Outcomes of management of intestinal obstruction at an urban tertiary hospital in sub Saharan Africa: a cross-sectional study.

BACKGROUND: Intestinal obstruction (IO) is a common cause of acute abdomen globally, it remains challenging as it increases surgical financial expenditure while also causing major morbidity. Clinically it presents with nausea, vomiting, colicky abdominal pain and cessation of bowel movements or passage flatus and stool. Diagnosis, especially in resource limited settings, can be clinical but is usually confirmed radiologically. We studied the current diagnosis, management and outcomes of IO in Mulago Hospital. MATERIALS AND METHODS: This was a prospective study done at all the surgical units of Mulago from January to May 2014 to assess general diagnosis and management of IO. Ethical approval was got in line with Helsinki declaration, we used pretested and validated questionnaires to collect data. Informed consent was got with eligible and consenting/assenting patients that fitted the inclusion criteria of age and presenting with suspected intestinal obstruction. Uni-variate and bi-variate variables analysis was done plus measures of association. RESULTS: We enrolled 135 patients, excluded 25 and recruited 110 patient. We had more males than females i.e. 71.8% males and 28.2% females. Colicky abdominal pain, abdominal distension, and vomiting were commonest symptoms, then abdominal distension, increased bowel sounds and abdominal tenderness were the commonest signs. Most patients' (51%) were diagnosed radiologically with a lesser number clinically diagnosed. "Dilated bowel loops" was the commonest radiological sign. Surgery was the main stay of management at 72.7% while 27.3% were conservatively managed. Postoperatively the bowels opened averagely on the 3rd post-operative day (POD) with return of bowel sounds occurring on 5th POD. Most discharges (73%) occurred by the 7th POD. Unfavourable outcomes were prolonged hospital stay followed by wound sepsis (surgical site infection) and then Mortality. CONCLUSION: This study noted that In Mulago we mostly diagnosed patients radiologically with most surgically managed and which is similar to regional practices. Postoperatively bowel opening happening on third POD with return of bowel sounds on fifth POD. Prolonged hospital stay followed by wound sepsis and then mortality were commonest unfavorable management outcomes.

Presentation, aetiology and treatment of adult intussusception in a tertiary Sub-Saharan hospital: a 10-year retrospective study.

BACKGROUND: Adult intussusception is a rare clinical condition worldwide. It contributes to less than 5% of all cases of intussusception. Few studies have been conducted in low-income countries compared to high-income countries; particularly Sub-Saharan Africa. Based on anecdotal evidence, the authors hypothesized that the condition is not as rare in a Sub-Saharan setting in comparison with western countries. We set out to conduct the first review study of adult intussusception in Uganda. METHODS: The medical records of 37 (out of a total of 62 cases) adolescent and adult patients with a postoperative diagnosis of intussusception at Mulago National Referral and Teaching Hospital, from January 2003 to December 2012, were analyzed. The clinical features, diagnosis, treatment and pathologic features of lesions for these patients were reviewed. Intraoperative findings were described with reference to: the site of the intussusception, and the triggering lesion (either idiopathic or with a lead point). RESULTS: The mean age was 33.6 years, with a range of 13 - 72 years. The male to female ratio was 1.85:1. The mean number of days for which symptoms had been present prior to presentation was 6.3 days, while the median was 4 days. All 37 patients presented with abdominal pain. Only 13 (35.1%) had the classical paediatric triad of abdominal pain, a palpable abdominal mass and bloody stool. Most of the remaining patients presented sub-acutely with non-specific symptoms. A lead point was present in 28 patients (75.7%). Of these, 24 (64.9%) cases involved tumours. Among the tumours, 54.2% were malignant. Treatment did not involve intussusception reduction in 14 patients (37.8%). Some form of operative surgery was conducted in 31 (83.8%) patients; mainly segmental bowel resections and hemi-colectomies. CONCLUSION: Adult intussusception is uncommon in the Uganda, though probably less so than in western countries. It presents sub-acutely or chronically and is often diagnosed at laparotomy. Lead points are the triggering lesion most times and are due mainly to tumours. The bulk of tumours are malignant. Most patients require surgical resection, with prior reduction done in selected cases.

Atypical gunshot injury to the right side of the face with the bullet lodged in the carotid sheath: a case report.

INTRODUCTION: Gunshot injuries of the head and neck from the AK-47 rifle (a common assault rifle, submachine gun type) are a significant contributor to morbidity and mortality among civilians in Sub-Saharan Africa. They may cause significant damage to the closely arranged structures in this region, and the bullet's trajectory can be very difficult to determine. We present an unusual case of gunshot injury with an atypical bullet entry wound, profound injury to the face, lodgment in the right carotid sheath, and 'wandering'; a first of its kind in East Africa. CASE PRESENTATION: A 27-year-old African-Ugandan woman of Nilotic ethnicity was referred to the Accident and Emergency Department of a tertiary hospital in Uganda, having sustained complex injuries due to an inadvertent AK-47 rifle gunshot injury. The gunshot injury was to the right side of her face with a large ragged entry wound and no exit wound. Prior basic wound care and radiological imaging showed a comminuted fracture of her mandible with lodgment of the bullet in her neck, anterior to her sixth and seventh cervical vertebrae. Standard debridement of her wound was done. A computed tomography scan showed an apparent cephalad shift ('wandering') of the bullet, leaving it lying partially anterior to her fifth cervical vertebra as well as within her carotid sheath. Other injuries were to her facial and trigeminal nerves, and her middle ear. The 'wandering' bullet was successfully removed surgically. It had caused no damage to any part of her neck structure. CONCLUSION: AK-47 rifle bullet injuries may present with uncharacteristically large entry wounds and cause complex structural injuries at the area of impact. The consequent trajectory is difficult to predict making regional examination and radiological investigations essential in management. Bullets may be retained, leaving no exit wound. Securing the airway, controlling hemorrhage and identifying other injuries are the first vital steps. This case illustrates all these interventions and the important decision to extract the entrapped bullet from the patient's neck because it had started to 'wander' and could have caused grave injury over time with further migration. Maxillofacial, plastic, trauma, general and military surgeons, otorhinolaryngologists and emergency physicians can gain from this experience because it calls for a multidisciplinary team approach.

Accreditation in a sub Saharan medical school: a case study at Makerere University.

INTRODUCTION: Of more than the 2,323 recognized and operating medical schools in 177 countries (world wide) not all are subjected to external evaluation and accreditation procedures. Quality Assurance in medical education is part of a medical school's ethical responsibility and social accountability. Pushing this agenda in the midst of resource limitation, numerous competing interests and an already overwhelmed workforce were some of the challenges faced but it is a critical element of our medical profession's social contract. This analysis paper highlights the process of standard defining for Medical Education in a typically low resourced sub Saharan medial school environment. METHODS: The World Federation for Medical Education template was used as an operating point to define standards. A wide range of stakeholders participated and meaningfully contributed in several consensus meetings. Effective participatory techniques were used for the information gathering process and analysis. RESULTS: Standards with a clear intent to enhance education were set through consensus. A cyclic process of continually measuring, judging and improving all standards was agreed and defined. Examples of the domains tackled are stated. CONCLUSION: Our efforts are good for our patients, our communities and for the future of health care in Uganda and the East African region.

The introduction, methods, results and discussion (IMRAD) structure: a Survey of its use in different authoring partnerships in a students' journal.

BACKGROUND: Globally, the role of universities as providers of research education in addition to leading in main - stream research is gaining more importance with demand for evidence based practices. This paper describes the effect of various students and faculty authoring partnerships on the use of the IMRAD style of writing for a university student journal. FINDINGS: This was an audit of the Makerere University Students' Journal publications over an 18-year period. Details of the authors' affiliation, year of publication, composition of the authoring teams and use of IMRAD formatting were noted. Data analysis gave results summarised as frequencies and, effect sizes from correlations and the non parametric test. There were 209 articles found with the earliest from 1990 to latest in 2007 of which 48.3% were authored by faculty only teams, 41.1% were authored by student only teams, 6.2% were authored by students and faculty teams, and 4.3% had no contribution from the above mentioned teams. There were significant correlations between the different teams and the years of the publication (rs = -0.338 p < 0.01 one tailed). Use of the IMRAD formatting was significantly affected by the composition of the teams (Χ2 (2df) = 25.621, p < 0.01) especially when comparing the student only teams to the faculty only teams. (U = 3165 r = - 0.289). There was a significant trend towards student only teams over the years sampled. (z = -4.764, r = -0.34). CONCLUSIONS: In the surveyed publications, there was evidence of reduced faculty student authoring teams as evidenced by the trends towards students only authoring teams and reduced use of IMRAD formatting in articles published in the students' journal. Since the university is expected to lead in teaching of research, there is need for increased support for undergraduate research, as a starting point for research education.