The United Kingdom National Health Service through the lens of an overseas clinical observer: A reflective account based on personal experience.

This article provides insight into an aspect of the National Health Service (NHS) of the United Kingdom (UK) through the perspective of an overseas clinical observer. The NHS is a government-funded medical and health care service in the UK and has developed over the years providing a high standard of medical care and professionalism. The Clinical Observership Programme has been designed primarily for International Medical Graduates to experience how the NHS functions and the kind of services it offers. This article explores the overseas observer's experience in a surgical unit of the NHS including the organisational structure, delivery of care and challenges of the system. This article also highlights the observer's perspective of surgical care in the NHS compared to surgical care in low-resource income countries. The Clinical Observership is useful in learning about UK medical practice and gaining experience in a different cultural and professional environment. This is a reflective first-hand account based on personal experience.

Clinicopathological Features and Treatment Outcome of Patients with Gastric Cancer in Lagos: Is the Outlook Getting Better?

Background: Gastric cancer (GC) is an important cause of morbidity and mortality in Nigeria. Significant advances in the management of GC in South-West Nigeria occurred in the last three decades. Patients and Methods: This was a retrospective comparative study of patients with GC that presented at our tertiary hospital in the last three decades. Information on clinicopathological features and treatment outcome were analysed. Data of two consecutive periods; 1991-2004 (Group I) and 2005-2018 (Group II) were compared. Results: Ninety-one patients were studied; Group I (47 patients), Group II (44 patients). The mean age was 56.4 ± 12.7 years and male-to-female ratio was 1.8 to 1.0. The predominant symptoms were epigastric pain in 81(89.0%) (43 vs. 38) and weight loss in 63(69.2%) (32 vs. 31), whereas the signs were epigastric tenderness in 44(46.1%) (24 vs. 20) and epigastric mass in 42(46.1%) (26 vs. 16). The overall mean duration of symptom was 12.3 ± 16.9 months. Barium meal diagnosed GC in 29(61.7%) patients in Group I vs. 4(9.1%) patients in Group II. Conversely, endoscopy diagnosed GC in 23(48.9%) patients in Group I vs. 37(84.1%) patients in Group II. Operations undertaken included palliative subtotal gastrectomy 26(28.6%), potentially curative subtotal gastrectomy 15(16.5%) and non-resectional surgeries in 27(29.7%) patients. The overall incidence of major post-operative complications was 33%. Thirty-nine (42.8%) of the studied patients were lost to follow up. The median postoperative survival for Groups I and II patients was 22 weeks and 58 weeks, P = 0.012, respectively. Conclusion: The outcome of management of patients with GC at our tertiary hospital has improved modestly in the past three decades. Patients are still presenting late with very advanced disease.

Comparison of rubber band ligation with 3% polidocanol injection sclerotherapy for the treatment of internal haemorrhoids at a Nigerian tertiary hospital.

BACKGROUND: The surgical treatment of internal haemorrhoids is yet to be fully elucidated. Rubber band ligation (RBL) and injection sclerotherapy (IS) are less invasive alternative day-case treatment options with lower morbidity than excisional haemorrhoidectomy. AIMS: This was a prospective study that compared the efficacy of RBL with 3% polidocanol IS in the treatment of Grades I to III internal haemorrhoids. PATIENTS AND METHODS: Sodergren haemorrhoid symptom severity (SHSS) scores of consecutive adult patients with internal haemorrhoids were calculated before and after each of three therapy sessions with RBL and IS. Outcome measures included SHSS scores after treatment, post-procedure pain and complication rates. Data were collated and analysed using SPSS version 23. RESULTS: A total of 74 patients participated in the study with 37 patients in each treatment group. The RBL and IS groups were not statistically different in age (P = 0.506), weight (P = 0.117), height (P = 0.462), BMI (P = 0.153) and gender (P = 0.639). The mean SHSS scores for both groups before therapy (P = 0.876), at 4 weeks (P = 0.669), 8 weeks (P = 0.168) and 12 weeks (P = 0.391) after commencement of therapy were not statistically different. The SHSS scores at 12 weeks after treatment were statistically significantly lower than before treatment in both the groups (P < 0.01). The post-procedure pain score was significantly higher in the RBL than IS group after the first (P < 0.001) and second (P < 0.006) but not after the third therapy session (P = 0.501). The complication rates were low and not significantly different for the RBL and IS groups (5.7% versus 8.1%; P = 0.643). CONCLUSION: The study concluded that RBL and IS are both effective and safe in the treatment of Grades I, II and III internal haemorrhoids.

A proposed research misconduct policy for universities and postgraduate colleges in developing countries.

Research misconduct policy (RMP) is a legal document that shows the definitions of the various types of misconduct, describes the inquiry and investigation of allegations, and the appropriate penalties that should be imposed. The presence of the adopted RMP on the website of a university or postgraduate college is an indication of the level of commitment to promote the proper handling of misconduct cases. Perusal of the websites of top universities in developing countries revealed that many do not have RMP on their websites. The probable starting point for combating research misconduct at the national or institutional level is by acquisition of RMP. The purpose of this article is to propose a modern, structured and cost-effective RMP for universities and postgraduate colleges in developing countries. The bibliographic database, PubMed, was searched using the terms 'research misconduct' and 'research misconduct policy'. All relevant articles from the search and some RMPs of universities, national agencies and global health organisations available on the Internet were carefully studied. A formulated RMP, based on the Final Rule of the United States, Public Health Services Policies on Research Misconduct of 2005 and the Regulations of the University Grants Commission of India of 2018, is hereby presented. In the proposed RMP, plagiarism was stratified into four levels in ascending order of severity so that imposed penalties are commensurate with the seriousness of misconduct. The zero tolerance for plagiarism in the core work areas was adopted. The proposed RMP was designed to act as a template. It should be modified as required based on the prevailing local circumstances and made fit for purpose. Universities, postgraduate colleges and journals should have RMP on the homepage of their websites.

An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital.

BACKGROUND: Intussusception in adults is considered rare in surgical practice. It is the causative lesion in a small proportion of cases of intestinal obstruction and lower gastrointestinal bleeding. In the last decade, the incidence of adult intussusception appears to be increasing at our centre. AIMS: This study aims to document the pattern of presentation and management outcome of adult intussusception at our institution during the last decade. We also observed the occurring trends of this lesion. PATIENTS AND METHODS: This was a 10-year retrospective study of consecutive adult patients with intussusception seen at our institution from July 2008 to June 2018. Information on biodata, clinicopathological features and management outcome retrieved from case notes and pathology records were analysed on a personal computer using SPSS version 23. RESULTS: Twenty adult patients who had intussusception were seen during this period. There were 9 (45%) males and 11 (55%) females giving a male-to-female ratio of 1:1.2. The mean age of presentation was 45 (range 18-66) years. Clinical features were abdominal pain (85%), abdominal distension (80%), vomiting (70%), rectal bleeding (70%) and palpable abdominal mass (35%). Majority of patients (70%) presented with features of intestinal obstruction. Idiopathic intussusception (55%) accounted for more than half of the cases with the jejunoileal variety (30%) as the most common pathological type. One patient who had intussusception in the postoperative period was treated with manual reduction at laparotomy. Bowel resections were performed in the remaining 19 (95%) patients. CONCLUSION: Adult intussusception is still uncommon in our general surgical practice. Bowel resection is the mainstay of treatment.

Acute perforated appendicitis in adults: Management and complications in Lagos, Nigeria.

Background: Acute perforation of the appendix is one of the complications of appendicitis that is associated with increased morbidity and mortality and hence regarded as a surgical emergency. Risk factors for perforated appencidicits include extremes of age, male sex, pregnancy, immunosuppression, comorbid medical conditions and previous abdominal surgery. Objectives: This study focuses on the pattern of presentation, risk factors, morbidity and mortality of patients managed for perforated appendicitis in our centre. Subjects and Methods: We conducted a seven-year retrospective review of consecutive adult patients who had surgery for perforated appendicitis in our centre. Results: The perforation rate in the study was 28.5%. The peak age of presentation was between 21-30 years. Forty-two (71.1%) of the patients under study were males. Only 3 (5.1%) of the cohorts had history of recurrent abdominal pain. Majority of the patients were in the American Society of Anesthesiologists (ASA) II (44.1%) and III (42.4%) categories. Surgical site infections (SSI) (18.6%), wound dehiscence (15.2%) and pelvic abscess (13.5%) were the most common complications. The Incidence of SSI was found to correlate with male gender, (P = 0.041), co-morbidity (P = 0.037) and ASA score (0.03) at 95% confidence interval. Routine use of intraperitoneal drain after surgery for perforated appendicitis did not appear to reduce the incidence of pelvic abscess. No mortality in the studied population. Conclusion: Appendiceal perforation was more common in male patients with first episode of acute appendicitis. Previous abdominal surgery and comorbid medical conditions were of lesser risk factors for appendiceal perforation in our patients. Surgical site infection was the commonest complication after surgery.

RésuméContexte: La perforation aiguë de l'appendice est l'une des complications de l'appendicite associée à une augmentation de la morbidité et de la mortalité et donc considérée comme une urgence chirurgicale. Les facteurs de risque pour les applications perforées comprennent les extrêmes d'âge, le sexe masculin, la grossesse, l'immunosuppression, les conditions médicales concomitantes et la chirurgie abdominale antérieure. Objectifs: Cette étude se concentre sur le schéma de présentation, les facteurs de risque, la morbidité et la mortalité des patients pris en charge pour une appendicite perforée dans notre centre. Sujets et méthodes: Nous avons effectué une revue rétrospective sur sept ans de patients adultes consécutifs ayant subi une chirurgie pour une appendicite perforée dans notre centre. Résultats: Le taux de perforation dans l'étude était de 28,5%. L'âge maximal de présentation était entre 21-30 ans. Quarante-deux (71,1%) des patients étudiés étaient des hommes. Seulement 3 (5,1%) des cohortes avaient des antécédents de douleurs abdominales récurrentes. La majorité des patients étaient dans les catégories II (44,1%) et III (42,4%) de l'American Society of Anesthesiologist (ASA). Les infections du site opératoire (SSI) (18,6%), la déhiscence des plaies (15,2%) et les abcès pelviens (13,5%) étaient les complications les plus fréquentes. L'incidence de SSI a été trouvée corrélée avec le sexe masculin, (p = 0,041), la co-morbidité (p = 0,037) et le score ASA (0,03) à intervalle de confiance de 95%. L'utilisation systématique d'un drain intrapéritonéal après une chirurgie pour une appendicite perforée ne semble pas réduire l'incidence des abcès pelviens. Aucune mortalité dans la population étudiée. Conclusion: La perforation appendiculaire était plus fréquente chez les patients masculins présentant un premier épisode d'appendicite aiguë. La chirurgie abdominale antérieure et les conditions médicales comorbides étaient des facteurs de risque moins pour la perforation appendiculaire chez nos patients. L'infection du site opératoire était la plus courante après la chirurgie.

Predictive factors of management outcome in adult patients with mechanical intestinal obstruction.

BACKGROUND: Mechanical intestinal obstruction (MIO) is a common and potentially fatal surgical emergency, which constitutes about 20% of all admissions to the surgical emergency departments. OBJECTIVE: To determine the predictive factors of morbidity and mortality in patients undergoing treatment for MIO at our tertiary hospital. PATIENTS AND METHODS: This was a prospective study of consecutive patients, 18 years and above, that presented with features of MIO during a 1-year period (May 2014 to April 2015). Each patient had resuscitation, comprehensive clinical evaluation, appropriate investigations and definitive treatment. The data were analysed using SPSS version 22. RESULTS: One hundred and five patients were studied. The age range was 18-86 years with a mean (standard deviation) of 45.6 (14.8) years. There were 54 males with a male to female ratio of 1.1-1. The common causes of MIO were post-operative adhesion (48.6%), tumour (25.7%), external hernia (15.2%) and volvulus (5.7%). Eighty-four patients (80%) had operative intervention while 21 patients (20%) had conservative management. Univariate analysis showed that dehydration, tachycardia (>90 bpm), pyrexia, abnormal levels of potassium, urea and creatinine, leucocytosis, American Society of Anesthesiologists (ASA) status >IIIE, bowel resection, intraoperative blood loss >500 ml and duration of surgery >2 h were significant predictors of mortality (P < 0.05). Multivariate analysis showed that elevated serum urea at hospital presentation and ASA status greater than IIIE were the independent predictors of mortality, but none of the factors could independently predict morbidity. The most common post-operative complication and cause of death were wound infection (29.6%) and sepsis (66.7%). The mortality rate was 14.3%. CONCLUSION: The most common cause of MIO was post-operative adhesion. Elevated serum urea and ASA status greater than IIIE were the independent predictors of mortality.

Abdominal stab wounds in Lagos: A review of fifty cases.

BACKGROUND: The optimum management of patients with abdominal stab wounds (ASWs) is yet to be fully elucidated. AIMS AND OBJECTIVES: To evaluate the pattern of injury, treatment offered and outcome in patients with ASWs seen at our tertiary hospital. PATIENTS AND METHODS: This was a retrospective descriptive study of patients who sustained ASWs seen from January 2011 to December 2015. Information obtained from case notes were analysed on a personal computer using SPSS version 22 (SPSS Inc., Chicago, IL, USA).P<0.05 was considered statistically significant. RESULTS: Fifty patients who sustained ASWs were included in the study. Forty-four (88%) were males, mean age was 27 years and 50% were between the ages of 21 and 30 years. The wounding weapon in patients was the knife in 26 (52%) and broken bottle in 14 (28%). Our patients presented at the hospital about 3 h after abdominal stabs and surgical intervention time was uniformly prolonged. Forty-eight (96%) patients had emergency laparotomy, whereas two (4%) patients with omental evisceration were treated using the policy of selective non-operative management. The commonly injured organs were stomach (22.9%), small bowel (20.8%), omentum (18.8%), colon (18.8%) and liver (14.6%). The negative laparotomy rate was 31.3%. The knife was a more lethal weapon than broken bottle in our patients (P<0.05). Seven (14%) patients suffered serious post-operative complications and two (4%) died. CONCLUSION: The high therapeutic laparotomy rates observed in our patients who had generalised peritonitis, evisceration and shock, support the fact that these findings should be indications for immediate laparotomy.

Colorectal carcinoma in Lagos and Sagamu, Southwest Nigeria: a histopathological review.

AIM: To study the frequency, gender and age distribution as well as pathological characteristics of colorectal carcinoma (CRC) in Lagos and Sagamu in SW Nigeria. METHODS: This is a retrospective pathological review of histologically diagnosed CRC from 5 laboratories in Lagos and Sagamu. The clinical data, such as age, sex and clinical summary were extracted from demographic information. Cases of anal cancer were excluded from this study. RESULTS: There were 420 cases (237 males and 183 females) of CRC. It peaked in the 60-69 year age group (mean: 50.7; SD: 16.2), M:F ratio 1.3:1 and 23% occurred below 40 years. The majority was well to moderately differentiated adenocarcinoma 321 (76.4%), mucinous carcinoma 45 (10.7%) and signet ring carcinoma 5 (1.2%), and more common in patients under 40 years compared to well differentiated tumors. The recto-sigmoid colon was the most common site (58.6%). About 51% and 34% of cases presented at TNM stages II and III, respectively. CONCLUSION: CRC is the commonest malignant gastrointestinal (GIT) tumor most commonly located in the recto-sigmoid region. The age and sex prevalence and histopathological features concur with reports from other parts of the world.

A ten-year study of penetrating injuries of the colon.

BACKGROUND: Colon injury has been associated with a high risk of septic complications and mortality. We prospectively studied the pattern, management, outcome, and prognostic factors in patients who sustained penetrating colon injuries. PATIENTS AND METHODS: Sixty patients who presented to our hospital with penetrating colon injuries over a ten-year period (1992 to 2001) were studied. RESULTS: Colon wounds were caused by gunshots in 55 (91.7 percent) patients and knife stabs in 5 (8.3 percent). There was a delay of more than 12 hours before laparotomy in 30 (50 percent) patients. Moderate or major fecal contamination of the peritoneal cavity occurred in 58 (96.7 percent) patients. The average penetrating abdominal trauma index score was 25.9 and 20 (33.3 percent) patients sustained Flint Grade 3 colon injury. Associated intra-abdominal injuries occurred in the small bowel (73.3 percent), liver (25 percent), stomach (23.3 percent), and mesentery (16.7 percent). Right colon wounds (35) were managed by primary repair in 24 (68.6 percent) patients and proximal diverting colostomy in 11 (31.4 percent), whereas left colon wounds (25) were managed by diverting colostomy in 22 (88.0 percent) patients and primary repair in 3 (12.0 percent) patients. Common complications included wound infection (56.7 percent), septicemia (31.7 percent), and enterocutaneous fistula (16.7 percent). The overall mortality rate was 33.3 percent and colon injury-related mortality was 21.7 percent. Presence of destructive colon injury was associated with a greater than fourfold increased incidence of death. Other significant risk factors included shock on admission, major fecal contamination, duration of operation more than four hours, penetrating abdominal trauma index score >25, and more than two postoperative complications. There was no difference in outcome between patients who had primary repair and those undergoing diverting colostomy. Colostomy closure-related morbidity was 21 percent and mortality was 5.3 percent. CONCLUSION: A more liberal use of primary repair is required in our patients with penetrating injuries of the colon.