Pre-adolescent gunshot injuries: anatomy of a Jamaican problem

This retrospective analysis explores the apparent increase in gunshot injuries among pre-adolescent Jamaican children. During the five-year study period (2001-2005), 74 children less than 12 years old were treated for gunshot injuries at the Bustamante Hospital for Children. In the last four years of the study, the hospital incidence of such child shootings rose by 155%. Children between six and eleven years of age were seen to be at particular risk. Shootings were likely to occur between 4:00 pm and 10:00 pm in the evening, at or near home, in inner city communities. Affected children were unlikely to have been under direct adult supervision at the time of injury and were reported to be intended targets of the shooting in 49% of cases. Injuries to the limbs occurred most frequently, resulting chiefly in soft tissue injuries and open fractures. Half required operative intervention, most avoiding blood transfusion. Hospital stay was usually less than a week. Though clearly needed, social support services were underutilized A mortality rate of 4% was seen but long-term morbidity was uncommon. Routine social and psychiatric evaluation of victims, organized after school-care, establishment of paediatric paramedical services, establishment of a dedicated paediatric interhospital transfer team and more widespread training in paediatric trauma management are recommended to improve the quality of care given to paediatric victims of firearm injuries.

Este análisis retrospectivo explora el aumento evidente de las heridas de bala entre los niños jamaicanos pre-adolescentes. Durante un período de cinco años de estudio (2001–2005), 74 niños menores de 12 años fueron atendidos debido a heridas de bala en el Hospital Pediátrico Bustamante. En los últimos cuatro años de este estudio, la incidencia en el hospital de heridas producidas con armas de fuego a niños aumentó en un 155%. Niños entre seis y once años de edad se considerabanparticularmente en riesgo. Los tiroteos ocurrían probablemente entre 4 pm de la tarde y 10 pm de la noche, en la casa o en el vecindario, en las comunidades de los suburbios citadinos internos (conocidos como inner cities). Es poco probable que los niños afectados hayan estado bajo supervisión directa dealgún adulto en el momento de recibir la herida, y se reportó que fueron objetivo expreso de los disparos en el 49% de los casos. Las heridas en las extremidades ocurrieron con mayor frecuencia, trayendo como consecuencia principalmente heridas en tejidos blandos y fracturas abiertas. La mitadde ellos requirió intervención quirúrgica, evitándose la transfusión sanguínea en la mayoría de los casos. La estadía en el hospital por lo general duró menos de una semana. Aunque evidentemente senecesitaban servicios de apoyo social, hubo una marcada subutilización de los mismos. Se observó una tasa de mortalidad del 4% pero la morbilidad a largo plazo resultó poco común. La evaluación psiquiátrica y social de rutina de las víctimas, organizada después de la atención en la escuela, el establecimiento de servicios paramédicos pediátricos, el establecimiento de un equipo dedicado de transferencia interhospitalaria pediátrica, y un entrenamiento más amplio en el tratamiento de traumaspediátricos, se recomiendan a fin de mejorar la calidad de la atención brindada a las víctimas pediátricas de heridas por arma de fuego.

Paediatric day surgery: revisiting the University Hospital of the West Indies experience

Day surgery is cheaper and allows for less time delay. In developing countries with limited health budgets, these factors lead to higher patient turnover and shortened waiting lists. The decreased psychological trauma for both parents and children is significant. Paediatric day surgery (PDS) has been done at the University Hospital of the West Indies (UHWI) for over 40 years. A total of 975 paediatric general surgical (PGS) procedures were performed on 963 patients at the UHWI during the four-year period, January 2001 to December 2004. Paediatric day surgery numbered 727 (74.6%). Males outnumbered females 2:1, the age range was 2 weeks to 15 years, with an average age of 4 years. Ninety-seven (13.3%) of these patients were less than six months old, including eight neonates. One hundred and forty-five (20%) had more than one surgical procedure. Most children, 314 (43.2%) had inguinal hernia repair. Umbilical/supra-umbilical/epigastric herniorrhaphy (20.1%) was the next most frequently performed procedure, followed by circumcision (13.3%) and orchidopexy (5.9%). Ninety per cent of these patients were discharged home within 2-4 hours after surgery. Unplanned admissions were 2.1% of the cases. These were due to age, unplanned extensive surgical procedure, drug reaction and fever There was no mortality in this study population. This review showed that the number of PDS has increased from 60% in 1984 to 75%. These procedures were performed safely with a low complication rate. Further expansion of the service is recommended.

Obstruction of the duodenum by a preduodenal portal vein in situs inversus

Mirror image transposition of abdominal and thoracic viscera is termed situs inversus. Duodenal obstruction in situs inversus is rare. A preduodenal portal vein, though not uncommon in situs inversus, rarely causes duodenal obstruction. Where obstruction by a preduodenal portal vein is diagnosed, a duodeno-duodenostomy is the recommended treatment. A duodenal diaphragm and other more common causes of duodenal obstruction should also be excluded in these patients.

Hermaphroditism: cytogenetics, gonadal pathology and gender assignment: a case report / Hermafroditismo: citogenética, patología gonadal y asignación de género

True hermaphroditism is a rare intersex disorder in which individuals possess both testicular and ovarian gonadal tissue. A case of true unilateral hermaphroditism presenting with ambiguous external genitalia, right scrotal testis and left pelvic ovotestis is herein outlined Phallic, gonadal and genetic factors were considered before male gender was assigned. Gender assignment procedures have been questioned by intersex activists opposed to early genital surgery. Western societies have a binary perspective on gender and this leads to a stigma being placed on intersex cases. A multidisciplinary approach to this problem involving paediatric specialists in the field, of endocrinology, surgery and psychiatry is necessary, along with educational programmes that promote tolerance in society to variations in gender.

Bile duct injuries in the laparoscopic era: the University Hospital of the West Indies experience / Lesiones de la vía Biliar en la Era Laparoscópica: la Experiencia del HUWI

During the ten-year period July 1994 to June 2004, 20 patients were seen with iatrogenic bile duct injuries. The case notes of these patients were reviewed. Half of the patients were referred after initial surgery at other hospitals. At the University Hospital of the West Indies, bile duct injury rate was 0.8and 1for open and laparoscopic cholecystectomy respectively. Sixty per cent of patients' injuries resulted from open cholecystectomy and the majority of these were during emergency cholecystectomies for acute cholecystitis. A wide range of treatment modalities were employed for patients with minor bile duct injuries but Roux en Y hepaticojejunostomy was the treatment of choice for patients with transection of the common hepatic or bile duct. Follow-up was available in seven of nine patients who had major bile duct injury repair to a median of 36 months and all but one were asymptomatic and had normal liver function tests. There were two deaths because of septic complications.

Open splenectomy in Jamaican children with sickle cell disease / Esplenectomía abierta en niños jamaicanos con la enfermedad de células falciformes

A total of 110 patients with sickle cell disease who had open splenectomy at the University Hospital of the West Indies over a 10-year period are reviewed Patients with homozygous sickle cell disease numbered 94, S beta0 and S beta+ thalassaemias (11 and 4 respectively) and one patient with SC disease. Postoperative acute chest syndrome was the most common complication (9 of 110). There were no life threatening emergencies and no mortalities. Eleven patients received preoperative blood transfusion and operative times were short averaging 60 minutes among the 110 patients. Open splenectomy remains the gold standard for patients with sickle cell disease requiring splenectomy.

El presente trabajo revisa un total de 110 pacientes con la enfermedad de células falciformes, que fueran sometidos a una esplenectomía abierta en el Hospital Universitario de West Indies, a lo largo de un período de 10 años. Los pacientes con enfermedad de células falciformes homocigóticas fueron 94, con talasemias S b0 y S b+ fueron 11 y 4 respectivamente, y un paciente presentaba la enfermedad por hemoglobina SC. El síndrome torácico agudo postoperatorio resultó ser la complicación más común (9 de 110). No hubo emergencias con riesgo de vida ni mortalidades. Once pacientes recibieron transfusión de sangre en el postoperatorio y los tiempos de operación fueron cortos, con un promedio de 60 minutos entre los 110 pacientes. La esplenectomía abierta sigue siendo la norma de oro para los pacientes con la enfermedad de células falciforme que requieren esplenectomía.

Laparoscopic cholecystectomy for chronic cholecystitis in Jamaican patients with sickle cell disease: preliminary experience / Colecistectomía laparoscópica para la colecistitis crónica en pacientes jamaicanos con anemia falciforme: una experiencia preliminar

Laparoscopic cholecystectomy, with its advantages of reduced postoperative pain and shorter hospitalization is the accepted standard of care for patients with symptomatic cholelithiasis. A retrospective study was done to assess the outcome of laparoscopic cholecystectomy in patients with sickle cell disease, a group known for its high postoperative morbidity. The study sample comprised of patients seen at the University Hospital of the West Indies during the period 1999 to 2004. Twelve patients were females and four were males. Their mean age was 28.5 years (range 13-43 years). Fifteen underwent elective cholecystectomy for recurrent episodes of cholecystitis while one patient required an emergency procedure. All patients underwent endoscopic retrograde cholangiopancreatography, which successfully removed common bile duct stones which were present in 25of the cases. There were four conversions to open cholecystectomy as a result of obscure anatomy due to scarring and adhesions. The duration of surgery ranged from 70-150 minutes. Six patients developed postoperative complications, four of whom had acute chest syndrome. This resulted in death in one patient. The mean postoperative hospitalization period was 5.5 days. This report indicates that patients with sickle cell disease remain a high risk group with the potential for significant morbidity even when subjected to minimal access surgery.

La colecistectomía laparoscópica, que tiene como ventajas la reducción del dolor postoperatorio y del tiempo de hospitalización, es ahora la norma aceptada en la atención a pacientes con colelitiasis sintomática. Se realizó un estudio retrospectivo a fin de evaluar el resultado clínico de la colecistectomía laparoscópica en pacientes que padecen la enfermedad de células falciformes – un grupo caracterizado por una alta morbilidad postoperatoria. La muestra para el estudio comprendía pacientes atendidos en el Hospital Universitario de West Indies durante el período de 1999 a 2004. Doce pacientes fueron hembras y cuatro varones. Su edad media fue de 28.5 años (rango 13-43 años). Quince fueron sometidos a una colecistectomía electiva debido a episodios recurrentes, en tanto que un paciente requirió un procedimiento de emergencia. A todos los pacientes se les practicó una colangiopancreatografía retrógrada endoscópica, eliminándose así con éxito piedras comunes en el conducto biliar presentes en el 25% de los casos. Hubo cuatro conversiones a la colecistectomía abierta, como resultado de una anatomía oscura debido a cicatrizaciones y adhesiones. El tiempo de duración de la cirugía fluctuó de 70 a 150 minutos. Seis pacientes desarrollaron complicaciones postoperatorias, cuatro de ellos con síndrome torácico agudo. Como resultado de ello se produjo la muerte de un paciente. El período postoperatorio medio fue de 5.5 días. Este reporte indica que los pacientes con anemia falciforme continúan siendo un grupo de alto riesgo, con un potencial de morbilidad significativo, incluso cuando son sometidos a cirugía de mínimo acceso.

"Minimal intervention management" for gastroschisis: a preliminary report / "Tratamiento de Intervención Mínima" para la Gastroquisis Un Informe Preliminar

The replacement of eviscerated bowel, without anaesthesia, has been performed safely in stable neonates with gastroschisis. This technique, termed [quot ]minimal intervention management[quot ], was used in three infants treated at the Newborn Special Care Nursery of the University Hospital of the West Indies. Two infants had excellent results but one had bowel perforation during the procedure, necessitating conversion to formal laparotomy under general anaesthesia. In selected patients, advantages of this technique include the ability to be guided by patient response during the procedure in order to avoid excessive intra-abdominal tension, the avoidance of anaesthesia and minimal cost. This technique is proposed for wider use in developing countries

El reemplazo del intestino eviscerado, sin anestesia, se ha realizado de manera segura en neonatos estables con gastroquisis. Esta técnica, denominada "tratamiento de intervención mínima", se usó en tres infantes tratados en la Guardería de Cuidados Especiales del Recién Nacido en el Hospital Universitario de West Indies. Los resultados fueron excelentes en dos de los infantes, pero el tercero tuvo una perforación intestinal durante el procedimiento, por lo cual se hizo necesaria la conversión a la laparotomía formal bajo anestesia general. En pacientes seleccionados, esta técnica incluye entre sus ventajas la posibilidad de ser guiada por la respuesta del paciente durante el procedimiento, para prevenir así una tensión intra-abdominal excesiva, evitar la anestesia, y asegurar un costo mínimo. Se propone que el uso de esta técnica se haga extensivo en los países en vías de desarrollo.

Newborn circumcision using the Plastibell device: an audit of practice

Circumcision of newborn male infants is widely practiced but controversial. Our experience gained circumcising 205 Jamaican neonates, using the Plastibell device is presented. Circumcisions, were requested by parents usually for hygienic reasons, and were brief outpatient procedures. Subcutaneous penile ring block with 1 lidocaine provided the most effective form of procedural analgesia. Bell separation usually occurred within 10 days of the procedure. Cosmetic results met with unanimous parental acceptance. Minor complications occurred in 2.4 of circumcisions. Physicians circumcising newborns must be readily accessible post procedure to address parental concerns and allay anxiety

Angiomatosis of the breast in a male child. A case report with immunohistochemical analysis

Angiomatosis is a benign vascular lesion that has been described rarely in the breast. We describe a case in a seven-year-old boy of African descent who presented with progressively increasing, unilateral breast enlargement, the first such report in a male child. The patient underwent excisional biopsy of the breast mass followed by mastectomy. Pathologic examination revealed a diffuse proliferation of variably-sized, thin-walled vascular channels lined by flattened endothelium that showed negative immunohistochemical staining for von Willebrand factor, factor VIII-related antigen, CD34 and S-100 protein. There is no evidence of recurrence after 24 months of follow-up

Antenatal diagnosis of a choledochal cyst. Case management and literature review

Antenatal abdomino-pelvic ultrasound done on a 36-year-old woman at 19 weeks' gestation revealed a subhepatic cyst in the foetus. Postnatally, a type I choledochal cyst was confirmed in the newborn female infant. Biliary obstruction necessitated cyst excision and hepaticojejunostomy at age 16 days. We recommend early surgical intervention for neonates with choledochal cysts manifesting objective evidence of biliary obstruction. Non-obstructed patients are best explored later (> three months of age) when the risk of iatrogenic injury to the biliary tree and hepatic vessels is reduced.

Colonic lipomas at the University Hospital of the West Indies

Lipomas of the colon are uncommon but cause diagnostic difficulty when they are symptomatic. The clinical and pathological features of 17 cases of colonic lipomas diagnosed at the University Hospital of the West Indies between 1970 and 1999 are reported. Ten cases were symptomatic, two of these being diagnosed with adult intussusception. Six patients had incidental lipomas in bowel resected for other pathology while one lipoma was diagnosed on sigmoidoscopy. Increased awareness of these lesions will enhance pre-operative diagnostic accuracy.

Trauma aetiology and cost in the Accident and Emergency Unit of the University Hospital of the West Indies

Trauma accounted for 37of 22,311 patients seen in the Accident and Emergency Unit (A&E Unit) at the University Hospital of the West Indies (UHWI) during 1996. Thirty-nine per cent of injuries were intentional and 18were due to motor vehicle accidents. Knives, machetes and rocks accounted for 75of the injuries compared with 5for gunshot wounds. Passengers were injured in about 40of motor vehicle accidents and pedestrians in 19. The admission rate was 16and the orthopaedic clinic received 75of the patients referred to specialist clinics. Victims of motor vehicle accidents made up a greater proportion of admissions (24) than those of intentional violence (13). The average cost of caring for each patient in the A&E unit was US$70 resulting in an annual cost of US$578,000.

Necrotising enterocolitis: a management protocol for developing countries

28 cases of necrotising enterocolitis (NEC) comprising 11 term and 17 preterm patients were diagnosed between January 1990 and December 1995 at the University Hospital of the West Indies (UHWI). Treatment was in accordance with a management protocol which emphasised aggressive screening of potential cases, early laparotomy for bowel perforation and primary anastomosis after small bowel resection. There were three deaths among the 13 cases of bowel perforation. Centres in developing countries can achieve rates of survival comparable to those in the developed world in babies with NEC weighing over 1000 grams by adopting the UHWI management protocol.

Hydrostatic reduction of acute intussusception. A prospective study

Data were collected prospectively on 57 Jamaican children presenting with 62 episodes of acute intussusception over a two year period, for whom operative and hydrostatic methods of reduction were employed. 31 (54) of 57 episodes were reduced successfully using barium (42), saline (11) and air (4) hydrostatically. Among the 31 other episodes, 15 had ileo-colic intussusception, seven caeco-colic, six ileo-ileo-colic and one ileo-ileal. Two patients had spontaneous reduction discovered at surgery. There were two episodes of barium hydrostatic perforation of the colon leading to death in one patient. Hydrostatic reduction is recommended as the first therapeutic option for acute intussusception because it spares the patient a major operative procedure when successful.

Torsion of an intra-abdominal testicle in a neonate. Case report and review of the literature

The thirty-ninth reported case of torsion of an intra-abdominal testicle is described in a neonate. The gonad was excised as is recommended because of the high incidence of malignancy (60of 37 cases). Torsion of an intra-abdominal testicle should be considered where an abdominal mass with calcification is found in an infant with undescended testis. Ultrasonography improves the diagnostic accuracy in infants because of the cystic nature of these masses in this age group.