Gastrointestinal perforation caused by obstruction in Trinidadian neonates.

A review was conducted of neonates treated over a 7-year period for gastrointestinal tract perforation secondary to obstruction, for comparison with previous reports. Demographic and clinical characteristics, results of laboratory studies, underlying diagnoses, surgical treatment, and outcomes were studied. Only 1 of the 6 babies was premature. The underlying cause of obstruction was Hirschsprung's disease (HD) twice, duodenal, sigmoid, and rectal atresia, and malrotation with midgut volvulus, once each. The perforation was located in the stomach in two cases, the jejunum in one case, and the large bowel in 3 children. There were no fatalities. Unusual features were that both gastric perforations were secondary to duodenal obstruction, and only 1 infant was premature. The jejunum was affected once, secondary to HD of the descending colon. In contrast to previous reports, there were no perforations of the ileum caused by intestinal obstruction in this neonatal population during the period reviewed.

Congenital intrinsic intestinal obstruction in a Caribbean country.

This study was undertaken to evaluate the clinical characteristics, perioperative features, and outcome of congenital intrinsic intestinal obstruction in a developing Caribbean country for comparison with previous literature reports. This study included retrospective data collection on all infants referred to the hospital with a diagnosis of congenital intrinsic bowel obstruction during the period 1999-2006. Data studied were demographic features, perioperative details, surgical procedures performed, postoperative course, and early outcome. Twenty-two infants were treated, with an incidence of 3.14 per 10,000 live births. Duodenal outnumbered jejuno-ileal lesions by 1.5 to 1. Complications occurred in 68.2% of cases, and the mortality rate was 27.3%. Lower gestational age, a high leukocyte count, and more distal small bowel obstruction were significantly associated with mortality. Improvement in the outcome of surgical treatment of this problem in this population requires more effective perioperative management of prematurity and sepsis.

A comparative study of different methods of orchidometry in a canine model.

PURPOSE: An investigation was carried out to compare the testicular volumes obtained by different methods of assessment in a series of dogs. METHOD: After obtaining ethical approval for the study, ten dogs were identified which were scheduled for castration, either at the owner's request or prior to being placed in suitable homes. A Prader orchidometer, which consists of a series of ovoid model testes inscribed with corresponding equivalent volumes, was used as an indirect method of assessing the volume of each testis. Percutaneous measurements of length and width of each testis were also carried out prior to surgery under general anaesthesia, using both a sliding and a pinch type caliper. After each testis was removed it was isolated and submerged in a beaker containing water in order to get a direct estimate of its volume by fluid displacement. Using the formula for deriving the volume of an ellipsoid from length and weight measurements, the volumes derived from the caliper measurements were estimated and compared with the orchidometer and fluid displacement values. Pearson correlation coefficients were calculated to obtain the correlations between the values produced by the four methods. RESULTS: The Prader orchidometer and the pinch type caliper both showed significant correlations, of 0.64 and 0.62 respectively, with the definitive values obtained by fluid displacement. The correlation obtained with the sliding caliper (0.4) was not significant. Despite the significant correlations, all the indirect methods consistently overestimated the real volumes obtained by fluid displacement. CONCLUSION: Estimates of testicular volumes obtained by orchidometer and pinch type caliper are useful for situations where a qualitative rather than quantitative assessment of testicular volume is required.

Intravesical tube knot in a neonate: a case report

Catheterization of the neonate urethra may be required to relieve urinary retention, monitor fluid balance, or obtain access for radiological studies, or a urine specimen for culture when sepsis is suspected. The small calibred male urethra may resist the introduction of a standard catheter and an infant feeding tube, which is generally narrower and more flexible, is frequently used as a substitute. Complications attending this practice include trauma during insertion and subsequent haematuria. Acutal knotting of the tube within the bladder is rare, and its subsequent removal may pose a major challenge. We were recently presented with this problem and thought it would be useful to present the implications and management of such a situation (AU)

The relationship of magnesium intake to serum and urinary calcium and magnesium levels in Trinidadian stone formers.

BACKGROUND: The present study was undertaken to investigate the relationship between the dietary intake of magnesium and the serum and urinary levels of calcium and magnesium in a group of Trinidadian stone formers. METHODS: A group of 102 confirmed stone formers presenting to urological clinics were interviewed using a questionnaire designed to obtain a semi-quantitative estimate of their oral magnesium intake. Patients were invited to give blood samples for serum calcium and magnesium levels and to provide 24-h urine specimens for the measurement of urinary levels of these minerals, as well as total urinary volumes. A group of 102 controls was subjected to a similar interview and blood and urinary testing. Chi-square tests and Student's t-tests were used to examine group demographic differences. The Mann-Whitney test investigated differences in biochemical indices. Binary logistic regression was used to identify predictors of stone formation. RESULTS: Blood samples were obtained from 60 patients and 98 controls. Urine samples were returned by 34 patients and 97 controls. Only 10 stones were retrieved from patients. Patients had a significantly lower magnesium intake, but higher median serum and urinary calcium levels, and higher serum calcium to magnesium ratios than controls. Independent variables capable of predicting stone formation included total magnesium intake and serum and urinary calcium levels. CONCLUSIONS: Increased serum and urinary calcium levels, calcium to magnesium ratios, and a low magnesium intake were predictive of stone formation in this Trinidadian population.

The relationship of magnesium intake to serum and urinary calcium and magnesium levels in Trinidadian stone formers

BACKGROUND:  The present study was undertaken to investigate the relationship between the dietary intake of magnesium and the serum and urinary levels of calcium and magnesium in a group of Trinidadian stone formers. METHODS:  A group of 102 confirmed stone formers presenting to urological clinics were interviewed using a questionnaire designed to obtain a semi-quantitative estimate of their oral magnesium intake. Patients were invited to give blood samples for serum calcium and magnesium levels and to provide 24-h urine specimens for the measurement of urinary levels of these minerals, as well as total urinary volumes. A group of 102 controls was subjected to a similar interview and blood and urinary testing. Chi-square tests and Student's t-tests were used to examine group demographic differences. The Mann–Whitney test investigated differences in biochemical indices. Binary logistic regression was used to identify predictors of stone formation. RESULTS:  Blood samples were obtained from 60 patients and 98 controls. Urine samples were returned by 34 patients and 97 controls. Only 10 stones were retrieved from patients. Patients had a significantly lower magnesium intake, but higher median serum and urinary calcium levels, and higher serum calcium to magnesium ratios than controls. Independent variables capable of predicting stone formation included total magnesium intake and serum and urinary calcium levels. CONCLUSIONS:  Increased serum and urinary calcium levels, calcium to magnesium ratios, and a low magnesium intake were predictive of stone formation in this Trinidadian population.

Risk factors for urinary tract calculi in Trinidad.

OBJECTIVE: To identify risk factors for urinary tract stones in Trinidad and Tobago. METHODS: A consecutive series of patients presenting to institutions in Trinidad for the management of proven urinary tract calculi was interviewed by questionnaires designed to obtain data on age, gender, ethnicity, occupation, stone location, a family history of stone disease, a past history of certain medical diseases and a semiquantitative estimate of the magnesium intake in food, 'over the counter' drugs and drinking water. An equivalent number of patients attending the same institutions for follow-up and verified from hospital records as having a previous radiological diagnosis of urinary tract stones, as well as a group of asymptomatic members of the community working in the same area, underwent the same interview. Chi-square, anova and Kruskal-Wallis tests were used to examine differences between the groups. Multiple logistic regression analysis was used to determine persistence of the significance of these differences after controlling for confounding variables. RESULTS: Data sufficient for analysis were obtained for 122 previous and 102 prospective patients and 102 controls. The mean age of the patients was 32 years. The ratio of males to females was 0.9-1.8:1 for the affected groups, but significantly more males than females had calculi in the lower urinary tract (19%vs. 6%; P = 0.004). More patients (30%) than controls (7%) gave a positive family history of urinary tract stone disease (P < 0.001). Affected persons had a lower dietary magnesium intake (P = 0.003), which accounted for a significantly lower total magnesium intake (P = 0.02). Logistic regression analysis of the variables studied indicated that independent predictors of the disease were a positive family history (P = 0.001), total magnesium intake (P = 0.001) and age (P < 0.001). CONCLUSION: A low magnesium intake and a positive family history are highly predictive of urinary tract calculi in this population.

Risk factors for urinary tract calculi in Trinidad

OBJECTIVE: To identify risk factors for urinary tract stones in Trinidad and Tobago. METHODS: A consecutive series of patients presenting to institutions in Trinidad for the management of proven urinary tract calculi was interviewed by questionnaires designed to obtain data on age, gender, ethnicity, occupation, stone location, a family history of stone disease, a past history of certain medical diseases and a semiquantitative estimate of the magnesium intake in food, 'over the counter' drugs and drinking water. An equivalent number of patients attending the same institutions for follow-up and verified from hospital records as having a previous radiological diagnosis of urinary tract stones, as well as a group of asymptomatic members of the community working in the same area, underwent the same interview. Chi-square, anova and Kruskal-Wallis tests were used to examine differences between the groups. Multiple logistic regression analysis was used to determine persistence of the significance of these differences after controlling for confounding variables. RESULTS: Data sufficient for analysis were obtained for 122 previous and 102 prospective patients and 102 controls. The mean age of the patients was 32 years. The ratio of males to females was 0.9-1.8:1 for the affected groups, but significantly more males than females had calculi in the lower urinary tract (19% vs. 6%; P = 0.004). More patients (30%) than controls (7%) gave a positive family history of urinary tract stone disease (P < 0.001). Affected persons had a lower dietary magnesium intake (P = 0.003), which accounted for a significantly lower total magnesium intake (P = 0.02). Logistic regression analysis of the variables studied indicated that independent predictors of the disease were a positive family history (P = 0.001), total magnesium intake (P = 0.001) and age (P < 0.001). CONCLUSION: A low magnesium intake and a positive family history are highly predictive of urinary tract calculi in this population

Trial of three methods of introperative bupivacaine analgesia for pain after paediatric groin surgery

To evaluate the relative effectiveness of three techniques of regional anaesthesia in the provision of postoperative analgesia in children. Methods: Random assignment of 183 children scheduled for groin surgery to one of three groups. Bupivacaine 0.5 percent plain (2 mg.kgˉ) was injected by the surgeon after skin incision. Group A received wound infiltration. Group B had regional nerve blockade. Group C had a combination of both methods. Post-operatively, pain was assessed using the CHEOPS behavioral scale at half-hourly intervals until discharge home. Satisfactory pain control was arbitrarily defined as CHEOPS score of ≤ six. Potential differences among the groups were sought using graphical presentation of mean pain scores, the frequencies of pain scores, and the incidence of postoperative vomiting and oral analgesic consumption. Results: Fifteen patients had to be excluded from analysis. This left 61 patients in Group A, 55 in Group B and 52 in Group C. There were no demographic differences among the groups. No differences were demonstrated among the groups either in CHEOPS pain scores at any observation point (P = >0.8), or in the incidence of vomiting or need for postoperative analgesia. (P = 0.52 and P = 0.41 respectively). Overall, 80 percent of the observations made (1135/1425) met our definition of satisfactory pain control. A post hoc calculation of the power of the study confirmed sufficient power to detect a 5 percent difference among groups. Conclusion: All three methods achieved analgesia with 80 percent of the pain scores meeting our definition of satisfactory pain control. None of the techniques enjoyed any apparent advantage (AU)

A scoring system for use in the diagnosis of acute abdominal pain in childhood

A statistical analysis was undertaken of 1158 children admitted to a surgical ward for the management of acute abdominal pain. Over two-thirds (40 percent) of the children had non-specific abdominal pain while 29.7 percent had appendicitis. The remainder were found to have had urinary tract infections (11.7 percent), constipation (7.5 percent), gastroenteritis (5.8 percent) or intussusception (5.3 percent). A stepwise discriminant analysis of the data collected during their evaluation was performed, using the BMDP statistical software package. Demographic and clinical features, as well as the results of ancillary investigations, were included in the data. The programme generated a classification function of a sub-set of 18 variables which best discriminated among the diagnostic groups. The coefficients of the classification functions were then combined with the rank order of selection of the variables to derive a scoring method for predicting the diagnosis. The results of urine culture were excluded since these would be unavailable during early clinical assessment. The scores for the diagnostic groups fell within the following ranges: - 1 - 23 non-specific abdominal pain; 20 - 48 appendicitis; 35 - 84 gastroenteritis; 75 - 88 constipation and 89 - 140 intussusception. It is suggested that this scoring method be evaluated by a prospective study to test its validity

Intracardiac extension of a Wilms' tumour

A case report is presented of a Wilms' tumour in a three-year-old child. Direct intravascular extension into the heart led to a fatal outcome. Though a rare complication, clinical suspicion, combined with appropriated investigation and management, should lead to salvage of such a patient

Intracardiac extension of a Wilms' tumour

A case report is presented of a Wilms' tumour in a three-year-old child. Direct intravascular extension into the heart led to a fatal outcome. Though a rare complication, clinical suspicion, combined with appropriated investigation and management, should lead to salvage of such a patient (AU)

A scoring system for use in the diagnosis of acute abdominal pain in childhood

A statistical analysis was undertaken of 1158 children admitted to a surgical ward for the management of acute abdominal pain. Over two-thirds (40 percent) of the children had non-specific abdominal pain while 29.7 percent had appendicitis. The remainder were found to have had urinary tract infections (11.7 percent), constipation (7.5 percent), gastroenteritis (5.8 percent) or intussusception (5.3 percent). A stepwise discriminant analysis of the data collected during their evaluation was performed, using the BMDP statistical software package. Demographic and clinical features, as well as the results of ancillary investigations, were included in the data. The programme generated a classification function of a sub-set of 18 variables which best discriminated among the diagnostic groups. The coefficients of the classification functions were then combined with the rank order of selection of the variables to derive a scoring method for predicting the diagnosis. The results of urine culture were excluded since these would be unavailable during early clinical assessment. The scores for the diagnostic groups fell within the following ranges: - 1 - 23 non-specific abdominal pain; 20 - 48 appendicitis; 35 - 84 gastroenteritis; 75 - 88 constipation and 89 - 140 intussusception. It is suggested that this scoring method be evaluated by a prospective study to test its validity (AU)

A multivariate analysis of childhood abdominal pain in Trinidad

This is a multivariate anaylysis of the data recorded in assessing 1158 consecutive admissions presenting to a children's surgical ward with acute abdominal pain. There were 56 binary variables available for entry into the analysis. A statistical software package was used to perform a stepwise discriminant analysis on the data. The program selected 18 variables as having discriminating power in assigning patients to the six diagnostic groups. In order of discriminating power these were, mainly, a positive urine culture, the bowel history, the findings on rectal examination, the location of abdominal tenderness, the presence of a mass, and the white cell count. Lesser discriminating potential was assigned to the presence of dehydration; fluid levels on erect abdominal films, a rise in temperature, an increased pulse rate, the presence of urinary symptoms, and the general appearance of the child. Use of these data led to an overall correct classification of 80.7 percent of cases. It is concluded that these variables should be included in the assessment of children with acute abdominal pain (AU)

Soft tissue infection in children in south Trinidad

A review of 391 children in the first decade of life admitted to surgical ward with soft tissue infectious revealed predisposing factors in 34.8 per cent of cases, mainly trauma and adjacent skin sepsis. Superficial abscess formation occurred in 90 per cent of cases, muscle abscess in 9.4 per cent, and necrotizing fascitis in less than 1 per cent. The most requent organism isolated was the staphylococcus aureus which was found in 52.8 per cent of the available cultures. Coliform organisms were found in 14.6 per cent, and haemplytic streptococci in just over 10 per cent. A study of the culture and sensitivity profiles obtained made it possible to formulate a programme for the empirical treatment of soft tissue infections based on the region of the body involved. (AU)

Wilm's Tumour in a horseshoe kidney

Wilms'tumor (nephroblastoma) is a common childhood tumour, with a reported annual incidence in the United States of 7.8 cases per million of population aged one to 14 years. Horseshoe-shaped kidney is a congenital malformation with a recognized risk of complications, yet an associated nephroblastic is exceeding rare. A case of this simultaneous but unsuspected occurrence of a Wilms' tumour co-existing within a horseshoe kidney, and diagnostic dilemma encountered is presented. (Au)

The pattern of gastro-intestinal obstruction in Trinidadian children

A review is presented of 156 children admitted to hospital with gastro-intestinal obstruction. The common underlying causes were obstructed hernia (46.8 percent), intussusception (23.7 percent) and pyloric stenosis (16 percent) of cases. There was a marked male proponderance in each of these three groups, and the predominance of patients of African extraction in the hernia group reached 100 percent when the hernia was umbilical. Well-known observations in children with obstructed inguinal hernias which were confirmed were a right-sided prediliction, and a tendency for tecurrent obstruction in the absence of early repair. All of the patients with intussusception were under the age of one year, and this was associated with an unusually low incidence of discomfort or irritability as a presenting complaint, and a paucity of anatomical lead points. Fifteen bowel resections were required in 14 children, seven for gangrenous or irreducible intussusceptions. There were nine fatalities, four in the group with intussusception, and the details of these suggest that all fatalities could be eliminated with improvements in respiratory care, and pre-and intra-operative management (AU)

A survey of children with burns in South Trinidad

A review is presented of 392 children under the age of ten years admitted to a paediatric surgical ward for the management of injuries sustained from burns. The majority of these admissions were due to scalds, but flash/flame burns were responsible for a significant number of cases and were also associated with a more severe type of injury. Improvement in the management of this problem awaits better education of the general public in preventive and first aid measures, but there is also a clear indication that the more severely burnt children would benefit from treatment in a specialised unit for burnt patients (AU)

Retroperitoneal teratoma in an infant

A case of retroperitoneal teratoma occurring in a ten-month-old infant is presented. Though rare, this tumour occasionally presents useful diagnostic features on simple investigations as illustrated in this report. Better overall management and improved investigatives techniques are likely to maintain favourable trends in prognosis (AU)