolar. Oculocutaneous albinism (OCA) is a known risk factor for skin cancer in Africans. Their contributions vary with race and geographic region. This study sought to evaluate the pattern, risk factors, and outcome of management of this lesion in our setting. METHOD: All the patients with histologic diagnosis of SCC between January 2006 and December 2007 were prospectively studied as part of the wider study of skin cancers. RESULTS: The 19 patients (12 males and 7 females) whose ages ranged between 16 and 70 years (mean = 46.2 years) accounted for 51.4% of skin malignancies. Marjolin's ulcers were recorded in 12 patients (63.2%) while 7 patients (36.8%) were non-Marjolin's including 2 OCA patients. The limb was the commonest site involved (57.9%). The outcomes were poor in some cases because of late presentation after topical treatment. CONCLUSION: Chronic ulcers, inflammation, and albinism were identified predisposing factors. Public health education on prevention, early presentation, and surgical evaluation of chronic ulcers would improve outcome.

Cutaneous manifestations of lightning injury: a case report.

BACKGROUND: Lightning injuries are relatively uncommon and have been a subject of awe since primitive times. It most significantly affects the cardiorespiratory, nervous, and integumentary systems. Surprisingly, cutaneous burn injuries caused by lightning are usually superficial. OBJECTIVE: To present the cutaneous manifestations of lightning injuries and the sequelae of improper management. CASE REPORT: A 22-year-old woman presented with cutaneous manifestations of lightning-induced burns and bilateral upper limb gangrene after 2 months of improper treatment. She refused amputation after counseling and left the hospital. CONCLUSION: This is a rare case of burns with cutaneous manifestations peculiar to lightning injury. These features serve as evidence of lightning injury, when in doubt, especially in societies where superstition is rife. Education concerning the nature of lightning and proper management would improve outcome.

HLA-DRB1 leprogenic motifs in nigerian population groups.

Amino acid residues involved in the peptide binding groove of HLA-DRB1 alleles were examined in three Nigerian ethnic groups with leprosy (n = 287) and 170 controls to determine the role of DRB1 alleles in disease outcome with Mycobacterium leprae. Nine positively charged motifs and two others with neutral charge to the binding groove were detected. These motifs occurred more frequently in leprosy (leprogenic) than was expected by chance (P < 0.0001). In contrast, five motifs with net negative or 'modified' neutral charges to the pocket were negatively associated with leprosy. We conclude that clinical outcome of infection with M. leprae is largely determined by a shared epitope in DRB1 alleles marked by several motifs. These motifs occur in otherwise normal DRB1 alleles, characterized by net positive or neutral charges in the binding groove. We hypothesize that these polarities cause poor binding of DRB1 to M. leprae. On presentation, the signal via the T cell receptor results in muted cell-mediated immunity. The resulting response translates to various forms of leprosy depending on degree of charge consonance between M. leprae and host DRB1 allele. Other factors within or without the HLA complex, such as the T cell receptor repertoire, may also influence the resulting disease.