Mohamed ElMakki Ahmed

Retrosternal Goiter: The Need for Median Sternotomy

IntroductionThe aim of this study was to analyze the features of patients with goiter who underwent thyroidectomy via a cervical incision and a median sternotomy in Khartoum.MethodsA total of 267 thyroidectomies were performed in Khartoum Teaching Hospital during the period from January 2002 to December 2003. There were 40 patients with evidence of retrosternal goiter (15%). Of those 40 patients, 13 had clinical and radiologic evidence of deep retrosternal extension of the goiter possibly necessitating sternotomy. Only 9 of the 13 patients actually required sternotomy, which accounted for 3.4% of all thyroidectomies performed (n = 267). The clinical, radiologic, and pathologic findings of those 9 sternotomy patients were analyzed and compared to those of the 258 patients who underwent cervical thyroidecomy.ResultsTotal thyroidectomy was undertaken in all nine patients. Six of them had retrosternal extension on the right side of the mediastinum, and three had bilateral extension. Seven patients had symptoms of respiratory distress, and two were asymptomatic. The duration of the goiter ranged between 7 and 30 years. The chest radiograph and computed tomography scan revealed that the retrosternal part was below the level of the aortic knuckle at the tracheal bifurcation in all cases. The histopathology revealed a simple multinodular goiter in eight of the nine patients (89%) and in one patient with papillary carcinoma. Five of the nine patients underwent intraoperative prophylactic tracheostomy due to tracheomalacia.ConclusionsA long-standing goiter with deep (below the aortic knuckle) mediastinal extension and tracheal space compromise can be postulated to increase the likelihood of sternotomy.

Implementation of diabetic foot ulcer classification system for research purposes to predict lower extremity amputation

BACKROUND: Patients with diabetic foot ulcers are at a high risk of having both minor or major lower extremity amputations. AIM: To identify the extent of risk factors for major and minor amputations in patients with diabetic foot ulcers. MATERIALS AND METHODS: This prospective study was conducted from 2003 to 2005. Using the guidelines for wound classification developed by the International Consensus of the Diabetic Foot, patients were assessed for ischemia, neuropathy, linear measurement of wound diameters, depth of wound, and infection. In addition, end stage renal failure was added as a criterion to assess the association of all these criteria with both toe and lower extremity amputation. RESULTS: 2,321 patients were studied and their mean age was 55 ± 12 years. Most (83.5%) of the patients presented with foot ulcers (n = 1394). Plantar ulcers were the most common (42.6%) followed by ulcers of the big toe (39%). Some (28.5%) of the patients had different types of amputations: 10% had major lower extreme amputation (MLEA) with 8.7% amputations being below the knee and minor (toe) amputations accounting for 18.5%. The most commonly amputated (9.9%) toe was the first toe. CONCLUSION: The guidelines for wound classification proposed by the International Consensus of the Diabetic Foot are reliable predictive factors and can determine the outcome of diabetic foot management. Significant factors associated with MLEA were ischemia, neuropathy, and end-stage renal disease and those associated with toe amputation were neuropathy, depth of wound, and grade of infection.

Hallux Ulceration in Diabetic Patients

We undertook a prospective cohort study to assess risk factors associated with hallux ulceration, and to determine the incidence of healing or amputation, in consecutive patients with diabetes mellitus who were treated over the observation period extending from September 2004 to March 2005, at the Jabir Abu Eliz Diabetic Centre, Khartoum City, Sudan. There were 122 diabetic patients in the cohort (92 males and 30 females) with an overall mean age of 58 +/- 9 years. Fifty-three percent of patients had complete healing within 8 weeks and 43% healed within 20 weeks. The overall mean time to healing was 16 +/- 8 weeks. In 32 (26.2%) patients, osteomyelitic bone was removed, leaving a healed and boneless hallux. The hallux was amputated in 17 (13.9%) patients; in 2 (1.6%) patients it was followed by forefoot amputation and in 7 (5.7%) patients by below-the-knee amputation. In 90 (73.8%) patients the initial lesion was a blister. In conclusion, hallux ulceration is common in patients with diabetes mellitus and is usually preceded by a blister. Neuropathy, foot deformity, and wearing new shoes are common causative factors; and ischemia, osteomyelitis, any form of wound infection, and the size of the ulcer are main outcome determinants. Complete healing occurred in 103 (85%) of diabetic patients with a hallux ulcer. Vascular intervention is important relative to limb salvage when ischemia is the main cause of the ulcer.

Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment

Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD = 11.4) compared to the control group of 56.3 years (SD = 12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n=271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P=0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate.

Fasting and feasting safely during Ramadan in the patient with diabetes

There are more than one billion Muslims in the world and fasting for Ramadan is an obligatory ritual for all adult Muslims. The majority of Muslims observe absolute fasting (no food or water) between dawn and sunset in the holy month of Ramadan. For people with diabetes who take part in such a fast there are potential benefits and possible risks of hypo- and hyperglycaemia. It is therefore important that medical professionals ensure patients and their relatives (if appropriate) have the knowledge and support to undertake fasting safely. This is as important in India, Pakistan and the Sudan, as it is in the UK, The Netherlands and the USA. This article summarises briefly the religious context of Ramadan together with its potential metabolic impact. It then focuses on providing practical guidance on changes in diet, exercise and drug regimen in patients preparing to fast in Ramadan. Copyright

First Report on Circulation of Echinococcus ortleppi in the one Humped Camel (Camelus dromedaries), Sudan

BackgroundEchinococcus granulosus (EG) complex, the cause of cystic echinococcosis (CE), infects humans and several other animal species worldwide and hence the disease is of public health importance. Ten genetic variants, or genotypes designated as (G1-G10), are distributed worldwide based on genetic diversity. The objective of this study was to provide some sequence data and phylogeny of EG isolates recovered from the Sudanese one-humped camel (Camelus dromedaries). Fifty samples of hydatid cysts were collected from the one- humped camels (Camelus dromedaries) at Taboul slaughter house, central Sudan. DNAs were extracted from protoscolices and/or associated germinal layers of hydatid cysts using a commercial kit. The mitochondrial NADH dehydrogenase subunit 1 (NADH1) gene and the cytochrome C oxidase subunit 1 (cox1) gene were used as targets for polymerase chain reaction (PCR) amplification. The PCR products were purified and partial sequences were generated. Sequences were further examined by sequence analysis and subsequent phylogeny to compare these sequences to those from known strains of EG circulating globally.ResultsThe identity of the PCR products were confirmed as NADH1 and cox1 nucleotide sequences using the Basic Local Alignment Search Tool (BLAST) of NCBI (National Center for Biotechnology Information, Bethesda, MD). The phylogenetic analysis showed that 98% (n = 49) of the isolates clustered with Echinococcus canadensis genotype 6 (G6), whereas only one isolate (2%) clustered with Echinococcus ortleppi (G5).ConclusionsThis investigation expands on the existing sequence data generated from EG isolates recovered from camel in the Sudan. The circulation of the cattle genotype (G5) in the one-humped camel is reported here for the first time.

Associated risk factors and management of chronic diabetic foot ulcers exceeding 6 months' duration

Background The management of chronic diabetic foot ulcers (DFU) poses a great challenge to the treating physician and surgeon. The aim of this study was to identify the risk factors, clinical presentation, and outcomes associated with chronic DFU>6 months’ duration. Methods This prospective study was performed in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A total of 108 patients who had DFU for >6 months were included. Recorded data included patients demographics, DFU presentation, associated comorbidities, and outcomes. DFU description included size, depth, protective sensation, perfusion, and presence of infection. Comorbidities assessed included eye impairment, renal and heart disease. All patients received necessary local wound care with sharp debridement of any concomitant necrotic and infected tissues and off-loading with appropriate shoe gear and therapeutic devices. Results The mean age of the studied patients was 56+SD 9 years with a male to female ratio of 3:3.3. The mean duration of DFU was 18±SD 17 months (ranging from 6 to 84 months). Ulcer healing was significantly associated with off-loading, mainly the use of total contact cast (TCC) (p=0.013). Non-healing ulcerations were significantly associated with longer duration of the chronic DFU>12 months (p=0.002), smoking (p=0.000), poor glycemic control as evidenced by an elevated HbA1c (>7%), large size (mean SD 8+4 cm), increased depth (p<0.001), presence of skin callus (p<0.000), impaired limb perfusion (p=0.001), impaired protective sensation as measured by 10 g monofilament (p=0.002), neuroischemia (p=0.002), and Charcot neuroarthropathy (p=0.017). Discussion Risk factors associated with chronic DFU of>6 months’ duration included the presentation of an ulcer with increased size and depth, with associated skin callus and neuroischemia, in a diabetic patient with a history of smoking and increased HbA1c >7%. Off-loading mainly with the use of TCC is an effective method of managing long-standing DFU.

Tracheostomy with thyroidectomy: Indications, management and outcome: A prospective study

OBJECTIVES This study aims to determine the indications, course and outcome of pre-operative and post-thyroidectomy tracheostomy. SUBJECTS AND METHODS This is a prospective descriptive study conducted in Khartoum Teaching Hospital in the period between March 2000 and March 2005. Fifty-nine patients had tracheostomy out of 964 thyroidectomy patients, giving an incidence of 6%. RESULTS The decision of doing tracheostomy was taken intra-operatively in 41 patients (69%), all presenting with strider. In 25 of those 41 patients there was intra-operative tracheal deformity with narrowing (>50% of tracheal circumference on radiology) and gland adherence to the tracheal wall; the remaining 16 patients had tracheomalacia. Of those 41 patients, 25 presented with severe strider and needed urgent surgery (5 with recurrent anaplastic carcinoma, 5 with intrathoracic goitres that necessitated median sternotomy and 15 with huge goitres (of whom 7 were recurrent goitres). In the remaining 18 patients (31%) emergency post-operative tracheostomy was done following endotracheal extubation up to 48 h post-operatively. There were 2 deaths (3.4%); one patient died due to tracheostomy care and the other from myocardial infarction. CONCLUSION Tracheostomy is a safe procedure and gives a good alternative to delayed endotracheal extubation in post-thyroidectomy patients expected to have respiratory failure in places where post-operative anaesthetic care is lacking.

First molecular characterization of Echinococcus granulosus (sensu stricto) genotype 1 among cattle in Sudan

BackgroundEchinococcus granulosus sensu lato (s.l.) is the causative agent of cystic echinococcosis (CE), which is a cosmopolitan zoonotic parasitic disease infecting humans and a wide range of mammalian species including cattle. Currently, little information is available on the genetic diversity of Echinococcus species among livestock in Sudan. In the present study, fifty (n = 50) hydatid cysts were collected from cattle carcasses (one cyst sample per animal) at Al-kadarou slaughterhouse, Khartoum North, Sudan. DNA was extracted from protoscolices and the germinal layer of each cyst and subsequently amplified by PCR targeting the mitochondrial NADH dehydrogenase subunit 1 (NADH-1) gene. The amplified PCR products were purified and subjected to direct sequencing for subsequent construction of phylogenetic tree and net work analysis.ResultsThe phylogenetic tree revealed the presence of Echinococcus canadenesis genotype 6 (G6) in 44 cysts (88.0%), Echinococcus ortleppi genotype 5 (G5) in 4 cysts (8.0%) and Echinococcus granulosus sensu stricto (s.s) genotype 1 (G1) in 2 cysts (4.0%). The phylogenetic network analysis revealed genetic variation among the different haplotypes/genotypes. This report has provided, for the first time, an insight of the role of cattle in the transmission of the zoonotic G1 echinococosis.ConclusionsThe results of the study illustrate that Sudanese breeds of cattle may play an important role in the transmission dynamics and the epidemiology of cystic echinococcosis in Sudan. This study reports the first molecular identification of E. granulosus s.s. in cattle in Central Sudan.

Diabetic Foot Infections with Pseudomonas: Jabir Abueliz Diabetic Center Khartoum Experience

Background: The isolation of Pseudomonas organism in diabetic foot infection (DFI), is notorious of being multidrug resistant. The objective of this study is to report on the incidence, antibiotic sensitivity, treatment and outcome of pseudomonas infection. Patients and methods: This is a prospective observational analytic hospital based study in which all diabetic patients with Pseudomonas aeruginosa infected wounds seen in JADC during 18 months period were included. Results: Pseudomonas was grown in 302 out of 3620 cultures (8.3%) of whom 70 cultures were true pathogenic (1.9%). 41.4% of patients infected with pseudomonas were clinically septic when first seen in the clinic of whom 92.9% were febrile at presentation and 67.1% had chills. Ceftriaxone and ciprofloxacin were the most commonly used antibiotics. Amikacin was the most sensitive antibiotics in 77.1%. All patients took antibiotics >21 days after the isolation of pseudomonas to complete the eradication in combination of daily sharp excision of all coloured infected tissues. Forty six patients (66%) needed amputation, 30 had minor toes (43%) and 16 had transtibial amputation, (23%). Conclusion: Diabetic foot infected with pseudomonas carries a higher risk for toe or lower limb amputation. For complete medical eradication of P. aeruginosa; antibiotics should be used for at least 21 days combined with daily sharp excision of infected discoloured tissues.