Nkeiruka Ameh

Providing safe surgery for neonates in sub-Saharan Africa.

Advances in neonatal intensive care, total parenteral nutrition and improvements in technology have led to a greatly improved outcome of neonatal surgery in developed countries. In many parts of sub-Saharan Africa, however, neonatal surgery continues to pose wide-ranging challenges. Delivery outside hospital, delayed referral, poor transportation, and lack of appropriate personnel and facilities continue to contribute to increased morbidity and mortality in neonates, particularly under emergency situations. Antenatal supervision and hospital delivery needs to be encouraged in our communities. Adequate attention needs to be paid to providing appropriate facilities for neonatal transport and support and training of appropriate staff for neonatal surgery. Neonates with surgical problems should be adequately resuscitated before referral where necessary but surgery should not be unduly delayed. Major neonatal surgery should as much as possible be performed by those trained to operate on neonates. Appropriate research and international collaboration is necessary to improve neonatal surgical care in the environment.

Congenital Vaginal Obstruction in Neonates and Infants: Recognition and Management

BACKGROUND Congenital vaginal obstruction commonly presents after puberty and presentation in infancy is uncommon. Due to lack of awareness, diagnosis may be missed in infants, sometimes with disastrous consequences. METHOD A retrospective review of 9 neonates and infants treated for congenital vaginal obstruction in 16 years. RESULTS The patients were aged 2 days to 4 months (median 28 days) at presentation. The main presenting feature was a lower abdominal mass, producing intestinal and urinary obstruction in 7 patients. In 2 patients, other conditions were suspected and diagnosis made only intraoperatively and in one patient, diagnosis was incidental during treatment for another condition. The cause of vaginal obstruction were low transverse vaginal septum 6, imperforate hymen 2, high transverse vaginal septum one. Associated anomalies were present in 5 patients (persistent cloaca 3, Hirschsprung disease 1, polydactyly 1). Low vaginal septum was treated by incision and drainage of hydrometrocolpos, imperforate hymen by hymenotomy and drainage of hydrometrocolpos and high vaginal septum by excision. There was recurrence of hydrometrocolpos in one patient who had low vaginal septum, requiring repeat surgery. One patient, in whom diagnosis was missed, died from overwhelming infection. Short term follow-up was good. CONCLUSION Congenital vaginal obstruction is an uncommon presentation in this setting. Missing the diagnosis can lead to disastrous consequences. A high index of suspicion is required for prompt recognition and treatment.

Application of queuing theory to patient satisfaction at a tertiary hospital in Nigeria.

Background: Queuing theory is the mathematical approach to the analysis of waiting lines in any setting where arrival rate of subjects is faster than the system can handle. It is applicable to healthcare settings where the systems have excess capacity to accommodate random variations. Materials and Methods: A cross-sectional descriptive survey was done. Questionnaires were administered to patients who attended the general outpatient department. Observations were also made on the queuing model and the service discipline at the clinic. Questions were meant to obtain demographic characteristics and the time spent on the queue by patients before being seen by a doctor, time spent with the doctor, their views about the time spent on the queue and useful suggestions on how to reduce the time spent on the queue. A total of 210 patients were surveyed. Results: Majority of the patients (164, 78.1%) spent 2 h or less on the queue before being seen by a doctor and less than 1 h to see the doctor. Majority of the patients (144, 68.5%) were satisfied with the time they spent on the queue before being seen by a doctor. Useful suggestions proffered by the patients to decrease the time spent on the queue before seeing a doctor at the clinic included: that more doctors be employed (46, 21.9%), that doctors should come to work on time (25, 11.9%), that first-come-first served be observed strictly (32, 15.2%) and others suggested that the records staff should desist from collecting bribes from patients in order to place their cards before others. The queuing method employed at the clinic is the multiple single channel type and the service discipline is priority service. The patients who spent less time on the queue (<1 h) before seeing the doctor were more satisfied than those who spent more time (P < 0.05). Conclusion: The study has revealed that majority of the patients were satisfied with the practice at the general outpatient department. However, there is a need to employ measures to respond to the suggestions given by the patients who are the beneficiaries of the hospital services.

Objective structured clinical examination vs traditional clinical examination: An evaluation of students' perception and preference in a Nigerian medical school

Background: Method of testing clinical competence of medical students in this setting has been controversial. This report evaluates the perceptions and preferences of 5th and 6th year medical students about traditional clinical examination (TCE) and objective structured clinical examination (OSCE). Materials and Methods: A cross-sectional study using a structured questionnaire, administered to 156 students, who had been previously exposed to TCE and OSCE. Results: There were 110 (70.5%) males and 46 (29.5%) females, with median age group of 26–30 years. One hundred and thirty-one respondents (84%) felt TCE is more difficult and 20 (12.8%) felt OSCE was more difficult. One hundred and forty-two (91%) felt OSCE was easier to pass, 8 (5.1%) felt TCE was easier to pass and 6 (3.8%) were undecided. Majority of the 5th and 6th year students (95.5% and 100%, respectively) preferred OSCE for assessment. In relation to validity and reliability of OSCE, 124 (79.5%) of all the students felt it provides a true measure of essential clinical skills, 130 (83.3%) felt its scores are standardised, 143 (91.7%) felt it is a practical and useful experience and 135 (86.5%) felt students’ personality, ethnicity and gender will not affect OSCE scores. Overall, there were no significant differences in preference and perceptions between 5th and 6th year students and between males and females. Conclusion: Students preferred OSCE as method of assessing clinical competence and considered it a more valid and reliable method of examination.

Knowledge and attitude towards child adoption among women in Zaria, northern Nigeria

Background: The success of marriages has largely been premeditated on child bearing in most African society and oftentimes women are at the receiving end of childlessness with possible psychological and physical torture. Objective: To assess the knowledge and attitude of women of reproductive age towards child adoption in Zaria, Northern Nigeria. Methodology: A cross-sectional descriptive study, structured closed and open ended questionnaires was administered to 200 consenting consecutive women aged 15–49years to obtain information on socio-demographic characteristics, reproductive profile, knowledge and attitude towards child adoption. Data was analysed using SPSS V17 with p value set at 0.05. Results: The majority 89.4% of respondents have heard and are aware of child adoption and 77% agreed it is a good practice. The most prevalent source of information is the Mass media in 35.0% of respondents. The female gender is preferred by majority 64.2% of respondent if they will adopt. There is a strong association between numbers of living children and willingness to consider child adoption with P value < 0.05. Conclusion: There is a high level of knowledge and acceptability of child adoption practices in our environment. Child adoption institutions should therefore be supported to meet the need of the infertile couples.

Infected huge prolapsed polypoidal fibroid: Issues of neglect and delayed access to surgical treatment

Gravitational pull and subtle uterine contractions on huge polypoidal submucous uterine fibroid may dilate the cervix and prolapse into the vagina. Such prolapsed fibroid can either be removed through the vaginal route if it is connected with a long stalk or through an abdominal route if it has a broad base or if it is coexisting with multiple uterine fibroids. We present two cases of grand multiparous women with huge prolapsed submucous fibroids where neglect led to presentation with life-threatening infection and bleeding.

Cervical adenoma malignum: Diagnostic dilemma of a rare form of cervical cancer

Adenoma malignum of the cervix is a rare variant of Adenocarcinoma of the uterine cervix. Its overall incidence rate is low. We report a case of a 51-year-old married multipara who presented with a 4-year history of recurrent, heavy, prolonged menstrual flow, postcoital bleeding, and passage of mucoid vaginal discharge. Pelvic examination revealed a bulky, firm, endophytic cervical mass with ulcerative areas. Ultrasonography showed features of multiple uterine fibroids. Cervical smear cytology and histology of cervical punch biopsy did not show evidence of malignancy. The patient subsequently had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a purportedly benign pathology of the cervix. Diagnosis of cervical adenoma malignum was made from the surgical specimen postoperatively.

Complete uterine didelphys: An incidental finding at emergency cesarean section

Uterine didelphys is a rare form of Mullerian duct abnormality. Women with this developmental anomaly are often asymptomatic although pregnancy complications are common. We present a 23-year-old para 0+1 that registered for antenatal care at 31 weeks gestation and in whom an ultrasound scan revealed a suspected huge cervical mass that turned out to be an undiagnosed ipsilateral nonpregnant half of a double uterus at emergency cesarean section, which was indicated because of preterm labor and a coexisting suspected huge cervical mass.

Evaluation of the infertile male

Infertility in a couple was for a long time, attributed mostly to the female partner. However, recent evidence indicates that the male contributes equally to the the male contributes equally to the problem, hence the need for a review of current evaluation of the infertile male. Common causes of infertility in the male can be due to pretesticular, testicular, and posttesticular factors. This categorization allows for a systematic evaluation ranging from simple semen analysis through serum hormonal assays, radiological investigations, and to testicular tissue biopsy for histological analysis. Following this evaluation, a rational treatment plan can be implemented. Male factor infertility should not be ignored in the management of the infertile couple and requires careful evaluation of the male partner and planning of appropriate treatment.

Postpartum urinary retention secondary to suture obliteration of the urethral orifice: A complication of home delivery conducted by an untrained birth attendant

Postpartum urinary retention (PPUR) secondary to suture obliteration of the urethral orifice by a traditional birth attendant (TBA) is a condition that may not have been heard of in modern day obstetric practice and has certainly not been reported before in our locality. Several risk factors to developing PPUR have been reported. However, following a careful search of the literature, there was no documented case of PPUR secondary to closure of the urethral orifice by TBA. We report a rare case of a 23-year-old multipara who had spontaneous vaginal delivery that was supervised by a TBA at home. She presented 3 days later with complaints of inability to pass urine, abdominal pain, abdominal swelling, and dribbling of urine on straining. She was evaluated and found to have a distended urinary bladder up to the level of the umbilicus. Pelvic examination revealed a vestibule that was almost completely obliterated up to the urethral orifice with continuous surgical silk suture. The vaginal orifice was also partially obliterated. Urine was noticed to be dribbling from the region of the urethral orifice on straining. Lochia was normal. About 2 L of clear urine was drained from the urinary bladder following cutting of the silk suture and passage of an indwelling size 16F Foley′s catheter. The uterus was contracted to 16 weeks pregnancy size following catheterization. She had successful bladder training and was discharged 5 days later.