EXPERIENCE WITH MANAGING RETROSTERNAL GOITRES IN IBADAN, NIGERIA.

BACKGROUND: There is no general consensus on the definition of retrosternal goitre (RSG) however thyroidectomy remains the gold standard of treatment with or without a sternotomy. AIM: To review the outcome of surgical management of retrosternal goitres. METHODOLOGY: Retrospective review of records of patients who had thyroidectomy for RSG over a 15-year period. RESULTS: Out of a total of 45 patients, 34(76%) were females and 11(24%) were males with a male/female ratio of 3:1; while their age ranged between 28 and 72years with a mean of 57+15SD. All the patients were euthyroid and a quarter did not have symptoms apart from a neck mass. In all, 15% of the patients had recurrent goitre. CT scan of neck and chest was done in 31 (72%) patients; while 44 (98%) patients had cervical retrosternal goitres, 1(2%) patient had ectopic retrosternal goitre. A cervical incision was sufficient in 28 (62%) patients while 17 (38%) patients required additional sternotomy. Total thyroidectomy was done in all the patients. There were post-operative complications in 19 (42%) patients. Histopathology showed that 3(6.6%) patients had papillary thyroid carcinoma while 42(93.4%) had benign pathology findings. CONCLUSION: Surgical removal is the treatment of choice. Most retrosternal goitres can be resected through a collar stud incision; however the possibility of a need for a sternotomy should always be planned. The simultaneous occurrence of cervical and ectopic retrosternal goitre should always be ruled out with a CT scan.

Comparison between NSAID and intra-articular corticosteroid injection in frozen shoulder of diabetic patients; a randomized clinical trial.

INTRODUCTION: Frozen shoulder or adhesive capsulitis is a relatively common encountered musculo-skeletal disease in which arouses following soft tissue involvement of glenohumeral joint and presents with pain and limitation of shoulder' active and passive motions. The incidence of frozen shoulder among diabetic patients is about 10-20%, stiffness in such patients is more severe and should be managed actively. Local Glucocorticoid injection, NSAIDs and physiotherapy each can relief the symptoms. The aim of this study was to compare the efficacy of glenohumeral injection of Glucocorticoid with NSAIDs in frozen shoulder of diabetic patients. METHOD: The randomized clinical trial study conducted during Feb 2009-Aug 2010 on diabetic patients with frozen shoulder that were referred to rheumatology and endocrinology clinics, Yazd, Iran. Diagnostic criteria of capsulitis were pain of shoulder and range of motion limitation in all directions. The patients were divided into 2 groups, patients of first group received NSAID while the latter group were undergone intra-articular corticosteroid injection. After 1 week, home exercise was done for both group and evaluation of the patients after first visit was done likewise 2nd, 6th, 12th and 24th weeks. All registered data were transformed into SPSS-15 software and analyzed. RESULTS: Totally 57 patients (19 males (33.3%) and 38 females (66.7%) were included in the analysis. There was no significant difference between sex (P=0.4) and age (P=0.19) of patients. No significant relation was detected between 2 groups after 24 weeks according to range of motion in flexion (P=0.51), abduction (P=0.76), external rotation (0.12) and internal rotation (P=0.91). Also any significant difference in pain score was not detected (P=0.91). CONCLUSION: Based on our study, both intra-articular corticosteroid and NSAID are effective in treatment of adhesive capsulitis and there is no significant difference between efficacies of these 2 treatment modalities in diabetic patients.

CIVILIAN VASCULAR INJURIES IN AN URBAN AFRICAN REFERRAL INSTITUTION.

OJECTIVE: To evaluate the pattern of civilian vascular injuries, demonstrate any change in pattern and document management challenges in a resource challenged environment. DESIGN: A retrospective study. SETTING: The division of Thoracic and Cardiovascular Surgery of University College Hospital a major referral centre, not only for south-west Nigeria but for the whole country. SUBJECTS: All patients presenting with vascular injury through the division during the study period were recruited. There were no exclusion criteria. RESULTS: Males accounted for 85% of the study group. Mean age was 31.98 years (± 14.94 S.D.) with peak in 20-29 years group (28.3%). Stab and gunshot injury were responsible in 36.7% and 30% respectively. Upper limb vessels were involved in 58.3%. Delayed presentation (> 4 hrs postinjury) occurred in 58.3% and presentation-operation interval was four to six hours in 55% of cases. Specific diagnostic investigation was required in only 20%. Morbidity, amputation and mortality rates were 10.1, 3 and 6.7% respectively. CONCLUSION: Penetrating vascular injuries are on the increase amongst civilian population. Poor transportation and lack of organised referral system contribute to delay in surgical intervention. Prompt evaluation for hard signs of vascular injury is of immense value in deciding for surgery in our environment where patients have financial challenges and resources are limited.

Presentation pattern and management of effusive-constrictive pericarditis in Ibadan.

BACKGROUND: Effusive-constrictive pericarditis is a syndrome in which constriction by the visceral pericardium occurs in the presence of a dense effusion in a free pericardial space. Treatment of this disease is problematic because pericardiocentesis does not relieve the impaired filling of the heart and surgical removal of the visceral pericardium is challenging. We sought to provide further information by addressing the evolution and clinico-pathological pattern, and optimal surgical management of this disease. METHODS: We conducted a prospective review of a consecutive series of five patients managed in the cardiothoracic surgery unit of University College Hospital, Ibadan, in the previous year, along with a general overview of other cases managed over a seven-year period. This was followed by an extensive literature review with a special focus on Africa. RESULTS: The diagnosis of effusive-constrictive pericarditis was established on the basis of clinical findings of features of pericardial disease with evidence of pericardial effusion, and echocardiographic finding of constrictive physiology with or without radiological evidence of pericardial calcification. A review of our surgical records over the previous seven years revealed a prevalence of 13% among patients with pericardial disease of any type (11/86), 22% of patients presenting with effusive pericardial disease (11/50) and 35% who had had pericardiectomy for constrictive pericarditis (11/31). All five cases in this series were confirmed by a clinical scenario of non-resolving cardiac impairment despite adequate open pericardial drainage. They all improved following pericardiectomy. CONCLUSION: Effusive-constrictive pericarditis as a subset of pericardial disease deserves closer study and individualisation of treatment. Evaluating patients suspected of having the disease affords clinicians the opportunity to integrate clinical features and non-invasive investigations with or without findings at pericardiostomy, to derive a management plan tailored to each patient. The limited number of patients in this series called for caution in generalisation. Hence our aim was to increase the sensitivity of others to issues raised and help spur on further collaborative studies to lay down guidelines with an African perspective.

Effects of a single post-partum injection of a high dose of vitamin D on glucose tolerance and insulin resistance in mothers with first-time gestational diabetes mellitus.

AIM: This study was performed to determine the effect of a single, large, intramuscular injection of vitamin D post-partum on glucose tolerance and insulin resistance in women with gestational diabetes. METHODS: Forty-five participants in a randomized controlled trial on gestational diabetes mellitus were divided into an intervention group and a control group. Only subjects in the intervention group received one intramuscular injection of 300,000 IU of vitamin D3. HbA(1c), serum 25-hydroxyvitamin D3, fasting insulin and blood glucose, C-peptide, homeostasis model assessment insulin resistance index (HOMA-IR), ß-cell function, insulin sensitivity and the Quantitative Insulin Sensitivity Check Index (QUICKI) were measured at baseline and after 3 months of intervention. RESULTS: Approximately 80% of the mothers had a degree of vitamin D deficiency. Post-intervention, this was found in 4.2 and 71.4% in the intervention and control groups, respectively. The medians of HOMA-IR indices before and after intervention were 0.6 and 0.5 (P = 0.7), respectively, in subjects in the intervention group, and 0.5 and 0.9 (P = 0.01) in subjects in the control group. The mean of the QUICKI fell only in the control group (P = 0.008). In the control group, ß-cell function increased by ~8% (P = 0.01) and insulin sensitivity decreased after 3 months (P = 0.002). Post-intervention, the median C-peptide decreased in the intervention group and increased in the control group, but the change was significant only in the control group (P = 0.03). CONCLUSIONS: A single injection of 300,000 IU of vitamin D3 achieves a 3-month serum 25-hydroxyvitamin D range of 50-80 nmol/l and is an efficient, effective and safe procedure for improving the vitamin status and indices of insulin resistance in mothers with gestational diabetes after delivery.

HIV/AIDS and the surgeon.

Human Immunodeficiency Virus and Acquired Immunodeficiency Disease (HIV/AIDS) are one of the most difficult challenges facing practicing surgeons worldwide. The challenge is more acute in sub-Saharan Africa as it currently has the highest prevalence of HIV infection in the world. Surgeons are at risk of occupationally acquired infection as a result of intimate contact with the blood and other body fluids of HIV patients requiring surgery. Patients also risk being infected by surgeons and other health care workers during surgical or dental procedures. The seropositive status of the majority of HIV positive patients may be unsuspected by the attending medical personnel who may not practice universal precautions against infection. The non-availability of relevant devices is however the most important factor militating against the use of universal precautions, especially in developing countries. There is therefore a need to increase the awareness about universal precautions and to provide the necessary devices to promote constant adherence to these procedures in order to reduce the risk of nosocomial HIV infection.

Aorto-femoral bypass in the HIV infected patient.

We describe a 49-year old male Nigerian with HIV infection who presented in our institution with aorto-iliac arterial occlusive disease and progressive severe ischaemic changes of the lower extremity. His preoperative CD4 count was 43 cells / microlitre. He underwent a successful intra-peritoneal aorto-femoral bypass. This report illustrates that vascular reconstruction in an HIV infected patient can be successfully performed with minimal morbidity despite a high risk factor for major infection. The histological finding was in keeping with an accelerated atherosclerosis resulting from HIV infection.

Congenital diaphragmatic eventration in a Nigerian child.

BACKGROUND: Diaphragmatic eventration is a rare cause of respiratory distress and failure to thrive in children. METHOD/RESULT: A report of a case of diaphragmatic eventration in a four-month-old child is presented with a review of the relevant literature. CONCLUSION: Clinicians should be aware of this diagnosis and avoid misdiagnosing the condition as a diaphragmatic hernia.