Nitrate and drinking water from private wells: will there be an epidemic of cancers of the digestive tract, urinary bladder and thyroid?

PURPOSE: To estimate the nitrate levels in private wells located in different parts of Enugu and discuss the future health implications following chronic ingestion of well water. MATERIALS AND METHODS: The map of Enugu was used to divide the city into many 25 units, using grid lines 1 cm apart. Cluster sampling method was used to collect samples. These samples were sent to two laboratories for estimation of nitrate levels. The people drawing water from the different wells were interviewed to determine what they used the water for. RESULT: The subjects who were interviewed said they ingested the water. The nitrate levels found in these wells (median value of 31 mg/L) were significantly higher than the internationally accepted levels of nitrate in water for ingestion, (P < 0.0001). CONCLUSION: High nitrate levels drinking water is dangerous to health and can cause methemoglobinemia in children. It may also increase cancer risk in adults because nitrate is endogenously reduced to nitrite and subsequent nitrosation reactions give rise to N-nitroso compounds (NOCs), which are highly carcinogenic and can act systemically.

Treatment of unilateral giant fibroadenoma by breast reduction skin incision: the inverted "T" technique.

BACKGROUND: Giant fibroadenoma (GFA) has been defined as fibroadenoma greater than 5 cm in it's the widest diameter and/or weighing more than 500 g. A benign lesion, its size also raises the possibility of malignancy requiring differentiation from a malignant breast disease. When unilateral GFA presents with a severe breast asymmetry, due to its size, it is not correctable by simple enucleation alone. Postoperative asymmetry from volume and ptosis disparity results, which needs to be addressed at the primary surgery. The inverted "T" technique, which is effective in volume reduction and ptosis correction in breast hypertrophy, can be applied in the treatment of unilateral GFA. AIM: This is a retrospective review of all GFA treated by inverted "T" method. MATERIALS AND METHODS: A retrospective review was carried out on all patients with GFA treated by inverted "T" skin pattern method over a period of 20 years (January 1988 to December 2007). The procedures were carried out at the University of Nigeria Teaching Hospital and the National Orthopedic Hospital, Enugu. Information, which included patients' demographics, pre-operative assessment, operative findings and outcome of surgery were obtained from the case files of the patients. The degree of ptosis was recorded for each patient. Diagnosis of GFA was made after clinical evaluation and pre-operative tissue biopsy. Immediate results of treatment were based on the patients' satisfaction, visual assessment of symmetry of size of breasts, correction of ptosis and position of nipple areola complex (NAC). RESULTS: A total of 27 patients underwent inverted "T" technique for excision of GFA in their breasts. Their average age was 17.5 years (range 12-25 years) delay in presentation ranged from 2 months to 15 months. In 16 patients (59.2%), the left breast was involved in GFA whilst the tumor occurred on the right breast in 11 (40.7%). The tumor weighed on the average 1500 g (range 655-2200 g). Average diameter of the tumor was 15 cm (range 12-20 cm). All quadrants of the breasts were involved at presentation. The inferior glandular pedicle bearing the NAC was used in all patients. The length of the pedicle ranged from 8 cm to 14 cm whilst the width ranged from 6 cm to 8 cm. Lactation was reported by three patients who went on to successfully breast feed. Complications were minimal. Most were minor wound healing problems and minor breast asymmetry. Epidermolysis in 2, hypertrophic scar in 6,minor breast asymmetry in 3 and delayed healing at the "T" junction in the inframammary fold in 4 were the common complications. All patients were satisfied with the result obtained. CONCLUSION: In GFA with a significant breast asymmetry, excision through inverted "T" technique was successful in achieving postoperative symmetry with the opposite breast in these patients. Complications were minimal.

Enterocutaneous fistula: a review of 82 cases.

OBJECTIVE: Enterocutaneous fistula is an unpleasant and troublesome complication of abdominal operations. The objective was to review the outcome of treatment of patients treated for enterocutaneous fistula. MATERIALS AND METHODS: This is a retrospective study of 82 teenage and adult patients, who suffered from enterocutaneous fistula, seen over an 11 year period, in the University of Nigeria Teaching Hospital, Enugu. Patients' charts were reviewed for biodata, etiology of the fistula, volume of the fistula output, and result of treatment. Majority of the fistulas occurred after abdominal operations; many by general practitioners. After treatment for correction of fluid and electrolyte deficits, they were all tried on conservative therapy with enteral nutritional support as the main stay of management. Those, whose fistulas did not close, underwent surgical treatment. Total parenteral nutrition, octreotide, fibrin glue, and wound vacuum assisted closure (VAC) were not used for treating these patients. RESULTS: Spontaneous healing of fistulas occurred in 26 patients (31.7%), whereas 42 patients out of 50 (84%) healed after definitive operation. Fourteen patients (17%) in this study, died. CONCLUSION: Proper management of fluid and electrolyte imbalances, enteral nutritional support, control of sepsis and correctly timed surgical therapy, resulted in this good healing rate and acceptable mortality, without the use of parenteral nutrition, biologic fibrin glue injection or VAC. Suggestions are offered about steps that may help in eradicating some of these enterocutaneous fistulas.

Adenoid cystic carcinoma of the breast at Enugu Nigeria.

BACKGROUND: (Adenoid cystic carcinoma (ACC) of the breast is a rare type of neoplasm that is histologically indistinguishable from other examples in other sites and generally has a good prognosis). To characterize the clinical and pathological features of ACC in our environment, as well as the treatment offered to our patients, a review of the clinical records of patients treated at the University of Nigeria Teaching Hospital Enugu was undertaken. PATIENTS AND METHODS: Case notes of breast cancer patients stored in the medical records department were retrospectively reviewed with a view to studying those with ACC. Follow up on these patients were documented. RESULT: Adenoid cystic carcinoma of the breast was diagnosed in 9 out of 222 patients treated for cancer of the breast, from 1995-2000. Patients aged 34-70 years were afflicted with this disease. A lump in the breast led to the initial suspicion of a tumor. Some of them had pain in the breast. Many of the patients came with advanced disease. Surgical treatment ranged from simple mastectomy to modified radical mastectomy with radiotherapy and chemotherapy in some patients. CONCLUSION: The disease is rare at Enugu but contrary to findings elsewhere, majority of our patients had advanced disease. Those with early disease appeared to have a good outcome.

Ileosigmoid knotting in a young adult in Enugu, Nigeria - a case report.

A 25-year old male student who was seen in the emergency unit of our hospital with symptoms and signs of acute intestinal obstruction of 4 days duration is presented. Following resuscitation, an exploratory laparotomy revealed a long gangrenous jejunoileal segment with its base firmly knotted around the mesentery of the sigmoid colon which was also gangrenous. Resection and primary anastomosis of the small bowel was carried out. Hartmann's colostomy was also done following resection of the sigmoid colon. The features of this uncommon presentation of intestinal obstruction described in the literature as ileosigmoid knotting or compound volvolus are highlighted, with particular note that its recognition, rapid resuscitation and exploration will improve prognosis.

Central nervous system infections in the rainforest zone of Nigeria.

OBJECTIVES: To ascertain incidence rates of central nervous system infections and provide information for health care planners. DESIGN: A two-stage screening through supervised case referrals and diagnostic evaluation at referral centre to establish a register of CNS infections. SETTING: A rural community in the rainforest zone of Nigeria with land area of 186500 m2, average daily temperature of 28 degrees C, annual rainfall of 2080 mm, adult population of 109851 and served by 26 primary, three secondary and twelve comprehensive care facilities. More than two per cent of the populations live in waterlogged areas. SUBJECTS: Adults aged sixteen years and above, constituting incident cases of CNS infections. MAIN OUTCOME MEASURES: Incident CNS infections per 100,000 populations averaged over a two year observational period. RESULTS: Incidence rates were 3.6, 4.1, 2.3, 09, 1.8, 0.9 for acute bacterial meningitis, aseptic meningitis, rabies encephalitis, non-rabies encephalitis, tuberculous meningitis and chronic non-tuberculous meningoencephalitis, respectively. Syphilitic neuroarthropathy had 0.46. CONCLUSIONS: Mortality from acute pyogenic meningitis and tuberculous meningitis remained distressingly high. Aseptic meningitis had the highest incidence rate, yet remained inadequately emphasised. Rabies encephalitis was the third commonest cause of CNS infection in the area.

Diabetic Ketoacidosis Presenting with Fournier's Gangrene

A case of survival of a patient with Fournier's gangrene and diabetic ketoacidosis is described. Careless handling of itchy scrotal disease in this diabetic patient was responsible for the onset of scrotal gangrene. Early recognition of diabetic ketoacidosis and Fournier's gangrene and prompt treatment led to survival. Consequently; early consultation of a physician/dermatologist is advised when diabetics have itchy groin lesions; while doctors are urged to routinely examine the scrotum of patients with diabetic ketoacidosis