4thStage Transvaginal omental herniation during VBAC complicated by shoulder dystocia: a unique presentation of uterine rupture

BACKGROUND: Uterine rupture is a common complication in women attempting their first virginal birth after caesarean section (VBAC) but the risk diminishes with subsequent VBACs. It occurs in rates of 0.5-9% and is influenced by various factors. CASE PRESENTATION: A unique case of uterine rupture in a Kenyan woman of African descent during a repeat VBAC complicated by shoulder dystocia was discovered during the 4(th) stage of labour when omentum was noted protruding through the vagina. She had delivered 4 years earlier by caesarean section. CONCLUSION: It is not common to experience uterine rupture among women attempting repeat VBAC. When it occurs, it may not always follow the known pattern intra-partum and is often associated with poor foetal outcome

From a dream to a resounding reality: the inception of a doctors union in Kenya

After two grueling years of determination and resilience, the Kenyan doctors have formed a doctors’ union. The Kenya Medical Practitioners, Pharmacists and Dentists Union(KMPDU)not only aims at agitating for better terms of service for its members, it also aims to influence the running of the Kenyan health sector and improve health services in Kenya. The union has been fully recognized by the Kenyan government and is engaging the government concerning various health sector policies besides improved terms and working conditions of the doctors in the country

Learning from the nurses and the paramedics: the experience of a Kenyan medical officer intern-a call for research

In the Kenyan medical educations system, one has to go through one year of internship after graduating from medical school in order to be licensed to practise medicine. This internship period is laden with work to the extent of overwhelming and stressing the medical officer interns. Irrespective of what competence interns come with into the field there is still a lot they have to learn from the nurses and the paramedics. Most of the learning takes place during the acute care settings when the intern is on call and is from the nurses. The paramedics most helpful to the intern are the theater assistants who teach interns how to use the various surgical instruments and sometimes direct during minor operations.Pan African Medical Journal 2012; 12:3

The Recurrent Laryngeal Nerve and Thyroid Surgery; Who to Scope, When to Visualize, Who to Stimulate

Thyroid surgery is a common general and specialist surgical procedure. Recurrent laryngeal nerve injury during thyroid surgery, though rare, is the most feared surgical complication. Various steps and perioperative assessments can minimize recurrent laryngeal nerve injury. In this opinion article, two clinical vignettes are used at the introduction to discuss this topic. Literature is reviewed and conclusions made in the aspects of intra-operative recurrent laryngeal nerve exposure, the utility of intra-operative nerve monitoring and the use of peri-operative laryngoscopy where indicated. In conclusion, the literature shows that nerve exposure during thyroidectomy is a must. Nerve monitoring does not reduce the incidence of recurrent laryngeal nerve injury. All patients with pre-operative voice changes, cancer, prior head and neck surgery and those due for re-do thyroidectomy require pre-operative laryngocsopy.Keywords: Recurrent Laryngeal Injury, Thyroidectomy, Nerve Exploration, Laryngoscop

Breast Abscess Management and the Role of Post Incisional Antibiotics

Introduction: Breast abscess is a common condition affecting women in the developing world, and is commonly treated with incision and drainage. Incision and drainage is associated with a long hospital stay, requires general anesthesia and daily wound care which is associated with a higher pain score and interrupts breastfeeding for puerperal cases. It is also associated with poor cosmetic results and often necessitates a return to theatre for wound closure.. The aim of the study was to describe the presentation and management of patients presenting with breast abscess at the Aga Khan University Hospital, Nairobi. Methods: We conducted a 7-year retrospective audit of all patients managed for breast abscesses at The Aga Khan University Hospital, Nairobi. Demographic data, clinical presentation, diagnosis, management and follow up were summarized. We later conducted a practice audit on the use of antibiotics for breast abscess among the delegates of a surgical conference. Results: A total of 75 patients were analyzed. Just over half (50.7%) had puerperal abscesses. The demographics, presentation and natural history do not differ between puerperal and non-puerperal abscesses. Nearly all patients (99%) underwent incision and drainage. Fifty two percent affected left breast, 45% right and 3% were bilateral. Majority of respondents of the survey used antibiotics afterincision and drainage. Conclusion: There is high rate of antibiotic use which is not backed by literature both at the institution and across the country. More needs to be done to assess if there is benefit of antibiotics after incision and drainage of breast abscesses. Tertiary level hospitals should popularize ultrasound guided aspiration for treatment of breast abscess as it may be non inferior to incision and drainageKeywords: Breast Abscess, Image Guided Drainage, Incision and Drainage, Antibiotic

Lumbosacral Corsets Improve the Outcome of Patients with Non-Specific Acute Low Back Pain

Introduction: Low back pain (LBP) is a common global problem affecting 60-90% of the population in their lifetime. It is a leading reason for hospital admission, healthcare spending, workplace absenteeism and years lived with disability. Up to 90% of patients suffering from low back pain do not have a serious pathology warranting imaging or further intervention. These are categorized as having non- specific low back pain. This has a good prognosis running a short course of 3 to 6 weeks. The use of corset as a physical therapy for non-specific acute LBP has not been clearly supported with scientific evidence. However, it is commonly prescribed for this category of patients. It is important to assess the effect of this modality on the outcome of patients with non- specific acute LBP. Methods: This study aimed to assess the outcome of patients with non-specific acute low back pain treated with a corset in addition to a standard analgesic protocol compared to those on a standard analgesic protocol alone over 3- week duration at the Aga Khan University Hospital, Nairobi, Kenya.Results: Seventy-nine patients were analyzed. There was a significant effect of time on the Oswestry Disability Index (ODI) (F= (1.38, 106.56) =207.89, P=.000). There was a statistically significant difference in ODI score between the two arms favoring the intervention arm (F (1, 27) =4.23, p=.043). The difference in pain score and days off duty was not statistically significant. The number of days off duty was comparable between the two arms. Compliance to use of corset was good with mean of 1 day off the corset. The maximal change in both ODI and pain score occurred between the first and second reviews indicating maximum clinical improvement within the first week.Conclusion: Compared to use of analgesia alone, the use of additional corset among patients with non-specific acute LBP resulted in a significant improvement in their back specific disabilityKey words: Non-Specific Low Back Pain, Lumbosacral Corset, Disabilit

Is There a Role of Lavage in Peritoneal Tuberculosis?

Abdominal tuberculosis (TB), an extrapulmonary manifestation of TB, can present with nonspecific symptoms that may resemble an acute surgical abdomen or abdominal malignancy. Peritoneal tuberculosis/TB peritonitis, typically manifests with abdominal pain, abdominal distension (possibly due to ascites), weight loss, and night sweats. We present two cases of peritoneal TB where patients exhibited abdominal distension and weight loss with features suggestive of intestinal obstruction or an abdominal malignancy. They were initially treated with standard anti-TB medication (RHZE regimen), but showed no improvement. However, after undergoing laparotomy and lavage, resulting in reduced focus of infection, they responded well to the 6-month course of anti-TB medication. The current management approach for abdominal TB recommends a 6-month regimen of anti-TB medication. Despite the lack of initial response to anti-TB medication, the substantial improvement observed when initiating anti-TB treatment after peritoneal lavage indicates its potential benefit in such patients. Further research is needed to explore this question

Effect of Additional Lumbosacral Corset on the Outcome of Patients with Non-Specific Acute Low Back Pain at The Aga Khan University Hospital, Nairobi

Introduction: Low back pain (LBP) is a common problem world over affecting 60-90% of the population in their lifetime. It is a leading reason for hospital admission, healthcare spending, workplace absenteeism and years lived with disability. Up to 90% of patients suffering from low back pain do not have a serious pathology warranting imaging or further intervention besides symptom relief. These are categorized as having non- specific low back pain. This has a good prognosis running a short course of 3 to 6 weeks. The management of non-specific acute LBP entails analgesia and non-pharmacologic interventions (back school and physical therapy). Many modalities of physical therapy are often employed for non-specific acute LBP. The use of lumbosacral corset as a physical therapy for non-specific acute LBP has not been clearly supported with scientific evidence. However, it is commonly prescribed for this category of patients. It is important to assess the effect of this modality on the outcome of patients with non- specific acute LBP. Objective: To assess the outcome (change in back specific disability) of patients with non-specific acute low back pain treated with a lumbosacral corset in addition to a standard analgesic protocol compared to those on a standard analgesic protocol alone over a 3- week duration at the Aga Khan University Hospital, Nairobi, Kenya. Methods: A two-arm single blinded randomized controlled trial was carried out involving 82 consecutively sampled patients. Patients were randomized to analgesic protocol alone or analgesic protocol and a lumbosacral corset and followed up weekly for three weeks. Back specific disability was assessed using the Oswestry Disability Index (ODI). The primary outcome was the mean change in the ODI score between the two arms. We analyzed the data by use of repeated masures ANOVA. Results: Seventy-nine patients were analysed. The baseline characteristics were similar. There was a significant effect of time on the ODI (F=(1.38, 106.56)=207.89, P=.000). There was a statistically significant difference in ODI score between the two arms favouring the intervention arm ( F (1, 27)=4.23, p=.043). The difference in pain score and days off duty was not statistically significant. The number of days off duty was comparable between the two arms. Compliance to use of lumbosacral corset was good with mean of 1 day off the corset. The maximal change in both ODI and pain score occurred between the first and second reviews indicating maximum clinical improvement with the first week. Conclusion: Compared to use of analgesia alone, the use of additional lumbosacral corset among patients with non-specific acute LBP resulted in a significant improvement in their back specific disabilit

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Editorial: Positioning surgery at the core of the universal health coverage agenda

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