SSMJ May 2022
Editorials
Obstetric fistula (OF) is an abnormal communication between the vagina and the bladder/urethra and/or the rectum, which results in the passage of urine and/or faeces through the vagina. This occurs because during obstructed labour, the bladder, the vagina, and the rectum are compressed between the baby’s head and the pelvis leading to ischaemic necrosis of the areas involved thus leading to either vesicovaginal fistula (VVF) or rectovaginal fistula (RVF) or both
News, Reports and Policy
Specialist job opportunities at the Juba Medical Complex
Clinical Guidance
Obstetric fistula is one of the most feared complications of labour, leaving a woman with a life of ostracism and shame due to her complete incontinence. Many women see this as a curse for something they did and many end up trying to take their life. Obstetric fistula patients present with a complicated array of physical and psychological needs which should all be addressed by the medical team caring for her. In the majority of cases, obstetric fistula is curable as long as the doctor is trained in and skilled in the right surgical techniques. However, the most important message is that obstetric fistula is preventable. Ensuring that all women receive proper, affordable and timely medical care in labour will ensure that women will not need to fear such dreadful sequalae of trying to have a baby.
The metabolic derangements that lead to Diabetic Ketoacidosis (DKA) are described. Understanding the pathogenesis is the key to rapid and accurate diagnosis and hence successful management. DKA may often be prevented by clear advice to patients about how to manage their type 1 or ketosis-prone type 2 diabetes during periods of intercurrent illness. DKA must be considered in the differential diagnosis of metabolic acidosis even where other diseases that may present similarly, such as malaria, are highly prevalent.
The priorities for the management of Diabetic Ketoacidosis (DKA) are to assess severity and establish intravenous (i.v.) 0.9% NaCl rehydration with the careful addition of potassium ([K+]). Ideally, a fixed rate insulin infusion should be used initially and addition of 10% glucose infusion when the blood glucose level has fallen to below 14 mmol/l. Regular clinical and laboratory monitoring, particularly of the rate of fall of blood ketones (beta-hydroxybutyrate) and of serum [K+] and glucose is essential to guide fluid and insulin infusion rates.
Prompt diagnosis and treatment of Diabetic Ketoacidosis (DKA) with the correct administration of intravenous (i.v.) fluids, fixed rate insulin infusion (FRII) and guideline-based K+ replacement are essential for optimum outcomes. However, treatment guidelines may need to be adapted in special situations such as pregnancy, end stage renal disease or where resources, such as infusion pump equipment, may not be available. Children require treatment according to specific paediatric guidelines particularly to minimise the risk of cerebral oedema. Although DKA is a serious and complex medical emergency, skilled medical care can reduce mortality rates to below 1%.
Research
Admission to hospital outside of normal working hours is consistently associated with poorer patient outcomes. Our aim was to determine the association of patients’ age and time of presentation to a low-resource Ugandan hospital with admission rate and in-hospital mortality. Prospective observational non-interventional audit in the emergency and outpatient departments of Kitovu Hospital in Uganda, a low-resource sub-Saharan hospital. Data on age, sex, time of admission was collected from all non-pregnant patients during 2020 and 2021, and outcomes analysed. Out of 17,133 patients who presented to the hospital 189 died in hospital (1.1% of all presentations and 7.9% of all admissions); 46 (24.3%) patients died within 24 hours of arrival (0.3% of all presentations and 1.9% of all admissions). Deaths within 24 hours of arrival in hospital were more likely in the very young and the old, and in those who presented at night and on the weekend. As many in-hospital deaths occur shortly after arrival, resuscitation skills are needed even in low-resource settings for as much of the 24-hour day as possible.
Cochlear Implant is a small medical electronic device that is surgically inserted partially in the cochlear (inner ear) to restore some hearing in patients with severe to profound hearing loss. Cochlear implantation is considered a rehabilitative measure of choice that positively impacts on the quality of life of patients. The objective was to describe the clinico-demographic characteristics of cochlear implantees and the outcomes of the intervention among the implantees at Muhimbili National Hospital (MNH) in Tanzania. This was a hospital based cross-sectional study which involved a total of 39 patients who underwent cochlear implantation from July 2017 to May 2021 at MNH. Clinico-demographic characteristics and outcomes of the intervention among the implantees were collected using structured questionnaires and data were analysed using Statistical Package for Social Sciences Version 20. Results were then presented in frequency tables and figures.
Results: This study recruited 39 patients with bilateral hearing loss with their ages ranging from 2 to 55 years. Their mean age was 4.7 years and median of 3 years. More than half, 24(61.5%) of implantees aged 2-3 years. Males predominated with male to female ratio of 1.2:1. Majority 37(94.9%) had pre lingual hearing loss and 36 (92.3 %) had bilateral profound sensorineural hearing loss. Ototoxicity was the commonest cause of hearing loss among the implantees contributing 16(41%) followed by birth asphyxia, 8(20.5%). A total of 37(94.9%) of these patients were implanted with a single cochlear device due to the high cost associated with this type of intervention. Cochlear implantation in limited resource settings is possible and cost effective if there is enough support from the government and other charitable organisations. The availability of rehabilitative services remains key for better outcome after cochlear implantation.
Vesicovaginal fistulae (VVF) and rectovaginal fistulae (RVF) are major public health concerns globally and especially in sub-Saharan Africa. Obstetric complications are the leading cause of fistulae in sub-Saharan Africa in a review of articles published from 1987-2008. The high rates of VVF and /or RVF or both in the region reflects the poor quality and the level of perinatal care provided by the local health systems. Approximately 50-80 women/ year attend fistula campaigns in South Sudan with around half having a fistula and receiving a repair. It was estimated in 2013 that at least 30 women out of 100,000 deliveries have obstetric fistulae either VVF or RVF or both despite the efforts being made by both health partners and the Ministry of Health. These fistulae are a serious health burden on the women of South Sudan which has the highest maternal mortality rate in the world at 2,054 per 100,000 live births,[4] 90% of deliveries occur in rural areas with only 10% attended by skilled midwives.
Case Reports
Treatment of gunshot wounds in the maxillofacial region is complex. Current literature supports immediate treatment. Wounds vary widely. The nature of the injuries must be carefully assessed using the Kanzanjian and Converse’s principles of plastic surgery as guidance, but always adapting to specific needs. Management is dependent upon the type of weapon, the bullet’s characteristics, kinetic energy, place of impact, as well as the patient’s general health status.
Summaries
Much of sub-Saharan Africa needs increased healthcare capacity. South Sudan is no exception, and for some years the government has prioritised this as a policy goal. The challenges to the provision of healthcare in South Sudan have been noted previously. More than 80% of medical services are provided by international organisations.