Kisiizi Hospital

Vertex epidural haematoma is a rare form of epidural haemorrhage and a complication of head trauma that is both a diagnostic and therapeutic challenge for the trauma surgeon. It's usually as result of laceration in the superior sagittal sinus. Whereas most patients with small vertex epidural hematomas improve with conservative treatment, large or rapidly expanding lesions are fatal and require emergency craniotomy. Ours was a 28-year-old male patient who arrived at our emergency department in rural Southwestern Uganda with Glasgow coma scale of 12/15 following a head on collision of two Boda Boda motorcycles. CT scan imaging revealed a large acute Vertex Epidural haematoma and a linear skull fracture of the parietal bones crossing the midline. The haematoma was evacuated through a single piece craniotomy and hemostasia achieved by surgicel. Patient was transfused with two units of whole blood. Patients Glasgow coma scale improved to 15/15 after 24h postoperatively. Vertex epidural hematomas are both diagnostic and therapeutic challenges. Small haematomas do not require surgical intervention. Large and expanding haematomas are fatal and require urgent surgical evacuation by neurosurgeons. In rural centres in lower- and middle-income countries like our own, surgery is often more challenging. This is mainly due to nonavailability of neurosurgeons and lack of medical supplies. With careful planning, available midlevel medical doctors can safely evacuate a large vertex epidural hematoma through a single piece craniotomy. When performed timely, emergency surgical decompression results into rapid improvement of brain function in patients with large vertex epidural hematoma and deteriorating brain function as observed in our patient. Massive haemorrhage from superior sagittal sinus and air embolism are important intraoperative complications that should be kept in mind. Careful pre operative planning is of paramount importance especially in centres without neurosurgeons and essential neurosurgery supplies.

Avulsion of the lesser trochanter is a rare but disturbing condition, which usually occurs in males between the ages of 7-16 years with significant physical activities or in athletes. Diagnosis is more often than not challenging, but with a good history, physical examination, and imaging modality, diagnosis can be clinched, and the prognosis is good even with a conservative management approach. This case report is that of a 12-year-old male who suddenly fell while participating in sporting activities in school. As a consequence of the fall, he felt severe pain in the left groin region with an associated inability to bear weight on the affected limb. A radiograph study of the hip revealed a fracture of the left lesser trochanter. Based on the diagnosis, a conservative approach, which entails the use of analgesics, and partial weight-bearing mobilization with axillary crutches to take the weight off the affected limb for a period, was the choice of management for this subject. Fifteen weeks following the conservative management for the avulsion of the left femoral lesser trochanter fracture, the subject sustained a similar injury to the contralateral groin, consequential to return to sporting activities. In conclusion, rare as avulsion of the lesser trochanter may be, a high index of suspicion must be raised in any adolescent with a painful limp following engagement in any sporting activities, and such individuals should have a radiograph study done to achieve prompt and effective care.

Kisiizi Hospital (KH) in partnership with Countess of Chester Hospital UK, as part of WHO African Partnerships for Patient Safety (APPS) has developed a programme to amplify crucial patient safety improvements to other district health facilities.

The new assay of cross-linked carboxyterminal telopeptide of type I collagen (ICTP), a serum marker for bone collagen degradation, was evaluated in serial measurements of 66 patients with early RA during a 3-yr prospective study. Initially 51% of RA patients had elevated levels of serum ICTP compared to healthy controls. During the subsequent months after starting anti-rheumatic treatment, the mean ICTP levels decreased in parallel with the clinical and laboratory variables measuring disease activity. Despite marked clinical improvement with anti-rheumatic treatment, a steady increase in radiological progression of joints was observed. Throughout the follow-up serum ICTP levels correlated with inflammatory parameters and from the first year on with the radiological changes assessed annually. However, initial serum ICTP levels correlated better than the other variables of disease activity with the subsequent erosive progression of joints indicating that measurement of serum ICTP may serve as one of the prognostic markers for joint damage in early RA.

The prognostic significance of HLA DR4 and B27 antigens was investigated in a 3-year follow-up of 87 patients with early rheumatoid arthritis (RA). The frequencies of DR1, DR4 and also of B27 were increased and the frequencies of DR2, DR3 and DR7 decreased compared with the normal Finnish population. During the follow-up with antirheumatic treatment, a similar improvement in clinical variables and laboratory measure assessing disease activity was found in both DR4-positive and DR4-negative RA patients. Despite clinical improvement a fast radiological progression in peripheral joints was observed but the presence of DR4 or B27 had no impact on the progression of joint damage. In some patients cervical changes developed early in the course of RA but were not related to DR4 or B27 positivity. The earlier observation of increased prevalence of HLA B27 in the Finnish RA patients was confirmed but the presence of B27 did not modify the clinical picture of RA.