Operation Open Heart in PNG, 1993-2006.

OBJECTIVE: To report on the 'Operation Open Heart' (OOH) cardiac surgical program in Papua New Guinea (PNG). To document the short-term surgical outcome, the experience gained and the skill transfer from the visiting team members to their PNG counterparts. METHODOLOGY: Analysis of the database compiled from the records of the patients who were operated on by the visiting cardiothoracic surgical team. RESULTS: Four hundred and seventy patients from all regions of the country received operations. Three hundred and thirty seven (72%) were children less than 12 years of age, 39 (8%) were between 12 and 18 years of age and 263 (56%) were females. One hundred and eighty five (40%) patients had open heart procedures. Complications were unremarkable and the short-term mortality was 1.9%. Clinical skills were transferred to, and experience was gained by national anaesthetists, surgeons, paediatricians, physicians and nurses from intensive and full nursing care units and the operating theatre. CONCLUSIONS: The program not only achieved a higher annual operation rate than previous programs but also had a lower mortality rate. It achieved its objective of service delivery and, to a considerable extent, its objective of skill transfer. There now is an established and active group of PNG doctors and nurses with the skills, experience and confidence to perform patent ductus repair safely and efficiently. The program is cheaper than its predecessors, and is less disruptive for parents, patients and families.

Superior orbital fissure syndrome in a latent type 2 diabetic patient.

Although isolated cranial nerve palsies are common in diabetic patients, multiple, simultaneous cranial neuropathies are rare. We describe the second case of a complete superior orbital fissure syndrome including the optic nerve in a middle-aged Papuan man with newly diagnosed diabetes mellitus. The differential diagnosis included septic cavernous sinus thrombosis and Tolosa Hunt syndrome, and management was initially directed at excluding these serious, treatable conditions.

Cryptococcus neoformans in Papua New Guinea: a common pathogen but an elusive source.

Around Port Moresby, Papua New Guinea (PNG), the annual incidence of cryptococcal meningitis is estimated to be up to 42.8 per million population; Cryptococcus neoformans var. gattii is the predominant causative agent. In Australia and California, environmental isolations have established an ecological association of C. neoformans var. gattii with Eucalyptus camaldulensis, E. tereticornis, and more recently E. rudis and E. gomphcephala. In PNG few E. camaldulensis survive experimental planting, E. tereticornis is endemic and there are no records of planting of the non-endemic E. rudis and E. gomphcephela. Despite extensive sampling of eucalypt-associated and other sources, we were unable to identify the ecological niche of C. neoformans var. gattii and neoformans in this region.

Electrophysiological findings in patients envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni).

Electrophysiological studies were done on patients with systemic neurotoxicity following the bite of a Papuan taipan (Oxyuranus scutellatus canni). Evoked compound muscle action potentials decreased and increased in tandem with clinical deterioration and recovery. Nerve conduction velocities did not change in envenomed patients and were consistent with control studies. Repetitive nerve stimulation studies showed decremental responses in envenomed patients with post-tetanic potentiation followed by post-tetanic exhaustion. The findings are consistent with studies in vitro which suggested that the major action of neurotoxins in Australian taipan venom is at the synapse. The observation that electrophysiological data correlate closely with the clinical condition of the patient has potential application in the assessment of interventions in the management of snake bite victims.

Failure of 3,4-diaminopyridine and edrophonium to produce significant clinical benefit in neurotoxicity following the bite of Papuan taipan (Oxyuranus scutellatus canni).

Progressive systemic neurotoxicity is a common feature in patients envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni). Respiratory paralysis, which commonly results, accounts for considerable morbidity and mortality. Established neurotoxicity does not respond to antivenom. In this study, a combination of clinical and electrophysiological variables was used to assess the effect of edrophonium and 3,4-diaminopyridine in patients with significant neurotoxicity. Both drugs produced minor electrophysiological and clinical changes in envenomed patients. This effect was maximal when the 2 drugs were used in combination, but was insufficient to be of significant clinical benefit. Neither drug can be recommended for use in the management of Papuan taipan bite.

The efficacy of antivenom in the treatment of bites by the Papuan taipan (Oxyuranus scutellatus canni).

A prospective series of 156 patients systemically envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni) were studied. All patients were treated with appropriate antivenom and clinical course and outcome were compared. The proportion of patients requiring intubation was significantly smaller, and the time to resolution of neurotoxicity and discharge from hospital significantly shorter, in patients receiving antivenom no more than 4 h after the bite. No significant difference in outcome was demonstrated between patients receiving antivenom at various times after 4 h. No difference was demonstrated in the times to restoration of coagulability between the 2 groups. The only significant difference between a small number of patients given 2 vials of antivenom and patients given a single vial at the same time after envenoming was a marginally shorter duration of intubation in those who required it. The study suggests that, to achieve significant clinical benefit in Papuan taipan bite, antivenom must be given as early as possible.

Analysis of referral letters to assess the management of poisonous snake bite in rural Papua New Guinea.

A prospective series of patients envenomed after snake bite was seen at Port Moresby General Hospital (PMGH), Papua New Guinea, between January 1991 and December 1992. Referral letters were received with 60 of the patients who had been initially seen at a health centre. These letters were analysed in conjunction with our own clinical observations. The importance of non-clotting blood and local lymphadenopathy as early signs of systemic poisoning did not appear to be universally recognized by staff in health centres. In some cases, no attempt was made to transfer the patient to hospital until signs of neurotoxicity were established with potentially dangerous delay. Analysis of both hospital and health centre records suggests that the majority of deaths which occurred in Central Province, Papua New Guinea, during the period of the study were due to delay in transfer to hospital. We suggest that all patients with unequivocal signs of envenoming in Central Province, Papua New Guinea, should be transferred to PMGH as soon as possible. Antivenom should also be given as soon as possible, but this does not remove the need for immediate transfer.

Ataxia in patients infected with Salmonella typhi phage type D2: clinical, biochemical and immunohistochemical studies.

Reversible cerebellar dysfunction has been described in association with typhoid fever by a number of authors. Ataxia and tremors are relatively common manifestations of typhoid fever in Papua New Guinea. A series of 14 patients with typhoid fever and ataxia was compared with non-ataxic typhoid patients. Hyponatraemia and hypoalbuminaemia were common in both groups and more severe in the ataxic group. Hypotension was also more common in the ataxic group. These features may reflect more severe disease. All isolates of Salmonella typhi, from both ataxic and non-ataxic patients, were phage type D2 which is endemic around Port Moresby. Tests for autoantibodies cross-reacting with cerebellar tissue were negative. It is possible that cerebellar dysfunction in typhoid fever is more common in association with phage type D2.

Clinical documentation of twenty cases of acute myocardial infarction in Papua New Guineans.

As predicted, coronary artery disease is being recognized with increasing frequency in the town hospitals in Papua New Guinea. This report contains the clinical characteristics of 20 patients with acute myocardial infarction admitted to the Port Moresby General Hospital. The clinical features of acute myocardial infarction were typical of the disease anywhere. The seemingly rare frequency of angina of effort in this group of patients is an interesting observation. The high in-hospital case fatality rate observed here is alarming. Urban dwelling, the male gender, smoking and diabetes were important risk factors in the development of this disease in these patients.

Coronary artery surgery in an indigenous Papua New Guinean male.

The first case of coronary artery surgery in an indigenous Papua New Guinean male subject is described. A 42-year-old male with multiple risk factors developed two episodes of myocardial infarction. Coronary arteriography demonstrated severe obstructive disease in all three coronary arteries with moderate left ventricular dysfunction. Prognostic coronary revascularization was performed, with placement of four bypass grafts with six distal anastomoses. Recovery was largely uncomplicated. Maximal exercise test 6 months postoperatively showed normal exercise capacity with no evidence of ischaemia. He is pursuing an intensive program of risk factor management.

Intentional chloroquine overdosage.

Twenty-six episodes of intentional chloroquine overdosage are documented. The over-all mortality rate of 19%, and 50% incidence of cardiac arrest for ingestion of 2.25 g or more of chloroquine base indicate the risk of overdosage. Life-threatening cardiac arrhythmias may be the first sign of overdosage. However, gastrointestinal and neurological symptoms generally precede this sign. Early recognition and attempts to decrease drug uptake are important as current therapy after absorption of the drug is inadequate.