Efficacy of dienogest vs combined oral contraceptive on pain associated with endometriosis: Randomized clinical trial

OBJECTIVE

To compare the efficacy of dienogest with the combined oral contraceptive pill (COC) Yasmin for the control of endometriosis-associated pelvic pain.

STUDY DESIGN

Seventy women with endometriosis-associated chronic pelvic pain, dysmenorrhoea or both for >6 months were randomized to either dienogest (Visanne) 2 mg/day or monophasic COC (Yasmin, 0.03 mg ethinyl estradiol and 3 mg drospirenone) for 24 weeks. The primary efficacy variable was change in non-cyclic pelvic pain and dysmenorrhoea from baseline to end of treatment, assessed using a visual analogue scale (VAS). The secondary efficacy variable was change in the Biberoglu and Behrman (B&B) scale scores for chronic pelvic pain, dysmenorrhoea and dyspareunia. Health-related quality of life (HRQoL) was evaluated using the Endometriosis Health Profile-30 (EHP-30) questionnaire at baseline and 24 weeks. Safety variables included incidence of side-effects, bleeding pattern and treatment tolerability.

RESULTS

Both treatments improved the mean VAS score for endometriosis-associated pelvic pain significantly: mean difference 6.0 [95% confidence interval (CI) 4.9-7.1; p < 0.0001] in the dienogest group and 4.54 (95% CI 3.1-5.9; p < 0.0001) in the COC group; the difference between them was not significant (p = 0.111). Similarly, both dienogest and COC improved HRQoL in various core and modular segments of the EHP-30 questionnaire with comparable requirements for supplemental pain medication (p = 0.782 and 0.258 at 12 and 24 weeks, respectively), and redistribution of the B&B severity profile for chronic pelvic pain (p = 0.052 and 0.526 at 12 and 24 weeks, respectively), dysmenorrhoea (p = 0.521 and 1 at 12 and 24 weeks, respectively) and dyspareunia (p = 0.376 and 0.835, respectively). Nevertheless, dienogest was associated with fewer side-effects, and hence had a better safety and tolerability profile than COC.

CONCLUSIONS

Dienogest (2 mg/day) is comparable to the COC Yasmin for the relief of endometriosis-associated pelvic pain and improvement in HRQoL.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov under number NCT04256200; date of registration 15/1/2020 (registered retrospectively).

TENS for surgical stabilisation of acetabular fracture in the skeletally immature: A novel technique

BACKGROUND

Acetabular fractures in childhood are rare and the literature is scarce to describe a standard protocol in surgical management of these injuries. As the patient is still growing, it warrants a detailed assessment with a sound surgical plan if operative intervention is deemed necessary to prevent late complications. Throughout literature, most fixation rely on using pins, screws, plates or combination of the three which require large surgical exposure and risk of secondary physeal injury, hence we come up with a method of using the Titanium Elastic Nail System (TENS) to overcome this issue. We describe a novel technique in managing acetabular fractures in this group of patients using the TENS.

METHOD

An 8 year old girl with a diagnosis of right anterior column posterior hemitransverse acetabular fracture was fixed with 3 TENS for supra-acetabular, anterior column and posterior column fragments. Surgery was performed in a minimally invasive manner. No drilling was performed during the surgery and implant insertion is done manually.

RESULTS

Advantages of this procedure include minimally invasive surgery with smaller wounds, minimal intraoperative bleeding and theoretically reduces the risk of premature fusion of the triradiate cartilage. Patient is allowed early rehabilitation with this method.

CONCLUSION

This novel method provides an alternative to traditional usage of wires, pins, plates and screws as is described in most literature. However, it requires the surgeon to appreciate that the safe corridors for the implant are much narrower than adults. We recommend this technique for fractures that are deemed suitable for intramedullary fixation and further research in the future will be needed.

Cumulative Live-Birth Rates by Maternal Age after One or Multiple In Vitro Fertilization Cycles: An Institutional Experience

Background

The aim of this retrospective study is to investigate the cumulative live birth rate (CLBR) following one or more completed in vitro fertilization (IVF) cycles (up to 6 cycles) stratified by maternal age and type of infertility.

Materials and Methods

In this retrospective study, five hundred forty-seven women who received 736 fresh ovarian stimulation/embryo transfer cycles between January 2016 and December 2016 were included in the study at a tertiary care center located in Lebanon.

Results

In all women, the live birth rate for the first cycle was 33.0% [95% confidence interval (CI): 27.8-38.2]. The CLBR showed an increase with each successive fresh cycle to reach 56.9% (95% CI: 51.2-62.4) after 3 cycles and 67.9% (95% CI: of 62.5-73.0) after 6 cycles. The CLBR following 6 cycles reached 69.9% (95% CI: 63.8-75.6) in women younger than 35 years. In women older than 40 years, however, the live birth rate for the first cycle was significantly low at 3.1% (95% CI: 0.3-9.5) with a plateau in success rates after 4 cycles reaching 21.9% (95% CI: 9.2-40.0). Couples with different types of infertility had CLBRs ranging from 65% to 72%, with the exception of women with low ovarian reserve, where CLBRs reached 29.4% (95% CI: 10.3-56.0).

Conclusion

The CLBR at a referral center in a Middle Eastern country reached 67.9 % after 6 cycles, with variations by age and type of infertility treatment. These findings are encouraging for patients insisting to extend their treatment beyond 4 to 5 cycles.

Effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures: a randomized clinical trial

BACKGROUND

Laparoscopic surgery has become a standard of care for many gynecological surgeries due to its lower morbidity, pain and cost compared to open techniques. Unfortunately, the use of carbon dioxide (CO2) to insufflate the abdomen is the main contributor to post-operative shoulder pain.

METHODS

We aim to assess the effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures. We hypothesize that maintaining the patient in Trendelenburg for 24 h postoperatively will significantly decrease postoperative shoulder pain and analgesic consumption. After obtaining written informed consent, 108 patients were prospectively randomized into two groups. In the control group, patients underwent standard gynecologic laparoscopic procedures; then after passive deflation of the pneumoperitoneum at the end of the surgery, the patients were placed in supine head up position in the post anesthesia care unit (PACU) and received our institution's common postoperative care. Patients in the intervention group were subjected to the same maneuver but were positioned in a Trendelenburg position (20 °) once fully awake and cooperative in the PACU and retained this position for the first 24 h. Numerical rating scale (NRS) was used to assess shoulder pain and nausea upon patient arrival to the PACU, at 4, 6, 12 (primary outcome) and 24 h postoperatively. Time to first rescue pain medication, total rescue pain medications and overall satisfaction with pain control were recorded. 101 patients were included in the final data analysis.

RESULTS

Both groups were comparable in terms of baseline characteristics. NRS pain scores were significantly lower in the intervention group at 12 h compared to the control group (0 [0-1] versus 5 [1-4], p < 0.001), furthermore improvement in postoperative shoulder pain between time of arrival to PACU (time zero) and 12 h postoperatively was significantly higher in patients allocated to the experimental group compared to the control group. Pain scores were significantly lower in patients allocated to the experimental group versus the control group (0 [0-1] versus 5 [1-4], p < 0.001).

CONCLUSION

In conclusion, Trendelenburg position is an easy non-pharmacologic intervention that is beneficial in reducing postoperative shoulder pain following gynecologic laparoscopic surgery.

TRIAL REGISTRATION

Retrospectively registered at Clinicaltrials.gov, registration number NCT04129385,  date of registration: June 28, 2019.

Street dust heavy metal pollution implication on human health in Nicosia, North Cyprus

The consequence of carcinogenic and non-carcinogenic health risks of the heavy metal concentrations in street dust of North Cyprus is yet to be reported. This study is aimed at investigating the concentration of six different heavy metals' concentration explicitly: As, Cu, Zn, Ni, Cr, and Pb, along leading highways in Nicosia. The result obtained was analyzed using an X-ray fluorescent machine. Multivariate and statistical methods were applied for the data analysis using xlstat MS-excel; furthermore, index of geo-accumulation (Igeo) and human health risk assessment using exposure pathways as defined by United State Environmental Protection Agency (USEPA) pollution mode were also used for level assessment and health risk implications. The average (M ± SD) concentrations of the metals in the dust are as follows: As (17.48 ± 1.53 mg/kg), Cu (51.86 ± 8.60 mg/kg), Cr (321.14 ± 8.20 mg/kg), Pb (35.62 ± 8.54 mg/kg), Ni (64.79 ± 8.72 mg/kg), and Zn (136.13 ± 30.85 mg/kg). Variation coefficient, Vc, and principle component analysis (PCA) suggested that As, Cr, Ni, and Pb have same source of pollution emission from both natural and anthropogenic activities, Zn from traffic emission while Cu from natural source. However, the result was compared with other nearby towns bordering North Cyprus; all the metal shows similar pattern of pollution with the exception of Cr which is 5 and 11 times higher than street dust of Amman (Jordan) and Tokat (Turkey), respectively. Additionally, Igeo result has the following decreasing order: Zn > Cr > Pb > Ni > Cu > As and also revealed that the As, Cu, and Ni have originated from natural source. Cr has mix source: one from traffic and the other one from atmospheric deposition. Also, Pb is emitted from industrial pollution, whereas 80% of Zn are from traffic-related emissions. The non-carcinogenic health risk (hazard quotient (HQ) and hazard index (HI)) follows the order Cr > As>Ni > Pb > Zn > Cu for children and adults. It is found that the HI of As, Cu, Ni, Pb, and Zn is less one; hence, the street dust does not exhibit non-carcinogenic health risk. But that of Cr content is greater than one, with HI values of Cr 1.44E+02 and 1.55E+01 for children and adults, respectively. The result for carcinogenic health risk (total cancer risk (TCR)) has the following order: Pb (1.42E-05) > Cr (4.81E-09) > (Ni 1.35E-09) > As (1.96E-10). With all the values less than threshed hole limit of TCR ≥ 10^-4, street dust does not possess carcinogenic health risk for the entire values of six heavy metals considered in this work.

Vaginoscopic resection of vaginal septum

We report the resection of a vaginal septum while preserving the virginity of a 12-year-old girl with Herlyn-Werner-Wunderlich Syndrome (HWWS) having a didelphys uterus, obstructed hemivagina, and an ipsilateral renal agenesis with follow-up at 18 months. Successful resection of the vaginal septum with conservation of the hymenal ring and complete drainage of both the hematocolpos and the hematometra were achieved. Cyclic dysmenorrhea and pelvic pain were completely resolved on follow-up visits at 4, 6, and 18 months. Office hysteroscopy performed during the last follow-up visit revealed a patent vaginal vault without evidence of adenosis or recurrence of the vaginal septum. Vaginoscopy is a safe, convenient, and efficient diagnostic and therapeutic modality that can be used in the management of patients with an obstructed hemivagina. It maintains the patient's virginity and it is useful in patients with a restrictive vaginal opening or narrow vaginal canal. Furthermore, the hysteroscopic excision of the vaginal septum offers minimal risk of recurrence of the septal defect.

Histological study of smoke extract of Tobacco nicotiana on the heart, liver, lungs, kidney, and testes of male Sprague-Dawley rats

Background:

Some of the effects of tobacco on man's health are well documented in many scientific reports. Whenever tobacco is used either in smoked or chewed form, nicotine is absorbed by the lungs and oral cavity and is spontaneously moved into the bloodstream where it is circulated throughout the body system.

Materials and Methods:

Ten male Sprague-Dawley rats were used for this investigation. The animals were randomly assigned into two groups, A and B, of five animals each. The animals in group B (treatment group) were exposed to smoke from a completely burnt 0.74 g leaf extract of Tobacco nicotiana, wrapped in 0.5 g of sterilized cotton wool for 5 minutes three times daily (7 am, 10 am, and 1 pm). The animals in group A (control group) were exposed to smoke from completely burnt 1.24 g of sterilized cotton wool with the same parameters as observed with the treatment groups. The duration of exposure was 5 days. Three hours after the last exposure, all the animals were killed by cervical dislocation. The heart, liver, lungs, kidney, and testes were carefully excised, blotted dry, and fixed in formol saline for histological analysis using Hematoxylin and Eosin stain.

Results:

Using the light microscope, it was observed that the histoarchitectural profiles of the studied organs in the sections obtained from the control animals were well preserved. Histopathological observations of the heart, liver, lungs, kidney, and testes in the treated animals showed a varying pattern of histological alterations, and distortions such as mild edema and occasional destruction of myocardial fibers, degeneration of the hepatocytes, reduction in the population of the germ cells, enlargement of the alveoli, alveolar hemorrhage, shrinkage of the glomerulus and glomerular hemorrhage were observed in the sections of the organs of the study of the animals in the treatment group when compared with the control group, hence showing that the smoke extract of Tobacco nicotiana has adverse and compromising effects on the heart, liver, lungs, kidney, and testes of male Sprague-Dawley rats.

Conclusion:

From these observations, it can be inferred that the exposure of male Sprague-Dawley rats to the smoke extract of Tobacco nicotiana may be associated with structural damage of some vital organs.

Diabetic foot lesions as seen in Nigerian teaching hospital: pattern and a simple classification

BACKGROUND

Diabetic foot syndrome is a complication of diabetes mellitus that has serious socioeconomic implications for the individual, family and the society as a whole. When there are ulcers, the condition becomes limb threatening. Early detection of the risk factors and appropriate management of the ulcers reduces the incidence of amputations, morbidity and mortality.

OBJECTIVE

To find the pattern of diabetic foot laesions (DFL) as seen at the orthopaedic clinic of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria over a five-year period and to present a classification of DFL.

MATERIALS AND METHODS

From June 2006 to June 2011 diabetics who had complaints arising from their feet were referred to the orthopaedic clinic at Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. At presentation each patient was examined and investigated. Each foot was examined thoroughly and all the laesions were documented and graded according to Wagner's classification. Out come of management of the cases of DFL was also recorded. All the data collected was analysed.

RESULTS

Two groups (A and B) of patients were identified. In group (A) were patients in whom there was good renal function, no septicaemia, mean value of fasting blood glucose most often was < or = 14 mmol/l. In this group only the feet were threatened. There was a second group (B) in whom there was septicaemia, mean value of fasting blood glucose most often was < or = 15 mmol/l, and impaired renal function (ketone bodies were identified in urine, high serum levels of urea and creatine). Most of these patients had gangrene of the whole foot. In some of the patients infections extended into the gastrosnemius muscle. In diabetic foot laesions grades 0-3, no part of the foot was amputated. In diabetic foot laesions grade 4, infections were controlled and part of the foot had to be amputated. In diabetic foot laesions grade 5, infections were controlled with difficulty and there were systemic symptoms. Amputation of the whole foot was always indicated in this group of patients. The level of amputation most often was far above the ankle joint, either below or above knee.

CONCLUSION

Outcome of treatment revealed three groups of feet. There were salvageable, difficult to salvage and unsalvageable feet. These three outcomes of treatment of diabetic foot lesions formed the basis of a new grading system: gradel (salvageable), grade 2 (difficult to salvage) and grade 3 (unsalvageable). The condition of the patient determines the urgency, extent of intervention and length of stay in the hospital.

Effect of female nargile smoking on in vitro fertilization outcome

OBJECTIVE

Smoking is a significant health hazard that has been associated with poor reproductive outcome and reduced fertility in reproductive age women. The aim of this study was to assess the effect of nargile smoking on intra-cytoplasmic sperm injection (ICSI) outcome.

STUDY DESIGN

A prospective analysis of the outcomes of 297 women who underwent ICSI treatment at the ART Unit at the American University of Beirut Medical Center between January 1, and December 31, 2006 was done. The patients were divided into 3 groups based on their smoking status: cigarette smokers (n=42), nargile smokers (n=51) and non-smokers (n=204).

RESULTS

The mean age of nargile smokers was significantly lower than the other groups; however, the 3 groups were similar with respect to the cause of infertility, total dose of follicular stimulating hormone (FSH), number of oocytes and embryos obtained, and number and quality of embryos transferred. There was no significant difference in the clinical pregnancy rate between nargile smokers and non-smokers (51.0% vs 43.6%). However, cigarette smokers had a significantly lower clinical pregnancy rate compared to non-smokers (23.8% vs 43.6%, p=0.0238). On multiple logistic regression analysis, factors that decreased the clinical pregnancy rates were cigarette smoking and maternal age.

CONCLUSION

Although this study did not find a deleterious effect of nargile smoking on ICSI outcome, the results need to be confirmed in prospective studies that would include larger number of women with more objective measures of nargile smoke exposure.

The use of drains in thyroid surgery

OBJECTIVE

To evaluate the necessity and benefits of the use of drains and their limitations in thyroidectomy and assess their relationship with cost of surgery and hospital stay.

METHODS

We conducted a prospective randomised study on 67 patients divided into two groups. A consisted of 35 patients with drain and B, 32 patients without drain between January 2005 and June 2007. All had subtotal thyroidectomy and the technique and method of closure were the same. No anticoagulant was used and the clotting profiles were within normal range in the two groups.

RESULTS

The sixty seven patients recruited for the study were made up of 60 females (89.6%) and 7 males (10.4%). The mean age for group A was 50.14 +/- 10.7 years, group B was 51.97 +/- 9.5 years. The P value for the mean ages of the two groups is 0.464 (p=0.05,t=3.98).There was no blood transfusion. Three patients developed features of respiratory obstruction (respiratory distress and stridor) -the first 2, one from each group was as a result of laryngeal oedema from trauma of difficult intubation. The third was from group B, as a result of hemorrhage and haematoma collection (she was one of the controlled thyrotoxic patients). Two patients (5.7%) developed wound infections in group A, which increased morbidity, hospital bill and prolonged hospital stay as compared to group B. The highest volume of drainage of 35ml was from a woman with a big goiter (120g). Average drainage was 17.7 +/- 6.9ml.

CONCLUSION

The use of drains is not necessary in all cases of thyroidectomy but for cases with large cavity post extraction and copious oozing in vascular glands. Some of the limitations to the use of drains are infections, this can prolong hospital stay and thereby increase hospital bill.

Multiple embolisations in rheumatic heart disease: a case report

BACKGROUND

Though systemic thromboembolism is not an infrequent complication of rheumatic valvular disease, multiple embolic phenomena are rare.

OBJECTIVE

To present a patient with rheumatic heart disease associated with multiple embolic complications.

CASE REPORT

A 44-year-old lady with rheumatic valvular disease and atrial fibrillation defaulted anticoagulant medication, and subsequently presented with acute chest pain, acute left ventricular failure, focal neurological deficit and gangrenous lower limb extremities. Electrocardiography showed atrial fibrillation and an old anteroseptal myocardial infarction. Echocardiography showed multiple valvular lesions and multiple thrombi in the left atrium. Computed tomogram scan demonstrated a large infarct involving the region supplied by the right middle cerebral artery. Bilateral above knee amputation was performed. Recovery from neurological deficit was complete. She had, during a 4-year follow-up and anticoagulation remained free of new clinically evident embolic complications. Serial echocardiography however showed that the atrial clots had persisted and presumably fibrosed.

CONCLUSION

Multiple systemic thromboembolisms are serious complication of atrial fibrillation of valvular aetiology, and their prevention requires continuous anticoagulation.

General and regional anaesthesia for thyroidectomy in rural/semi-urban Nigerian centres

OBJECTIVE

To evaluate the feasibility and benefits of regional anaesthesia (RA) for thyroidectomy in rural/semi-urban centres.

DESIGN

A prospective study.

SETTINGS

Missionary Hospital Saki, Nigeria and Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.

SUBJECTS

One hundred and seventy five patients with goitre.

RESULTS

The average time for the anaesthetists to put patients to sleep was 4.06 +/- 1.02 minutes, while it took 17.8 +/- 2.9 minutes to give the regional block. Post operative laryngeal complications in RA group were very minimal, while in general anaesthesia (GA) group, there were significant complications in 32 (36%) patients laryngeal oedema 15 (17%), erosions in 10 (11%) and ulcer in seven (8%). Cost of surgery in GA was thrice as much as in RA group. Thirty one (35%) with GA had steam inhalation for sore throat. It was possible to converse (laryngeal nerve monitoring) with the patient during operation but not possible with GA group. There was early discharge of patients in RA group.

CONCLUSION

Regional/local anaesthesia is feasible for some cases of thyroidectomy with a lot of advantages and specifically allows surgeons to converse with the patients during operation-direct laryngeal and other nerve monitoring. Despite advancement in cuff design a lot of lesions still occur from endotracheal intubations.

Effect of powdered gloves, worn at the time of embryo transfer, on the pregnancy outcome of IVF cycles

PURPOSE

To assess the effect of wearing powdered gloves during embryo transfer as compared to un-powdered gloves on the pregnancy outcome of IVF cycles.

METHODS

Patients, undergoing embryo transfer procedures, were prospectively randomized into two groups: In the first (group A, n=356) group embryo transfer was performed while wearing powdered gloves; in the second (group B, n=356) group embryo transfer was performed while wearing un-powdered gloves. The primary end point of the study was the clinical pregnancy rate.

RESULTS

The two groups were comparable with respect to the mean age, mean number of grade one embryos obtained, and the mean number of embryos transferred. The clinical pregnancy rates of the two groups were not different.

CONCLUSIONS

Powdered gloves, worn during embryo transfer, have no adverse effect on the pregnancy outcome of IVF cycles.

Emergency partial thyroidectomy under cervical block to relieve severe acute airway obstruction from thyroid cancer

A 75 year old male, Nigerian, retired civil servant presented to the Surgical Endocrine Unit of the Olabisi University Teaching Hospital, Sagamu, Nigeria with features of severe acute airway obstruction from advanced thyroid cancer. He was immediately worked up for an emergency partial thyroidectomy within an hour of arrival in the hospital under superficial bilateral cervical blockage using 2% xylocaine with aderanalin (30 mls) 1:100,000 with mild sedation, using 10 mg pentazocine and 5 mg diazepam as other forms of anaesthesia were not feasible because of his worsening respiratory distress. Findings at operation were a very haemorrhagic, friable thyroid gland with all the lobes matted together. He had isthmusectomy with bilateral partial lobectomy to relieve pressure on the trachea. Respiration improved in the immediate post-operative period as reflected by the values of arterial blood gases. He was maintained on respiration and intranasal oxygen therapy in Intensive Care Unit (ICU) for 2 days. He had an uneventful recovery and was discharged 2 weeks after surgery. He had radiotherapy and was followed up in the clinic for a year.

Rectal carcinoma in a nine-year-old Nigerian male child: case report

Carcinoma of the colon and rectum are rare in children and under the age of 40 years. A case of coro-rectal carcinoma in a nine-year-old Nigerian male child is reported. Family history was significant in the patient, it revealed that his father died three years earlier because of chronic diarrhoea and mucoid stool with associated on and off constipation and one of his elder brothers died eight years ago of colonic cancer at the age of twenty years. Exploratory laparotomy was done for the patient which revealed fixed rectosigmoid tumour with metastases to the liver, omentum and small intestine and ascites was also found. Hartmann's procedure with sigmoid colostomy was performed and the tumour was resected. Histological report of the biopsy specimen was consistent with poorly differentiated adeno-carcinoma. To the best of our knowledge, the youngest patient recorded in the literature is seven years old, which is younger than our patient, but this is still the youngest in our records.

Surgical complications from local herbal practitioners: report of five cases

Over a 12-month period, five patients (out of a total of 72) with serious complications resulting from use of herbs by traditional healers were seen at the surgical unit of Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. The age range was one and a half to five years with a mean age of 23.4 +/- SD years and a male to female ratio of 3:2. All the cases were misdiagnosed and mismanaged and ended up with various complications. Such as penile amputations, digital necrosis, upper and lower limb gangrene as well a severe sepsis among others. Ignorance, cultural beliefs and attitudes, delusion, poverty and inaccessibility to orthodox medical practice were some of the factors responsible for the patronage of traditional healers.

A review of diagnosis and modes of presentation of tropical idiopathic lower limb gangrene

BACKGROUND

Tropical idiopathic lower limb gangrene (TILLG) is also known as Symmetrical gangrene in the African, Idiopathic gangrene in the African and Idiopathic peripheral gangrene of the tropics. The aetiopathogenesis of this clinical entity is a mystery.

OBJECTIVE

To review methods of diagnosing tropical idiopathic lower limb gangrene (TILLG) and highlight its clinical variants.

METHOD

All Literature on idiopathic gangrene of the extremities was searched from libraries, colleagues and internet but only literature on TILLG (in Africans) from 1947 to date was scrutinised. Each case was studied to find out the basis of diagnosis.

RESULT

TILLG is not fully understood and not easy to recognise. Two sets of criteria are known to be helpful in establishing diagnosis. These criteria can be classified as major and minor criteria. Major criteria are those clinical data that can establish the diagnosis of TILLG. No devices are required to identify them. Minor criteria are pathological changes that are consistent with TILLG. Devices are required to identify them. Three pathomorphological types of TILLG were described in literature and are classified as types A, B and C.

CONCLUSIONS

This review is supposed to sensitise the clinician and make diagnosis easier. This will also encourage more researches. As more information becomes available, aetiopathogenesis of TILLG will be clearer and more clinical variants of the disease may be reported. This additional information will help in the prevention of gangrene, reducing the socioeconomic problems arising from amputation.

Ruptured false iliac artery aneurysm--a case report from Nigeria

A 23 year old male Nigerian presented to the Nephrology unit of the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria with features of chronic renal failure secondary to chronic glomerulonephritis. He was referred to the surgical department of the hospital on account of severe torrential uncontrollable bleeding from an infected cannulation site. He was maintained on regular hemodialysis but developed femoral triangle sepsis at the cannulation site and aneurysm of the external iliac artery. The aneurysm later ruptured with severe jet exsanguinations bleeding. Exploration revealed a-4 cm rent in the external iliac artery that was sutured with 6/0 prolene, interrupted, using clamp and suture technique. Perfusion was satisfactory in the immediate post-operative period. The patient was transfused with 11 pints of blood within 12 hours and had an uneventful post-operative period.

Case Report: Acute Limb Ischaemia and Gangrene associated with Peripartum Cardiomyopathy

Thromboembolic complications are frequent in patients with peripartum cardiomyopathy (PPCM). Peripheral artery occlusions are however rare. This case report describes a 30-year-old grand multiparous woman with PPCM complicated by acute lower limb ischaemia and gangrene. This followed left intraventricular thrombi despite maintenance of sinus rhythm. We suspect that the thrombosis is caused by the hypercoagulable state of peripartum period, ventricular dilatation and hypokinesis. The impacts of economic and sociocultural factors in the management of this rare complication of PPCM in a resource depleted nation are highlighted.

KEYWORDS

peripartum cardiomyopathy, limb ischaemia.

Basic trauma life support: knowledge of medical students

BACKGROUND

The first hour of management (golden hour) of any trauma patient might be the determining factor if he/she will survive. The first contact most patients have in an emergency room is with a young medical graduate. The knowledge of basic trauma life support (BTLS) by all doctors therefore becomes important.

AIMS AND OBJECTIVES

This study set out to assess how much knowledge medical students had about BTLS in their final year compared with their knowledge at the beginning of clinical postings.

METHOD

A cross-sectional study of fourth and sixth (final) year medical students to evaluate their knowledge of BTLS using a test of 30 questions under examination conditions. One hundred and twenty-three fourth year students were given a test after a lecture on the care of injured patients. The same test was administered on 41 sixth year students without prior lecture on day of test, having had a similar lecture 2 years before. Data analysis was performed using the SPSS 11.0 for Windows statistical software and EPI INFO version 6.04.

RESULT

Mean scores were 25.8 +/- SD1.91 for the 4th year students and 21.0 +/- SD2.93 for the 6th year students. There was a statistically significant difference between scores of the 4th year and the 6th year (P < 0.000001).

CONCLUSION

Knowledge was imparted in the 4th year but was forgotten by the 6th year. It is essential that courses in BTLS be given periodically to all medical graduates and all personnel involved in care of the traumatised patient.

Thermal injuries in under-4-year-old children: the Lesotho experience

The Queen Elizabeth II Hospital is the apex of the health care services in the Kingdom of Lesotho but has no designated burns unit. A review of patients managed during a 5-year period was done to document our experience so as to show what can be achieved even without a standard burns unit. We reviewed the clinical course of children who were admitted for care of acute thermal injuries during a 5-year period, May 1997 to April, 2002 inclusive. All were treated in the children surgical ward in accordance with a protocol of care emphasizing urgent care of shock, accurate fluid therapy, open wound care and early enteral feeding. Ninety-eight children (51 males and 47 females) aged 4 months to 43 months (mean 21.66 +/- 11.30 months) were admitted on account of acute thermal injuries during the study period. The injuries included scalding (46%) involving predominantly the upper part of the body and full thickness burns (87%). Skin grafting was needed in 82% of the patients. The common complications were infection, fluid imbalance, respiratory problems, and contracture deformities. The mean duration of hospital stay was 40 +/- 4.43 days and the case fatality rate was 9%. The case fatality rate in this series is considered high and could be improved if there were a well staffed specialized burns unit.

A preliminary report of fine-needle aspiration biopsy in superficially accessible lesions in children

BACKGROUND

Fine-Needle Aspiration Biopsy (FNAB) is a diagnostic technique which has achieved widespread use and acceptance. Its clinical use has continued to widen with the availability of more sophisticated methods of imaging. Its minimal invasiveness, cheap cost and easy application make it a technique of choice in investigating swellings even in children.

AIMS AND OBJECTIVES

To investigate the reliability, safety and diagnostic value of FNAB in superficial masses including lymph nodes in children.

PATIENTS AND METHODS

Superficial masses and lymph nodes of twenty consecutive children aged 2-13years were subjected to FNAB. Open biopsies were also performed on them to validate the FNAB. All specimens were subjected to examination by a cytopathologist and a histopathologist.

RESULTS

Nine of the patients (45 %) had malignant diseases (lymphoma and osteosarcoma); seven had tuberculous lymphadenopathy while four had reactive lymphadenitis. Open biopsies corroborated these findings. There were no false-negative or false-positive cytology results from aspirates. There were no complications related to the procedures.

CONCLUSION

Fine-needle aspiration biopsy is a reliable, safe, less invasive and relatively cheaper alternative method of establishing a pathologic diagnosis, compared to open biopsy, in children.

Humeroulnar synostosis: case report

This is a report of a case of humeroulnar synostosis at the right elbow of a native Nigerian girl in whose family there is no history of genetic/hereditary diseases. This defect was not associated with any other deformity. This is a rare defect that has never been mentioned in literature. By excluding any causes, this case has been proved to be a failure of differentiation that is one of the major categories in the classification of congenital limb defects by Alfred B. Swanson.

Femoral hernias in children at the Olabisi Onabanjo University teaching Hospital, Sagamu, Nigeria

OBJECTIVE

To ascertain the diagnostic accuracy and outcome of surgical treatment in Nigerian children referred for paediatric surgical opinion at the Olabisi Onabanjo University Teaching Hospital, Sagamu, South-west Nigeria.

DESIGN

A retrospective review of our practice experience over a 15-year period; between January, 1989 and December, 2003.

SETTING

The Olabisi Onabanjo University Teaching Hospital (OOUTH), serves as a referral centre for other government and private hospitals in and around the Ogun State, South-west Nigeria. The OOUTH, though a tertiary medical centre also receives patients who present directly at the General Out-Patient Clinics and the Emergency Units of the hospital. The catchment population is estimated at 7.5 million.

SUBJECTS

The medical records of all patients under 14 years of age with a final diagnosis of femoral hernia who presented between January, 1989 and December, 2003 were reviewed.

METHODS

The age, sex, mode of presentation, findings at surgery, procedure performed, immediate post-operative and 12 months follow-up details were recorded.

RESULTS

Seven of 1,213 (0.58%) patients with groin hernias within the study period had femoral hernias; four (57%) were girls and three (43%) were boys. Age range was 3 to 9 years. The mode of presentation in all the children was recurrent lump in the groin. Five patients (71%) had right sided lump while the lump was on the left side in two of the patients. The duration of symptoms ranged from two years to eight years. The provisional diagnosis by the referring general practitioners and paediatricians were incorrect in all seven patients. Five patients (71 %) were correctly diagnosed preoperatively by the attending surgeon while two were thought to be inguinal hernias.

CONCLUSION

The diagnosis of femoral hernia remains a challenging problem in childhood because of its rarity and similar clinical presentation as inguinal hernia.

Anal complaints in Nigerians attending Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu

The objective of this study was to determine prospectively the prevalence of anal complaints amongst Nigerians attending the General Out-patient Department (GOPD) of the hospital and review the records of those admitted to the surgical service with related complications. All the 272 patients attending the GOPD of OOUTH in November, 1999 were interviewed using a structured questionnaire. Information concerning age, sex, educational status, present or past history of at least one of the following symptoms viz recurrent bleeding per rectum, anal prolapse, anal/perianal pain, pruritus ani and anal discharge were obtained. Also obtained were reason(s) for current hospital attendance and any previous medical consultation. Those with at least one of the symptoms were classified as symptomatic. The symptomatic group had rectal examination including proctoscopy. The results showed that 82/272 (30.15% ) were symptomatic. Rectal examination on these 82 patients showed that 10(3.7% of 272) had haemorrhoids, 2(0.7% ) had rectal prolapse, 0.7% had peri-anal warts; 15(5.5% ) anal tags, 10(3.7% ) chronic anal fissure, 2 (0.7% ) perianal fistulae. In 29(10.4% ), the examination was normal and in 12 the rectum was too loaded with feaces to permit proctoscopy. However, only 5/272 (1.84% ) attended the clinic for the anal complaint, while 12(4.4% ) had previously consulted a physician for same. Fear of impotence following surgery in 24 males and belief in herbal remedies in 32 patients were the main reasons for not consulting a physician. During the year 1999, out of a total of 558 admissions into our surgical service, only 4(0.6% ) were for complications related to anal complaints. This study indicated the prevalence of anal complaints in the study population of Nigerians as 30.15% , haemorrhoids constitute 3.7% and anal fissure 3.7% , contrary to low rates reported for developing countries. While this result cannot be extended to represent prevalence amongst Nigerians, it may be a pointer to what is to be expected.

Mature sacrococcygeal teratoma: a case report and literature review

BACKGROUND

Sacrococcygeal teratomas are derived from embryonic germ cell layers. They present mostly in infancy and are extremely rare in adults; with an associated risk of malignancy. Modern imaging technique may be helpful to delineate the extent of the mass but surgical excision is generally indicated at the time of detection.

PATIENTS AND METHODS

A case report is presented with a review of literature utilising MEDLINE, Microsoft Net and Yahoo search engines.

RESULTS

A three day old female baby presented with a mature sacrococcygeal teratoma containing well-developed limb buds. She had surgical excision and primary repair with good results. A two-year follow up utilising serial serum alpha-fetoprotein assay and CT Scan revealed no evidence of tumour recurrence.

CONCLUSION

Sacrococcygeal teratoma is a rare tumour that may be benign or malignant. Complete excision is the primary therapy and is adequate if the tumour is benign. Chemotherapy and radiotherapy are however indicated in malignant cases and in recurrence after previous excision.

Purulent pericarditis complicating septicaemia: report of two cases

Intrapericardial (Pericardial) abscess is quite rare as a complication of sepsis and as a cardiac complication of typhoid septicaemia. It is rapidly fatal if untreated. We report two cases of a schoolboy eight years old with septicaemia from pyomyositis of the right thigh and another of nine and a half years with typhoid perforation and typhoid septicaemia that developed pericardial abscesses. In well-developed centres, computerised tomography, ultrasonography and other radiological investigations are employed for both diagnosis and therapy. We emphasise that these can be accomplished by good clinical examination, radiography of chest and the use of 18-G intra-venous cannula for percutaneous pericardiocentesis without aggressive surgical intervention.

How to adapt an ordinary drilling machine for orthopaedic surgery

An orthopaedic drilling machine has number of revolutions per minute (r/min) < or = 750. This low r/min. accounts for low friction and less tissue damage during bone drilling. This is an advantage over the ordinary drilling machine whose r/min. > 2800. A method of converting it into an orthopaedic drilling machine is described here.

Tropical idiopathic lower limb gangrene: case report

Tropical idiopathic lower limb gangrene is a rare disease. It was first described by Gelfand amongst the indigenous inhabitants of present day Zimbabwe. It is a bilateral and simultaneous gangrene of both lower extremities due to no obvious cause and usually seen in men during the second and fourth decade of life. The onset is always sudden and the first sign is oedema of both feet accompanied by pain. The patients are usually people who have been previously healthy. This is a report of a clinical variant of the disease.

Indigenous hospital technology in Nigeria: problems and recommendations

In Nigeria, after gaining independence there arose a national desire for industrialization in order to reduce the high cost of sustaining national development. This desire has its accompanying problems which are examined with reference to indigenous hospital technology. Solutions to these problems are also suggested.

Methods of assessing spinal radiographs in scoliosis are functions of its geometry

The most important feature of scoliosis is the lateral curvature of the spine. It can be treated either conservatively or by surgery; however, treatment choice depends mainly on curve progression which is determined by frequent curve assessment. This is a review of methods of curve measurement and proof of the relationship between them.

A portable Bohler-Braun splint

Bohler-Braun is used in the conservative management of fractures of the lower limb. The splint is cumbersome making it difficult to work with in situation where compactness of the splint is required. This work is a modification of the splint into a portable version.

The effect of improving maternity services in a secondary facility, Zaria, Nigeria. The Zaria PMM Team

PRELIMINARY STUDIES

Facility review at the secondary hospital in Makarfi revealed a lack of drugs and skilled personnel and delays in treating and referring women with obstetric complications.

INTERVENTIONS

In 1994, maternity facilities were renovated, a revolving drug fund was introduced, midwives were trained and an ambulance was restored to service. Attempts to secure a physician with skills in treating obstetric emergencies were unsuccessful. Prior to these activities, obstetric services at the referral hospital were improved. Community interventions focused on improving utilization by women with complications.

RESULTS

Between 1990 and 1995, substantial increases occurred in antenatal attendance (2517 to 5565 per year) and deliveries (325 to 1952 per year). The number of women with complications seeking care at this facility, however, dropped from 85 in 1990 to 28 in 1995. Referrals to higher level facilities increased from four in 1990 to 17 in 1995.

COSTS

The cost of the interventions was approximately US $32,000. Ninety-eight percent was paid by the government and 2% by PMM.

CONCLUSIONS

Improving the quality of maternity services can increase utilization by women with uncomplicated pregnancies. However, utilization of emergency services appears to be influenced by other factors, such as the ability to treat obstetric complications and prevailing economic conditions.

Mathematical modeling of fetal organ growth using the Rossavik growth model: IV. Lung

Growth of the fetal lung has been monitored by left lung area (LLA), right lung area (RLA), and total lung area (TLA) from 14 to 41 weeks menstrual age in 116 normal Japanese fetuses. Growth of the fetal heart and chest has also been monitored by heart area (HA) and chest area (CA), respectively. Growth curves for these parameters have been determined by using a Rossavik growth model [p = c(t)k+s(t)]. R2 values of 95.3%, 90.3%, 89.0%, 88.7%, and 92.1% were obtained for CA, HA, LLA, RLA, and TLA, respectively. Variability analysis indicated a progressive increase in variability with fetal age for these five parameters. Variability data were used with the growth curve models to determine standard curves for these parameters. These standard curves provide a superior means for evaluating the normal fetal lung growth in the fetus and for identifying pulmonary hypoplasia in utero.

Serum CA-125 and 17 beta-estradiol in patients with external endometriosis on danazol

Serum concentration of CA-125 and 17 beta-estradiol (E2) were measured by radioimmunoassay in 40 patients with stage III or IV endometriosis to evaluate their usefulness in assessing the outcome of disease. Patients were categorized into good responders and poor responders depending on the result of the second-look laparoscopy 8 weeks after danazol therapy. CA-125 decreased significantly in all subjects after initiation of treatment. However, after 12 weeks of treatment a significant increase (p less than 0.05) in serum CA-125 was noted in the poor-response subjects as compared to the good-response subjects. In addition, 8 weeks after treatment CA-125 levels in the poor-response group were significantly higher (p less than 0.001) than in the good-response group. On the other hand, in the good-response group, E2 levels decreased for 8 weeks during danazol therapy to return to almost basal levels after 12 weeks, while in the poor-response group E2 levels did not change as compared to pretreatment levels. We conclude that the determination of CA-125 and E2 may be helpful in assessing the response of patients with advanced endometriosis on danazol treatment.