Background: Quality surgical training is crucial to meeting manpower needs and creating a vibrant healthcare delivery. Feedback from trainees provides insight to understanding training challenges and needs to improve the programme. The objective of this study was to determine the challenges faced by surgical trainees and their perception of their training in Nigeria. Materials and Methods: A questionnaire survey of trainees in 16 academic surgical training centres in Nigeria between September and December 2012. Results: Of 235 respondents, 227 were males (96.6%) and 8 females (3.4%) with mean age of 33.9 years. A significant proportion (62.3%) of the respondents believed that the volume and diversities of surgical cases managed during their training were sufficient; however, 53.9% were less satisfied with their operative experience. Majority (71.8%) of the respondents felt " supported" by their trainers but they also believed that the training was skewed towards service provision. They were not actively involved in research due to lack of funds in 77.7%, lack of time/motivation in 15.8%, indifference in 11.8% and poor knowledge of research methods in 9.2%. Inadequate training facilities (50.7%), poor welfare (67.2%), inadequate sponsorship (65.9%) and poor remuneration (88.3%) were identified among their challenges. On the whole, majority (62.3%) believed that their training would adequately prepare them to function independently. Conclusion: Surgical residents in Nigeria face a variety of challenges. Based on our findings, a training that tracks and keeps trend with global changes through a higher investment in surgical training, improved facilities and residents' well-being from both the teaching authorities and government will more likely improve the quality of training.

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Background: Studies of hepatitis A virus (HAV) seroprevalence in sub-Saharan Africa have generally found very high anti-HAV IgG seroprevalence rates, but economic development and improved drinking water access may be contributing to decreasing incidence. Materials and Methods: This review evaluates all 19 articles that have been published on HAV epidemiology in West Africa. Results: Nearly all studies conducted before 1990 found that the majority of preschool-aged children had already developed immunity due to prior infection. However, several recent studies have observed that the age at midpoint of population immunity in some urban populations has shifted to school-aged children. Conclusion: There is preliminary evidence that some West-African countries are beginning the transition towards lower hepatitis A endemicity levels. Additional studies of child seroprevalence rates in diverse parts of West Africa are required in order to clarify the extent to which an early transition may be occurring.

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Background: Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) is a lifestyle-related disease. This disease is transmitted through unprotected sex, contaminated needles, infected blood transfusion and from mother to child during pregnancy and delivery. Prevention of infection with HIV, mainly through safe sex and needle exchange programmes is a solution to prevent the spread of the disease. Knowledge about HIV state helps to prevent and subsequently reduce the harm to the later generation. The purpose of this study was to assess the willingness rate of couples referred to the family regulation pre-marital counselling centre for performing HIV test before marriage in Yazd. Patients and Methods: In this descriptive study, a simple random sampling was done among people referred to Akbari clinic. The couples were 1000 men and 1000 women referred to the premarital counselling centre for pre-marital HIV testing in Yazd in the year 2012. They were in situations of pregnancy, delivery or nursing and milking. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software and chi-square statistical test. Results: There was a significant statistical difference between the age groups about willingness for HIV testing before marriage (P < 0.001) and also positive comments about HIV testing in asymptomatic individuals (P < 0.001). This study also proved a significant statistical difference between the two gender groups about willingness to marry after HIV positive test of their wives. Conclusion: The willingness rate of couples to undergo HIV testing before marriage was significant. Therefore, HIV testing before marriage as a routine test was suggested.

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Background: India is one of the high tuberculosis (TB)-burden countries in the world. Resistance to anti-tuberculosis (anti-TB) drugs has already become an important and alarming threat in most of the regions worldwide. India ranks second in the world in harbouring multi-drug resistant cases (MDRTB). Prevalence of MDR-TB mirrors the functional state and efficacy of TB control programmes and realistic attitude of the community towards implementation of such programmes. The most important risk factor in the development of MDRTB is improper implementation in the guidelines in the management of TB, and high rate of defaults on the part of the patients. The study was carried out to evaluate the drug resistance pattern to first line anti-TB drugs in Northern Karnataka region, India. Materials and Methods: A prospective study was conducted at J. N. Medical College and its associated Hospitals, Belgaum. Between January 2011 and December 2012, 150 sputum samples of suspected pulmonary TB patients based on the history were examined for the AFB culture by Lowenstein-Jensen (LJ) culture technique. A total of two early morning samples were collected for the smear [Ziehl-Neelsen (ZN) staining] and culture methods. It was observed that ZN staining for AFB was positive in 113 patients (75%), while AFB culture by LJ medium yielded growth in 66 cases (44%). Thus, a total of 66 AFB culture-positive samples by LJ medium were subjected for AFB drug-sensitivity testing (DST). DST was done for Isoniazid (INH), Rifampicin (RIF), Pyrazinamide (PZA), Ethambutol (EMB) and Streptomycin (SM) after isolation by using the resistance proportion method. Results: A total of 66 AFB culture-positive specimens, 20 (30.3%) cases were sensitive to all the five drugs while 46 (69.7%) cases showed resistance to one or more drugs. Among these, the resistance to rifampicin was highest (80.4%), while resistance to isoniazid, pyrazinamide, ethambutol and streptomycin were observed to be 60%, 58.7%, 52.1% and 63%, respectively. It was also observed that, resistance to all five drugs was highest (39.18%). MDR isolates were obtained in 52.2% of the cases. Illiteracy, low socio-economic status, previous history of TB and alcoholism were found to have statistically significant association for the development of MDR. Conclusions: The prevalence of drug resistance in the present study was observed to be 69.7%. More than half of the cases were multi-drug resistant. The most common resistant pattern observed in this study was resistance to all the first-line drugs. Therefore, during initiation of new case proper explaining and completion of the treatment is very important to avoid the development of future drug resistance in the society.

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Background: Postpartum haemorrhage (PPH) is the third-most common cause of maternal death in the United States and it is still the first prevalent cause of maternal death in developing countries. Active prevention of haemorrhage with an uterotonic or other new drugs leads to a decrease in postpartum vaginal haemorrhage. The aim of this study was to compare anti-haemorrhagic effect of Tranexamic acid (TXA) and Misoprostol for PPH. Patients and Methods: In a double-blinded randomised control clinical trial, 200 women were included after Caesarean or natural vaginal delivery with abnormal PPH. They were divided into two equal intervention and control groups. Effect of intravenous TXA and Misoprostol for postpartum haemorrhage was examined. Results: The mean age of patients was 26.7 ± 6.5 years which ranged from 14 to 43 years. The sonographic gestational age in the group treated with TXA was 37.7 ± 3.4 weeks and it was 37.4 ± 3.3 weeks for the other group (P = 0.44). The haemorrhage in the TXA and Misoprostol groups was 1.2 ± 0.33 litres and 1.18 ± 0.47 litres, respectively (P = 0.79). The haemoglobin levels after 6-12 hours of labour, in TXA group was more than that of the Misoprostol group, but this difference was not statistically significant (P = 0.22 and P = 0.21, respectively). Conclusion: Regarding to the superior results in Misoprostol group in one hand and lack of significant differences between two groups in haemorrhage during labour, post-partum haemoglobin level and discharge haemoglobin level, we can state that Misoprostol has no specific preferences to TXA, but more studies with greater population are needed.

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Background: Although maximal heart rate (HR) _max is used widely to assess exercise intensity in sport training and particularly in various team sports, there are limited data with regards to the use of age-based prediction equations of HR _max in sport populations. The aim of this study was to compare the measured-HR _max with three prediction equations (Fox-HR _max = 220-age and Tanaka-HR _max = 208-0.7×age and Nikolaidis-HR _max = 223-1.44×age) in young team sport athletes. Materials and Methods: Athletes of soccer, futsal, basketball and water polo, classified into three age groups (u-12, 9−12 years, n = 50; u-15, 12−15 years, n = 40; u-18, 15−18 years, n = 57), all members of competitive clubs, voluntarily performed a graded exercise field test (20 m shuttle run endurance test) to assess HR _max . Results: Fox-HR _max and Nikolaidis-HR _max overestimated measured-HR _max , while Tanaka-HR _max underestimated it (P < 0.001). However, this trend was not consistent when examining each group separately; measured-HR _max was similar with Tanaka-HR _max in u-12 and u-15, while it was similar with Nikolaidis-HR _max in u-18. Conclusion: The results of this study failed to validate two widely used and one recently developed prediction equations in a large sample of young athletes, indicating the need for specific equation in different age groups. Therefore, coaches and fitness trainers should prefer Tanaka-HR _max when desiring to avoid overtraining, while Fox-HR _max and Nikolaidis-HR _max should be their choice in order to ensure adequate exercise intensity.

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Background: Method of testing clinical competence of medical students in this setting has been controversial. This report evaluates the perceptions and preferences of 5 ^th and 6 ^th 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 5 ^th and 6 ^th 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 5 ^th and 6 ^th 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.

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Background: Traffic-related air pollution (TRAP) is a major source of air pollution but the impact on health in Nigeria is not well described. Patients and Methods: A descriptive cross-sectional study of road traffic workers and university students in Lagos. Eligible, accessible and willing participants were included in the sample. Respiratory symptoms and anthropometry were obtained from all the participants using an adapted Medical Research Council (MRC) questionnaire and they all did a spirometry test and exhaled carbon monoxide (CO) test. Results: Fifty-nine individuals participated with complete data, including 47 traffic policemen and 12 students who acted as controls. The mean age (SD) was 35.1 (8.0) and 35.4 years (6.3) for the traffic workers and students, respectively. All the respondents were men. The mean (SD) duration of occupation as a traffic policeman was 4.4 (4.4) and a median of 4 years (range 1-25). There was no significant difference in the presentation of respiratory and non-respiratory symptoms between the two groups. Compared with the students, the traffic workers had higher age, height and sex adjusted forced expiratory volume in one second and forced vital capacity. Traffic policemen had significantly higher levels of exhaled CO than the students (1.18 vs 0.73 ppm, P < 0.006). Conclusion: There is a high prevalence of respiratory symptoms in both traffic policemen and non-traffic residents of Lagos metropolis, indicating widespread pollution.

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Background: Measurement of serum or plasma bicarbonate (HCO3⁻ ) from a sample of peripheral venous blood is routinely practiced in hospital patient managements. HCO3⁻ status can also be obtained by a simple calculation during blood gas analysis requiring arterial blood as sample which is cumbersome for both patient and doctor. This study compared the measured bicarbonate levels with calculated arterial values in intensive care unit (ICU) patients to determine whether traditionally measured venous HCO3⁻ and calculated HCO3⁻ values [from arterial blood gas (ABG) analyzers] can be used interchangeably. Materials and Methods: This prospective study was carried out at a tertiary care teaching hospital in Dhaka, the capital of Bangladesh. A total of 56 adult patients with diverse medical conditions, presenting at the ICU of the health centre were enrolled in this study when deemed by the treating physician to have an ABG analysis. Arterial and venous samples were taken as close in time as possible for gas analysis and routine blood tests. Results: The HCO3⁻ levels from ABG and traditionally measured serum showed acceptably narrow 95% limits of agreement using the Bland-Altman method. Conclusions: More widely prescribed venous HCO3⁻ measurements can also be a useful substitute for an expensive ABG analyzer in resource-constrained health care sectors when required. However, accuracy of venous blood in assessment of additional ABG parameters is yet to be discovered.

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Background: Since laboratory assessments of HIV-infected patients by flow cytometric methods are expensive and unavailable in resource-limited countries, total lymphocyte count by haematology cell counter is supposed to be a suitable surrogate marker to initiate and monitor course of the disease in these patients. The aim of this study was to evaluate the utility of total lymphocyte count as a surrogate marker for CD4 count in HIV-infected patients. Patients and Methods: In a prospective study 560 HIV-positive individuals evaluated for total and CD4 lymphocyte count. For correlation between CD4 count and total lymphocyte count, haemoglobin and haematocrit we defined cut-off values as 200 cell/μl, 1200 cell/μl, 12 gr/dl and 30%, respectively, and compared CD4 count with each parameter separately. Positive predictive value, negative predictive value, sensitivity and specificity of varying total lymphocyte count cutoffs were computed for CD4 count ≤ 200 cell/μl and ≤ 350 cell/μl. Results: Strong degree of correlation was noted between CD4 and total lymphocyte count (r: 0.610, P < 0.001). Mean and standard deviation of total lymphocyte count, haemoglobin and haematocrit in relation to CD4 count were calculated which indicated significant correlation between these variables. Kappa coefficient for agreement was also calculated which showed fair correlation between CD4 200 cell/μl and total lymphocyte count 1200 cell/μl ( 0.35). Conclusion: This study reveals that despite low sensitivity and specificity of total lymphocyte count as a surrogate marker for CD4, total lymphocyte count is of great importance and benefit in resource-limited settings.

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Coronary vasospasm can lead to myocardial injury and even sudden cardiac death. It has generally been overlooked as a diagnosis since atherosclerosis is a more common cause of acute coronary syndromes and because of the dilemma involved in its diagnosis. A middle-aged man with a history of smoking and cocaine use presented to the emergency department with left-sided arm/chest discomfort and diaphoresis. The electrocardiogram showed anterior ST elevation and hyper-acute T waves, which completely resolved shortly after sublingual nitroglycerin was administered. Subsequent angiogram revealed a 70% focal stenosis in the mid-left anterior descending artery. Coronary vasospasm occurs more commonly in arteries with underlying atheromatous disease, although normal vessels are not excluded. Cigarette smoking and cocaine use are among the major culprits that have been implicated as risk factors for the occurrence of coronary vasospasm. Eventually, the patient had percutaneous coronary intervention of his left-anterior descending artery and remained asymptomatic.

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Background: The objective of this study was to assess nodal vascularity by Doppler sonography and to find out the correlation between clinical and various Doppler sonographic features for the detection of the metastatic nodes in oral cancer patients. Patients and Methods: A total number of 55 patients of histopathologically proven oral cancer presenting with enlarged superficial cervicofacial lymph nodes were included in the study. Patients were subjected to clinical examination according to a specially designed proforma and the TNM staging was done. If more than one enlarged nodes were present, then the node with the largest diameter was chosen for further Doppler ultrasonographic examination followed by fine needle aspiration cytology test of the same node. Results: Correlations of patterns of color Doppler flow signals with cytological diagnosis showed that central type of vascular pattern was statistically significant parameter for benign lymph nodes and peripheral type of vascularity was highly significant parameter for malignant lymphadenopathy. It was found that the cut-off value of resistive index 0.6 was statistically significant in the assessment of metastatic node (P < 0.01) with a sensitivity of 45.5% and specificity of 93.9%. On comparison of the clinical features (TNM staging) with Doppler sonographic features, it was found that the characteristic features suggestive of malignant lymph nodes on Doppler sonography such as peripheral blood flow and high resistive index were more consistently and frequently associated with the higher sub-stages of T3 and T4 and N2b and N2c of TNM staging system. Conclusion: Nodal vascularity may be used to differentiate benign from malignant lymphadenopathy. Proper judicious use of non-invasive color Doppler ultrasonographic examination provides an opportunity to eliminate the need for biopsy in reactive nodes and provide treatment in a more precise manner.

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Background: The use of prosthetics for open repair of incisional hernia is very recent in our practice. We highlight our experience repairing incisional hernias with polypropylene mesh. Patients and Methods: Patients presenting with incisional hernia >5 cm in length or width received open polypropylene mesh repair and were followed for two years. Data obtained included age, sex, primary surgery causing the hernia, the length of the fascial defect and previous attempts at repair. Post-operative wound complications were recorded. The integrity of the scar and patient satisfaction or concerns with the repair was assessed at each visit. Results: Nineteen females with a mean age of 35 years (range 30-54) underwent repair; most arising from obstetric or gynaecological procedures. Sixteen (82.2%) had midline, 2 (10.5) transverse and 1 (5.3) Pfannenstiel scars. One patient had no previous repair (R0), 7 had undergone one repair (R1), 9 had undergone two repairs (R2) and 1 had three previous repairs (R3). The length of fascial defects ranged from 8 to 18 cm and seroma collection and stitch sinus were the common problems encountered. Two (10.5%) recurrences were recorded in two years. Conclusion: Open mesh repair of incisional hernia carries a low risk of infection and recurrence in two years.

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Background: Many mothers still rely on palpation to determine if their children have fever at home before deciding to seek medical attention or administer self-medications. This study was carried out to determine the accuracy of subjective assessment of fever by Nigerian mothers in Under-5 Children. Patients and Methods: Each eligible child had a tactile assessment of fever by the mother after which the axillary temperature was measured. Statistical analysis was done using SPSS version 19 (IBM Inc. Chicago Illinois, USA, 2010). Result: A total of 113 mother/child pairs participated in the study. Palpation overestimates fever by 24.6%. Irrespective of the surface of the hand used for palpation, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of tactile assessment were 82.4%, 37.1%, 51.9% and 71.9%, respectively. The use of the palmer surface of the hand had a better sensitivity (95.2%) than the dorsum of the hand (69.2%). The use of multiple sites had better sensitivity (86.7%) than the use of single site (76.2%). Conclusion: Tactile assessment of childhood fevers by mothers is still a relevant screening tool for the presence or absence fever. Palpation with the palmer surface of the hand using multiple sites improves the reliability of tactile assessment of fever.

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The importance of ventilator graphics cannot be over emphasized that provide the useful information about airway, ventilation, compliance and lung mechanics. Some bizarre forms of graphics are usually overlooked in view of artifacts, but sometimes these tracings may in fact predict some relevant information.

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Background: The aim of this study was to determine diagnostic value of cervicovaginal ferretin and serum ferretin levels at midgestation time in predicting preterm delivery in singleton pregnancies. Patients and Methods: A diagnostic test study through a prospective cohort design was carried out on 300 singleton pregnant women in 2012. A blood sample was obtained from all the patients within 22-24 gestational weeks for laboratory assessment of serum ferretin, and cervicovaginal sample was also taken to assess cervicovaginal ferritin level. Ferritin levels were compared between term and preterm deliveries at 37, 34 and 32 weeks of gestation. Receiver operating characteristics (ROC) curves were plotted to assess the diagnostic test values. Results: Mean serum ferritin level was 55.38 [standard deviation (SD 23.8)] ng/mL in term deliveries versus a mean of 91.27 (SD 25.2) ng/mL in preterm deliveries, which showed a statistically significant difference (P < 0.001). The ferritin levels in cervicovaginal term delivery group had mean of 11.29 (SD 16.2) ng/mL compared with a mean of 21.95 (SD 10.1) ng/mL among those with preterm delivery before 37 weeks of gestational age(P < 0.001). The cervicovaginal ferritin level had a moderate to good diagnostic value with an area under curve being above 0.8 for all assessments. The serum ferritin level had a moderate to good diagnostic value with an area under curve being above 0.8 for all assessments. In both tests, its diagnostic value was higher for predicting preterm delivery at earlier gestational age. Conclusions: The results of this study indicate that high levels of serum and cervicovaginal ferritin in singleton pregnancies may alert the clinician of the risk of preterm delivery. Serum and cervicovaginal ferritin measurement at midgestation may be used as a predictive scale for preterm delivery in singleton pregnancies.

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We report an exceptional case of, 33-year-old woman presenting with, dyspnoea and chest pain, Cardio respiratory sign and symptom related to diastolic dysfunction caused by mass effect of thrombosis on diastolic filling of left ventricule (LV). The common aetiologies of these devastating complication results in thrombophillia diagnosis, and echocardioghraphy showed a large mass in left ventricular cavity. In laboratory exam, protein C-S deficiency was confirmed however, others related test of thrombophillia were negative. The patient underwent cardiopulmonary bypass with thrombosis extraction and her sign and symptom, recovered uneventfully. This case report illustrates an exceedingly rare case of thrombophilia-induced left ventricular clot formation.

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