Management of the mass casualty from the 2001 Jos crisis.

BACKGROUND: We report our experience in the hospital management of mass casualty following the Jos civil crisis of 2001. MATERIALS AND METHODS: A retrospective analysis of the records of patients managed in the Jos civil crisis of September 2001, in Plateau State, Nigeria. Information extracted included demographic data of patients, mechanisms of injury, nature and site of injury, treatment modalities and outcome of care. RESULTS: A total of 463 crisis victims presented over a 5 day period. Out of these, the records of 389 (84.0%) were available and analyzed. There were 348 (89.5%) males and 41 females (10.5%) aged between 3 weeks and 70 years, with a median age of 26 years. Most common mechanisms of injury were gunshot in 176 patients (45.2%) and blunt injuries from clubs and sticks in 140 patients (36.0%). Debridement with or without suturing was the most common surgical procedure, performed in 128 patients (33%) followed by exploratory laparotomy in 27 (6.9%) patients. Complications were documented in 55 patients (14.1%) and there were 16 hospital deaths (4.1% mortality). Challenges included exhaustion of supplies, poor communication and security threats both within the hospital and outside. CONCLUSION: Most patients reaching the hospital alive had injuries that did not require lifesaving interventions. Institutional preparedness plan would enable the hospital to have an organized approach to care, with better chances of success. More effective means of containing crises should be employed to reduce the attendant casualty rate.

The conundrum of polytrauma on the jos plateau.

BACKGROUND: The leading cause of morbidity and mortality from the end of the first year of life to the forty fifth is trauma. This is true worldwide but especially so in our environment. In no other situation are the complexities of the management of trauma more manifest than in the context of polytrauma. For this we undertake to study the problem of polytrauma in Jos. AIMS AND OBJECTIVES: To determine the frequency and pattern of occurrence of poly trauma in Jos university teaching hospital. PATIENTS AND METHODS: Consecutive patients presenting with polytrauma to the casualty department were prospectively studied. Data regarding demographics and a detailed description of injuries were entered into a proforma and collated over a one-year period. RESULTS: A total of 131 patients were studied. There were 103 males and 28 females giving a male to female ratio of 3.7:1. The ages ranged from 2 to 61 years with a mean of 28.4 ± 12.4 years. Road traffic accident was the most common aetiology in 113 (86.3%) patients, while falls 7 (5.3%), gunshots 5 (3.8%) and assaults 2 (1.6%) were observed. The most frequently encountered injuries were head, extremity and chest in 71.8%, 68.5% and 29.2% respectively. The combinations most frequently observed were head\extremity (43.5%), head\chest (17.6%) and chest\extremity (10.7%) injuries. Complications were observed in 20.6% while death occurred in 7.6%. CONCLUSION: Polytrauma occurs with sufficient frequency to warrant serious attention. As majority follow RTA, there is a need to intensify measures aimed at improving road safety. There is also a need to establish pre-hospital care\ambulance services. It is suggested that improved orthopaedic and neurosurgical care will lead to improved polytrauma care and most importantly, the establishment of dedicated trauma teams in tertiary institutions is proposed as a prelude to the establishment of regional trauma centers.

Hepatitis B surface antigen, hepatitis C and HIV antibodies in a low-risk blood donor group, Nigeria.

We investigated the seroprevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) infection among 258 clergymen-in-training (age range 18-39 years) who represented a donor population that fulfilled the criteria for safe blood transfusion. In all, 15.1% of the men were positive for HBsAg, 4.3% were positive for anti-HCV and 2.7% were HIV-positive; 22.1% were infected with at least one of these viruses. Co-infection with HIV and HBV was found in 0.4% of the subjects, HBV and HCV in 0.4%, and HIV and HCV in 0%. This underscores the importance of routine screening of blood before transfusion, regardless of the donor background.

Anterior abdominal wall hydatid cyst; an unusual presentation.

BACKGROUND: Hydatid disease is common in sheep rearing communities, often presenting with hepatic cysts in a majority of cases. Musculo-skeletal involvement as occurred in our patient is an unusual manifestation. Hydatid disease should be considered a differential of superficial and soft tissue swellings in our environment. METHOD: A 27-year-old HIV positive widow on antiretroviral therapy, who presented with intramuscular hydatid cyst in the right lower quadrant of the anterior abdominal wall is presented. RESULT: Following total excision and chemotherapy with albendazole, the patient did well and remained symptom free two years later. CONCLUSION: Though a rarity, hydatid cyst does occur in the musculo-skeletal system, presenting as a superficial swelling. Correct surgical management, including the intra-operative avoidance of spillage of cyst fluid demands pre-operative diagnosis or at least a high index of suspicion. Hydatid cyst should therefore be kept in mind in the differential diagnosis of superficial swellings of musculo-skeletal origin in sheep rearing communities such as ours.

Hepatitis B surface antigen, hepatitis C and HIV antibodies in a low-risk blood donor group, Nigeria

We investigated the seroprevalence of human immunodeficiency virus [HIV], hepatitis B virus [HBV] and hepatitis C virus [HCV] infection among 258 clergymen-in-training [age range 18-39 years] who represented a donor population that fulfilled the criteria for safe blood transfusion. In all, 15.1% of the men were positive for HBsAg, 4.3% were positive for anti-HCV and 2.7% were HIV- positive; 22.1% were infected with at least one of these viruses. Co-infection with HIV and HBV was found in 0.4% of the subjects, HBV and HCV in 0.4%, and HIV and HCV in 0%. This underscores the importance of routine screening of blood before transfusion, regardless of the donor background

Male breast malignancy in Jos University Teaching Hospital.

BACKGROUND: Male breast malignancies are rare. Cancer of the male breast accounts for about 1% of all breast cancers. Poor level of awareness often results in late presentation and delayed diagnosis in our environment. PATIENTS AND METHODS: A retrospective study of all cases of male breast cancer (MBC) managed in Jos University Teaching Hospital over a 17-year period (January 1987-December 2003.) RESULTS: A total of 302 cases of breast malignancies were managed over the study period. Twenty-six (8.6%) of these were males giving a male:female ratio of 1:10.6. The ages of the 26 MBC cases ranged from 12 years to 85 years, with a mean of 57.9 years and median age of 67 years. The right breast was affected in 15 and the left in 11. Mean duration of symptoms before presentation was 6 months with a range of 3 months to 4 years. All the patients had history of breast lumps, 21 (80.8%) of which were painless. Skin ulceration and axillary node enlargement were present in 19(73.1%) and 24(92.3%) respectively. Five (19.2%) were stage II; 15(57.7%) stage III and 6(23.1%) stage IV. There were 23 (88.5%) carcinomas, 2 (7.7%) fibrosarcomas and a case of Hodgkin's lymphoma. Invasive ductal carcinoma was the most common histological type in 20 (76.9%) of all breast malignancy and 20 (87.0%) of all breast carcinomas. Modified radical mastectomy (mastectomy with axillary clearance with or without division of the pectoralis minor muscle) was done in 10(38.5%) patients. Two of these were fibrosarcomas. Simple mastectomy was done in 13 (50%) as toilet procedures for advanced disease. The only case of Hodgkin's lymphoma had chemotherapy. Bilateral orchidectomy (BO), Tamoxifen, chemotherapy and radiotherapy were offered in 7(26.9%), 13(50%), 17(65.4%) and 7(26.9%) patients respectively. Wound infection was the most common complication in 14(53.8%) patients. There was no case of hospital mortality. CONCLUSION: MBC accounts for 8.6% of all breast cancers in our centre. It affects elderly males. Late presentation with advanced disease and ulceration is a common feature in our environment.

Acute appendicitis in inguinal hernia: report of two cases.

We report two cases of acute appendicitis in right incarcerated inguinal hernia (Amyand's hernia). One patient had gangrenous appendicitis that affected the adjoining caecum. A limited right hemicolectomy was done by extending the groin incision laterally and proximally. The second patient had simple appendicectomy. Posterior wall was repaired using nylon darn in both cases. Acute appendicitis should be considered in the differential diagnosis of obstructed right inguinal hernia.

Mass casualty management: Jos University Teaching Hospital experience.

Three experiences of management of mass casualties in Jos University Teaching Hospital were analysed. Classification into minor, moderate and major mass casualties was done using multiple criteria of number of casualties, number of doctors required to contain the situation, number of nurses and paramedical staff, degree of distruption of hospital services and time required to handle the immediate stabilisation of the casualties. The classification recognises a category called "regional disaster" and attempts to enunciate a principle of initiation, mobilisation and co-ordination of management of such disasters among hospitals and human and material resources within the region. It is envisaged that coalescence of "regional disaster preparedness" would from the bedrock of national ambulance services system.

Acalculous cholecystitis in Nigerian children.

Sixteen children with acalculous cholecystitis (AC) were treated over a 9-year period (13 male and 3 female). Their ages ranged from 8 to 18 years (median 11). Eight (50%) presented with complications (perforation 4, gangrene 2, empyema 2); 13 (80%) presented with acute AC with a duration of symptoms of 2 weeks or less while 3 (20%) presented with chronic AC with symptoms present for more than 3 months. The diagnosis was made by ultrasound except in the patients with complications, who were diagnosed at laparotomy. Salmonella typhi was cultured in the bile and blood in 2 cases and the Widal titre was significantly elevated in 4 others. One child had chronic blockage of the cystic duct by a lymph node; in 9 there was no identifiable cause. Open cholecystectomy was successfully performed in 15 cases, while 1 child was managed non-operatively. The need for early diagnosis of cholecystitis in children is obvious if the potentially life-threatening complications of perforation and gangrene are to be avoided.

Open haemorrhoidectomy revisited.

The open method of haemorrhoidectomy has been criticized because of slow wound healing, severe pain and prolonged post operative care. This has led to a shift of interest to other methods of haemorrhoidectomy. These grounds of criticism need to be re-appraised for a rational conclusion and recommendation. Thirty nine consecutive patients who had open haemorrhoidectomy between 2nd and 3rd degree haemorrhoids from May, 1998 to April, 1999 were prospectively assessed for wound healing rate and complication rate. There were 26 males and 13 females (ratio 2:1). The average length of hospital stay was 3 days. Post operative pain and acute retention of urine were the commonest complications. The mean wound healing rate was 5 weeks, with a peak (30.8%) in the 5th post operative week. The mean cost of management was thirty eight U.S. Dollars ($38.00) or four thousand, five hundred and ninety three Naira. (N4,593.00). Open haemorrhoidectomy remains a safe and simple surgical technique that should not be discarded in complete preference to newer innovative methods.

Malignant colorectal tumours: a ten year review in Jos, Nigeria.

One hundred and forty-four cases of histologically confirmed colorectal cancer in patients managed at the Jos University Teaching Hospital (JUTH) over a 10 year period from January, 1989 to January, 1999 is discussed with special consideration to incidence, distribution and unfavourable prognosis. Altogether, 144 patients were treated for colorectal carcinoma. Eighty-seven were males while fifty-seven were females, giving a male to female ratio of 1.51:1. The mean age was 44.3 years. The commonest clinical presenting features were weight loss, bloody mucoid diarrhoea, anorectal mass, anaemia, low-back pain and constipation/increased noise in the abdomen, present for not less than 3 months. The rectum and rectosigmoid junction were the commonly affected sites. All, except four patients, had advanced disease at first presentation. Treatment was basically palliative with only 43.5 percent of those offered such treatment alive at 6 months while 25 percent had died. Prognosis is unfavourable. Though, predisposing factors are not clear, promotion of educational programme highlighting the dangers of concealing chronic large bowel symptoms and screening efforts will most probably reduce morbidity and mortality rates associated with this condition.

Safety of daycare hernia repair in Jos, Nigeria.

OBJECTIVE: To evaluate the safety of day surgery for inguinal hernia. DESIGN: A randomised prospective study of patients presenting for elective inguinal hernia repair. SETTING: Jos University Teaching, Jos, Nigeria. SUBJECTS: One hundred and twenty one patients who completed a six-week follow up period. INTERVENTIONS: Sixty one patients had elective hernia repair as daycares while 60 patients were treated as inpatients. Forty six herniotomies and seventy five herniorrhaphies were performed under local or general anaesthesia. MAIN OUTCOME MEASURES: Early post-operative complications, including wound complications were evaluated. RESULTS: Early post-operative complications occurred in two of the 61 daycares and 15 of 60 inpatients (p=0.002). There were twelve and ten wound complications in daycares and inpatients respectively (p=0.668). There was no mortality. CONCLUSION: Outpatient elective inguinal hernia repair in carefully selected patients is relatively safe in our environment.

Intraoperative colonic irrigation in the management of left sided large bowel emergencies in Jos University Teaching Hospital, Nigeria.

OBJECTIVES: To evaluate the safety and benefits of antegrade intraoperative colonic irrigation (lavage) and primary anastomosis, after colonic resection, in the treatment of left sided large bowel emergencies. DESIGN: A prospective descriptive study. SETTING: Jos University Teaching Hospital, Jos, Nigeria. PARTICIPANTS: Thirty seven patients with an average age of 44.86 +/- 16.15 years. INTERVENTION: Sigmoid colectomy was performed in twenty two sigmoid volvulus, five sigmoid cancer, two faecal fistulae and one sigmoid injury. Left hemicolectomy was offered in four descending colon cancer, one descending colon injury, while anterior resection was carried out in two rectal cancers. Primary anastomosis was performed after intraoperative colonic lavage. RESULTS: The operative mortality was 2.7%, anastomotic leakage rate 2.7% and superficial wound infection occurred in 10.81%. The average duration of hospital stay was 22.76 +/- 11.26 days. Intraoperative colonic lavage added 35.79 +/- 7.25 minutes to the operating time. CONCLUSION: The results of this study suggest that intraoperative colonic lavage is an effective method enabling the surgeon to perform a primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.

One-stage procedure in the management of acute sigmoid volvulus.

In a descriptive prospective study, twenty-seven patients with sigmoid volvulus and three with ileosigmoid knotting had primary resection of the redundant sigmoid colon with immediate anastomosis after intraoperative antegrade colonic irrigation. There was no clinical anastomotic leak nor mortality in any of our patients. Superficial wound infection occurred in four patients (13.3%). Intraoperative colonic irrigation time ranged between 25 to 50 minutes with a volume of saline/Hartmann's required to achieve a clean colon ranging between 1.5 to 5.0 litres. The duration of hospital stay ranged between 7 and 14 days. The result of this study suggests that resection of acute sigmoid volvulus and primary anastomosis after antegrade intraoperative colonic lavage is safe provided the patient is reasonably fit.

Patient acceptance of outpatient treatment for inguinal hernia in Jos, Nigeria.

BACKGROUND: Patient acceptability constitutes an important component of outpatient treatment for hernias. It is essential that patients are properly selected so that only those who need admission are admitted and cared for with the limited available resources. It is also equally important that those who qualify for outpatient care are adequately informed that there is no added risk attributable to outpatient treatment and that they are free to accept or reject such treatment. OBJECTIVE: To determine the acceptability of day care treatment for inguinal hernia in our environment. DESIGN: Prospective cross sectional study. SETTING: Jos University Teaching Hospital. SUBJECTS: 121 selected patients were randomized to undergo elective inguinal hernia repair either as outpatients (61) or inpatients (60). MAIN OUTCOME MEASURES: Six weeks after operation, an assessment of patients' opinion was made as to their preferred method. RESULTS: 52 of 61 day cases and 24 of 60 inpatients preferred outpatient treatment, while two daycare patients and 36 inpatients preferred hospital admission (p < 0.001). Altogether, acceptability rate for outpatient treatment was 68.6%. CONCLUSION: in carefully selected and adequately informed patients, outpatient elective inguinal hernia repair is readily acceptable.

Upper gastrointestinal endoscopy in an urban hospital in northern Nigeria: association of presenting features with endoscopic findings.

In 326 fibreoptic upper gastrointestinal (GI) endoscopies performed in Evangel Hospital (Jos, Nigeria), pathology was found in 210 patients, and of a major nature such as peptic ulcer disease or cancer in 129 of these. The three most useful features to predict the presence of major pathology were epigastric tenderness (the single most useful feature), loss of weight and epigastric pain of a burning nature. These features were selected by stepwise discriminant analysis, which also led to the conclusion that the presence of at least two of these three features is an even more powerful predictor of major pathology.