Severe Chest Injury Revisited - An Analysis of The Jos University Teaching Hospital Trauma Registry.

BACKGROUND: Chest injury remains a major source of morbidity and mortality in trauma as approximately two-thirds of all severe traumas involve the chest. OBJECTIVE: To determine the changes in the profile management and outcome of severe chest injury in Jos University Teaching Hospital, Jos, Nigeria. MATERIALS AND METHODS: This is an analysis of the Trauma Registry of Jos University Teaching Hospital-a prospectively gathered database. Patients' entries with severe chest injuries for 7 years, from January 2012 to December 2018, were entered into a database and analyzed using the Epi Info Statistical Software, using simple statistics. RESULTS: In all, 162 patients presented with severe chest injury over a 7-year period, of whom 78 (48.1%) had polytrauma, while 84 (51.9%) had isolated chest injury. There were 139 males and 23 females, giving male: female ratio of 6:1. Over 95 (58.6%) of them were between 20 and 39 years. Blunt injury was predominant, constituting 66.7%. Motor vehicular crash was the most common mechanism of injury constituting 87 (53.7%), while gunshot injuries were responsible for 34 (21%). In managing these severe chest injuries, 146 (90%) of the patients had closed-chest tube thoracostomy as the definitive treatment, while 16 (9.9%) had thoracotomy. The mean and median duration of hospital stay was 13.3 and 10 days, respectively. The commonest complication was wound infection in 8 (4.9%) patients and a mortality of 5.9%. CONCLUSION: Blunt chest injury remains the commonest mechanism of chest injury but with an increasing proportion of penetrating injuries affecting predominantly young males. Most severe chest injury patients survive with simple interventions of resuscitation, and closed-chest tube thoracostomy for definitive treatment.

CERVICAL LIPOSARCOMA IN A 22 YEAR OLD MAN- AN UNCOMMON PRESENTATION.

Liposarcomas are uncommon malignant growths, most of which occur in the retroperitoneum and lower extremities. Liposarcoma arising in the head and neck is an uncommon and a potentially life threatening malignancy. We present a 22 year-old male with a dedifferentiated cervical liposarcoma, who had local excision, with no recurrence at twenty months of follow-up. This patient has drawn our attention to the fact that although liposarcomas are rare in the neck and commonly occur in patients between 40 and 60 years, any neck swelling in the young with atypical features should raise suspicion as to the possibility of malignancy.

COMPLETE OESOPHAGEAL STRICTURE FOLLOWING THYROIDECTOMY FOR BENIGN GOITRE: A CASE REPORT.

Oesophageal injury leading to stricture is a dreaded disease with clinical course and prognosis that are dependent on the etiology, early recognition, and prompt and effective treatment. Commonly, iatrogenic oesophageal injury occurs during endoscopic procedures, and often in a diseased oesophagus. Though uncommon, injury can occur during thyroidectomy. We therefore present the case of a Nigerian woman with complete oesophageal stricture resulting from oesophageal injury sustained during thyroidectomy.

TRAUMATIC DIAPHRAGMATIC HERNIA WITH INTESTINAL OBSTRUCTION IN A CHILD: A CASE REPORT.

Diaphragmatic ruptures caused by blunt or penetrating trauma are relatively uncommon in children, however, they are the most commonly missed or delayed injuries in trauma patients because of its rarity and its coexistence with more obvious and serious injuries. We present a case of acute intestinal obstruction in a 6-year old boy with traumatic diaphragmatic hernia presented four years after trauma, underscoring the fact that clinical scenario in paediatric patients may not always correlate with the degree of severity of the injury and that some of the classical features of intestinal obstruction could be absent.

HUMAN BITE INJURIES ON THE JOS PLATEAU.

BACKGROUND: Human bite injuries with the associated morbidity are not uncommon in this environment. OBJECTIVE: To determine the pattern, management modalities and treatment outcome of human bites in Jos, Plateau State, Nigeria. DESIGN: A prospective study of all human bite injuries managed at the Jos University Teaching Hospital, Jos, Nigeria between January 2012 and December 2014. SETTING: Jos University Teaching Hospital, Jos, Nigeria. MAIN OUTCOME MEASURES: The pattern and management outcome. RESULTS: A total of 63 patients with human bite injuries were studied during the three-year period. There were 43 males and 20 females with a male:female ratio of 2:1. The age ranged from 8 - 65 years with a mean age of 30.2+/-17 years; in all about 75% of the patients fell into the 20 - 40 years bracket. Though all the social strata were affected, the bites were more common (50%) among the lower social classes and 70% of the patients presented late after 24 hours of sustaining bite injuries. Pain, bleeding, infected wounds, bite and scratch marks were the main presenting features. About 70% of the patients sustained major bites involving the underlying muscles and deeper structures while 89% of the patients sustained their bites during a fight, 8% while raping their victims, and in 3% of patients as they were being mugged. The bites were between spouses in 39% of cases, and between women in polygamous settings in 16%. The sites commonly affected were the upper limbs in 46%, chest in 21%, ears in 13%, abdomen in 10% and the penis in 6%. The associated injuries were scratch marks in 89%, blunt abdominal injuries in 29%, skin lacerations in 16% and urinary bladder/urethral injuries in 3%. There was no mortality but morbidity was 57% which included infections in 29%, disfigurement in 29%, penile injuries in 6% and minor urethral injuries in 3% of cases. CONCLUSION: Human bite injuries in this tropical environment commonly affected the young male, the lower social class and the upper limbs; they were commonly sustained in assaults and domestic conflicts.

IMPALEMENT HEAD INJURY WITH A SPEAR.

Impalement injuries to the craniofacial region are uncommon due to the fact that the face is a smaller target in relation to the rest of the body. We report a case of a 26-year old man who was attacked on the face with a spear. He was promptly evaluated and resuscitated; the blade of the spear was successfully extracted under general anaesthesia. He was discharged home after 2 weeks hospitalization; he has been followed up for three months with good outcome.

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.

HIRSCHSPRUNG'S DISEASE IN AN ADULT: A CASE REPORT.

Hirschsprung's disease in the adolescents and adults is not a common diagnosis in our environment. However this may be as a result of misdiagnosis or late presentation as is the case with other causes of recurrent constipation in older age groups. We present a case of a 19-year old male who presented with recurrent episodes of constipation from infancy with none requiring any intervention except for the index presentation that lasted for 3 weeks with associated progressive abdominal distension. Diagnosis was made with a barium enema and full thickness rectal biopsy. He had staged procedures with an initial divided colostomy thereafter followed by a definitive Souave endorectal pull-through with a good short-term outcome.

FACTORS DETERMINING THE RESULTS OF THE EXAMINATION OF THE WEST AFRICAN COLLEGE OF SURGEONS IN GENERAL SURGERY.

BACKGROUND: The general surgery results of the West African College of Surgeons (WACS) post-graduate fellowship examination could not be regarded as satisfactory when compared with the results of similar post-graduate examinations in some developed countries. For example the pass rate of the West African College of Surgeons examination was usually under 40% whereas the pass rate in oral examination in a similar post-graduate examination, the American Board of Surgery was 84% in 2006, 73% in 2012. The first time pass rate in general surgery of final year general surgery residents at the American Board of Surgery qualifying and certifying examinations were 74% - 78% between 2000 and 2007. AIM & OBJECTIVES: To identify the factors responsible for the high failure rate at the general surgery fellowship examinations of the West African College of Surgeons. STUDY DESIGN: Descriptive study .We studied and analyzed the West African College of Surgeons examination results for April 2012, October 2012, April 2013 and October 2013 with emphasis on the results, the conduct of the examination and the opinion from fellows about the examiners. Well structured questionnaires were sent to fellows who had passed all the various fellowship examinations of the West African College of Surgeons in general surgery to indicate their opinion about the examination, and the examiners. SETTING: University College Hospital, Ibadan, and Jos University Teaching Hospital, Jos, Nigeria. METHODOLOGY: The first part of the study dealt with an analysis of each section of the examination prospectively studied over a 2-year period. This consisted of four sets of examination results. The second part was a questionnaire-based study administered to Fellows who had passed the WACS final fellowship examination in general surgery. The questionnaire had three sections: primary, part 1 and part 2 and included basic demographics, date at attempts in each grade of the examinations and the outcome. It also included the views of the respondents on the conduct of the examination and outcome. The data were analyzed using Microsoft Excel. RESULTS: A total of 720 candidates with age range of 28 - 39 years and a mean of 33.2 years sat for the Part 1 Fellowship examinations in 2012 and 2013 with an average of 180 candidate per examination. At the Part 2 fellowship examination, 84 candidates with the age range of 31 - 42 year and a mean of 36.5 years sat the Part 2 Fellowship examination with an average of 21 candidates for each Part 2 examination in general surgery during the same period. The examinations held in April and October of each year. While an average of 28.8% of the candidates passed, an average of 71.2% of the candidates failed the Part 1 Fellowship examinations in 2012 and 2013. The aggregate clinical score was responsible for failure in 59.5% of the candidates. In the Part 2 Fellowship examination in general surgery during the same period, 31.5% of the candidates passed while an average of 68.5% of the candidates failed per examination. The aggregate clinical score was responsible for 53.3% of the candidates who failed the Part 2 examination. Furthermore, 60 - 69.7% of the candidates had a favourable opinion about the conduct of the examination, 54.5 - 63.6% rated the professionalism of the examiners high, even though the pass rate at the first attempts of the various grades of the examination by the respondents was about 50 percent. CONCLUSION: The clinical part of the examination is a major factor responsible for the high failure rate in the general surgery fellowship examinations of the West African College of Surgeons. In order to mitigate this, residents in training should be exposed to the clinical management of a wide range of cases in the discipline with majority of the operations performed by them under the direct supervision of their consultants.

The evolution of surgical procedures in the management of duodenal and gastric ulcers.

Surgical procedures for the surgical management of duodenal ulcer had evolved through many stages, over the years. It started with gastroenterostomy alone, then followed by subtotal gastrectomy, vagotomy alone, vagotomy and gastro-jejunostomy, vagotomy and pyloroplasty, and highly selective vagotomy - all which started as open surgical procedures. Now unless there are complications the treatment is essentially medical following the work of Marshall and Warren. Currently, even when surgery is indicated, minimal invasive procedures are preferred. Four main types of pyloroplasties are well known. They are Weinberg, Heinecke-Mikulicz, Finney and Jaboulay. Vagotomy can be truncal, selective, and highly selective. Accepted surgical treatment for gastric ulcer is the distal gastric resection to include the ulcerated area, but not resecting more than 50-60% of the stomach. In the uncommon cases of Zollinger-Ellison syndrome, aggressive gastric surgery, the use of drugs, and the resection of the tumour have all been recommended in appropriate cases. With the discovery of Helicobacter pylori and its effective medical treatment, surgery has little role in the initial management of peptic ulcer disease. The place of the history of the surgical procedures employed earlier in the treatment of this disease would remain relevant.

What should constitute the clinical component in fellowship examinations in surgery.

The consensus of opinion is that in all medical examinations, a failure in the clinical aspect of the examination automatically means a failure in the whole examination regardless of what the total score may be. But opinion differs as to what constitutes the "clinical aspect" of the examination. Some think it should be the average score of only long case and short cases. Others think it should be the total score of long case, short cases and viva voce. Yet others think when the orals are of two parts it should be the average score of long case, short cases and a part of the orals. We therefore used the result of 197 surgical residents that sat for the part 1 fellowship examination of the West African College of Surgeons in April 2012 for this study. We collated the scores of various categories of clinical aspect of the examination to see whether there is any difference in the pass rate of the group.

Traumatic Intracranial Aerocele With Progressive Blindness - A case report.

BACKGROUND: Traumatic intracranial aerocele, also known as pneumocephalus, is an uncommon condition that may be asymptomatic or may present with progressive neurological deficits and life threatening conditions that demand urgent decompressive craniotomy to reduce the acute rise in intracranial pressure and the sequelae. AIMS & OBJECTIVES: A high degree of suspicion and continuous neurological monitoring are essential for the early detection and the prompt neurosurgical intervention demanded for the achievement of a good outcome in patients following traumatic acute severe head injury with life threatening neurological complications. METHOD: Presentation of a young motorcyclist who was not wearing a crash helmet and was involved in a road traffic accident in which he sustained a compound cranio-facial injury with loss of consciousness and symptomatic intracranial aerocele. RESULTS: The case of a 28-year old motorcyclist without a helmet, following a road traffic accident, sustained compound skull fracture with CSF rhinorrhea, ventricular aerocele and progressive blindness who recovered his vision fully following bitemporal decompressive craniotomy. CONCLUSION: A high index of suspicion enabled early detection and prompt decompressive craniotomy that stemmed the progressive loss of vision in this patient with an uncommon but symptomatic intracranial aerocele and cranio-facial compound head injury.

Fracture of the penis. A report of two cases.

We present two cases of fracture of the penis in two young men at the extremes of the social strata the first an unemployed tailor while the other a practicing engineer. The first one was a bachelor while the other was married with children. In the first case, the fracture occurred during masturbation while in the second case it occurred during consensual intercourse with his wife on top. In the first case the fracture occurred at the base of the penis with associated rupture of the deep dorsal vein while in the second case it affected the mid-shaft with urethral rupture and blood at the tip of the penis at presentation. Both of them presented within two hours of their injuries with deformed, swollen and tender penis. Laubscher's subcoronal sleeve operation with evacuation of clots and repair of the tear with absorbable sutures to ensure a leak-proof repair was promptly performed with no complications. Both patients experienced spontaneous erection whilst in hospital even with indwelling catheter in place. The wife of the second case became pregnant six months after the repair. Counseling was successful with the engineer but was unsuccessful with the tailor-bachelor who continued with masturbation despite professional help. Though we published the first case of fracture of the penis in this centre almost a decade ago, we still found it necessary to report these new cases managed after we created awareness of this uncommon condition in our environment in order to highlight the presentations and the factors that influenced outcome.

Thyroidectomy under local anaesthesia: how safe?

BACKGROUND: In order to compliment the inadequate health facilities in the rural areas in Nigeria, nongovernmental organisations provide adhoc outreach health camps that offer treatment in various medical specialties including surgery. SETTING: Rural outreach health camps. OBJECTIVE: To evaluate the safety of thyroidectomy under local anaesthesia at rural outreach setting with inadequate facilities for general anaesthesia. PATIENTS AND METHODS: This was a prospective descriptive study of 33 consecutive cases of thyroidectomy performed using field block with 1% lignocaine and adrenaline 1: 200,000 dilution during two free medical outreaches that held at Jos, Nigeria in March and October 2005 respectively, lasting two weeks each. RESULTS: A total of 33 primary thyroid operations were performed consisting of 30 subtotal thyroidectomies (91%), 2 lobectomies (6%) and one total thyroidectomy (3%), The patients were aged between 23 and 62 years with a mean age of 45.8 years. There were 3 males and 30 females with a male: female ratio of 1:10. There was no mortality but morbidity was 2/33 (6%) Two complications were recorded in 2 patients and were superficial surgical site infection (3%) and reactionary haemorrhage (3%). CONCLUSION: We conclude that thyroidectomy under local anaesthesia is a safe procedure in experienced hands at rural settings with inadequate facilities for general anaesthesia.

Ileosigmoid knotting--a case for primary anastomosis.

BACKGROUND: Resection of gangrenous/non-viable bowel followed by primary anastomoses is known to be a viable option for treatment of ileosigmoid knotting. We here report a case of ileosigmoid knot and examined the options for treatment. METHOD: A case report of a patient with ileosigmoid knotting and discussion of relevant literature for surgical treatment. RESULT: A 26 year old man presented to the accident and emergency unit with two weeks' history of fever and alternating diarrhea and constipation followed by features of intestinal obstruction and later, generalized peritonitis. Plain abdominal X-rays showed dilated loops of bowel and multiple air-fluid levels. The diagnosis of ileosigmoid knotting was missed preoperatively. At exploratory laparotomy, ileosigmoid knot was encountered with non-viable segments of the sigmoid colon and ileum. Resection of the non-viable bowel was carried out with primary anastomoses with good postoperative outcome. CONCLUSION: Primary anastomoses after resection of gangrenous bowel is a safe surgical treatment option in ileosigmoid knotting.

Arrow-chest injuries in north central Nigeria: case series.

BACKGROUND: Metal arrows are still used in communal conflicts on the Jos Plateau in the north central region of Nigeria, even at the turn of the 21st Century with yet undetermined pattern and outcome. OBJECTIVE: To determine the pattern of the injuries and the factors that influence the outcome of this uncommon condition. METHODS: A prospective study of nine patients managed over a 6-year period. Information obtained on each patient included sex, age, site of and event leading to the injury, treatment offered and its outcome. The data were analyzed using Microsoft Excel Software. RESULTS: Nine cases of metal tipped arrow chest injuries are reported. They were all males. Six (67%) cases arrived at the Accident & Emergency Department alive with the arrows partly or completely in the chest. Three cases died in the field of combat giving a mortality rate of 33. The other six (66.6%) were received alive. All the six (67%) had emergency thoracotomy and all of them survived with two (22%) morbidities. In five (56%) cases, including the three dead cases, the arrows were partly inside the chest and partly protruding outside while in four (44%) cases the metal arrows were completely inside the chest. The left hemithorax was more commonly involved with 6 (67%) cases, 2 (22%) on the right and the manubrium sterni in one (11%) case. The associated injuries were arrow injury of the thigh in one (11%) patient and Colles fracture in two (22%) patients. Hospitalization period ranged between 10 to 18 day while mortality was 33% and morbidity was 22% as a result of wound infection. CONCLUSION: Arrow chest injuries on the Jos Plateau result from communal conflicts among young male adults. Emergency thoracotomy resuscitation produce good outcome in majority of the patients. Bow, arrows and crossbows should be banned as weapons, and instruments for hunting and sports.

A four-year analysis of manuscripts submitted for publication in West African Journal of Medicine (June 2001 to May 2005) (a brief report).

There are various criteria that could be used to rate a tertiary institution. One of these is the productivity of the members of staff which is shown by the research conducted, publications submitted and manuscripts published in indexed journals. Manuscripts submitted and published in one of the highly rated indexedjournals in our locality were analysed with a view to identifying how the institutions add to knowledge by their contributions. Our findings show that the four top-rated institutions in terms of manuscripts published in West African Journal of Medicine (WAJM) are University College Hospital (UCH), lbadan, University of Ilorin Teaching Hospital (UITH), Obafemi Awolowo University Teaching Hospital (OAUTH), and Jos University Teaching Hospital (JUTH).