Simultaneous spontaneous bilateral pneumothoraces in an asthmatic / Neumotórax espontáneos bilaterales simultáneos en un asmático

The occurrence of simultaneous spontaneous bilateral pneumothoraces is a very rare event. We present a case of a 14-year old asthmatic female patient who presented to the emergency room for routine treatment. While receiving nebulizations, she suddenly developed supraclavicular fullness with crepitus. Further examination revealed a clinical diagnosis of bilateral pneumothoraces. Although this phenomenon is more commonly associated with patients on mechanical ventilation, this case illustrates that physicians must be cognizant of this unique presentation in order to initiate early and aggressive life- saving therapy. With rapid bilateral needle thoracocentesis followed by placement of bilateral thora-costomy tubes, the patient recovered well. In this report, we also attempt to briefly review the possible pathophysiology of this form of spontaneous pneumothorax.

La incidencia del neumotórax espontáneo bilateral simultáneo en un asmático es un acontecimiento raro. Presentamos un caso de una paciente asmática hembra de 14 años de edad, quien acudió a la sala de emergencia para tratamiento de rutina. Mientras recibía nebulizaciones, desarrolló súbitamente plenitud supraclavicular con crépito. El examen posterior reveló un diagnóstico clínico de pneumotórax bilateral. Aunque este fenómeno se halla más comúnmente asociado con pacientes en ventilación mecánica, este caso ilustra que los médicos tienen que tener conciencia de esta presentación única para iniciar una terapia agresiva y temprana que haga posible la salvación del paciente. Con una rápida toracocentesis bilateral mediante aguja, seguida de colocaciones de tubos de tora-costomía bilateral, la paciente se recuperó bien. En este reporte también intentamos realizar una breve revisión de la posible patofisiología de esta forma de neumotórax espontáneo.

Acute renal failure post coronary artery bypass grafting at the University Hospital of the West Indies / Fallo renal agudo tras injerto bypass de la arteria coronaria en el hospital universitario de west indies

OBJECTIVES: The purpose of the study was to determine the period prevalence of acute renal failure (ARF) after coronary bypass surgery (CABG) at the University Hospital of the West Indies and to identify risk factors. METHOD: A retrospective analysis of patients who underwent CABG during the period 1994-2004 was done. Data collected included; age, gender, weight, the presence of hypertension (HTN), diabetes mellitus (DM), hypercholesterolaemia, previous myocardial infarction (MI), blood pressure on admission, urea and creatinine one year prior to surgery, on admission for surgery and post-surgery, duration of intra-operative hypotension, duration of cardiopulmonary bypass, perfusion pressure and the perioperative medications. RESULTS: The case notes of 62 patients (68.9%) were obtained for analysis. There were 47 (75.8%) males and 15 females (24.2%)--a 3:1 ratio. The prevalence of HTN and DM in the study sample was 78% and 72% respectively, hypercholesterolaemia was 31% and a previous MI was 29%. There were no differences based on gender. Post CABG complications were: persistent postoperative hypotension (6.8%), congestive cardiac failure (CCF) (6.8%), arrhythmia (6.8%), sepsis (6.8%), lower respiratory tract infection (LRTI) and pleural effusion (5.1%), heart block (3.4%), pulmonary embolism (1.7%), cellulitis and haematoma formation were 1.7%. Three patients had increases in postoperative creatinine values > 89 micromol/L over the postoperative value resulting in a prevalence of ARF of 5%. One of the three patients died and none received dialysis. There were no statistical difference in pre-operative clinical and biochemical characteristics based on the presence or absence of ARE. The presence of diabetes and increased length of stay were significant predictors of increasing postoperative creatinine values adjusting for pre-operative creatinine values. In addition, the presence of diabetes mellitus and...

Thal-Hatafuku oesophagogastroplasty: an effective option in the palliation of non-chagasic megaesophagus / La esofagogastroplastia Thal-Hatafuku: una opción efectiva en la paliación del megaesófago no chagásico

The palliation of patients with megaesophagus secondary to achalasia of the cardia presents significant challenges to the surgeon. Experience with palliation of megaesophagus secondary to Chagas' disease suggests that options other than cardiomyotomy or oesophagectomy can result in satisfactory outcomes. A small series of patients with non-chagasic megaesophagus who were treated with a gastroesophagoplasty procedure is discussed.

El alivio de pacientes con megaesófago secundario a la acalasia del cardias, presenta desafíos significativos al cirujano. La experiencia con la paliación del megaesófago secundario a la enfermedad de Chagas, sugiere que otras opciones distintas de la cardiomiotomía o la esofagotomía pueden producir resultados satisfactorios. Se discute una serie pequeña de pacientes con megaesófago no chagásico, que fueron tratados con un procedimiento de gastroesofagoplastia.

Thirty-five years of cardiac surgery in Jamaica

A retrospective review of the files of all patients who underwent cardiac surgery at the University Hospital of the West Indies (UHWI) and the Bustamante Hospital for Children (BHC), during the period April 1968 to June 2003 was undertaken. Data collected included age, gender New York Heart Association risk score, type and date of cardiac surgery. The mortality rate of patients who underwent surgery during the period January 1994 to June 2003 was also analyzed A total of 2202 patients had undergone cardiac surgery (CS) in Jamaica during the study period of 35 years and two months. The common surgical procedures were valve surgery--replacement and repair (37.65), correction of patent ductus arteriosus (25.2) and repair of congenital heart disease (24.2). Coronary arterial bypass grafting procedures constituted a small percentage (4.1) of the cardiac surgical operations. A considerable number of patients have undergone CS in Jamaica, but much more needs to be done as the patient load exists. The future of the cardiac surgical service therefore depends on improvement in the facilities at both institutions and the cadre of the intensive care nursing staff The building of the Cardiothoracic-Neurosurgical Unit (commenced in March, 2003) is an essential step towards this

Initial experience with beating-heart single valve replacement surgery at the University Hospital of the West Indies, Kingston, Jamaica

The objective of this study was to examine the consequences of performing single cardiac valve replacement procedures utilizing a beating-heart technique on typical patients presenting to the cardiothoracic surgery service for aortic or mitral valve replacement. Beating heart aortic (4) or mitral valve (1) replacement was performed on patients from July 2000 to November 2002. A stratified sample of five patients who underwent standard arrested-heart single valve replacement procedures between April 1997 and November 2002 was selected for retrospective comparison with the beating-heart group. Operative and post-operative variables were compared between the two groups of patients and subjected to statistical analysis. There was no statistical difference between the two groups with respect to age, pre- or post-operative New York Heart Association (NYHA) scores, cardiopulmonary bypass time, aortic cross-clamp time, intra-operative blood transfusion, or post-operative hospital stay. Post-operatively, in the beating heart group, ventilation time, mediastinal blood loss and requirements for inotropic drugs were significantly reduced (p = 0.0054), p = 0.0019 and 0 = 0.02 respectively) compared to the arrested-heart group. Single cardiac valve replacement surgery utilizing a beating heart technique may offer benefits to patients over traditional arrested-heart surgery. Post-operative blood loss, inotrope requirements and ventilation times are significantly reduced, possibly resulting in better recovery and potentially fewer complications in the post-operative period. There may be cost benefits, important in the context of healthcare delivery in developing nations. These early results suggest the need for a regional prospective randomized trial to compare beating-heart single valve replacement surgery with traditional techniques

A simple, inexpensive simulation exercise in the construction of sutured intra-thoracic oesophageal anastomoses

The ability to perform a hand-sutured intra-thoracic oesophago-gastric anastomosis remains an important skill for surgeons in the developing world to master. In the developed world, this skill is no longer widely practiced due to the prevalent use of surgical staplers in most centres. A simple preparation for teaching aspects of hand-sutured anastomotic techniques is described. The set-up accurately evokes the spatial relationships and restrictions encountered during the course of an intra-thoracic oesophago-gastric anastomosis, and enables trainees to gain immediate feedback regarding their progress towards mastering this important thoracic surgical skill

A simple preparation for introductory training in the construction of distal coronary anastomoses

A simple laboratory preparation for use in training of junior level residents in the construction of distal coronary anastomoses is described. The preparation is easily stored and rapidly set-up, and provides a realistic substrate upon which basic anastomotic technical skills can be taught and the trainee's effort can be immediately assessed

A case of pulmonary lymphangioleiomyomatosis

A case of pulmonary lymphangioleiomyomatosis (PLAM) occurring in a 48-year-old Jamaican female is presented. The clinical, radiological, and pathological findings are typical of this rare condition, and serve to emphasize the need for a high index of suspicion in order to make the diagnosis and commence therapy early in the course of the disease. The outlook for patients with PLAM continues to be poor

Thymic surgery in Jamaica 1992-2000

The treatment for thymic tumours and/or myaesthenia gravis (MG) includes thymectomy. Controversy exists as to the optimal timing and operative approach to thymectomy. At the University Hospital of the West Indies, Kingston, Jamaica, the results of thymic surgery during the period 1992 to 2000 were studied retrospectively. There were 26 patients operated on, 17 females and nine males. Twenty-three underwent thymectomy to treat MG, and three to remove a thymoma. The average age for females was 30.7 years, and 25.1 years for males. Average duration of symptoms prior to surgery was 16 months (all patients), and the interval between diagnosis and referral averaged 2.6 months. All patients underwent thymectomy via median sternotomy with a cervical extension of the incision if required. A policy of phrenic nerve preservation, even if residual tumour was left behind, was followed. Patients with thymomas were given post-operative radiotherapy. Chemotherapy was not given to any patient. The medium and long term results of thymic surgery in a developing country are presented. The results are within international norms, although the small patient population makes statistical analysis difficult. There appears to be no need to change current practice, despite the reported efficacy of less invasive approaches to thymic surgery

Scleroderma with cardiac tamponade, hyperthyroidism and incidental papillary thyroid carcinoma

Cardiac tamponade and malignancy are associated with a poor prognosis in Progressive Systemic Sclerosis (PSS). We present the case of a 31-year-old African-Jamaican woman with PSS and a thyroid neoplasm who presented with cardiac tamponade requiring pericardiocentesis. Despite the presence of two poor prognostic markers, she has had a favourable postoperative course.

Surgery for patent ductus arteriosus. Still the gold standard

The surgical treatment of Patent Ductus Arteriosus (PDA) at the University Hospital of the West Indies, Kingston, Jamaica, was examined over an eight-year period. The results of standard surgical modalities were comparable to large published series. A review of the literature regarding the treatment options for PDA does not support a change in management strategy in favour of non-surgical methods. The treatment of PDA at this centre has shown excellent long-term results, with minimal mortality and morbidity.