The impact of introduction of the Canadian CT – head rule on the use of CT-scan on minor head injury patients at Aga Khan University Hospital, Nairobi

Background: Head injury is a common traumatic condition seen in Kenya. Among the head injury patients seen at the Aga Khan University Hospital Nairobi, minor head injury patients are the highest proportion of non–fatal trauma patients. Minor head injury is described as witnessed loss on consciousness, definite amnesia or witnessed disorientation in a patient with a GCS score of 13–15 who has suffered a traumatic event. There has been considerable disagreement about the indication for a Computed Axial Tomography Scan of the Head (CT-head) in the large number of patients clinically classified as minor. The Canadian CT Head Rule was derived as a sensitive decision rule on the use of CT with the aim to standardize and improve the management of patients with minor head injury. The rule comprised of five high risk factors and two moderate risk factors(Appendix 1). At the Aga Khan University Hospital Nairobi, there are no protocols that guide the decision making by physicians on when to do a CT-head for patients who have suffered a minor head injury. According to a pilot study done, approximately 96% of patients with minor head injury have a CT–head done. Objective: To determine the change in proportion of CT-scan done in patients with minor head injury after introduction of the Canadian CT Head Rule Guide at the Aga Khan University Hospital Nairobi. Secondary objectives were to determine the proportion of patients with minor head injury and moderate risk factors according to the Canadian CT Head rule for whom CT was ordered, probability of neurosurgical intervention in patients with minor head injury and their outcomes on follow up. Study design: A Before - After study Method: A total of 84 eligible patients diagnosed with minor head injury were recruited at the Accident and Emergency Department. Forty - two patients were assessed and data on high risk factors and moderate risk factors of the CCHR, Glasgow coma scale, age, management plan and the Glasgow outcome score on follow-up collected with data collection form 1 (see appendix 2) in the \u27before\u27 group, thereafter the Canadian CT Head Rule (CCHR) was introduced and another forty-two patients were assessed according to data collection form 2 (see appendix 3). Results: The proportions of CT scans done in the \u27before\u27 and \u27after\u27 groups were 95.2% and 21.4% respectively. The difference of 73.8% between the two groups was statistically significant (CI 0.55 to 0.84).The proportion of patients with moderate risk factors in the \u27before\u27 group was 90.5%. This group of patients represents the proportion of patients in the \u27before\u27 group who did not require a CT scan. None of the patients required neurosurgical intervention. All patients had good recovery on follow up. Conclusion: On the basis of the results of this study, there was a statistically and clinically significant difference in the number of CT scans done for patients with minor head injury in the \u27before\u27 group at the Aga Khan University Hospital, Nairobi, compared to the \u27after\u27 group. This was associated with no need for neurosurgical intervention and good recovery on follow up as depicted by the Glasgow Outcome Score. This implications of this study will guide physicians on improving management practice of minor head injury patients. Other important implications include avoiding timely and costly transfers from resource scarce or distant areas for CT scan. Moreover this approach will present opportunities to roll out standardized patient care

Spontaneous Lumbar Hernia: A Case Report

Lumbar hernias are rare, and the diagnosis can be easily missed. Acquired lumbar hernias can occur spontaneously; however, they are increasingly being reported due to trauma or flank surgery. A good history and examination can aid in diagnosis with imaging confirming the condition. Hernia repair can be laparoscopic or through open surgical approaches. We report a case of primary spontaneous lumbar hernia which was managed by an open approach to close the defect with retromuscular mesh placement

Surgeons’ practice and preferences for the anal fissure treatment: results from an international survey

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results