Clinical predictors of Covid-19 mortality in a tertiary hospital in Lagos, Nigeria: A retrospective cohort study

Background

The predictors of mortality among patients presenting with severe to critical disease in Nigeria are presently unknown.

Aim

The aim of this study was to identify the predictors of mortality among patients with COVID-19 presenting for admission in a tertiary referral hospital in Lagos, Nigeria.

Patients and Methods

The study was a retrospective study. Patients' sociodemographics, clinical characteristics, comorbidities, complications, treatment outcomes, and hospital duration were documented. Pearson's Chi-square, Fischer's Exact test, or Student's t-test were used to assess the relationship between the variables and mortality. To compare the survival experience across medical comorbidities, Kaplan Meir plots and life tables were used. Univariable and multivariable Cox-proportional hazard analyses were conducted.

Results

A total of 734 patients were recruited. Participants' age ranged from five months to 92 years, with a mean ± SD of 47.4 ± 17.2 years, and a male preponderance (58.5% vs. 41.5%). The mortality rate was 9.07 per thousand person-days. About 73.9% (n = 51/69) of the deceased had one or more co-morbidities, compared to 41.6% (252/606) of those discharged. Patients who were older than 50 years, with diabetes mellitus, hypertension, chronic renal illness, and cancer had a statistically significant relationship with mortality.

Conclusion

These findings call for a more comprehensive approach to the control of non-communicable diseases, the allocation of sufficient resources for ICU care during outbreaks, an improvement in the quality of health care available to Nigerians, and further research into the relationship between obesity and COVID-19 in Nigerians.

Ivermectin shows clinical benefits in mild to moderate COVID19: a randomized controlled double-blind, dose-response study in Lagos

INTRODUCTION

In vitro studies have shown the efficacy of Ivermectin (IV) to inhibit the SARS-CoV-2 viral replication, but questions remained as to in-vivo applications. We set out to explore the efficacy and safety of Ivermectin in persons infected with COVID19.

METHODS

We conducted a translational proof of concept randomized, double blind placebo controlled, dose response and parallel group study of IV efficacy in RT-polymerase chain reaction proven COVID 19 positive patients. Sixty-two patients were randomized to three treatment groups. (A) IV 6 mg regime, (B) IV 12 mg regime (given Q84 h for 2 weeks) (C, control) Lopinavir/Ritonavir. All groups plus standard of Care.

RESULTS

The Days to COVID negativity (DTN) was significantly and dose dependently reduced by IV (P = 0.0066). The DTN for Control were, = 9.1+/-5.2, for A 6.0 +/- 2.9 and for B 4.6 +/-3.2. Two way repeated measures ANOVA of ranked COVID 19 +/- scores at 0, 84, 168 and252h showed a significant IV treatment effect (P = 0.035) and time effect (P < 0.0001). IV also tended to increase SPO2% compared to controls, P = 0.073, 95% CI-0.39 to 2.59 and increased platelet count compared to C (P = 0.037) 95%CI 5.55-162.55 × 103/ml. The platelet count increase was inversely correlated to DTN (r = -0.52, P = 0.005). No SAE was reported.

CONCLUSIONS

12mg IV regime given twice a week may have superior efficacy over 6mg IV given twice a week, and certainly over the non IV arm of the study. IV should be considered for use in clinical management of SARS-COV2, and may find applications in prophylaxis in high risk areas.

Development and practice of laparoscopic surgery in a Nigerian tertiary hospital

Background

For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list.

Aims

We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice.

Methodology

This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS).

Results

A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16-87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality.

Conclusion

Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

Is the plastibell of any haemostatic value after 24 h?

BACKGROUND

The Plastibell is the most popular circumcision method among mothers in our city. Haemorrhage is its major problem. At our centre, we have recorded many circumcision problems resulting from prolonged retention of the Plastibell ring and this study, therefore, sought to explore the ways of reducing complications resulting from prolonged retention of the ring.

PATIENTS AND METHODS

This was a prospective study, in which a total of sixty consecutive male neonates were recruited with all undergoing circumcision using the Plastibell device. Thirty patients were assigned to the subject group, in whom the Plastibell ring was removed by the investigator at 24 h while the other thirty constituted the control group whose Plastibell rings were allowed to fall off on their own. The patients selected were aged between 7 and 28 days.

RESULTS

Overall, 4 (6.6%) of the sixty neonatal circumcisions in this study were complicated by haemorrhage. There was minor bleeding in 3 (10%) of the thirty subjects and 1 (3.3%) of the thirty controls. There was no statistically significant difference between the groups (P = 0.3006). One patient each from the subject and control groups bled following slipped ligature a few hours after Plastibell circumcision. The other two patients in the subject group bled following the removal of the Plastibell ring at 24 h. All the bleeding episodes were effectively controlled within 5 min by firm digital pressure only administered through a piece of dry, sterile gauze.

CONCLUSION

Post-circumcision haemorrhage was not significantly different between circumcised babies whose Plastibell rings were removed at 24 h and those in whom it was left to fall off on its own.

Routine hemoglobin electrophoresis for pediatric surgery day case in at-risk populations: Suggested algorithm for screening using clinical risk factors

BACKGROUND

Hemoglobin electrophoresis (HBE) is a part of the preoperative routine requested by anesthetists. However, the prevalence of hemoglobinopathy in the population is low. This study aims to determine the clinical risk factors for hemoglobinopathies and propose clinical guidelines for preoperative screening of patients for pediatric day care surgery.

PATIENTS AND METHODS

A prospective study carried out over 12 months. Consecutive patients aged 6 months and older who had day case surgery were recruited to the study. Biodata and relevant clinical data were collated and documented in a proforma and analyzed using a statistical package for social sciences version 17.

RESULTS

There were 124 patients106 boys and 18 girls. The median age was 3 years. Scrotal lesions were the most common conditions managed (71.7%). Seventy-eight percent of patients had HbAA, 15.3% had HbAS, and 4.8% had HbAC while 0.8% each had both HbSC and HbSS. At least one parent of 78.2% knew their Hb phenotype, of which, 79% were HbAA. A history of jaundice (P = 0.0001), hand and foot syndrome (P = 0.0001), frontal bossing (P = 0.0001), and low packed cell volume at surgery (P = 0.001) were found significant in predicting hemoglobinopathies. There was no mortality.

CONCLUSION

Risk factors for hemoglobinopathies from this study included a positive history of jaundice, hand and foot syndrome, frontal bossing, and anemia. Proposed guidelines for HBE screening include the presence of hemoglobinopathy in one parent if one parent has sickle cell trait, and the other parent's genotype is unknown or if any of the risk factors is present.

Preoperative localization of undescended testes in children: comparison of clinical examination and ultrasonography

BACKGROUND

Preoperative localization of the testis aids effective management of undescended testes. Various diagnostic techniques have been applied in the localization of undescended testes with varying results. The aim of this study was to compare clinical assessment and ultrasound evaluation in the preoperative localization of undescended testes in children.

METHODS

A prospective evaluation of all boys undergoing operation for undescended testes at the Lagos University Teaching Hospital, Idi Araba, from July 2010 to June 2011 was carried out. The findings on preoperative clinical and ultrasound examinations were compared with intraoperative findings.

RESULTS

Forty boys with 52 undescended testes were studied. The median age of the boys at the time of surgery was 4 years (range 1-11 years). Forty-five testes (86.5%) were accurately localized preoperatively by ultrasound while 25 testes (48.1%) were accurately localized on clinical examination. Ultrasound evaluation had an accuracy of 86.5% in preoperative localization of undescended testes. Clinical examination had an accuracy of 48.1% in preoperative localization of undescended testes. Ultrasound was more accurate than physical examination (p < 0.001).

CONCLUSIONS

Ultrasonography is more accurate than clinical examination in the preoperative localization of undescended testes in children and could play a role in preoperative evaluation of patients with undescended testes.

Routine haemoglobin electrophoresis screening in day case herniotomy in Nigerian children: Is it evidence-based?

Background:

To determine the prevalence of haemoglobinopathies in children who require day case herniotomy in our centre and ascertain if routine screening is necessary in all patients who require herniotomy.

Materials and Methods:

A 12-month retrospective analysis of patients requiring herniotomy in our centre. Data including age, sex, diagnosis, haemoglobin electrophoresis status, surgical outcome and hospital stay were analysed.

Results:

Ninety-five patients had complete records. There were 84 boys and 11 girls. M:F ratio: 7.6:1. The mean age was 3.2 ± 0.6 years. Fifty-five point eight per cent of the patients had right inguinal hernias while 35.8% had left inguinal hernias. Eight patients (8.4%) had bilateral inguinal hernias. Twenty-six patients (27.4%) had haemoglobinopathies while 69 patients (72.6%) had homozygous Haemoglobin A. The Sickle Cell trait (HbAS) was found in 22 patients (23.2%) while the HbAC was found in three patients (3.2%). One patient (1.1%) had Sickle Cell disease (Haemoglobin SS). He had had blood transfusion and previous history of jaundice. All patients survived and all patients were discharged on the day of surgery (mean hospital stay: 4hrs (range: 2.5 hrs–12 hrs)) except the patient with Sickle Cell disease who was admitted a day before surgery and discharged a day after the operation.

Conclusion:

One in four children coming for day case herniotomy in our centre had the Sickle Cell trait while only 1% had the Sickle Cell disease. These findings are in keeping with the prevalence in the Nigerian population. Routine screening may not be necessary for all patients coming for herniotomy in our centre. Clear indication(s) should be outlined for screening.

H-type tracheo-oesophageal fistula: a diagnostic challenge in a resource-poor country. A case report

H-type fistula is a rare form of congenital tracheo-oesophageal fistula accounting for 4% of all cases of Tracheo-oesophageal fistula. The typical picture is that of recurrent chest infection due to both missed and delayed diagnosis as well as cyanosis and choking during feeds. In resource poor countries this problem is further exaggerated by ignorance, poverty and lack of access to basic investigative modalities. This is the case of [abstract incomplete].

Non-trauma related paediatric abdominal surgical emergencies in Lagos, Nigeria: Epidemiology and indicators of survival

Background:

Pediatric surgical emergencies are associated with higher morbidity and mortality. The aim of this study is to describe the epidemiology of non-trauma related pediatric abdominal surgical emergencies in our centre and determine the indicators for survival in a cohort of patients.

Patients and Methods:

A retrospective study of children aged 1 day to 15 years who presented with non-trauma related abdominal emergencies at the Lagos University Teaching Hospital (LUTH).

Results:

There were 129 children. The median age at presentation was 5 months (range: 1 day-15 years). There were 104 males and 25 females. Sixty-four (49.6%) patients presented within 48 hours of the onset of the symptoms while 65 (50.4%) presented after 48 hours. Intestinal obstruction is the commonest indication for pediatric emergency surgery in our centre accounting for 76 patients (58.9%). Appendicitis is the second most common indication for emergency surgery with 13 patients (10.1%). Thirteen patients (10.1%) had postoperative complications. There were 13 deaths in all (10.1% mortality rate). Eleven out of 43 (25.6%) neonates died compared with 2 (2.3%) out of 86 patients in the other age groups (P=0.002). Seven out of 107 (6.5%) patients that had surgery within 72 hours died while 5/22 (22.7%) patients died who had surgery after 72 hours (P=0.003). There were 4 mortalities (28.6%) among patients with postoperative complications compared with 9 (7.8%) mortalities among 116 patients without any postoperative complications (Pp=0.001).

Conclusion:

Intestinal obstruction is the commonest pediatric surgical emergency seen in LUTH. Neonatal age, admission to surgery intervention time >72 hours, and severe postoperative complications are associated with high mortality.

Pediatric trauma in sub-Saharan Africa: Challenges in overcoming the scourge

All over the world, pediatric trauma has emerged as an important public health problem. It accounts for the highest mortality in children and young adults in developed countries. Reports from Africa on trauma in the pediatric age group are few and most have been single center experience. In many low-and middle-income countries, the death rates from trauma in the pediatric age group exceed those found in developed countries. Much of this mortality is preventable by developing suitable preventive measures, implementing an effective trauma system and adapting interventions that have been implemented in developed countries that have led to significant reduction in both morbidity and mortality. This review of literature on the subject by pediatric and orthopedic surgeons from different centers in Africa aims to highlight the challenges faced in the care of these patients and proffer solutions to the scourge.

Surgically correctable morbidity from male circumcision: indications for specialist surgical care in lagos

AIM/OBJECTIVE

To determine the pattern of morbidity and outcome among patients referred to the Pediatric Surgery Unit of the Lagos University Teaching Hospital (LUTH) following circumcision.

MATERIALS AND METHODS

Retrospective descriptive study of all patients with complications of circumcision who were managed in LUTH between 2008 and 2010.

RESULTS

There were 36 patients. The age range was between 2 days and 9 years (median-3 months). Fifteen cases (42.9%) were due to urethro-cutaneous fistula while there were six cases (16.7%) of postcircumcision bleeding. There were four cases (11.1%) each of partial penile amputation and buried penis. There were also cases of meatal stenosis, penile implantation cyst and glanulo-preputial skin bridge. With respect to the treatment offered, eleven (30.6%) patients had urethroplasty for the urethro-cutaneous fistulae while seven (19.4%) patients had penile refashioning for the buried penis and penile amputation. Appropriate surgical treatments were performed for the other complications.

CONCLUSION

Urethrocutaneous fistula and penile amputation are the commonest complications of circumcision for which referral is made to LUTH. Treatment outcome was satisfactory. Health education and legislation to ensure procedure is performed by qualified medical and paramedical staff may reduce the morbidity.

Early outcome of open primary pull through versus staged pull through in Hirschsprung's disease: a single centre experience from Nigeria

BACKGROUND

The treatment of Hirschsprung's disease has followed a trend from 2 or 3-staged pull-through (SPT) procedures to a single stage primary pull-through (PPT) procedure and from open surgery to laparoscopy-assisted, and trans-anal pull through procedures. The (PPT) procedure has the advantage of avoiding a stoma and its complications.

OBJECTIVE

This study compares the outcomes in open PPT and SPT in our centre.

METHODS

Retrospective observational study at a single centre from Nigeria over a 4year period.

RESULTS

Of 46 patients with Hirschsprung's disease, 29 patients had pull-through procedures during the study period; 19 had SPT and 10 had PPT. There were 21 boys and 8 girls (M:F = 2.6:1). Five (17.1%) were diagnosed in the neonatal period and median age at surgery was 30 months (1 month - 31 yrs). The mean length of hospital stay was 30 days (+/- 7) in the SPT group while it was 16 days (+/- 3) in the PPT group, p < 0.05. Colostomy morbidity such as prolapse and skin excoriation showed statistical significant difference compared to other complications associated with pull-through (p < 0.05); however morbidity from pull-through procedures alone were similar. There was no statistically significant difference in post operative bowel habit irrespective of type of pull through operation performed (p > 0.05). Patients were followed up for between 3 months and 36 months. Two patients died giving a mortality rate of 6.7% overall.

CONCLUSION

PPT significantly reduced both hospital stay and colostomy complications compared to SPT.

Accreditation of Training Programmes by the West African College of Surgeons

The establishment of surgical training programmes of the West African College of Surgeons started in six teaching hospitals the early 1970s in Nigeria and Ghana; it was championed by College Fellows, surgeons who had returned to the sub-region after having trained in Europe and America. Surgical programmes accreditation, captured in the College's constitution and mission statement, uses objective guidelines in the identification and encouragement of suitable institutions for surgical training through periodic peer-review audits of installed manpower, facilities, clinical services and academic programmes. This pan-regional model adopted by the five Anglophone countries of West Africa has standardized and nurtured surgical training in the disciplines of surgery, obstetrics and gynaecology, ophthalmology, otorhinolaryngology, dental surgery, radiology and anaesthesia. It has also proven to be a useful template in the current drive for the ongoing harmonization of surgical training programmes with Francophone West African as a prelude to an integrated sub-regional accreditation body. This paper details the evolution of surgical programmes accreditation in West Africa, its progress, challenges, opportunities and future trends.

Survey of teaching, research and conference experiences of paediatric surgical trainees in Nigeria

AIM

To determine the teaching methods used by residents in paediatric surgery in Nigeria and their exposure to research and conferences.

MATERIALS AND METHODS

A structured questionnaire was administered to trainees in paediatric surgery in Nigeria seeking information regarding different teaching methods used, frequency of use, involvement in research and participation in conferences.

RESULTS

There were 11 respondents (91.6%) of 12 questionnaires that were distributed. All of them were training in accredited teaching hospitals in Nigeria. All of them had been involved in teaching medical students. Ten residents were involved in teaching in wards/bedside two times or more in a week and all were involved in teaching at the clinics. Only one resident used audiovisual aid at least once a week to teach students. Eight trainees used tutorial or seminar group discussion as a teaching tool once a week. Four trainees had not used written essay as a way of teaching students while five had never given students lectures in a classroom before. All the respondents had participated in retrospective research while nine had been involved in prospective research. Nine residents had attended conferences nationally while two had attended international conferences. Six trainees presented a paper or more at national conferences while one presented at an international conference.

CONCLUSION

Trainees in paediatric surgery in Nigeria are significantly involved in the teaching of undergraduate medical students and clinical research. This should be encouraged and further enhanced by motivating the trainees to attend international conferences.

Penile injuries from proximal migration of the Plastibell circumcision ring

BACKGROUND

Although circumcision is the commonest surgical procedure performed on male neonates, complications still arise from all methods used by operators.

PATIENTS AND METHOD

This was a prospective study of penile injuries resulting from proximal migration of the Plastibell device in neonate boys referred to the Lagos University Teaching Hospital, Lagos, Nigeria. The parameters measured were patients' biodata, presentation, management and treatment outcome.

RESULTS

Twenty-three injuries resulting from circumcision with the Plastibell device all occurred from prolonged retention of the ring. In each case, the ring was retained and had migrated proximally. There was extensive skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result in nine (39%) of these cases, while partial necrosis of the glans penis occurred in four (17%). These complications resulted from the use of wrong-sized Plastibell kits, lack of follow-up by the medical staff, and inadequate maternal knowledge of ring fall-out time.

CONCLUSION

Proximal migration of the Plastibell ring can result from employment of an inappropriate size, causing grievous penile injury. Adequate information should be provided to mothers of circumcised babies about possible complications of the Plastibell kit when employed. There is a need to redesign the Plastibell kit to eliminate its migration up the penile shaft.

Appropriateness of intra-operative blood transfusion in children at the Lagos University Teaching Hospital--an initial survey

BACKGROUND

The decision to transfuse intra-operatively is based on preoperative haemoglobin (Hb), estimated blood loss and physiological variables. The visual estimate of blood loss is notoriously unreliable especially with small volumes of blood losses in children.

OBJECTIVES

We sought therefore to determine the appropriateness of intra-operative blood transfusion in a sample of children

METHODS

All children requiring intra-operative blood transfusion between May and June 2008 were prospectively studied. Neonates and children already on blood transfusion at induction were excluded. Transfusion was prescribed at the discretion of the attending anaesthetist. The Estimated blood volume (EBV) and estimated blood loss (EBL)were determined. Appropriate transfusion was defined as blood transfusion at EBL > 15% of EBV, maximum allowable blood loss to PCV of 27% and pre-transfusion Hb < 8g/dl.

RESULTS

Twenty-five patients were studied with a mean age of 4.16 +/- 3.59 years (Range 0.33-11 years). The mean preoperative PCV was 31.14 +/- 3.53% (range 25-34%). Twelve patients (48%) were appropriately transfused when MABL was calculated to PCV of 27%. Nine patients (36%) had appropriate blood transfusion at an EBL greater or equal to 15% of the EBV. Of the 12 patients that had pre-transfusion Hb measured, 2 (16.6%) were appropriately transfused at Hb < 8 g/dl.

CONCLUSION

The use of near patient monitoring devices should be encouraged as this will give an accurate assessment of Hb and appropriate indication for transfusion. Equipment should be made available to perform gravimetric estimation of blood loss as the visual method is notoriously unreliable.

Presentation and management outcome of childhood intussusception in Lagos: a prospective study

BACKGROUND

Intussusception is the commonest cause of bowel obstruction in infancy and childhood. Early diagnosis and effective management have reduced its morbidity and mortality in developed countries.

AIM

To document the presentation, management and treatment outcome of intussusceptions at the Lagos University Teaching Hospital (LUTH).

PATIENTS AND METHODS

One hundred seventy-four consecutive cases of this condition seen in children presenting at LUTH over a 5-year period were prospectively studied. Details of symptoms and signs, pre-hospital care, treatment, and outcome in LUTH were documented.

RESULTS

The triad of abdominal pain, bloody mucoid stools and palpable abdominal mass was seen in 106 (61%) of the cases. One hundred thirty-five (77.6%) had been admitted and treated with antibiotics and intravenous fluids in primary healthcare centers for an average of 3 days before referral to the LUTH. Prolonged mean duration of recognizable symptoms of 3 days accounted for a 70.4% bowel resection rate. Wound infection occurred in 61 (36.1%), whereas fecal fistulae developed in six (3.6%), and burst abdomen in five (3%) of cases. Seven (4.1%) patients developed incisional herniae. Overall, mortality rate was 12.1%.

CONCLUSION

The early symptoms of intussusception would seem to be missed by primary healthcare workers in Lagos, with consequently high morbidity and mortality. There is an urgent need to re-emphasize these symptoms to first-line healthcare providers and parents through public enlightenment campaigns.

A comparative study of the haemodynamic effects of atropine and glycopyrrolate at induction of anaesthesia in children

BACKGROUND

Bradycardia following administration of halothane and suxamethonium in children leads to reduced cardiac output, which can be prevented with prophylactic anticholinergics. Anticholinergics may result in tachycardia and arrhythmias. This study was designed to compare haemodynamic changes and incidence of cardiac arrhythmias following intravenous atropine and glycopyrrolate.

STUDY DESIGN

Ninety ASA I and II children between one month and twelve years were studied. Premedication was with oral promethazine 1mg/kg. Anaesthesia was achieved with 3 % halothane in 33 % oxygen and nitrous oxide. Patients were randomly allocated to receive atropine 0.01mg/kg (Group I) or glycopyrrolate 0.005mg/kg (Group II). Tracheal intubation was facilitated with suxamethonium 1.5mg/kg.

RESULTS

Patients in Group I had a 35.7% rise in heart rate from baseline, compared to 22.5 % in Group II two minutes after anticholinergic administration (p=0.001). Following intubation, heart rate rose by 9.7 % and 13.2 % (p<0.05) in Groups I and II respectively. MAP rose similarly in both groups. Arrhythmia occurred in 44.4 % of patients in Group I and 11.1% in Group II (p=0.001) and were mainly sinus tachycardia. 2.2% of patients in Group I exhibited bigemini. No patient experienced bradycardia. Hypoxia occurred in 2.2 %, hypotension in 13.3% and mild laryngeal spasm in 0% of Group I and 11.1%, 4.4% and 4.4% of Group II respectively.

CONCLUSION

The use of glycopyrrolate compared to atropine, offered better cardiovascular stability in Nigerian children. Arrhythmias occurred more in patients who had atropine and occurred most frequently after tracheal intubation.

Endothelin-like action of Pausinystalia yohimbe aqueous extract on vascular and renal regional hemodynamics in Sprague Dawley rats

The bark of the African tree Pausinystalia yohimbe has been used as a food additive with aphrodisiac and penile erection enhancing properties. The effect of an aqueous extract of P. yohimbe (CCD-X) on renal circulation was assessed in order to test the hypothesis that it possesses additional effects on nitric oxide production and/or endothelin-1 (ET-1)-like actions. In vivo studies with CCD-X in Sprague Dawley rats demonstrated a dose-dependent (1-1000 ng/kg) increase in mean blood pressure (p < 0.001) and an increase in medullary blood flow (MBF) (p < 0.001). Both the pressor action and renal medullary vasodilation were blocked by endothelinA (ETA) receptor antagonist BMS182874 and endothelinB (ETB) receptor antagonist BQ788 in combination. L-Nomega-nitro-l-arginine methyl ester (L-NAME; 10 mg/kg) also inhibited the increase in MBF induced by CCD-X. In vitro studies in isolated perfused kidney and in pressurized renal microvessels confirmed the dose-dependent vasoconstrictor action of this extract. ETA receptor antagonist BQ610 and ETB receptor antagonist BQ788 separately and significantly attenuated the renal vasoconstrictor actions of the extract (p < 0.001 ANOVA). These preliminary observations indicate that, in addition to the alpha-adrenergic antagonist actions that characterize yohimbine, CCD-X possesses endothelin-like actions and affects nitric oxide (NO) production in renal circulation. These findings suggest a strong possibility of post-receptor cross-talk between alpha2-adrenoceptors and endothelin, as well as a direct effect of alpha2-adrenoceptors on renal NO production.

Surgical swab foreign bodies--observations on 7 cases in Lagos

Foreign bodies inadvertently left in body cavities are a rare complication of abdominal and other surgeries. The true incidence of this condition is not known. The author reports on 7 such cases occurring over a 16-year period and comments on preventive measures, early diagnosis, tactful handling and the need for damage control when dealing with this unwelcome issue in a surgical setting.

Viral isolates of intussusception in Nigerian infants

Idiopathic intussusception is associated with viral pathogens of gastrointestinal respiratory and febrile diseases of infancy and early childhood. These agents are known to vary from one region to another. No such specific viruses have, however, been reported from Nigeria. We therefore collected stools from 28 infants with intussusception as well as 20 age- and sex-matched healthy controls and subjected these specimens to viral isolation techniques. Of the 21 viral isolates obtained from the two groups, 17 (81%) were from the intussusception group while 4 (19%) were from the controls. Ten (58.8%) of the 17 isolates from these subjects were identified as adenoviruses using monoclonal antibody. All of them were from the intussusception group. None of the four isolates from the controls significantly reacted with this antibody. We concluded that adenoviruses are strongly associated with primary intussusception in Nigerian infants.

Factory floor injury in a Lagos sawmill

We retrospectively reviewed injuries sustained in 36 consecutive accidents in a wood-processing factory and managed at a private hospital over a 2-year period in Lagos. The commonest injuries were lacerations by revolving saws, followed by crush injuries from entrapment by machines and from falling logs and planks. The upper limbs were involved in 24 (66%) of these accidents cases. Of 137 workers on the factory floor, the highest injury rate (64%) occurred among machine operators. While 80.6% of these injuries were simple ones treated by suturing and dressing, 7 (19.4%) were life-threatening enough to warrant hospitalisation and major surgery, with 6 sustaining a mean permanent disability of 7.1 +/- 6%. Although factory-floor injuries constituted only 6.5% of 553 hospital attendance recorded within the period from the company, they were responsible for 44.2% of total medical expenditure by the company within the same period. Non-use of protective gears and disregard for safety procedures were noted in most of the accidents. The in-house first-aid program was adjudged as life-saving in the few major cases managed. We concluded that while many factory-floor injuries in wood-processing factories may be minor hand injuries, provision and strict observance of safety protocols as well as an active first-aid program are invaluable to minimise morbidity, cost and loss of productive man-hours in wood processing factories.

Abuse and neglect in the surgically ill child

Child abuse and neglect are a global phenomenon often symptomatic of underlying psychosocial family problems, which may represent a transferred aggression from one or both disturbed parents onto the child. Although the scope has been widely explored in Africa, little has been written on children presenting with surgical lesions. We report 31 children abused by their parents on accounts of frustrations engendered by the children's surgical conditions in Lagos. 26 (83.9%) of these children had major congenital defects while only 5 (16.1%) had acquired lesions. The commonest form of abuse was child abandonment, seen in 9 (29%) of cases. Neglect was recorded in 7 (23%) cases while 2 children were mutilated because of surgical lesions. Three patients were starved, 3 children with colostomy were evicted by landlords while 2 were locked up by parents out of shame. One child died of infanticide. Reasons for abuse included financial constraints, hopelessness and shame associated with grotesque lesions, broken homes and maternal pregnancy. Doctors and nurses engaged in the care of gross congenital anomalies and other major surgical lesions should anticipate this problem and evolve appropriate strategies to deal with it. The social worker should be involved early enough in the management. Provision of adequate social safety nets, affordable medical care and specific legal protection for children will curtail this ugly trend in our society.

Entero-cutaneous fistula of the vermiform appendix in childhood: case report

Entero-cutaneous fistula involving only the vermiform appendix is rare in childhood. We report a case recently managed in our practice, the first of such report from West Africa, along with a review of world literature on the subject.