Kelechi E. Okonta

Impact of Warden's procedure on the sinus rhythm: our experience.

OBJECTIVES Our experience with the use of Wardens procedure for the repair of sinus venosus ASD with anomalous right upper pulmonary venous connection. METHOD Fifty-eight patients had Wardens procedure from September 2008 to May 2011. The demographic data, preoperative and postoperative ECG, aortic cross-clamp time, cardiopulmonary bypass time, Holter monitoring, complications length of ICU and hospital stay were analysed. RESULT The male to female ratio was 1:1. The median age was 10.9 years (range 2-48 years). Preoperatively all patients were in sinus rhythm. Twenty-six patients had associated left superior vena cava and two patients had also Tuckers procedure at the same time. The mean follow up was 1.2 years (range 1 months-2.8 years). Postoperative Holter monitoring showed sinus rhythm in all the patients. The mean CPB time was 83.6 min (range 54-163 min), mean aortic cross-clamp time was 48.0 min (range 22-112 min), mean ICU stay was 1.26 days (range 1-4 days) and length of hospital was 8.3 days (range 5-13 days) Postoperative echocardiography showed less than 1 mm Hg gradient across the SVC-RA appendage anastomotic site in all the patients. No mortality was recorded. CONCLUSION This is the largest reported series of Wardens procedure in the literature till date. It is known from other studies that sinus node dysfunction and conversion to junctional nodal rhythm were quite a concern with the conventional techniques and Wardens procedure specifically avoids these problems.

Multi-center survey of House officers’ choice of Medical specialties in Nigeria: preferences and determining factors

The objective of the study was to determine preferences and factors influencing the choice of medical specialties by House officers. Questionnaires were distributed to House-officers in 4 tertiary hospitals namely: the National hospital, Abuja, the University of Port-Harcourt, the Jos University, and the University of Uyo Teaching Hospitals. The data were simultaneously collected and analyzed using SPSS 20.0 version. Of the 150 questionnaires distributed, 129(86%) were duly filled. The mean age was 22.4 years (range 21-40 years), 79(61.2%) of the respondent were male. Fifty-nine(45.7%) chose training within the country while 32(24.8%) preferred outside as 107(86%) chose training in Teaching Hospitals. Teachers, Resident doctors and parents influenced choices in 34(26.3%), 17(13.1%) and 16(12.4%) respectively. Thirty-four(26.3%), 28 (21.7%), 13(10.1%) and 15(11.6%) preferred obstetrics, surgery, internal medicine and paediatrics respectively. Seventy (46.7%) chose specialties for personal likeness and 17(11.3%) for role models in that specialty. House officers preferred to pursue medical specialty in teaching hospitals within the country and they are motivated by personal fulfillment, independence of practice and role models while more prefer to specialize in more Obstetrics/ Gyaenocology and surgery.

Theoretical knowledge of cardiopulmonary resuscitation among clinical medical students in the University of Port Harcourt, Nigeria

Aim: To assess the knowledge of cardiopulmonary resuscitation (CPR) among clinical medical students of the University of Port-Harcourt. Materials and Methods: A cross-sectional study on the knowledge of CPR among clinical medical students (4 th -6 th year classes) of the University of Port Harcourt. The data collected were analyzed using the Epi info version 7 statistical packages and Chi-square test was used to compare proportions with P < 0.05 considered significant. Results: Two hundred and forty-five questionnaires were distributed with 177 (72.2%) duly filled. The male to female ratio was 1.5:1, the age range was 19-40 years with a mean of 24.50 ΁ 2.79 years. The 6 th year class had 109 (61.6%) respondents, 5 th year had 49 (27.7%) and 4 th year had 19 (10.7%). Forty-six (26.0%) of students had some form of CPR training and 11 (6.2%) admitted having performed CPR. Of the 46 students that had CPR training, 39 (84.8%) did so because it was given to them at some point in their medical training, while 7 (15.5%) acquired the training due to personal interest. One hundred and two (74.6%) students scored <50%, while 45 (25.4%) scored >50%. The number of students scoring >50% increased with increasing class level (P < 0.001). Students with some prior training in CPR (50.0%) scored above average compared to the students without CPR training (16.8%) (P < 0.001). Conclusion: There is a need to periodically and constantly organize CPR for the medical students and incorporating the training in their medical curriculum to enhance better understanding of the procedure.

Basic cardiopulmonary resuscitation knowledge of house-officers in a tertiary institution: factors determining accuracy.

Background To assess the level of knowledge of CPR among House-Officers (HO) and some factors determining accuracy of knowledge. Methods A total of 50 structured questionnaires were administered to HO with 35 (70%) questionnaires duly filled and returned. Data on the participants’ brief biodata and the understanding of basic skills of BLS were collected and analyzed using International Business Machine SPSS Statistics version 21 for Windows. The t-test for independent samples was applied for the grouped data with P < 0.05 taken as level of significance. Results The age of the respondents ranged from 20-37 years with the mean age of 25.4 + SD2.7 years and the male/female ratio was 1:1.3. Eleven (31.4%) out of the 35 HO had no prior CPR training while 68.6% had prior training; Eighteen (51.4%) had training within the last 2 years. Twenty (57.1%) had performed CPR in a real situation, while 42.9% had not. Six (17.1%) HO scored above 50% while 82.9% scored below 50%. The female HO got more correct answers than the males (25% versus 6.7%, p = 0.167). The number of respondents who had prior CPR training had more correct answers than those who did not (25% versus 0%, p = 0.083) while those who had previously performed CPR had more correct answers than those who had not (33.3% versus 5%, P <0.05). Conclusion There was a general poor knowledge of the performance of basic CPR amongst HOs. However, previous experience of having performed CPR in real setting, or the use of mannequins, improved their theoretical knowledge of CPR.

Omentoplasty as an effective surgical modality for managing a high risk patient with deep sternal wound infection

Poorly managed diabetes and hypertensives are risk factors for deep sternal wound infection (DSWI) following cardiac surgery; leading to increased morbidity and mortality. To reappraise the effectiveness of omental flap in the management of High risk patient with DSWI. A middle aged man with extensive mediastinitis following cardiac surgery (from outside referral). He was a known Diabetic and Hypertensive who was poorly compliant on medications. The history, physical examination, gycosylated Haemoglobin (HbA1c) and microbiological analyses showed high blood pressure, poor glycaemic control, septicaemia with staphylococcal DSWI. Resuscitation was achieved with the use of oral antihypertensives, Human insulin and antibiotics respectively. The DSWI was managed with serial debridement and subsequent wound cover with omental flap. The hospital stay was shorter and outcome was good. The management of DSWI with omental flap may be an effective surgical modality that reduces morbidity and mortality even in high risk patients.

Experience with permanent pacemaker insertion at the University College Hospital, Ibadan, Nigeria

Objective: The aim is to determine the characteristics of patients for permanent pacemaker insertion (PPI), treatment outcome, and factors affecting the early insertion of the pacemaker. Methods: Fifty patients who had permanent pacemaker implanted (PPI) between July 2008 and June 2011 were prospectively followed-up. The patients′ demographic data, medical history, details of pacemaker hardware used, complications were collected into a proforma.The data were analyzed using the SPSS Version 17 statistical software package (SPSS, Inc. Chicago Illinois). Results: During the 3 year period, a total of 50 patients had PPI with a mean age of 66.1 years (ranged 30-88 years). Thirty-three (66%) were males 15 (30%) had hypertension as a co-morbidity, 39 (78%) had complete heart block. In 48 (96%), the cause was not known, 1 (2%) was chloroquine induced. The breakdown of the symptoms showed that syncope accounted for 21 (36.2%), dyspnea 20(34.5%) and recurrent dizziness 9 (15.5%). The pulse rate in 29 (58%) was <40/min. The mean pulse rate 39.4 min (range, 32-65), the mean pre-operation days on admission was 16.09 (ranged 2-60 days) while the mean post-operation days was 7.06 (ranged 2-14 days). The complications included lead dislodgement in 2(4%) patients, infective endocarditis in 1 (2%) and diaphragmatic pacing in 1 (2%). Two (4%) deaths were recorded. The mean survival in months was 14.9 (ranged 12-48 month) during the follow-up. Conclusion: PPI is well-acceptable in the elderly with improvement in their clinical state. However, plans should be put in place to ensure reduction in the time spent while in the hospital when trying to procure the pacemaker by creating a pacemaker bank in Hospitals that engage in pacemaker insertion in the country.

eComment. The cheaper and efficient methods of prevention of deep sternal wound infection

I read with interest the work of Shaikhrezai and colleagues, in which they elaborated on the influence of the number of sternotomy mechanical fixation points on deep sternal wound infection (DSWI) and stated that the reasons for adopting the method was its non-association with increased cut-through in the sternum, sinuses or sternal wound infection. Furthermore, they showed that the risk of DSWI was significantly increased in patients in whom 8 or fewer paired points of sternal wire fixation were used compared to patients in whom 9 or more paired points of fixation were used (P= 0.002) [1]. The prevention of DSWI focuses mainly on achieving mechanical sternal stability and preventing infection; and biomechanical failure is usually due to sternal wire cut-through.[2] So, using more sternal wires will similarly entail more assaults on the sternum, and more when used singly as the force will be more concentrated on the horizontal axis as opposed to using the figure-of-eight type of sternal wiring where the force is distributed along both the horizontal and diagonal axes. For a given force, an increased area occasioned by the use of figure-of-eight type sternal wiring will make the cut-through pressure on the sternum lesser as compare to the use of the single sternal wiring technique; for pressure is force per area. Again, they stated that the incidence of wound sinuses was not associated with the number of wires [46 (4.9%) vs 157 (5.8%), P = 0.16][1]. This statement is also difficult to accept. Logically, the number of wires, especially when the tip is not properly buried into the sternum could irritate the skin and give rise to sinus formation with possible infection. If the number of such wires with the tip pointing out increases, the number of sinuses formed will increase accordingly and vice versa. Thus, the number of wound sinus formation is directly proportional to the number of sternal wires used. The methods of achieving biomechanical sternal stability and prevention of DSWI go beyond the mere application of sternal wires alone. Cheaper and efficient surgical manoeuvres that could also be applied are: the use of an interlocking sternotomy which is a safe, simple and reproducible lazy-S-shaped incision that provides efficient interlocking of the sternum and significantly reduces the incidence of sternal instability and prevents sternal dehiscence and mediastinitis, especially in diabetics [3]. The second method is sternal strapping, which in addition to helping to achieve haemostasis and avoid the use of bone wax, also offers mechanical protection, acting as a shield against bacterial contamination with beneficial effects on sternal healing [4], and prevents direct repeated trauma to the sternal edges during the application of spreader. Lastly, the adoption of surgical techniques such as the proper use of diathermy, judicious use of antibiotics, proper application of sternal wires and adopting good aseptic techniques will lead to the maintenance of low incidence of sternal wound infection [5]. In conclusion, DSWI can be reduced to a low level or prevented by adopting simpler, cheaper and efficient techniques as enumerated. Conflict of Interest: None declared

Tension Pneumatocele due to Enterobacter gergoviae Pneumonia: A Case Report

Pneumatocele formation is a known complication of pneumonia. Very rarely, they may increase markedly in size, causing cardiorespiratory compromise. Many organisms have been implicated in the pathogenesis of this disease; however, this is the first report of tension pneumatocele resulting from Enterobacter gergoviae pneumonia. We report a case of a 3-month-old Nigerian male child who developed two massive tension pneumatoceles while on treatment for postpneumonic empyema due to Enterobacter gergoviae pneumonia. Tube thoracostomy directed into both pneumatocele resulted in complete resolution and recovery. Enterobacter gergoviae is a relevant human pathogen, capable of causing complicated pneumonia with fatal outcome if not properly managed. In developing countries where state-of the-art radiological facilities and expertise for prompt thoracic intervention are lacking, there is still room for nonoperative management of tension pneumatocele especially in very ill children.

Challenges with the establishment of congenital cardiac surgery centers in Nigeria: survey of cardiothoracic surgeons and residents.

BACKGROUND There are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors. METHODS A descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package. RESULT Thirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit. CONCLUSIONS The obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service.

Massive Pleural Fluid Collection in Adult Nigerians

Background. There are no available literatures on massive pleural effusions (MPE) in our country. Aim. To determine the aetiology of MPE and compare the mortality rate between malignant and nonmalignant MPE in adult Nigerians. Methods. A prospective study of all the patients diagnosed with nontraumatic pleural fluid collections for one year in two tertiary federal hospitals in Southern Nigeria. A total of 101 consecutive patients with pleural fluid collections were studied. Diagnoses were made by clinical features and laboratory and radiological investigations. Results. Forty-eight patients (47.5%) had MPE with a mean age of 43 years ± 14.04 and 35 were females. Thirty patients (62.5%) were diagnosed with nonmalignant conditions (21 from pulmonary tuberculosis (PTB) and 9 from other causes). Haemorrhagic pleural collections were from malignancy in 12 (30.8%) and from PTB in 6 (15.4%). Straw-coloured collections were from malignancy in 9 (23.1%), from PTB in 8 (20.1%), and from posttraumatic exudative effusion in 3 (7.7%). Compared with nonmalignant MPE, patients with malignant collections had higher mortality within 6 months (8/18 versus 0/30 with a P value of 0.000). Conclusion. The presentation of patients with nontraumatic haemorrhagic or straw-coloured MPE narrows the diagnosis to PTB and malignancy with MPE cases being a marker for short survival rate.