Robotic Repair of an Acquired Abdominal Intercostal Hernia.

Introduction: Intercostal hernias are a rare clinical entity. They are divided into trans-diaphragmatic intercostal or abdominal intercostal hernias based upon the presence or absence of diaphragmatic injury. There are various means of repair for these hernias, including open, laparoscopic, and robotic approaches. We present the second known robotic repair of an abdominal intercostal hernia and review of the relevant literature. Case Description: A 54-year-old morbidly obese male was found to have an abdominal intercostal hernia on the right between the 9th and 10th ribs. His symptoms were significant for a large, tender right chest wall mass. Through a three-port approach, polypropylene mesh and circumferential sutures were used to create a double-wall of reinforcement to secure the area of weakness. Discussion: This rare case of an intercostal hernia utilized robotic-assisted laparoscopic repair and led to a favorable outcome, whereby the patient reported significant improvement in pain, comfort, and quality of life. Thus, minimally invasive robotic surgery for this complex structural pathology can be safer and have less complications than other current treatments.

Treating sepsis with vitamin C, thiamine, and hydrocortisone: Exploring the quest for the magic elixir.

The administration of ascorbic acid (vitamin C) alone or in combination with thiamine (vitamin B1) and corticosteroids (VCTS) has recently been hypothesized to improve hemodynamics, end-organ function, and may even increase survival in critically ill patients. There are several clinical studies that have investigated the use of vitamin C alone or VCTS in patients with sepsis and septic shock or are ongoing. Some of these studies have demonstrated its safety and potential benefit in septic patients. However, many questions remain regarding the optimal dosing regimens and plasma concentrations, timing of administration, and adverse effects of vitamin C and thiamine. These questions exist because the bulk of research regarding the efficacy of vitamin C alone or in combination with thiamine and corticosteroids in sepsis is limited to a few randomized controlled trials, retrospective before-and-after studies, and case reports. Thus, although the underlying rationale and mechanistic pathways of vitamin C and thiamine in sepsis have been well described, the clinical impact of the VCTS regimen is complex and remains to be determined. This review aims to explore the current evidence and potential benefits and adverse effects of the VCTS regimen for the treatment of sepsis.

Neonatal septicemia.

Full text is available as a scanned copy of the original print version.

Neonatal septicemia.

Full text is available as a scanned copy of the original print version.

Cerebro-spinal lactate status in childhood pyogenic meningitis in Nigeria.

This study was undertaken to ascertain the status of cerebrospinal (CSF) lactate level in Nigerian children with pyogenic meningitis. Forty patients aged from 1 month to 12 years with proven meningitis were the subjects in the study which lasted 8 months. All the patients who had pyogenic meningitis had mean cerebrospinal lactate level over 25 mg/dl. The patients who recovered with neurological deficit had higher level of cerebrospinal lactate than those who recovered without any neurological deficit, on admission and on-discharge, although the differences were not statistically significant. The patients who died had persistently high mean CSF lactate on admission and at death. The study suggests that persistently elevated CSF lactate in cases of pyogenic meningitis receiving adequate antibiotic therapy might indicate poor prognosis with increased mortality. It is not being suggested that CSF lactate determination should replace the conventional tests for meningitis. However, it can provide pertinent, rapid, and reliable diagnostic information, and can also provide useful evaluation information at different stages of treatment of proven meningitis with appropriate antibiotics.

Cerebrospinal fluid/serum lactic acid in Nigerian children with febrile convulsions.

Cerebrospinal fluid (CSF) and serum lactic acid levels were prospectively assayed in 42 children less than 5 years old with febrile convulsions who were divided into two groups for analytical purposes, irrespective of aetiology of pyrexia. One group (24 children) had brief febrile seizures and the remaining 18 children had prolonged febrile seizures. CSF and serum lactic acid values were obtained for brief and prolonged seizures. On admission, the mean CSF lactic acid was significantly higher (p < 0.05) in children with prolonged than with brief seizures, but the mean serum lactic acid was not significantly different between the two groups. Twelve of the 18 children (67%) with prolonged seizures and elevated CSF lactate had seizure recurrence. There were no recurrences of seizures in children with a brief initial seizure and low CSF lactate. CSF lactic acid is elevated in children with prolonged seizures and this may be useful in detecting those with a prolonged seizure where the history of the duration of the seizure is not clear. Prolonged seizure has been associated with the risk of recurrence and therefore such children with elevated CSF lactic acid levels might benefit from long-term anticonvulsant therapy.

Childhood febrile seizures (Benin City experience).

About 20% of children admitted during the study period had febrile convulsions, of which 5% were aged below 5 months or above 5 years. The study confirms the view that there is a strong familial predisposition in febrile seizures. Major causes of the rise in temperature in those studied included malaria, which accounted for 32.7%, followed by bronchopneumonia (16.8%), measles (15.4%), otitis media (13.4%) and tonsillitis (10.5%). The morbidity and mortality could be attributable to the socio-cultural background of the community which practices modes of therapy that are often detrimental to the health of patients.

PIP: A febrile convulsion is a generalized seizure occurring during a febrile illness whose cause is extracranial. Most scholars agree that strong evidence exists of familial predisposition to febrile seizures. The events are more common among men, with the pattern of such convulsions in Europe and North America apparently different from that in Africa. The authors report their findings from an examination of the pattern of febrile seizures at the Children's Emergency Room of the University of Benin Teaching Hospital in Benin City, Nigeria. 1046 children were admitted over the course of the study conducted January-September, 1988. Seven of the 202 patients with febrile convulsions died, five from aspiration pneumonia and two from tetanus following traditional treatment. 5% of patients with febrile convulsions were younger than 5 months or older than 5 years. The male:female ratio was 1.3:1. 140 children had a family history of febrile convulsion; in 55% the relative was a close family member. The authors point out that the number of families with a positive history of febrile convulsions may have been underreported because the average Nigerian family is loathe to admit that any member suffers from a socially stigmatized illness. These findings confirm the view that a strong familial predisposition exists for febrile seizures. Major causes of the rise in temperature in those studied included malaria, which accounted for 32.7%, followed by bronchopneumonia among 16.8%, measles at 15.4%, otitis media at 13.4%, and tonsillitis at 10.5%. Observed morbidity and mortality could be attributed to the sociocultural background of this community which practices modes of therapy which are often detrimental to patient health.

Cerebrospinal fluid/serum lactic acid in febrile convulsions.

Cerebrospinal fluid/serum lactic acid was prospectively assayed in 42 patients with febrile convulsions. Patients were divided into two groups for analytical purposes. Those with brief febrile seizures (30 patients) and the remaining 12 patients had prolonged febrile seizures. CSF and serum lactic acid values were within normal range in patients with brief seizures while elevated values were obtained in patients with prolonged seizures. The mean CSF lactic acid on admission was significantly higher (P less than 0.001) in patients with prolonged seizures than corresponding values in those with brief seizures. Mean serum lactic acid on admission was also significantly higher in patients with prolonged febrile seizures compared to the corresponding mean value in patients with brief seizures (P greater than 0.001). Patients who recovered with neurological deficits had significantly higher CSF lactic acid on admission (P greater than 0.001). Similarly 8 patients who had recurrent febrile convulsions had significantly higher CSF lactate on admission. It is suggested that measurement of CSF lactate can be used as a biochemical marker to identify children with prolonged seizures and those who are likely to have recurrent febrile seizures.

Tissue damage in sickle cell disease as assessed by serum acid phosphatase.

The extent of tissue damage caused by vaso-occlusion in sickle cell disease in those organs rich in acid phosphatase was assessed by measuring serum acid phosphatase in 33 patients with homozygous sickle cell disease Hb-SS (sicklers) and comparing the result with that of 31 persons with normal haemoglobin-AA (non-sicklers) matched for age and sex. The result showed a decrease in the level of total, labile and tartrate-resistant serum acid phosphatase in sicklers compared to non-sicklers, though the decrease is not statistically significant (p greater than 0.1). Though serum acid phosphatase is unlikely to be a useful index for the assessment of organ damage, the result is in consonance with reported decreases in other body secretions such as serum testosterone or aldosterone due to organ damage by vaso-occlusion of the micro-circulation by sickled red cells in sickle cell disease.

Educational rehabilitation of mentally and physically handicapped children in Benin City, Nigeria.

Handicapping diseases have remained major problems associated with immense suffering and superstition in the African setting. There are no accurate vital statistics of the incidence of mental and physical retardation in children in Nigeria, but it is presumed to be higher than in the U.S.A. or Europe. This study shows that provision for education and rehabilitation for handicapped children, such as school accommodation, transportation, teaching aids, specialist teachers etc., attract low priority in the minds of the education planners. In developing countries, the efforts of voluntary organizations to supplement government efforts should be encouraged by the Government and by the public. Intensive health education is needed for the public and also for the teachers who come in contact with handicapped children.

Neurological diseases as seen at the outpatient Paediatric Neurology Clinic in Benin City.

There is a paucity of literature about the pattern of neurological diseases in children attending out-patient departments in Africa. In this study more boys than girls presented at our clinic. Almost all the principal diseases seen are eminently preventable. There appears to be no effective immunization programme. There is need for epidemiological studies to ascertain the true incidence of subacute sclerosing panencephalitis in view of the high incidence of measles in the community.

Childhood hyperpyrexia in Benin City, Nigeria.

Childhood hyperpyrexia is associated with serious infections particularly bronchopneumonia, infective diarrhoea, meningitis, measles, urinary tract infections, otitis media, septicemia and sickle cell crisis Hyperpyrexia was found most in children aged 6-12 months followed by children aged 12-18 months. Hyperpyrexia occurred least in children aged 2-6 months. Febrile convulsion was associated with 38% of the cases. Malaria was a cause of convulsion in 27% of children with fever. This appears to contrast earlier reports by Lennox (1953) and Familusi (1971). The study confirms the rarity of hyperpyrexia in children aged 3 months and under. Deaths recorded were in children brought at the late stages of their ill health. Intensive health education is recommended to obviate unnecessary death of children through ignorance and poor knowledge of simple first aid measures.

Protein energy malnutrition: children at risk in Benin City, Nigeria.

Protein energy malnutrition is a problem associated with social and economic factors. Not all socially and economically deprived families have children who present with protein energy malnutrition. The study identified the group of children "at risk" in the economically and socially deprived families. It is suggested that anticipatory intensive health education should be aimed at the "at risk" families.

Broken paediatric appointments at the University of Benin Teaching Hospital, Benin City.

Appointment system was introduced to the University of Benin Teaching Hospital at the initial stage of the Hospital development. This is a new experience to the local community which is largely illiterate. The appointment breaking was low contrary to expectation. Indifference or negligence accounted for a high percentage of defaulting. The system was deemed to be good by 66.4 per cent of the defaulters interviewed only 1.2 per cent felt that it was bad. Efforts by the health visiting Sister to visit the defaulters at home and persuade them to attend the clinic reduced the number of broken appointments. The habit of breaking appointments by parents/guardians of children who showed indifference or negligence were more difficult to remedy. For a referral system to be effective in a largely illiterate community where referral system is new, knowledge of the reasons for breaking appointments in the community should be known and remedied. Promotion of personalized attention and intensive health education are essential.