Preventable trauma deaths in Ibadan: a comparison of revised trauma score and panel review

BACKGROUND

The proportion of preventable trauma-related deaths may be a reflection of the quality of trauma care in a health institution.

OBJECTIVE

To classify mortality in trauma patients in the emergency room and to determine the proportion of preventable trauma related mortality in a teaching hospital.

METHODS

The records of patients who died in the emergency room following trauma from January 1996 to December 2005 were reviewed. Data extracted from the patients' records included the demographics, the mechanism of injury; and the duration of injury prior to presentation. The Probability of Survival (Ps) was calculated for each patient using the Revised Trauma Score (RTS). The RTS includes three physiologic parameters namely the Glasgow Coma Score [GCS], systolic blood pressure and respiratory rate which were recorded soon after the patient' presentation at the emergency department.

RESULTS

There were 286 patients who died following trauma from January 1996 to December 2006. There was a male: female ratio of 3.4:1. Eighty-one percent were preventable deaths based on the revised trauma score while the panel review considered approximately 22% as preventable. Fifty-nine percent or 168 of the patients arrived in the hospital within six hours of sustaining injury.

CONCLUSION

Despite access to emergency care within the first six hours (golden hours) the overall survival of our trauma patients is poor. The severity of the injuries, inadequate resuscitation, and missed injuries by medical personal are some of the factors associated with poor outcome of trauma care.

Genotype and phenotype data standardization, utilization and integration in the big data era for agricultural sciences

Large-scale genotype and phenotype data have been increasingly generated to identify genetic markers, understand gene function and evolution and facilitate genomic selection. These datasets hold immense value for both current and future studies, as they are vital for crop breeding, yield improvement and overall agricultural sustainability. However, integrating these datasets from heterogeneous sources presents significant challenges and hinders their effective utilization. We established the Genotype-Phenotype Working Group in November 2021 as a part of the AgBioData Consortium (https://www.agbiodata.org) to review current data types and resources that support archiving, analysis and visualization of genotype and phenotype data to understand the needs and challenges of the plant genomic research community. For 2021-22, we identified different types of datasets and examined metadata annotations related to experimental design/methods/sample collection, etc. Furthermore, we thoroughly reviewed publicly funded repositories for raw and processed data as well as secondary databases and knowledgebases that enable the integration of heterogeneous data in the context of the genome browser, pathway networks and tissue-specific gene expression. Based on our survey, we recommend a need for (i) additional infrastructural support for archiving many new data types, (ii) development of community standards for data annotation and formatting, (iii) resources for biocuration and (iv) analysis and visualization tools to connect genotype data with phenotype data to enhance knowledge synthesis and to foster translational research. Although this paper only covers the data and resources relevant to the plant research community, we expect that similar issues and needs are shared by researchers working on animals. Database URL: https://www.agbiodata.org.

Axillary nodal metastasis and resection margins as predictors of Loco Regional Recurrence in Breast Cancer Patients

Background

Surgical resection margins (RM), axillary nodal involvement and lymph node ratio (LNR) determine loco-regional control (LRC) in breast cancer management. Late presentation precludes breast conservation therefore surgical option is usually mastectomy and adjuvant chemoradiation minimize loco-regional recurrence (LRR).

Objective

We investigated the prognostic role of lymph nodes positive for malignancy (pN), LNR and RM on LRR of breast cancer in a tertiary hospital in Ibadan, Nigeria.

Methods

Longitudinal cohort study of 225 females with breast carcinoma managed and followed up for 5-years with end point of LRR or not. Chi-square test and logistic regression analysis were used to evaluate the interaction of resection margin and proportion of metastatic lymph nodes with LRR. The receiver-operator curve was plotted to determine the proportion of metastatic lymph nodes which predicted LRR.

Results

Ninety-nine percent had modified radical mastectomy and 163 (72.4%) had negative resection margins. A mean of 11 axillary lymph nodes were harvested at surgery. The age, positive resection margin and number of harvested nodes with malignant cells are associated with LRR. The overall 5-year LRR rate was 16%.

Conclusion

LRR is dependent on lymph node involvement as well as and tumor aggressiveness.

Correlation of the association of serum lactate, random blood sugar, and revised trauma score as predictors of outcome in hemodynamically unstable abdominal emergencies

BACKGROUND

Elevated levels of serum lactate and glucose during resuscitation have been demonstrated to be predictors of morbidity and mortality in hemodynamically unstable patients with surgical abdominal conditions. However, the rate of return to normal levels of both lactate and blood glucose may be better predictors of mortality and morbidity. The aims of this study are: (I) To determine the pattern of serum lactate and glucose changes in patients with surgical abdominal conditions requiring resuscitation within 48 hours of presentation. (II) To correlate the predictive capability of these two independent parameters. (III) To correlate the predictive values of these parameters with the revised trauma score (RTS).

PATIENTS AND METHOD

This is a prospective observational study conducted over three months. The patients admitted by the general surgery division requiring resuscitation from shock was included in this study. Resuscitation was carried out with crystalloids. The estimation of serum lactate and glucose levels was done at presentation (0 hours), 12, 24 and 48 hours after admission. The revised trauma score (RTS) was calculated for each patient at presentation and at 12, 24 and 48 hours subsequently. The patients were followed up four weeks or when death occurred within four weeks of presentation.

RESULTS

Forty four patients were recruited in the study. There were seven mortalities. The mean serum levels of Plasma glucose and lactate of all the patients were elevated at presentation in the emergency department.

CONCLUSION

Survival was better with a return to normal serum lactate within 12 hours. On the other hand the random plasma glucose (RPG) levels may not be useful in prognosticating patients. However a combination of serum lactate, RTS (at 24 and 48 hours) and RPG at 48 hours may improve predictive parameters in trauma related cases.

Pattern of the cases seen in the accident and emergency department in a Nigerian Tertiary Hospital over a period of twelve months

INTRODUCTION

There is a dearth of information on emergency medical services in Nigeria. This study was conducted to determine the age, sex distribution and the pattern of patient presentation in the Accident and Emergency Department of a Nigeria teaching hospital.

METHODS

A retrospective study of all cases seen at the accident and emergency department of the University College Hospital in 2003 was carried out. The information extracted from the records includes age, sex, and diagnosis, department to which the patient was referred, the month of presentation and the outcome within the first twenty four hours of presentation.

RESULTS

A total of 4674 patients attended the casualty, with a male: female ratio of 1.2:1. The third decade was the peak age distribution. There was a predominance of surgical cases (61%). In the treatment outcome, 52.1% were referred to other departments while there were ten (0.2%) mortalities. Trauma related cases constituted 45.1%. Road traffic accidents were the commonest cause of trauma.

CONCLUSION

The largest proportion of patient were in the active third decade of life. Trauma is the commonest cause of presentation in the Accident and Emergency Department. A significant proportion of patients do not require admission. The doctor in the Accident and Emergency Department must be skilled in basic trauma care.

Anorectal malformation in an adult: a case report

BACKGROUND

Anorectal malformations (ARM) are usually diagnosed at birth, although, some patients have presented in the hospital beyond the newborn period without recognition of the anomaly. Late presentation in adulthood has also been reported. We report a case of adult ARM whose mother was instructed not to present in the hospital until she was old enough.

METHOD

An adult female patient was evaluated and investigated preoperatively for high ARM with rectovestibular fistula. She had an initial colostomy which was followed by a primary posterior sagittal anorectoplasty (PSARP). Post-operatively, continent level was assessed using the Kelly continent score.

RESULTS

She had good post-operative recovery with an episode of faecal soilage. The Kelly continent score was 3 which later improved to 5.

CONCLUSION

Although the sphincteric tone may be weak in the adult patient with ARM with reduced continent level at the initial stage, overall outcome of management of ARM with primary PSARP is good and comparable to outcome in children.

Surgical treatment of perineal giant condylomata acuminata (Buschke Lowenstein tumor): Case series from a developing country

INTRODUCTION

Giant condylomata acuminatum (GCA) also referred to as Buschke-Lowenstein tumor (BLT) is a rare tumor primarily associated with low-risk HPV 6 and 11, which is believed to be a slow growing intermediate tumor with low potential to transform into invasive cancer.

CASE PRESENTATION

We presented our experience with three cases of BLT (one woman and two men).

CLINICAL DISCUSSION

The three patients had surgical excision and two of them had reconstruction of the surgical defect with good clinical outcome.

CONCLUSION

We highlighted the importance of early identification of symptoms, treatment options and risk of recurrence as well as primary preventive strategies.

Adult sacrococcygeal teratoma: a case report

Sacrococcygeal teratomas are extremely rare in adults. We present an adult female with a sacrococcygeal teratoma managed in our hospital.

GEOGRAPIC INFORMATION SYSTEMS IN DETERMINING ROAD TRAFFIC CRASH ANALYSIS IN IBADAN, NIGERIA

BACKGROUND

Road traffic accidents are frequent in this environment, hence the need to determine the place of geographic information systems in the documentation of road traffic accidents.

AIM & OBJECTIVES

To investigate and document the variations in crash frequencies by types and across different road types in Ibadan, Nigeria.

MATERIALS & METHODS

Road traffic accident data between January and June 2011 were obtained from the University College Hospital Emergency Department's trauma registry. All the traffic accidents were categorized into motor vehicular, motorbike and pedestrian crashes. Georeferencing of accident locations mentioned by patients was done using a combination of Google Earth and ArcGIS software. Nearest neighbor statistic, Moran's-I, Getis-Ord statistics, Student T-test, and ANOVA were used in investigating the spatial dynamics in crashes.

RESULTS

Out of 600 locations recorded, 492 (82.0%) locations were correctly georeferenced. Crashes were clustered in space with motorbike crashes showing greatest clustering. There was significant difference in crashes between dual and non-dual carriage roads (P = 0.0001), but none between the inner city and the periphery (p = 0.115). However, significant variations also exist among the three categories analyzed (p = 0.004) and across the eleven Local Government Areas (P = 0.017).

CONCLUSION

This study showed that the use of Geographic Information System can help in understanding variations in road traffic accident occurrence, while at the same time identifying locations and neighborhoods with unusually higher accidents frequency.

An affordable laparoscopic surgery trainer for trainees in poor resource settings

BACKGROUND

Laparoscopic surgery requires acquisition of new skills such as hand eye coordination of instruments whose working tips can only be seen in two dimensions on a monitor screen and depth perception. Simulators have been demonstrated as necessary to acquire these skills safely. However these simulators are expensive and not readily available in developing countries.

METHODS

I describe a cheap homemade adaptation of a laparoscopic trainer using a polyethylene fluid container, a webcam and a laptop computer as a monitor. This simulator can be easily be assembled by any surgical resident for use in his private time.

CONCLUSION

This simulator for laparoscopic surgery is cheap and can be readily assembled. A major limitation is the fixity of the camera which limits the working area to within ten to thirty centimeters of the camera. On the contrary the inability to alter the camera position eliminates the need for an assistant to hold the camera.

An audit of deaths in the emergency room in the University College Hospital Ibadan

INTRODUCTION

Death rates in the accident and emergency department may be a reflection of the quality of care in the hospital. Trauma related mortality is a significant cause of preventable death.

METHOD

A retrospective study was conducted in the accident and emergency department of the University College Hospital Ibadan (Nigeria) using the hospital records to determine the pattern of mortality over one year.

RESULT

Five thousand one hundred patients attended the accident and emergency department in the year reviewed. One hundred and sixty eight (3.3%) mortalities were recorded .There were 97 males and 71 females with mean ages of 49+/-37.8 and 42+/-30.7 years respectively. 46% of the patients had medical (non-trauma non-surgical) related diagnoses. Trauma constituted 31% of the mortalities with an average probability of survival of 80% at presentation. Head injury and multiple long bone fracture were the commonest causes of trauma related mortalities.

CONCLUSION

Trauma is a preventable cause of death. The poor outcome of the trauma patients underscores the need to equip the attending doctors in the emergency room with basic skills in trauma care.

Incidence of pyramidal thyroid lobe in the university college hospital Ibadan

Introduction

The pyramidal lobe of the thyroid gland is derived from remnant of the thyroglossal duct. Its presence may be missed clinically; however radiologic and intra-operative findings reveal its presence in up to 50% of cases. The incidence of pyramidal lobe is however not clearly known in Sub-Saharan Africa, particularly in Nigeria. Our aim is to determine the incidence and histological variation of pyramidal lobe of the thyroid gland among surgical patients who underwent thyroid surgery in the University College Hospital, Ibadan.

Methodology

Consecutive surgical patients that underwent total thyroidectomy in the Endocrine Surgery Division, Department of Surgery, University College Hospital, Ibadan between April 2013 and April 2017 were recruited irrespective of age, sex and clinical diagnosis. The presence, anatomy and subsequent histological diagnosis of the pyramidal lobe were noted.

Results

One hundred sixty thyroid surgeries were done. Pyramidal lobe was found in 70 patients (44.0%). The presence of the pyramidal lobe was most often associated with multinodular goitres 42 (61.8%) and least found in thyroids with malignant tumours 3 (4.4%). The pyramidal lobe originated commonly from the midline (50.0%) and least from the right (10.3%). The length of the pyramidal lobes ranged from 8 to 80 mm (average 50 mm) in males and 5 to 54 mm (average 42 mm) in females.

Conclusion

The presence of a pyramidal lobe is not uncommon in people of southwestern Nigeria with its morphologic and histologic profile akin to what obtains in other geographical locations of the world.

ADULT ABDOMINAL WALL HERNIA IN IBADAN

BACKGROUND

Abdominal wall hernias are very common diseases encountered in surgical practice. Groin hernia is the commonest type of abdominal wall hernias. There are several methods of hernia repair but tension-free repair (usually with mesh) offers the least recurrent rate.

AIM

To describe the clinical profile of anterior abdominal wall hernias and our experience in the surgical management of identified hernias.

METHOD

The project was a retrospective study of all patients with abdominal wall hernia presenting into surgical divisions of University College Hospital Ibadan during a 6 year period (January 2008 to December 2013). Relevant information was retrieved from their case notes and analysed.

RESULTS

The case records of 1215 (84.7%) patients out of 1435 were retrieved. Elective surgery was done in 981(80.7%) patients while 234 (19.3%) patients had emergency surgery. There were 922 (84.8%) groin hernias and post-operative incisional hernia accounted for 9.1% (111) of the patients. About half (49.1%) of those with incisional hernia were post obstetric and gynaecologic procedure followed by post laparotomy incisional hernias 16 (14%) and others (23.5%). The ratio of inguinal hernia to other types in this study is 3:1. Hollow viscus resection and emergency surgery were predictors of wound infection statistically significant in predicting wound infection (P < 0.001). Peri-operative morbidity/mortality at 28 days post operation was documented in 113 patients (12.1%). One year recurrence rate of groin hernia was 2.1%.

CONCLUSION

The pattern of presentation and management of anterior wall hernias are still the same compared with the earlier study in this hospital. New modality of treatment should be adopted as the standard choice of care. Abdominal wall hernias are very common clinical presentation. Modified Bassini repair was the preferred method of repair due to its simplicity. Mesh repair is becoming more common in recent time but high cost and initial non-availability of the mesh limit its use in our centre.

Comparison of postoperative pain in diathermy and conventional scalpel Skin incision after mastectomy in Ibadan, Nigeria

INTRODUCTION

Pain control is a challenge after surgery. Inadequate control of acute postoperative pain in mastectomy patients may lead to chronic post mastectomy pain syndrome. The study aimed to compare the effect of diathermy incision with scalpel incision on the severity of acute postoperative pain after mastectomy.

METHOD

Sixty three females had mastectomy under general anaesthesia. Thirty two patients had skin incisions made with scalpel while 31 patients with diathermy. Both groups received intraoperative Fentanyl and Tramadol. Tramadol was also employed as postoperative analgesic while Paracetamol was given as the rescue analgesic. The outcome measures were pain scores using visual analogue score (VAS) and analgesic consumption within the twenty four hours postoperatively.

RESULTS

The mean VAS in the diathermy group versus scalpel group at 6th, 12, 18th and 24th hour post operatively were 11.84 +/- 6.15 mm versus 16.18 +/- 8.5 mm (p=0.001), 11.10 +/- 4.26 mm versus 15.84 +/- 5.12 mm (p=0.001), 11.07 +/- 4.15 mm versus 17.32 +/- 6.01 mm (p=0.001), 10.6 +/- 8.08 mm versus 19.19 +/- 8.7 mm (p = 0.001) respectively. The mean dose of Tramadol was 264 +/- 84 mg in the diathermy group versus 278 +/- 64 mg in the scalpel group p=0.189, three patients required rescue analgesic (paracetamol) in the diathermy group mean dose 1.5.7 +/- 0.54 g versus 7 patients in the scalpel group, mean dose 1.67 +/- 0.58 g p=0.75.

CONCLUSION

Diathermy can contribute to reduction in the acute postoperative pain in patients undergoing mastectomy.

A Fifteen Year Experience of Total Thyroidectomy for the Management of Simple Multinodular Goitres in a Low Medium Income Country

INTRODUCTION

Total thyroidectomy as a treatment for simple multinodular goitre is not well recognised in most centres in low middle income countries.

METHOD

This paper is a retrospective review of outcomes of total thyroidectomy for simple multinodular goitres in the last fifteen years in a tertiary hospital in Nigeria.

RESULTS

A total of 652 thyroidectomies were done from January 2001 to December 2015. Simple multinodular goitres were indication for a total thyroidectomy in 447 patients (68.6%) with a male to female ratio of 1:6. Postoperative complications were hypocalcaemia in 22 (4.9%), unilateral recurrent laryngeal nerve palsy in 13 (2.8%) and haemorrhage in 2 patients. Others were seroma and cellulitis. Tracheostomy was required in 35 (5.8%) patients but none was permanent.

CONCLUSION

Total thyroidectomy is a relatively safe treatment option for patients who have simple multinodular goitre. It provides a permanent cure with a low postoperative morbidity risk. The burden of replacement l-thyroxine needs to be discussed with the patients.

The challenges and solutions of laparoscopic surgical practice in the developing countries

Laparoscopic surgery has become the preferred standard in developed countries. New procedures in laparoscopic surgery are continually being developed. Despite these innovations Nigeria and many other African are yet to fully embrace this surgical approach. Few therapeutic laparoscopic surgery procedures are performed annually in Nigerian teaching hospitals. Appropriate personnel and the initial high cost of acquiring state of the art equipments are some of the challenges in laparoscopic surgery in developing countries. A few centres have developed ways of solving these challenges. We discuss the envisaged problems with laparoscopic surgery in Nigeria and some other African countries and suggest solutions to these problems.

Gastrointestinal stromal tumour in Ibadan, Nigeria: a case report and review of current treatment

Gastrointestinal stromal tumours (GIST), though rare, present to the gastric surgeon not infrequently making a heightened awareness of this condition a pre-requisite of prompt recognition and timely treatment.. We describe the presentation, diagnosis and the limitations of treatment and follow up of a patient with GIST in a developing country. Surgery still remains as the only readily available modality of treatment in developing countries.

EXPERIENCE WITH MANAGING RETROSTERNAL GOITRES IN IBADAN, NIGERIA

BACKGROUND

There is no general consensus on the definition of retrosternal goitre (RSG) however thyroidectomy remains the gold standard of treatment with or without a sternotomy.

AIM

To review the outcome of surgical management of retrosternal goitres.

METHODOLOGY

Retrospective review of records of patients who had thyroidectomy for RSG over a 15-year period.

RESULTS

Out of a total of 45 patients, 34(76%) were females and 11(24%) were males with a male/female ratio of 3:1; while their age ranged between 28 and 72years with a mean of 57+15SD. All the patients were euthyroid and a quarter did not have symptoms apart from a neck mass. In all, 15% of the patients had recurrent goitre. CT scan of neck and chest was done in 31 (72%) patients; while 44 (98%) patients had cervical retrosternal goitres, 1(2%) patient had ectopic retrosternal goitre. A cervical incision was sufficient in 28 (62%) patients while 17 (38%) patients required additional sternotomy. Total thyroidectomy was done in all the patients. There were post-operative complications in 19 (42%) patients. Histopathology showed that 3(6.6%) patients had papillary thyroid carcinoma while 42(93.4%) had benign pathology findings.

CONCLUSION

Surgical removal is the treatment of choice. Most retrosternal goitres can be resected through a collar stud incision; however the possibility of a need for a sternotomy should always be planned. The simultaneous occurrence of cervical and ectopic retrosternal goitre should always be ruled out with a CT scan.

HER 2 expression status in gastric carcinomas in Ibadan, Nigeria: a preliminary study using immunohistochemistry

MATERIALS AND METHODS- Archival formalin fixed paraffin embedded gastric Adenocarcinoma tumour tissue from the Department of Pathology, University College Hospital, Ibadan were studied for HER 2 protein status using immunohistochemistry. RESULTS- HER 2 protein receptor status was determined in 36 cases using immunohistochemistry. The male: female ratio was 1.4:1. The age range of the patients was 30 to 86 years, with peak age-groups being in the 6th and 7th decade of life. Mean age of the patients was 57.6 years while the median age was 56years. Four cases were positive for the HER 2 receptor protein representing about 11% of the cases. Two cases had staining score of 2+ while another 2 cases had score of 3+. The four positive cases were intestinal variants of gastric adenocarcinomas based on Laurens classification. Three were well differentiated tumours and one was moderately differentiated. CONCLUSION- HER 2 protein overexpression by immunohistochemistry can be demonstrated in black Africans with gastric carcinoma. More detailed and multicentre studies will be needed to draw firm conclusions in this regard.