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.

Determinants of patronage of traditional bone setters in the middle belt of Nigeria.

BACKGROUND: Traditional bone setting is a practice that is common in our environment. This is a community based survey of opinions concerning orthodox and traditional fracture management in four states of the middle belt of Nigeria. We set out to ascertain the factors influencing preference of treatment of fractures among populations in the middle belt of Nigeria. METHODOLOGY: A community based questionnaire survey of randomly selected adults regarding preference of choice of treatment between orthodox and traditional fracture management. RESULTS: One hundred and eighty-six questionnaires were found analyzable with a male to female ratio of 2:1. There was a preponderance of preference for orthodox fracture management (70.4%). Decisions were mainly collegiate, outside the influence of the individual; only 9.9% decided to attend traditional bone setters on their own. CONCLUSION: Reasons adduced for preference of traditional bone setters were incongruous and inconsistent. A fixated cultural outlook was recognized as being the motivating factor for patronage of traditional bone setters. Need for enlightenment campaign of the public against patronage of traditional bone setters is emphasized. A gradual phasing out of traditional bone setting with a road map towards making orthodox fracture management available to all is advocated.

Gastrointestinal perforation following blunt abdominal trauma.

OBJECTIVE: To highlight the pertinent management problems of bowel perforation following blunt abdominal trauma. DESIGN: A prospective descriptive study. SETTING: Hospital-based cohort over a nine year period in Jos University Teaching Hospital, Jos, Nigeria. SUBJECTS: A total of 23 patients with bowel perforation out of 8,970 trauma victims with a mean age of 28.5 years. INTERVENTION: Exploratory laparotomy, drainage of septic peritoneal fluid and wound saline lavage and closure of perforations were performed in all the 23 patients with clinical features and imaging signs suggestive of bowel perforation following blunt abdominal trauma. Femoral fractures were splinted and tube thoracostomy were carried out in four and two patients respectively. MAIN OUTCOME MEASURES: There is an apparent delay in presentation and diagnosis of traumatic bowel perforation following blunt abdominal trauma. Signs of peritoneal sepsis remain the most consistent findings in our environment. The morbidity and mortality following blunt abdominal trauma and bowel perforation are high because of established peritonitis. Delayed presentation or large leakage of bowel content into the peritoneal cavity and the attendant ease with which peritonitis develops in the latter are factors responsible. RESULTS: Delayed presentation (mean 3.05 days) was observed in seven of 23 patients. Eight patients had concomitant injuries; two to the head, four had right femoral fracture and two blunt chest injury. Features of peritonitis were present at initial evaluation in 19 patients. Seventeen patients were victims of motor vehicle accident. Radiological evidence of perforation (pneumoperitoneum) was present in only two of four patients with difficult diagnosis. Free peritoneal fluid without solid organ injury was detected in two patients with ultrasound. Diagnostic peritoneal lavage was, therefore, not used in any of our patients. The mean time from admission to laparotomy was six hours. Sites of perforations were: stomach (2), jejunum (9), ileum (8), jejunum/ileum (2) and colon (2). Sepsis originating from the perforated bowel was responsible for mortality in our patients who died in the perioperative period with concomitant injury playing significant role in three of 11 patients with such injuries. CONCLUSION: Peritonitis following a bowel perforation after blunt abdominal trauma is often present at the time of presentation and diagnosis is usually made. In the few doubtful cases, often in patients presenting soon after trauma, X-ray and trans-abdominal ultrasonography will assist in making a diagnosis. Delayed presentation still accounts for a high mortality in bowel perforation following blunt abdominal trauma.

Epidemiology of soft tissue sarcomas in Jos, North Central Nigeria.

BACKGROUND: Soft tissue sarcomas are a complex heterogeneous group of tumours that often cause a diagnostic problem. Special stains are often employed for further differentiation of these tumours. As a group, soft tissue sarcomas are not uncommon as previously believed. OBJECTIVE: To undertake a ten year retrospective study of soft tissue sarcomas in a Nigerian Teaching Hospital and to also discuss the pathology of the disease. METHODS: The study consisted of all records of histologically confirmed cases of soft tissue sarcomas from 1994 2003, seen at JUTH. The slides were retrieved and read separately by two pathologists. Special stain such as Reticulin, PTAH, Oilred O, were used to demonstrate basement membrane, muscle striation and lipids respectively. These aided confirmation of the diagnosis. Information extracted from patients' records included age, site of lesion and sex. RESULTS: A total number of 266 cases of soft tissue sarcomas were recorded out of 2353 histologically confirmed cancers. These accounted for 11.3% of all cancers. One hundred and eighty three occurred in males and 83 in females, with male, female ratio of 2:1. Kaposi sarcoma (KS), Rhabdomyosarcoma (RMS), Malignant Fibrous Histiocytoma (MFH), and Fibrosarcoma (FS) were the commonest histological subtypes accounting for 69 (25.9%), 63 (23.7%), 56 (21.1%) and 49 (18.4%) respectively; with Rhabdomyosarcoma occurring more in paediatric and adolescent age groups, while the rest subtypes were more prevalent in adults. The commonest sites affected were leg/foot 71 (26.7%), head/neck 68 (25.6%) and thigh 50 (19%). CONCLUSION: Soft tissue sarcomas constituted a significant proportion of cancers in our centre and are not uncommon as previously reported in the literature.

Digital rectal examination for prostate cancer: attitude and experience of final year medical students.

OBJECTIVE: Prostate cancer which tends to take an aggressive course in black populations can be detected by digital rectal examination (DRE). There are concerns however that medical students are not acquiring the necessary DRE skills. We therefore studied their experience and attitude towards DRE for prostate cancer to assist us make any necessary adjustments in training. METHODS: This was a self-administered questionnaire based study of final year medical students two months to graduation carried out at the Jos University Teaching Hospital, location for clinical studies of the Medical Faculty ofthe University of Jos. RESULTS: There were 100 students in the study, with a male: female ratio of 3.6:1. The ages ranged from 24 to 35 with a mean of 28 years. Fifty-one percent and 94% agreed they had been taught DRE in class and on the ward/clinic respectively. Almost half (45%) had never performed a DRE and 43% performed it only 1-2 times. Sixty-two percent of the students had never confidently palpated a prostate; while 30% had palpated it 1 2 times. Eighty-six percent and 7% respectively have never felt a clinically malignant prostate or felt it 1 2 times. There was no statistically significant difference in the number of DREs performed by sex or age (p> 0.05). On supervision 43% were never supervised to do DRE while 23% were supervised all the time. Ninety-five percent believed DRE is an essential requirement for a medical practitioner and 96% believed they should have the skills before graduating. Only 36%, however, believed their teachers have been supportive, teaching them DRE (p value = .033). Ninety percent agreed that DRE is useful for screening for prostate cancer. The major reason for not performing DRE more than half the time was the student not feeling competent (54%). CONCLUSION: Students have received adequate teaching on DRE, have the right attitude and perspective, have adequate knowledge on DRE findings suggestive of prostate cancer but have not translated this knowledge into practice. This is mainly due to the students not feeling competent. Teachers need to intensify practical supervision to enable medical students acquire the necessary experience during clinical training.

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.

Incarcerated umbilical hernia in children.

BACKGROUND: Umbilical hernia is common in children. Complications from umbilical hernias are thought to be rare and the natural history is spontaneous closure within 5 years. PATIENTS AND METHODS: A retrospective analysis was performed of the medical records of a series of 23 children who presented with incarcerated umbilical hernias at our institution over an 8-year period. RESULTS: Fifty-two children with umbilical hernias were seen in the hospital over the period. Twenty-three (44.2%) had incarceration. Seventeen (32.7%) had acute incarceration while 6 (11.5%) had recurrent incarceration. There were 16 girls and 7 boys. The ages of the children with acute incarceration ranged from 3 weeks to 12 years (median 4 years), while the ages of those with recurrent incarceration ranged from 3-15 years (median 8.5 years). Incarceration occurred in hernias of more than 1.5 cm in diameter (in those whose defect size was measured). Twenty-one children (15 with acute and all six with recurrent incarceration) underwent repair of the umbilical hernia using standard methods. The parents of two children with acute incarceration declined surgery after spontaneous reduction of the hernia in one and taxis in the other. One boy had gangrenous bowel containing Meckel's diverticulum inside the sac, for which bowel resection with end-to-end anastomosis was done. Operation led to disappearance of pain in all 6 children with recurrent incarceration. Superficial wound infection occurred in one child. There was no mortality. CONCLUSION: Incarcerated umbilical hernia is not as uncommon as thought. Active observation of children with umbilical hernia is necessary to prevent morbidity from incarceration.

The acute scrotum: aetiology, management and early outcome-preliminary report.

BACKGROUND: Most patients with acute scrotal pain may require urgent exploration. We determined the aetiological factors, treatment and early complications in such patients. METHODS: This was a prospective study of consecutive patients presenting with the acute scrotum at Jos University Teaching Hospital, Nigeria from January 2001 to December 2002. RESULTS: Twenty-nine patients were studied with a mean age of 29.4 years (range 12 days to 80 years). Seventeen (58.6%) were 11 to 30 years old. The clinical diagnostic accuracy for testicular torsion was 75% because out of the 24 patients initially thought to have testicular torsion, 18 (62.1%), four (14.8%) and two (6.9%) had testicular torsion, epididymoorchitis and torsion of appendix testis respectively at exploration. The diagnosis in other patients was intrascrotral abscess in two (6.9%), Fournier's gangrene in one (3.4%) and haematocoele in one (3.4%). Only four (13.9%) patients presented within the first 24 hours of illness (all explored within 6 hours) and 14 (48.3%) in one to five days. Thirteen (44.6%) patients had orchidopexy while seven (24.2%) had orchidectomy as a result of testicular torsion (five) and intrascrotal abscesses (two). Testicular exploration only, with antibiotics was the treatment for patients eventually found to have epididymoorchitis, with good response. Testicular salvage rate was 72% in patients with testicular torsion. Postoperative complications observed in three patients were wound infection (two) and wound dehiscence (two). CONCLUSION: We conclude that testicular torsion is the most common cause of acute scrotum in our environment. Majority of our patients with acute scrotum present to hospital late. Health education of the public and attending physicians is required in order to reduce delay in presentation, improve diagnostic skills, testicular salvage rate and prognosis.

Typhoid intestinal perforation in north central Nigeria.

BACKGROUND: Typhoid intestinal perforation is a surgical problem with severe morbidity and high mortality in North Central Nigeria. PATIENTS AND METHODS: In order to determine the pattern and the prognostic indices, we studied 101 patients with typhoid intestinal perforation managed over a ten-year period RESULTS: Children constituted 49% of the cases and majority (78%) of the patients were in the low socio-economic strata. The incidence peaked to 67% between November and March - the dry season in Nigeria. The male/female ratio was 1.9:1 with a mean age of 19 years and a mean hospitalization period of 18 days. There were 167 perforations; four involved the large bowel and appendix, and in 72.2% cases, the perforation was single. The mortality rate was 13.9%, affected mostly children and significantly worsened by prolonged perforation-surgery interval > 72 hours, jaundice, convulsion, ASA V, faecal peritonitis and re-exploration for early intra-peritoneal complications. Morbidity rate was 65.3% and significantly affected more children than adults and associated with perforation-surgery interval of between 24 and 72 hours, haematochezia and multiple perforations. Moribund patients fared better when operated upon under local anaesthesia with adequate analgesia. The least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results. Children who survived up to 5 days and adults who survived up to 10 days after surgery had better chances of survival. CONCLUSION: The most significant prognostic factor is late presentation which prolongs perforation-surgery interval and the other complication and mortality indices are directly influenced by it.

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.

A review of the radiological diagnosis of small bowel obstruction using various imaging modalities.

Radiological investigation is an important tool in the diagnosis of small bowel obstruction (SBO). While plain abdominal radiograph remains the commonest investigation done in SBO, contrast gastrointestinal radiography, ultrasonography (US), computerised tomography (CT) scan -- with or without contrast enhancement are increasingly being advocated particularly in equivocal cases of SBO. We conducted manual, medicine and internet search for relevant literature on diagnosis of SBO using radiological investigations. Plain abdominal radiograph has a diagnostic accuracy for SBO that varies widely from 50 - 92% . Contrast gastrointestinal radiograph in equivocal cases of adhesive SBO can readily differentiate between complete and partial obstruction. Abdominal ultrasound is cheap and readily available. Accuracy of as high as 89% has been reported in experienced hands. CT scan has an added advantage of predicting the site and cause of obstruction. In developing countries like ours, plain abdominal radiography still remains an important diagnostic tool. The role of abdominal ultrasonography needs further evaluation since it is safe, readily available and affordable.

Lower limb amputation in Jos, Nigeria.

OBJECTIVE: To determine the pattern of lower limb amputation (LLA) and highlight preventable causes in our hospital. DESIGN: A retrospective study. SETTING: University Teaching Hospital, Jos, Nigeria. SUBJECTS: Eighty seven patients who had LLA over a five and a half year period. There were 62 males and 25 females aged between three and 83 years (mean+/-SD = 44.5+/-21.1). MAIN OUTCOME MEASURES: Indications, morbidity and mortality. RESULTS: A total of 94 LLA were performed in the 87 patients managed. Trauma, diabetic foot sepsis and malignant conditions of the limb were the main indications for LLA in 26(29.9%), 23(26.4%) and 20(23%) patients respectively. Others were peripheral vascular gangrene (PVG) in eight (9.2%) patients; chronic osteomyelitis, three (3.5%); chronic leg ulcers, three (3.5%); Ainhum, three (3.5%) and snake bite in one patient (1.1%). Above knee amputation (AKA) was the most common procedure performed (48.9%) followed by below knee amputation (BKA) in 37.2%. There were 11 deaths (12.6%), out of which eight were due to sepsis with multiple organ failure following diabetic foot sepsis, two cases of clostridial myonecrosis complicating compound fractures and a case of metastatic osteosarcoma in a child. CONCLUSION: Majority of the cases of LLA could have been avoided with early presentation and appropriate management. A case is made for community health education on the need for early presentation to hospital for limb lesions.

Acquired rectal fistula in human immunodeficiency virus-positive children: a causal or casual relationship?

Acquired rectal fistula in human immunodeficiency virus (HIV)-positive children is a new and worrisome entity. The aim of this paper is to highlight the relationship between HIV infection and acquired rectal fistula (RF) in children in order to create awareness among clinicians who attend to children. Over a 1-year period, 11 girls aged 4 weeks-11 months (median 5 months) with acquired RF were managed at our institution. Ten were HIV-positive by enzyme-linked immunosorbent assay and confirmed by Western blot test. One child defaulted before the test. All the mothers and three fathers of the 10 children were seropositive for HIV. Bronchopneumonia, otitis media, oral thrush, diarrhoea, and lymphadenopathy were common associations. Treatment was essentially conservative because the result of surgical intervention was disappointing. Two of the infants and one of the fathers are now dead from full-blown acquired immunodeficiency syndrome. Acquired RF seems to be a sign of HIV infection in children. It will be necessary to screen any child presenting with acquired RF for HIV infection.

Prevalence of umbilical hernia in a private school admission-seeking Nigerian children.

BACKGROUND: Despite the claims that umbilical hernia (UH) is common among Nigerian children, the socio-economic class-related prevalence or incidence rate of UH in the Nigerian children is not known. We therefore undertook this study to determine the prevalence of UHs among Nigerian children of high socio-economic class. PATIENTS AND METHODS: This 7- years prospective study assessment of the prevalence of primary umbilical hernias among a private school admission seeking Nigerian children. Clinical evaluations of the umbilicus were conducted on 7,968 Nigerian children, attending interview into Nigerian Airforce Military schools from across the country. RESULTS: Umbilical hernia was present in 102 (1.3% ) out of 7968 children, giving a prevalence of 12.8 per 1,000. Fifty-three (52.% ) were boys and 49 (48% ) were girls; their ages ranged from 6 to 9 years (mean 6.5 years). Umbilical hernia was 1.4 times as common in the girls as in the boys, with a prevalence of 15.3 per 1,000 and 11.1 per 1,000, respectively. The overall prevalence in this study is comparatively lower than those previously reported. CONCLUSION: Our study suggests that there is a low prevalence rate of UH among the children of high socio-economic class in Nigeria.

Thyroglossal duct lesions in childhood--a review of experience in Nigerian children.

This is a retrospective study of 36 children with thyroglossal duct lesions managed at a tertiary hospital in Nigeria, between 1993 and 2003. The aim was to determine the pattern of presentation and outcome of management. The majority of patients presented with a chronic thyroglossal sinus with associated recurrent inflammation. The location and relationship of the lesions to the hyoid bone were similar to those encountered in the rest of the world. Despite their well-documented clinical features, thyroglossal duct lesions were misdiagnosed in some patients. The main complications were surgical site infections and recurrence. A plea is made for clinicians to pay attention to clinical and operative details so as to diagnose these lesions accurately and manage them properly.

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.

Acute colonic pseudo-obstruction (Ogilvie's syndrome). A case presentation and review of literature.

The syndrome of acute colonic pseudo-obstruction popularly known as Ogilvie's syndrome is an infrequent pathology and has been the subject of numerous medical communications in the past two decades. Its aetiology and pathophysiology remains poorly understood and patients are still treated inappropriately. In this report, a patient with acute colonic pseudo-obstruction managed surgically is presented. The pathogenesis and surgical management of this condition is also reviewed.