Ivermectin treatment of mansonellosis in Blanchisseuse, Trinidad, West Indies - abstract

The first double-blind-placebo field trial, using the drug ivermectin to control M. ozzardi microfilariae, was conducted in Blanchisseuse, North Trinidad. A preliminary trial indicated that there were no major constraints in administering the drug ivermectin within the community. In 16 patients before treatment, the microfilariae density ranged from 1 to 5,679 mf/ml, and the geometric mean was 697 mf/ml compared to 4 to 2,042 mf/ml and 362 mf/ml in the 14 patients given the placebo. Following treatment 87.5 percent (14/16) experienced side effects including fever and arthralgia (12 cases), myalgia (3 cases), headaches (11 cases) and chills (8 cases). All symptoms disappeared after 24 hours. Twenty-four hours after the ivermectin treatment the M. ozzardi microfilariae densities significantly (p < 0.001) declined to zero in 11 out of 16 cases (68.8 percent) while in 5 cases densities declined by > 95 percent. One week post-treatment there were no microfilariae observed in 93.8 percent (15/16) of cases, with one patient not attending the clinic. Blood samples collected 1 and 5 months after ivermectin treatment revealed M. ozzardi microfilariae in 3 patients. These 3 patients were re-treated with 6 mg of ivermectin, but two patients demonstrated persistent parasitaemias in subsequent blood samples. Within the placebo group, fluctuating levels of microfilariae were observed (AU)

Perinephric abscess mimicking fulminant hepatic failure

We describe a female diabetic patient who presented with features suggestive of hepatobiliary disease and who exhibited clinical signs of fulminant hepatic failure. Identification and drainage of a right perinephric abscess resulted in prompt resolution of both the physical signs and biochemical indices of liver disease. Infection remote from the hepatobiliary tree can mimic fulminant hepatic failure, and recognition of this unusual presentation of infection is important if dangerous delay in diagnosis and treatment is to avioded. (AU)

Complications of diverticulosis coli: the pattern of an emerging disease entity - abstract

The prevalence of diverticular disease of the colon in Trinidad is higher than in the other developing countries. A 46-month review yielded 52 cases with complications of the entity. Haemorrhage was the most common complication (65 percent) but required surgery in only 11.7 percent of cases. Acute diverticulitis and pericolic abscess accounted for 23 percent of the total and required surgery in 58 percent (7/12). There were 4 cases of colovesical fistula and 2 with chronic abdominal pain. The sigmoid colon was the most often affected segment of the large bowel. In the only case where bleeding was localized pre-operatively, the site was in the hepatic flexure. Sigmoid colectomy was the most frequently performed procedure (59 percent) with wound infection complicating 26 percent of the cases. Only one patient managed conservatively had recurring symptoms (2.8 percent). Conservative therapy appears to be the management of choice of this emerging disease entity (AU)

Familial colonic carcinoma: a study of three Trinidadian families - abstract

Familial occurrence of colorectal carcinoma in the absense of polyposis is an uncommon but well-documented entity. Although colonic carcinoma is relatively uncommon in the developing world, 3 families with clustering of this tumour have been identified in Trinidad. In this first reporat of familial colonic cancer from the West Indies, the families were (one each) of African, Chinese and East Indian origin. There was slight male predominance (M:F = 1.2:1). Early onset of the disease and poor prognosis were uniform features, with average age at death being 45.4 years. The right colonic involvement synchronously or metachronously occurred in the remainder. An aggressive policy of surveillance in affected members and screening in asymptomatic relatives should favourably alter the prognosis in such stricken families (AU)

Bacteriology of diabetic feet - abstract

In a prospective study of 203 patients with lwoer limb ulcers, there were 38 positive wound cultures. The total study group consisted of 124 diabetics and 79 non-diabetics. The vast majority of patients who were culture positive were diabetic (35/41, 85 percent) and only 3.7 percent (3/79) ofnon-diabetic ulcers were culture positive. In diabetics, polybacterial infections were most common, affecting over 90 percent of the cases. The most common pathogens were Pseudomonas (12), Klebsiella (13) and Proteus (10). Gram-positive organisms were present in 7 cases due to Staphylococci, and to Streptococci in 6 cases. The low culture rate was probably related to failure to culture anaerobic organisms and to prior antibiotic therapy. A follow-up study to include anaerobic cultures is planned, to better elucidate the bacteriology of this common surgical problem (AU)

Does surgery have to be expensive? - abstract

Because of increasing cost in health care, it was thought valuable to examine critically our current pratice of surgery with specific reference to measures that could result in cost reduction, while maintaining quality surgical care. Our study at Port-of-Spain General Hospital revealed that routine admission of minor head injuries results in necessary hospitalization and X-rays in over 1,000 patients per year. Review of routine chest X-ray and ECG in 1063 consecutive pre-operative cases showed that 95 percent of these indicated. Group and cross-matching of blood, though performed, was found to be unnecessary in 430 major, consecutive cases. In 2946 consecutive minor operations, an haemoglobin assay was found to be indicated in only 8 cases though it was done in all. Nasogastric tubes, urinary catheters and drains were found unnecessary in over 500 cases in one year. Vigilance in other areas such as use of I.V. fluids, I.V. drugs, antibiotics and wound dressings could significantly reduce health care cost. Attention must be paid to cost attainment if we are to continue to provide good care at affordable cost (AU)

Same day thyroidectomy - abstract

Thyroidectomy, to date, remains a procedure accompanied by a morbid fear of haemorrhage. This is translate in clinical practice with the routine use of drains and hospitalization for observation post-operatively. Following our favourable experience of performing thyroidectomy without drainage, we embarked on a trial of "same day thyroidectomy", where the patient is discharged home on recovery from anaesthesia. During the 5-year study (1982-1992), 41 thyroidectomies were performed for non-toxic goitre. These comprised 12 unilateral total lobectomies, 7 unilateral subtotal lobectomies, 14 bilateral subtotal lobectomies and 5 isthmic excisions. No drains were used and patients were allowed to leave on recovery from anaesthesia (average 6 hours). There were no cases haemorrhages or deaths, no wound infections, no haematomas and no cases of recurrent laryngeal nerve injury. Same day thyroidectomy is a safe and cost-effective procedure for non-toxic thyroid goitre (AU)

The profile of trauma presenting to an accident and emergency department in Trinidad - abstract

In a prospective 2-week survey of 4,041 consecutive admissions to the accident and emergency service at the Port-of-Spain General Hospital, 1,458 cases were related to trauma (36 percent). There were 964 males (66.1 percent) and 494 females (33.9 percent). The home was the most common site of trauma; 571 (39.2 percent) and (67 percent) of the injured were between the ages of 15 and 64 years. The total number of motor vehicle accidents was 201, of which 61 involved pedestrians (13.8 percent). Assault incurring blunt or penetrating trauma consisted of 293 cases (20 percent). The most common injury was related to the soft tissues (33 percent) contusion, abrasion, ligamentous strain; followed by lacerations (19.3 percent) and fractures (19 percent). Direct penetrating injuries accounted for only 35 cases (2.4 percent); 43.7 percent of patients had radiological and 3.4 percent had haematological investigations, compared withe 13 percent and 13.4 percent respectively of non-traumatic admissions. Ward admissions in the trauma and non-trauma groups were, however, similar (40 percent). This large database would be useful for future strategy, in the prevention and provision of emergency care in the West Indies (AU)

Rectus repair for midline ventral abdominal wall hernia

Recurrence-free repair of midline vntral abdominal wall hernia continues to elude surgeons, despite the abundance of described techniques. Based on the observation that spontaneous herniation through the rectus abdominis muscles is unknown, a new technique of repair was devised. The rectus muscles and their sheaths on either side of the hernial drfect are directly brought together to obliterate the hernia, the intervening linea alba and intact hernia sac being 'keeled' into the abdominal cavity. Using this technique, 85 consecutive midline abdominal hernias were repaired over an 11-year period. Follow-up was from 18 months to 12 years; there was one recurrence. The rectus repair is recommended as an effective method of dealing with ventral midline abdominal wall hernia (AU)

Surgery of the obstructed left colon without colonic lavage: a prospective study - abstract

Twenty-two consecutive patients with obstructing left colonic carcinoma underwent resection of the tumour and colocolic anastomosis, without intra-operative colonic lavage. There were two wound infections (9 per cent) but no anastomotic leaks or intra-abdominal abscesses. One death occurred 12 hours following surgery. At postmortem, the cause was attributed to myocardial infarction. The average duration of hospitalization was 8 days. Emergency surgery on the obstructed left colon can be safely carried out without intra-operative colonic lavage (AU)

Problem-based learning (PBL) at Mount Hope: the student's view - abstract

The new curriculum at the Mount Hope Medical School, Trinidad, has introduced many novel concepts in medical teaching in the Caribbean. The preclinical exposure has been increased to 3 years where problem-based learning (PBL) is employed and introduction to clinical skills is done in a skills laboratory rather than on the wards. Fewer lectures are given and more (applied) basic science education is imparted via PBL sessions where 6 to 8 students are assigned to a tutor. Students are exposed to 2 rather than 3 years' clinical experience on the wards. In order to assess the students' views of this curriculum, a questionnaire was designed and given to 62 students of the class of 1994 after they had completed their first clinical clerkship. Data from 41 (66 per cent) students were analysed, using a personal computer. Most students (82 per cent) preferred to shorten their preclinical exposure to 2 years or less, and felt they could learn the same amount of basic science in the time. They preferred to have more lectures (68 per cent) and to have more tutor participation in PBL sessions (80 per cent). All students felt learning clinical skills on the wards was far superior to developing these in the skills laboratory. In view of these findings, consideration should be given to reviewing the curriculum, and further studies should be done to continue assessment of curriculum changes (AU)

The in-patient profile of lower limb neurovascular disease in a Trinidadian population - abstract

Lower limb neurovascular disease is an extremely common problem in Trinidad, accounting for about 55 per cent of the surgical in-patient population. Because detailed information on the profile of these patients is not documented a prospective survey of lower limb disease was carried out among all patients admitted to 116 adult surgical beds over a 3-month period. A form was designed to collect demographic data, diagnosis, operations dressings, antibiotics and risk factors, and completed for each patient on admission and updated till discharge. Of a total of 203 patients with lower limb disease 7 with varicose vein as the underlying pathology were excluded. There were 100 males in the 196 cases and Afro-Trinidadians (75.5 per cent) were predominant over Indo-Trinidadians (21.4 per cent). Wet gangrene accounted for 36 per cent, other infections 30 per cent, non-healing ulcer 19 per cent, dry gangrene 9 per cent and rest pain 7 per cent. Trauma initiated 35 per cent of the septic lesions. Forty-two (21.4 per cent) patients had major amputations. Patients stayed in hospital for a long time (average 22.2 days), used dressings frequently (15.1 dressings per patient) and required considerable antibiotic medication (20.7 days). Diabetes mellitus was the commonest associated disease (63 per cent). Lower limb ischaemia and gangrene result in considerable cost to our medical institutions. Foot care especially in diabetics could reduce the incidence of these problems since trauma is often a precipitating factor (AU)

The rectus sheath block for post-operative pain: a medical intra-operative approach - abstract

This study was designed to test the hypothesis that if early post-operative pain is adequately controlled then subsequent analgesia would be more effectively maintained. An intraoperative rectus sheath block was designed in which about 20 cc of 0.5 per cent bupivacaine were infiltrated into the plane containing the segmental spinal nerves within the rectal sheath just prior to wound closure. Twenty-six adult patients undergoing abdominal surgery via a mid-line incision were randomly allocated to 2 groups which were matched for age, sex, type of procedure and size of patient. The control group of 10 patients received pethidine 100 mg/i.m. every 4 hours for the first 24 post-operative hours. The rectus sheath group of 16 patients, in addition to the rectus sheath block, also received pethidine 100 mg/i.m. every 4 hours for 24 hours post-operatively. Pain scoring was done at six hours and twenty-four hours post-operatively, using a verbal rating scale. Statistical analysis, using The Mann-Whitney U test at the 5 per cent level, showed that post-operative analgesia, using the rectus sheath block and intra muscular pethidine, was superior to that obtained by pethidine alone at both 6 and 24 hours post-operatively (AU)

Thyroid surgery without drainage: 15 years of clinical experience

Drainage in thyroid surgery has been a routine but empirical practice with no scientific evidence to support its benifit. The largest series to date of nondrainage in thyroid surgery is presented, comprising 260 patients over a 15-year perios. No case selection for non-drainage was employed. Two hundred and fifty-nine cases were not drained and included toxic goitres, and bilateral and redo procedures. There was one thyroid storm and two cases of subcantaneous fluid collection, treated by needle aspiration. No cases of recurrent laryngeal nerve injury, airway obstruction or death were recorded. This study strongly demonstrates the safety of non-drainage in routine thyroid surgery (AU)

Peripartum cardiomyopathy and arterial embolism

A severely pre-eclamptic patient developed peripartum cardiomyopathy and bilateral femmoral emboli. Medical therapy for cardiac failure was commenced prior to delivery by caesarean section. Bilateral femoral embolectomy was performed on the sixth postpartum day. (AU)

The impact of the ATLS course on traffic accident mortality in Trinidad and Tobago

Advanced Trauma Life Support (ATLS) training of medical staff did not improve outcome of the trauma victim. Potential benefit of this course may have been masked by weak links in the trauma care chain such as pre-hospital care and in hospital investigative and therapeutic facilities. (AU)

Sphincter saving procedures in low rectal cancer - abstract

Radical resection for rectal cancer has not improved survival over the past 50 years, and leaves the patient with the permanent burden of a colostomy. Methods of sphincter conservation, evolved over the past decade, achieve the same level of control of disease locally and do not impair survival. In view of this, a policy of sphincter conservation was prospectively adopted since 1983 for low rectal tumours: 33 consecutive cases were managed, of which 12 had local excision; 9 abdomino-anal pull through and 12 low anterior resections were performed. There were 2 local recurrences treated by abdomino-perineal resection and one anastomotic leak which healed with stricture formation. One patient had persistent mild faecal soiling. Sphincter conservation is safe and effective, and should be considered the treatment of choice in the management of low rectal cancer (AU)