Tetanus: continuing problem in the developing world

Despite diligent efforts by the World Health Organization and the governments of developing world countries, tetanus persists as a global health problem. This retrospective study was undertaken to assess the outcome for victims of tetanus presenting to the Baptist Medical Centre in Ogbomoso, Nigeria and to develop better management techniques for future patients. Sixty patients (46 males, 14 females) with nonneonatal tetanus were seen over a 5-year period (1995-1999). The mean age was 26 years, and 74% were 30 years or younger. All patients were treated with antitetanus serum, antibiotics, wound débridement (when a wound was identified), and antispasmodics. No patients underwent tracheostomy or gastrostomy. The mortality rate was 44%. Factors significant for predicting mortality were age greater than 14 years, occupation as a farmer, short incubation period, short symptom duration, high degree of severity on presentation, and high temperature during hospital care. The best hope for improvement in the treatment of tetanus in our institution is more conscientious titration of antispasmodics to control spasms without causing significant respiratory depression. The only real hope for reducing the global mortality for tetanus, however, lies in renewed immunization efforts by all health care providers in developing world countries, not just community health workers.

Incidence of Umbilical Hernia in African Children: Redefinition of "Normal" and Reevaluation of Indications for Repair

This study was undertaken to assess the degree of ubiquity of umbilical hernias (UHs) in Nigerians and to determine if a laissez faire approach to the presence of UHs is justified. A prospective evaluation was conducted of the umbilical area of 4052 Nigerians living in the vicinity of the Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria. The diameter of the fascial defect was measured with the subject supine and the protrusion of the umbilical skin with the subject erect. Subjects were divided into three groups: group 1 (1 month to 18 years old); group 2 (older than 18 years); and group 3 (pregnant women in an antenatal clinic). "Outies" (defined as any protrusion of the umbilical tip past the periumbilical skin) were present in 92% of group 1, 49% of group 2, and 90% of group 3 subjects. UHs (defined as protrusion of at least 5 mm and diameter of at least 10 mm) were present in 23% of group 1, 8% of group 2, and 15% of group 3 subjects. Spontaneous closure of UHs seems to occur until age 14. A retrospective analysis identified 11 patients undergoing emergency operations for UH-related problems during the past 15 years. With a low incidence and 0% mortality rate associated with management of these emergencies, a policy of prophylactic repair is not justified at BMCO. Because most of the children we examined had outies, repair for cosmetic reasons is rarely requested. The only logical indication for repair of UHs at BMCO is incarceration, and this rarely occurs.

Prospective randomized comparison of two preoperative skin preparation techniques in a developing world country

Povidone-iodine (PI) is a scarce and expensive item for some hospitals in developing countries. This prospective, randomized study was performed at Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria to determine if the use of PI for preoperative skin preparation would result in a lower postoperative wound infection rate and to identify other factors influencing the infection rate. Two hundred patients undergoing inguinal hernia repair were randomized to receive skin preparation with either: (1) locally available, inexpensive market soap and methylated spirit or (2) imported PI. The two groups were equally stratified. The overall postoperative wound infection rate was 5.5%, and there was no significant difference between the groups (5.1% vs. 5.9%). Factors that did not affect the infection rate included gender, age, type of anesthesia, type or duration of the operative procedure, and number of breaks in optimal technique. There were eight abscesses and three cases of cellulitis without suppuration diagnosed an average of 10 days postoperatively. Staphylococcus was the only bacterium identified on Gram stain or culture. The expense of procuring PI is not justified at BMCO. Available funds may better be used for preoperative antibiotics or for improvement in hospital infrastructure, which should result in fewer breaks in optimal operating room technique.

Operative management of thyroid abnormalities in a general medical practice hospital in sub-Saharan Africa

This is a retrospective analysis of 82 patients undergoing thyroid operations in a general medical practice hospital in sub-Saharan Africa. All patients complained of neck swelling, and in 75% of patients this was the only symptom. Indications for operation included cosmesis in 74%, suspected malignancy in 13%, hyperthyroidism in 7% and pressure symptoms in 5%. Operative complications included recurrent laryngeal nerve injury in two (2.4%), wound haematoma in two (2.4%), wound infection in three (3.6%) and hypoparathyroidism in one (1.2%). There were no deaths and no instances of thyroid storm. Thyromegaly can be operatively managed in a hospital such as ours with a relatively low morbidity rate using conservative gland extirpation techniques. This conservative approach may result in under treatment for thyroid malignancies but should result in a lower incidence of recurrent nerve damage and hypoparathyroidism in the majority of people who undergo thyroidectomy solely for cosmetic indications.

Aortoiliac occlusive disease and gastrointestinal malignancy: changing therapeutic options

Treatment of gastrointestinal malignancy encountered unexpectedly during procedures involving the abdominal aorta continues to be debated. Previously, simultaneous vascular procedures with intra-abdominal malignancy were rare. Most underwent vascular reconstruction followed by a delayed aortic procedure. With recent improvement in axillobifemoral graft patency, a one-stage procedure for aortoiliac disease should be entertained. We recently encountered a small bowel lymphoma while beginning an aortic replacement for aortic occlusion. Resection of a near-obstructing small bowel tumor immediately after axillofemoral reconstruction provided treatment of both entities at one time. Since the early description of axillofemoral bypass in 1963, varying success with extra-anatomic bypass has been reported. Early data for axillofemoral bypass were dismal, but with recent technical and graft improvements patency has been improved. Occult malignancy during aortic procedures is uncommon, about 2 to 4 per cent, but when met is usually dealt with after the patient recovers from the vascular procedure. With improvements in extra-anatomic bypass results, a single operative period can be entertained.

Typhoid intestinal perforations in Nigerian children

This study was a retrospective analysis of 75 children with perforated typhoid enteritis treated at the Baptist Medical Centre in Ogbomoso, Nigeria over a 4-year period. The mean age was 11.4 years. The usual symptoms were fever and abdominal pain, with a mean duration of 10.5 days. The diagnosis of perforation was usually based on the history and physical examination alone. The time interval from hospital presentation to operation was 11 hours, during which intravenous crystalloid and antibiotics were administered. Among the 75 children, 53 (71%) had a single perforation, and 22 had multiple perforations. Débridement and two-layered closure was performed in 71 (95%) and resection with anastomosis in 4 (5%). Ileus resolution was usually not complete until the eighth postoperative day, and the mean time until the surviving children were afebrile was 10 days. Complications other than death occurred in 7 (9%) children, and there were 15 deaths (20% mortality). All deaths were attributed to overwhelming sepsis, and all but one of the deaths occurred during the first 72 postoperative hours. The only factor statistically significant as a predictor of mortality was the duration of abdominal pain. Improvement in perioperative management including intensive care nursing and more effective antibiotics, although expensive, could result in decreased mortality. A significant decrease in mortality can occur only when the prevention of typhoid fever becomes a higher priority than its treatment.

Dephosphorylation and deactivation of Ca2+/calmodulin-dependent protein kinase II in betaTC3-cells is mediated by Mg2+- and okadaic-acid-sensitive protein phosphatases

The alpha-toxin-permeabilized betaTC3 cell has been utilized as an experimental model for the identification of protein phosphatases responsible for the dephosphorylation and deactivation of Ca2+/calmodulin-dependent protein kinase II (CaM kinase II) in situ. In this model, the elevation of Ca2+ from 0.05 to 10 microM induced the near-total conversion of CaM kinase II into a Ca2+/calmodulin-independent (autonomous) form characteristic of autophosphorylated, activated enzyme. On the removal of Ca2+, the activation state of CaM Kinase II rapidly returned to prestimulated levels. This reversal was slowed, but not prevented, by the inhibitors of protein phosphatase-1 (PP-1) and PP-2A, okadaic acid and calyculin A, and by the selective chelation of Mg2+ by the addition of EDTA. Near-complete prevention of enzyme deactivation, however, was observed in the combined presence of both okadaic acid and EDTA. Under these conditions, CaM kinase II phosphatase was more sensitive to calyculin A relative to okadaic acid, characteristic of the involvement of PP-1. CaM kinase II deactivation was not affected by FK-506, eliminating the involvement of PP-2B in this process. These data suggest that CaM kinase II dephosphorylation and deactivation in the pancreatic beta-cell is mediated by the combined action of an okadaic-acid-sensitive phosphatase and a Mg2+-dependent phosphatase, such as PP-2C.

Intussusception in children: international perspective

Fifty consecutive cases of children with intussusception treated at a hospital in a developing country were compared with 50 consecutive cases treated at an American inner city children's hospital and 50 consecutive cases treated at an American referral children's hospital. The plan was to recommend ways of improving the treatment of children with intussusception in the developing world. Nonoperative reduction was attempted in the two American hospitals but was not available in the developing world hospital where all children were treated operatively. Children in the developing world hospital had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality of 18%. There were no deaths in either American hospital. The poorer outcome for developing world children was related to delay in treatment, the higher incidence of nonviable bowel, and the lack of adequate nursing care for acutely ill children. The use of nonoperative reduction would not have significantly improved the mortality rate among the developing world children. The mortality can best be reduced by: (1) earlier recognition and treatment of the intussusception; and (2) improvement in the postanesthetic care with better monitoring leading to prompt recognition and treatment of postoperative complications.

The outcome of suprapubic prostatectomy: a contemporary series in the developing world

OBJECTIVES

To assess the appropriateness of the technique of suprapubic prostatectomy using a removable bladder neck partition suture for use in a developing world hospital and to provide contemporary open prostatectomy outcome data currently lacking in the world's literature.

METHODS

From 1984 to 1994, 240 consecutive patients presenting to a developing world hospital with acute urinary retention underwent suprapubic prostatectomy using a removable bladder neck partition suture. The average length of time from bladder decompression until operation was 2.5 months. The outcome of these cases was retrospectively analyzed.

RESULTS

The overall early complication rate was 19.6%. There were no deaths. The transfusion rate was 4.6%. Clot retention occurred in 6.7%, and 2.9% required return to the operating room for evaluation. For the second half of the series, the early complication rate decreased to 8.3%, the clot retention rate to 0.8%, and the transfusion rate to 1.7%. Other early and late complications were minimal. The length of delay from decompression until operation did not affect outcome.

CONCLUSIONS

The technique of suprapubic prostatectomy using a removable bladder neck partition suture is appropriate for use in developing world hospitals because of its low morbidity and mortality rates. The outcome in this contemporary series of open prostatectomy cases compares favorably with the outcome from reported contemporary transurethral resection of the prostate (TURP) series. These data demonstrate that suprapubic prostatectomy is an acceptable option when the patient's anatomy or the state of local medical facilities precludes TURP.

Perforated typhoid enteritis: operative experience with 108 cases

A retrospective review of 108 consecutive patients with perforated typhoid enteritis managed operatively over a 4-year period at Baptist Medical Centre, Ogbomoso, Nigeria is presented. There were 75 males and 33 females with an average age of 19.7 years. Presenting symptoms were fever, abdominal pain, vomiting, and either diarrhea or constipation. One hundred patients (93 percent) underwent debridement of the perforation and two-layer bowel closure. Postoperative morbidity included intraabdominal abscess, wound dehiscence, and subsequent bowel perforation. Most of the 35 deaths (32 percent mortality) were attributed to overwhelming sepsis which progressed despite aggressive operative management and antibiotic administration. The key to improved survival in this deadly disease lies not in a better operation or improved perioperative care but in the prevention of typhoid fever by providing safe drinking water and improved sanitation methods for all of the global community.

Host immunocompetence in genitourinary cancer: relation to tumor stage and prognosis

We used delayed hypersensitivity skin testing, in vitro lymphocyte blastogenesis, and lymphocyte surface markers to examine the relationships among host immunologic competence, tumor type, tumor stage, prognosis, and the effects of cancer treatments in patients with genitourinary cancer. We found correlations between host immune competence and both tumor stage and prognosis among patients with bladder cancer, renal cell cancer, and those with advanced prostate cancer not receiving endocrine therapy, but not among patients with prostate cancer receiving endocrine therapy. Radiation and chemotherapy suppressed T-lymphocyte levels, but a chemotherapy-induced tumor remission resulted in a rebound of T-cell counts to above normal levels. In tissue sections of bladder cancers, regions of mononuclear infiltration were virtually devoid of cells with complement receptors or receptors for cytophilic antibody, which suggested that lymphocytes infiltrating bladder cancers are predominantly T-lymphocytes.

In vivo and in vitro measurements of the relationship of human squamous carcinomas to herpes simplex virus tumor-associated antigens

An additional 244 unfiltered sera have now been studied in a series of controlled, coded tests to determine the relationship of squamous carcinomas of the head and neck and cervix to the presence of complement-fixing antibodies to herpesvirus-tumor-associated antigens (HSV-TAA) in both tumor-bearing and cured patients. Ninety % of sera from patients with squamous carcinomas had antibodies to HSV-TAA, in contrast to 11% of sera from patients with nonsquamous cancers and 4% of sera from noraml individuals. The temporal relationship of Stage 1 laryngeal carcinomas suggests that HSV-TAA appearance precedes the immune defects. An in vitro correlate of the previously demonstrated specific delayed hypersensitivity reactions in controlled skin tests of squamous carcinoma patients with HSV-TAA is reported. In leukocyte migration inhibition tests, the migration indices after incubation with HSV-TAA of peripheral blood leukocytes from patients with squamous carcinoma (x = 0.847) were in definite contrast to migration indices seen for normal leukocytes (x = 1.037) and patients with nonsquamous solid cancers (x = 1.03). Thus, these polypeptides elicit both humoral antibody response and cell-mediated reactivity.

High dose methotrexate as a preoperative adjuvant in the treatment of epidermoid carcinoma of the head and neck. A feasibility study and clinical trial

Thirty patients with operable epidermoid carcinoma of the head and neck were treated with intravenous high dose methotrexate and leucovorin rescue prior to resection. Their clinical courses were compared with those of thirty randomly selected patients matched for tumors site and clinical stage who were treated by surgery alone. No medical or surgical complications associated with methotrexate were encountered. An objective decrease in tumor size (primary lesion or nodal metastases) was noted prior to resection in twenty-three patients (77 per cent). The number of recurrences in the two groups was similar. However, these was a significantly greater disease-free interval in the methotrexate-treated patients (p less than 0.05). No significant differences in survival have been noted to date between the two groups. In view of the absence of complications, the regressions in tumor size, and the increase in postoperative disease-free interval in this trial, evaluation as preoperative adjuvants of higher doses of methotrexate and of other chemotherapeutic agents in combination with methotrexate appears warranted.

Histocompatibility antigens and solid malignant neoplasms

To evaluate the relation between histocompatibility antigen phenotypes and solid malignant neoplasms, HL-A type was determined in 633 cancer patients and compared with those of 489 normal controls. HL-A8 was elevated in patients with squamous cancer, melanoma, and adenocarcinoma. The highest incidence occurred in patients with salivary gland adenocarcinoma (67% vs only 17% in normal controls). A threefold increase in HL-A5 was detected in patients with connective tissue sarcomas (28% incidence vs 9% in normal controls). Antigen frequencies did not vary when analyzed by time of diagnosis or interval after treatment. The finding that certain malignant neoplasms have associations with increased frequency of individual HL-A antigens may give clues to cause and genesis for these tumors.

Prolonged depression of cellular immunity in cured laryngopharyngeal cancer patients treated with radiation therapy

Immune competence was evaluated in cured patients who had been treated by irradiation for carcinoma of the laryngopharynx, and compared with that of similar patients treated by surgery alone, and normal controls. Cellular immunity was determined by quantitation of in vitro phytohemagglutinin (PHA)-induced lymphocyte reactivity and peripheral blood thymus-dependent lymphocyte (T cell) levels. Humoral immunity was assessed by measurement of serum immunoglobulin levels and by the effect of serum on in vitro normal lymphocyte reactivity to PHA. In 21 patients who were studied for 4-23 years (mean 8.4) after surgical treatment alone for laryngopharyngeal carcinoma, neither cellular nor humoral immunity differed from that of 44 controls. In contrast, 14 patients who had been irradiated and subsequently cured for 4-15 years (mean 9.0) prior to evaluation displayed significantly impaired cellular immune competence when compared to normals and patients treated by surgery alone. Since previous determinations of the effects of radiation therapy have been in patients who received irratiation to the thymic region or large area of bone marrow, this study indicates that radiation therapy for cancer administered via portals that encompass a minimal area of the immune system may be associated with prolonged impairment of cellular immunity.

Correlations among cutaneous reactivity to DNCB, PHA-induced lymphocyte blastogenesis and peripheral blood E rosettes

Comparisons of the results obtained in a study of fifty-two patients with genitourinary malignancies using three assays to monitor the thymus-dependent immune system (delayed cutaneous hypersensitivity to DNCB, PHA-induced lymphocyte blastogenesis, and peripheral blood E rosette-forming lymphocyte counts) yielded statistically significant positive correlations between the DNCB and PHA assays in twenty-one of twenty-eight instances, the DNCB and E rosette assays in thirteen of sixteen instances, the PHA and E rosette assays in twenty-eight of thirty-six instances, and among the DNCB, PHA and E rosette assays in ten of fourteen instances. The results suggest that both PHA-stimulated lymphocyte blastogenesis and peripheral blood E rosette-forming lymphocyte levels provide meaningful in vitro correlates of cell-mediated immunity.

Antibodies to herpesvirus nonvirion antigens in squamous carcinomas

Serums from tumor-bearing patients, cured patients, and normal subjects were examined for antibodies to the separated complement-fixing reactive components of nonvirion antigens of herpesvirus type 1 and type 2. The occurrence of antibodies to the antigens was similar in serums from tumor-bearing patients and cured patients. Antibodies to the antigens were observed among 21 of 24 (87 percent) cervical cancer cases, 44 of 49 (90 percent) laryngeal cancer cases, 15 of 24 (62 percent) cases of squamous cell carcinomas of the head and neck excluding the larynx, 2 of 24 (8 percent) nonsquamous cell cancer cases, and 3 of 51 (6 percent) normal subjects. By contrast, no differences were found in the titers of neutralizing antibodies to the virus in serums from laryngeal cancer patients and controls. The observations support an etiologic role of herpesviruses in cervical cancer and in laryngeal cancer, and possibly other squamous cell cancers of the head and neck.