SUMMARYImpalement injuries of the chest are uncommon in civilian practice with few reports in the literature. We report three cases of thoracic impalement seen over a 5 year period with unusual underlying mechanisms. In two of the cases, the impalement was obvious; in the third, the impalement was concealed having occurred 5 months earlier. In Case 1, the underlying mechanism was a high-speed road traffic accident. The patient was impaled by a metallic square pipe piled by the roadside. In Case 2, the gun-housing of a locally-made rifle gave way as it was fired and allowed a reverse ejection of the barrel during recoil that impaled the hunter's chest. In Case 3, a domestic assault with an old umbrella caused an impalement injury as one of the umbrella spokes broke off, penetrated and lodged in the left chest going unnoticed for 5 months. Persistent chest pain and haemoptysis led to a request for chest radiographic examination upon which the foreign body was discovered. Massive haemoptysis brought the patient to emergency thoracotomy. All three patients underwent thoracotomy with a successful outcome.Keywords: Impalement injuries, thoracic, mechanisms, debridement, management. CASE REPORTSCase 1 A 22 year-old lady was referred to the National Cardiothoracic Centre (NCTC) with an impalement injury of the left upper chest following a road-traffic accident that morning as a passenger. When the van in which she was travelling skidded off the road, she got impaled on a metallic pipe piled by the roadside. She had chest pain and dyspnoea on admission. Examination showed a metallic square pipe lodged in the left chest in through-and-through fashion antero-posteriorly (Figure 1). She was conscious, alert and haemodynamically stable with a blood pressure of 110/80mmHg and a pulse of 104/minute. Respiratory examination showed signs of a left haemopneumothorax and left lung collapse. Apart from a laceration of the right arm and forearm the rest of the physical examination was normal. A left chest tube was inserted and preparations were made for thoracotomy. Broad-spectrum antibiotic prophylaxis (1 gram ceftriazone and 500mg metronidazole) and tetanus immunoglobulin were administered prior to surgery. Figure 1 Case 1 with impaled metallic objectAt surgery, the foreign body was extracted carefully without sequelae. There was a laceration of the left upper lobe; no major vessel or cardiac injury was found. The injured part of the left lung was debrided and the resulting defect repaired. Debridement of the chest wall at the entry and exit wounds was carried out. The pleural cavity and chest wall wounds were copiously lavaged with saline, a chest tube was passed and the incisions closed primarily. The patient was returned to the Intensive Care Unit. She made an uneventful recovery and was discharged on the 14 th post-operative day.

Majority of the residents are sponsored by the training institutions.

A role for nitric oxide (NO) in the regulation of blood leukocyte numbers was examined in BALB/c mice by employing the NO synthase inhibitor NG-nitro L-arginine methyl ester (L-NAME). Treatment of animals with a single dose of 50 mg/kg body wt caused a dramatic increase in the number of circulating neutrophils and a moderate decrease in the number of circulating lymphocytes. These effects were partially reversed by the simultaneous inoculation of L-arginine (250 mg/kg body wt.) but not by D-arginine. A second NO synthase inhibitor, NG-nitro L-arginine, induced changes comparable to those elicited by L-NAME. Because catecholamines and glucocorticoids are well-known modulators of blood leukocyte counts, experiments were carried out in adrenalectomized mice. It was found that adrenalectomy did not modify the increase in the number of circulating neutrophils induced by L-NAME but completely prevented the decrease of circulating lymphocytes. Taken together, these findings support the hypothesis that NO plays an important role in the regulation of the peripheral blood number of neutrophils and lymphocytes, and that this function involves, in each case, the participation of different mechanisms.

The practice of vascular surgery in Zaria, Nigeria, is fraught with challenges. The gap created by the dearth of skilled vascular surgeons is filled by competent cardiothoracic surgeons. Infrastructure decay and lack of prostheses limit the number and variety of operable cases. These challenges result in preventable morbidity and mortality.

Aims and Objectives Trauma continues to be a major cause of morbidity and mortality world over. This study is aimed at the patterns of presentation and the outcome of management. Materials and Methods A prospective study of trauma patients admitted to Ahmadu Bello University Teaching Hospital through the Accident and Emergency units was commenced in January 2008.This preliminary report is for the period of 27months.The clinical history, physical examination and outcome of management recorded in a predesigned proforma, were analysed with SPSS 15 and the patients were followed up in the surgical outpatient department. Results A total of 4784 patients (3143 men and 1641 women) were admitted during this period for trauma. There were a total of 628(13.13%) deaths. Of the 42 consecutive patients identified with chest trauma35 (83.3%) were males and 7(16.7%) were females. The age range was from 5-75years and the mean age was 35.4years, while the most affected ages were in the range of 20 to 49years. Blunt injury constituted 71.4% and penetrating injury constituted 28.6%. Road traffic accident was responsible for 61.9%, stab injury 21.4%, falls 7.1%, gunshot injury 4.8%, impalement 2.4% and animal attack also 2.4%. The average time taken between accident and admission was 31hours,40minutes and 12seconds while the average duration of hospital stay was 16.10 days. The injury pattern included rib fracture(s) (23.8%), hemopneumothorax (14.3%), hemothorax (7.1%), pneumothorax (4.8%), combinations of chest injuries (7.1%), chest laceration 7.1%, bruises 11.9%, lung contusion 4.8%, subcutaneous empyema 2.4%, flail chest 4.8% and no specific injury (11.9%). Associated injuries included head injury (63.6%), orthopaedic injury (27.3%) and combinations (abdominal, head, orthopaedic (9.1%). The fatality of road traffic accident was 36.8%. No patient was attended to by paramedics at the scene of accident while 21.9% of the patients had prehospital resuscitation in peripheral clinics before admission. The transfusion requirement was 14.3%. One patient (2.4%) required a median sternotomy and cardiopulmonary bypass, 54.8% required tube thoracostomy while 42.9% had general resuscitation /non-operative intervention. Only one (2.4%) required ICU care. The complication rate was 4.8%. The mortality rate was 2.4%. Only 7(16.7%) patients were seen beyond the first outpatient clinic appointment. Conclusion Most patients arriving at the hospital survived, requiring general resuscitation or simple tube thoracostomy with few complications. Mortalities from trauma and the cause of death at the site of accident are often not accounted for due to nonpresentation to the hospital and lack of autopsy for those that present.