Surgical Outpatient Department Research Articles

Tuberculosis of the penis: rare clinical entity

A 35-year-old male presented to the surgical outpatient department with an ulcerated growth over the penis for one year. No history of recent sexual exposure was available. On examination of the penis, an ulcerated foul-smelling growth was present. The inguinal nodes on both sides were palpable, firm in consistency and non-tender. Serum testing for VDRL and HIV were negative. Biopsy was taken and showed changes of chronic granulomatous inflammation (tuberculosis). No other source of tuberculosis was found.

Solitary Neck Swelling of 2-Week Duration in a 27-Year-Old Woman

Solitary Neck Swelling of 2-Week Duration in a 27-Year-Old Woman

Prescribing pattern of non-steroidal anti-inflammatory drugs at outpatient departments of teaching hospitals

The prescribing pattern of non-steroidal anti-inflammatory drugs (NSAIDs) in prescriptions prescribed by the qualified medical personnel in the outpatient departments of three selected teaching hospitals in Dhaka city were studied. A total of 600 prescriptions containing NSAIDs were collected. The clinical conditions for which NSAIDs prescribed were identical in all the three hospitals, although there were wide variations in the prescribing pattern with respect to pharmacological sub-classes of NSAIDs. Analgesics with no or minimal anti-inflammatory effects were the most commonly prescribed NSAIDs in the medical outpatient departments of Dhaka Medical College Hospital (DMCH) and Bangabandhu Sheikh Mujib Medical University Hospital (BSMMUH) whereas analgesics with potent anti-inflammatory effects were the most commonly prescribed NSAIDs in a private teaching hospital (PH). Moreover, the prescribers in PH had to prescribe additional drugs than those of the prescribers of DMCH and BSMMUH to counter the adverse effects of NSAIDs. Proton pump inhibitors were mainly used in medical outpatient departments whereas H 2 blockers were in surgical outpatient departments. Consequently, the cost of prescribed NSAIDs per prescription and ultimately the cost of total drugs per prescription became more expensive in PH compared to DMCH and BSMMUH. In conclusion, it may be said that the overall prescribing pattern of NSAIDs among three hospitals is rational.

Partial Matrix Excision or Orthonyxia for Ingrowing Toenails

We wanted to evaluate whether partial matrix excision and orthonyxia are equally effective in the treatment of ingrown toenails of the hallux. We conducted a prospective randomized clinical trial with 12-month observer-blinded followup, in the surgical outpatient department of a teaching hospital. We randomized 105 consecutive patients with a total of 109 ingrown toenails to either partial matrix excision (n=58) or an orthonyxia procedure (n=51). The main outcomes measurements were rate of recurrence after 12 months, postoperative morbidity, and time to complete recovery. The 12-month followup was completed in 55 of 58 patients undergoing partial matrix excision and 47 of 51 patients having orthonyxia. There were four ingrown toenails, four recurrences in the partial matrix excision group, and eight in the orthonyxia group (NS, p=0.14). Postoperative morbidity parameters (redness, pus, postoperative bleeding); time to complete recovery, wearing shoes (p < 0.01), and performing activities of daily living and hobbies; postoperative symptoms; and patient satisfaction all favored orthonyxia. Partial matrix excision and orthonyxia are equally effective treatments for ingrown toenails. But the orthonyxia procedure showed better results, with less postoperative morbidity, shorter time to complete recovery, fewer postoperative symptoms, and greater patient satisfaction.

Paediatric Preputial Pathology: Are we Circumcising Enough?

Preputial problems are a common reason for referral to the paediatric surgical out-patient department. Many boys referred do not need surgical intervention. One indication for intervention is balanitis xerotica obliterans (BXO), a potentially serious condition previously considered rare in childhood. Consecutive boys referred to a paediatric general surgical out-patient department with problems relating to their prepuce during a period of 4 years were included. The out-patient diagnosis and management was recorded. All foreskins excised were sent for histological analysis. A total of 422 boys were referred, median age 6 years 2 months (range, 3 months to 16 years). Over half the boys referred simply required re-assurance that all was normal with their penis. However, 186 boys (44.1%) were listed for surgical procedures - 148 circumcision, 33 preputial adhesiolysis, and 5 frenuloplasty. There were histological abnormalities in 110 specimens (84.8%); chronic inflammation (n = 69; 46.6%), BXO (n = 51; 34.5%), and fibrosis (n = 4; 2.7%). Nineteen (12.8%) specimens were reported as histologically normal. The overall prevalence of BXO in the boys referred was 12.1%. In this series, the percentage of boys circumcised and the prevalence of BXO were both higher than in other published series. BXO may be more common and present at a younger age than previously thought.

Das Interdisziplinäre Hepatologische Zentrum Mainz

In October 2004, an Interdisciplinary Hepatological Centerwas established at the University Hospital Mainz. Thecenter involves a hepatological ward of the Medical Departmentand the Department of Transplantation/HepatobiliopancreaticSurgery. In 2005 almost 2,000 patientswere treated in 45 beds. Patients from the surgical outpatientdepartment were increasingly treated (+17%) inthe hepatological part of the unit, and the hospital stay ofpatients with complicated postoperative courses were reducedby 21% due to the generation of common clinicalpathways. In 2005, the DRG proceeds increased by 30%compared to 2004.

An alternative surgical approach to a difficult case of Mirizzi syndrome: A case report and review of the literature

Mirizzi syndrome (MS) is an uncommon complication of gallstone disease and occurs in approximately 1% of all patients suffering from cholelithiasis. The syndrome is characterized by extrinsic compression of the common hepatic duct frequently resulting in clinical presentation of intermittent or constant jaundice. Most cases are not identified preoperatively. Surgery is the indicated treatment for patients with MS. We report here a 71-year-old male patient referred to the surgical outpatient department for diffuse upper abdominal pain and mild jaundice (bilirubin rate: 4.2 mg/dL). Ultrasound examination revealed a stone in the cystic duct compressing the common hepatic duct. The patient had a history of gastrectomy for gastric ulcer 30 years ago. MRCP revealed a stone impacted in the cystic duct causing obstruction of the common hepatic duct by extrinsic compression. With these findings the preoperative diagnosis was indicative of MS. At laparotomy a moderately shrunken gallbladder was found embedded in adhesions containing a large stone which was palpable in the common bile duct. The anterior wall of the body of the gallbladder was opened by an incision which extended longitudinally along the gallbladder towards the common bile duct. The stone measuring 3.0 cm in diameter, was then removed setting astride a large communication with the common bile duct. A Roux-en-Y cholecysto-choledocho-jejunostomy was performed. The subhepatic region was drained. The patient had an uneventful recovery. He was discharged eleven days after operation and remained well after a 30-mo follow-up.

Superficial abscess formation: an unusual presenting feature of tuberculosis.

Abstract Tuberculous abscess formation in the absence of underlying osteo-articular, tendon-sheath, or lymphnode infection is uncommon in this country, but is likely to become more important with increasing immigration. Details are reported of 32 patients notified to the City of Birmingham Public Health Department between January, 1964, and December, 1968. The disease was encountered mainly in immigrants attending casualty and surgical out-patient departments. The presenting feature in all cases was a superficial, fluctuant, relatively painless swelling of several weeks' duration. Lesions were widespread although there was a tendency for the chest wall to be involved (15 patients). Chest radiographs showed evidence of pulmonary disease in approximately one-third of the case and an elevated erthroyte sedimentation rate with a normal white-cell count were constant findings. Prompt chemotherapy combined with either aspiration or incision and primary suture achieved rapid and complete resolution in nearly all patients. Incision without closure was inevitably followed by sinus formation and delay in healing.

Pattern of congenital orthopeadic malformations in an African teaching hospital

Congenital Orthopaedic malformations are common malformations that are usually unacceptable to the common populace in the West African sub-region. There is paucity of knowledge about the common types of Orthopaedic congenital malformations in our environment This study was undertaken to determine the pattern of congenital Orthopaedic malformations in a Teaching Hospital. This was a prospective study of all the Orthopaedic congenital malformations seen in our surgical outpatient departments and the inpatient referrals from the wards between January 1995 and December 2003. There were 284 patients in total with a male to female ratio of 2:1 and age range between two days to nine years. Clubfoot (CTEV) accounted for 52.8% of all the malformations while Congenital knee dislocation (CDK) and calcaneovalgus deformity accounted for 8%. Congenital hip dislocation (CDH) accounted for only 2.2% of all the cases. Congenital talipes equinovarus deformity is the most common congenital orthopaedic malformation in this environment while congenital hip dislocation (CDH) is rare when compared with the Caucasians.

Osteochondritis Dissecans Of The Knee Joint (Osgood-Schlatters Disease)

An 18-year-old male professional footballer presented in the surgical outpatient department (SOP) of University of Nigeria Teaching Hospital Enugu complaining of bilateral knee-joint pains and tenderness severe enough to prevent him from participating in training sessions and professional league matches. Both knee joint were X-rayed and the radiographs revealed bilateral Osteochondritis dissecans of the knee joints (Osgood schlatters disease). This case is being reported to highlight on the epidemiology, etiology clinical appearance, possibilities for radiological diagnoses, classification of osteochondritis dissecans, the various treatment modalities available complications of osteochondritis dissecans and above all emphasizes on the benignity of the disease.Key words: Osteochondritis dissecans, Knee joints, Osgood Schlatters disease

Assessment of smoking status in patients with peripheral arterial disease

To assess the utility of a novel rapid urinary cotinine assay to detect and quantify the level of smoking in patients with peripheral arterial disease. This was a cross-sectional study in a vascular surgical outpatient department of a large teaching hospital. Participants were 100 consecutive subjects presenting to a hospital outpatient clinic with a diagnosis of intermittent claudication confirmed by a positive Edinburgh claudication questionnaire and an ankle-brachial pressure index of less than 0.9. Main outcome measures were patient-offered smoking history, exhaled breath carbon monoxide levels, urinary cotinine levels as measured by a novel rapid assay, and laboratory-measured creatinine-adjusted urinary cotinine levels. Results Fifty-five subjects declared that they were current smokers, 40 declared that they were ex-smokers, and 5 declared that they were never-smokers. Of the 40 ex-smokers, 6 subjects (15%) had urinary cotinine levels greater than 500 ng/mL (regular smokers), and a further 2 (5%) had urinary cotinine levels between 100 and 500 ng/mL (light, irregular, or passive smokers). The rapid urinary cotinine assay had a sensitivity and specificity of 100% and 98%, respectively, in its ability to detect active smoking, and the degree of smoking correlated well with laboratory creatinine-corrected urinary cotinine levels (Spearman coefficient, 0.805; P < .001). By contrast, exhaled carbon monoxide had a sensitivity and specificity of 95% and 89%, respectively, and although it correlated well with urinary cotinine (Spearman coefficient, 0.782; P < .001), it was found on linear regression analysis to be unreliable in differentiating light smokers from nonsmokers. Patient-offered smoking history is unreliable because there is no correlation between the patient-reported number of cigarettes smoked per day and urinary cotinine levels. The novel rapid assay for urinary cotinine described here is superior to exhaled carbon monoxide measurement in detecting the level of smoking exposure among patients with intermittent claudication, and its results correlate well with laboratory-measured cotinine.

Diagnostic peritoneal lavage in the evaluation of abdominal trauma using the dipstick.

To determine the accuracy and sensitivity of diagnostic peritoneal lavage in the assessment of intra-abdominal injury using the dipstick method. Prospective study, involving the performance of diagnostic peritoneal lavage in the out patient department and surgical wards prior to surgical intervention. Kenyatta National Hospital-General Surgical and Orthopaedic wards and outpatient department. The study was conducted over a duration of six months, starting from January 1995 to July 1995. Ninety six patients with penetrating (68) and blunt (28) abdominal trauma underwent diagnostic peritoneal lavage as evaluation of the severity of abdominal trauma. Dipstick (combur 9 strips) was used to evaluate lavage effluent for red blood cells, white blood cells, protein and bilirubin. Forty three patients had positive diagnostic peritoneal lavage (DPL) results, of which 40 (93%) had positive findings at laparatomy and three (7%) had negative findings at laparatomy. The remaining 53 patients had negative DPL results and were managed conservatively. One patient with a negative DPL result became symptomatic and had a positive laparatomy. Conservatively managed patients were discharged after 24 hours observations without any complications. DPL had an accuracy and sensitivity of 93% and specificity of 98%. Diagnostic peritoneal lavage is a cheap, safe and reliable method for assessment of abdominal trauma. The method is easy to perform by trained junior doctors in the OPD, or as a bedside procedure. Use of this method reduced negative laparotomy rate from 50% to 6.9% and average duration of stay from 6.5 days to 1.9 days. This method is recommended as a basic tool in the assessment of abdominal trauma patients.

Dehydration related abdominal pain (DRAP).

To describe the frequency of dehydration as a medical cause of acute abdomen. Cross-sectional analytical study. The study was conducted at Combined Military Hospital, Malir Cantonment Karachi between March 1, 2000 to March 1, 2002. All the patients reporting with abdominal pain to the surgical outpatient department or the emergency department, were reviewed in the study. The clinical findings in all these cases were studied along with the mode of their management and outcome. Of all the patients presenting with abdominal pain, 303% (n=68) were suffering from dehydration related abdominal pain. They were predominantly males in a ratio of 8.7:1, mostly in the 2nd and 3rd decades of their lives. All these cases were suffering from acute or chronic dehydration were provisionally diagnosed by general practitioners as 'acute abdomen' and referred for surgical consultation. Associated symptoms included vomiting in 42.6% backache in 91.2%, headache in 95.6%, and pain in lower limbs in 97.1% of the cases. 83.8% required indoor management with intravenous fluids. All the patients became asymptomatic with rehydration therapy. Dehydration is a possible cause of severe abdominal pain. There is a need to educate the general public about the benefits of adequate fluid intake.

Measurement of outpatients' views of service quality in a Finnish university hospital.

To describe the development of service quality in the surgical and medical outpatient departments of a university hospital. Measurement and documentation of service quality and the use of these data as a basis for improvement are prerequisites for service improvement. A survey conducted over a 3-week period using a 12-item questionnaire measuring service quality on a rating scale from 4 to 10 (extremely poor - excellent quality). Nineteen outpatient departments participated at a Finnish university hospital, 7679 voluntary patients visiting the outpatient departments between 1997 and 1999 completed the questionnaires. The questionnaire, which has not been described in use previously, proved to be a good tool enabling systematic access to patient feedback on service quality in outpatient departments. The instrument allowed the detection of strengths of the service provided by a large organization and long-term trends from patients' perspective. Patient evaluations were mainly good and the results improved year by year, although the instrument was built on questions concerning issues that were rated poorest by patients. The poorest ratings were related to access to information and adherence to appointment times. The service quality instrument offers a means to generate information to be used for service quality improvement in outpatient departments.

A Correlation Study Of Ulcer Status With Bacterial Colonization And Invasion

Wound biopsy is a reliable way of diagnosing wound infection in patients with chronic ulcer of the limbs and in burn patients. The biopsy specimen is subjected to both histological and microbiological analysis. While wound swabs often cultured mixed contaminants, biopsy specimens usually reveal single organism growth. This is a prospective study of fifty patients with chronic leg ulcers attending surgical outpatient department over a period of 10 months. The ulcers were subjected to histopathology study. The clinical status of the ulcers were correlated with the histopathology result. There was both statistical and clinical significance between the ABDEFS' and HISTOPATHOLOGY scores. A clinician can therefore reasonably predict the degree of bacterial invasion of the ulcer based on the assessment of its clinical appearance and thus commence appropriate treatment before further complication sets in. (Af. J. of Clinical and Experimental Microbiology: 2002 3(1): 11-12)

What effect does the duration of an inguinal hernia have on patient symptoms?

Background: Despite the fact that repair of an inguinal hernia is one of the most common operations performed in general surgery, we have very little information on the natural history of the untreated hernia. The aim of this study was to evaluate the association between hernia symptoms and the duration the patients had their hernias before presentation to a surgical outpatient department for an elective or emergency operation. Study Design: Data were gathered prospectively on a consecutive series of 699 patients admitted to two University Departments of Surgery for scheduled operations for an inguinal hernia. Results: More than one third (267) of patients had their hernias for 1 year or longer, up to 65 years, before presentation. The most common symptom on presentation was pain or discomfort at the hernia site, which occurred in 457 (66%) patients. The cumulative probability of pain increased with time to almost 90% at 10 years. The hernia had become irreducible in 48 patients (6.9%). The cumulative probability of irreducibility increased from 6.5% (95% confidence interval 4% to 9%) at 12 months to 30% (95% confidence interval 18% to 42%) at 10 years. Leisure activities were affected in 29% of patients although only 13% of patients had to take time off work because of hernia-related symptoms. Only two patients (0.3%) required resection of infarcted bowel or omentum. Conclusions: Because many patients with an inguinal hernia are asymptomatic or mildly symptomatic, prospective clinical trials to assess the role of operations for such hernias are required.

Warfarin-related bleeding following open heart surgery in Nairobi.

To review anticoagulant-related bleeding in heart valve patients on warfarin at the Kenyatta National Hospital and to determine the variables associated with anticoagulant-related bleeding. A combined retrospective and prospective review of patients operated at the Kenyatta National Hospital. Retrospective period from June 1973 to 31st July 1997, while prospective period from August 1st 1997 to June 1st 2000. Surgical Outpatient Department, Kenyatta National Hospital, Nairobi. Linearised occurrence rate of anticoagulant-related bleeding and the one- five- and ten- year bleed free rates. Independent risk factors associated with anticoagulant-related bleeding determined using Cox's proportional hazards. Thirty one bleeding episodes were recorded in 150 patients followed up for a total of 745 patient-years. The risk of occurrence of the first bleed was 16.0%; while the risk of a subsequent bleed increased thereafter with a 16.7%, 50% and 50% risk after the first, second and third bleeds respectively. The linearised rate for minor anticoagulant-related bleed was 4.16% per patient per year however, half the bleeds occurred within the first year of valve implantation or previous bleeding episode. The one-, five- and ten-year bleed free rates for all valves combined were 93%, 85% and 78% respectively. There was no statistically signicant difference between the curves comparing the bleed free rates for the first and second bleeding episodes (p=0.098). The number of valves implanted, the site of implant and the time to the occurrence of bleeding were independent risk factors associated with the occurrence of bleeding (p<.05). The occurrence of anticoagulant-related bleeding is relatively common being slightly above the internationally reported range. Most episodes of bleeding will occur within one year of hospital discharge or the previous bleeding episode. The risk of another bleeding episode occurring increases with each episode with up to a 50% risk of re-bleed after the second bleeding episode. In this study, the number of valves implanted, their position and the time of occurrence of the bleed were risk factors to the occurrence of bleeding.

Use of telemedicine in undergraduate teaching of surgery.

Telemedicine as an undergraduate teaching method was evaluated by exposing medical students to outpatient videoconferencing. Forty clinical students on a 10-week surgical rotation participated in the study. Telemedicine sessions involved videoconferencing from the general surgical outpatient department located in a sister hospital 8 km away, using a roll-about system connected by ISDN at 384 kbit/s. A questionnaire was used to assess the quality of time spent and educational information obtained by the students. On a scale of 0-10, the students gave an overall rating of 9.7 for outpatient teaching using telemedicine. All 40 students indicated a willingness to return for similar teaching sessions. Even though the results were encouraging, an objective assessment of the knowledge gained by the students is required before the inclusion of this teaching technique in an existing medical curriculum can be recommended unequivocally.

Tuberculosis diagnosed in a surgical department during 1974-93: a report of 32 cases.

During the period 1974-93, 32 patients (18 males, 14 females) with previously undiagnosed tuberculosis were admitted to the department of surgery and the surgical outpatient department of Buskerud Central Hospital. Of these, 26 were native Norwegians and 6 immigrants of Asian origin with an average age of 65 and 26 years, respectively. Of the native Norwegians, 14 patients had a past history of tuberculosis and 7 cases were associated with concomitant cancer. With 1 exception, all immigrants had extrapulmonary tuberculosis. Cultural identification of Mycobacterium tuberculosis occurred in 28 cases and Mycobacterium bovis in 1 (immigrant). A total of 30 patients were cured, whereas 2 of 3 patients with miliary dissemination died.

TELEPHONE FOLLOW‐UP: AN EXTENSION OF THE SURGICAL OUTPATIENT DEPARTMENT

SUMMARYA total of 112 surgical patients took part in telephone follow‐up, conducted by non‐medical staff, after discharge home. Successful telephone follow‐up was achieved in 93% of patients at 6 weeks, 91% at 3 months and 79% at 12 months. Telephone follow‐up by non‐medical staff is a practical method of assessing patient outcome after surgery. Wider use of this technique would free up time in the surgical clinics, without compromising audits of outcome and purchaser demands for evidence of efficacy.