Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital [abstract]

During the period 1st January, 2000 to 30th June, 2000, 156 patients who presented to the Accident and Emergency Department and had a blood pressure defined by WHO-ISH as grade 3 (severe) hypertension and received nifedipine 10 mg, were reviewed. The most common presentation was epigastric pain. All patients responded rapidly and effectively to nifedipine without tachycardia, gastrointestinal or other notable side effects of nifedipine. Contrary to current medical opinion, the study found that nifedipine was safe and effective, creating a possible dilemma for its use by primary care physicians in a developing country. (AU)

Acute severe asthma in Trinidad and Tobago

SETTING: Accident and emergency department, General Hospital, Port of Spain, Trinidad and Tobago. OBJECTIVE: To measure the occurrence and clinical management of acute severe asthma. DESIGN: Data collected prospectively for consecutive attendees with asthma over a period of 3 months. RESULTS: Asthma accounted for 8.8 percent of attendances. Treatment for the acute attack included nebulised salbutamol in 1031 (85 percent) and nebulised atrovent in 769 (63 percent). Systemic corticosteroids were given to 623 (51 percent) patients. Only 247 (20 percent) had planned follow-up arrangements recorded. Usual maintenence treatment inlcuded inhaled salbutamol in 767 (63 percent) and inhaled corticosteroid in 286 (24 percent). Inhaled corticosteroids were more often used by patients aged > or =15 years or who had had previous hospital admissions for asthma. CONCLUSION: The survey identified deficiencies in the clinical management of acute asthma attacks and in longterm asthma care. Caribbean guidelines for asthma care have subsequently been published, and follow-up surveys should be carried out to evaluate their implementation.(Au)

Acute severe asthma at the Port-of-Spain General Hospital, Trinidad

We studied attendance for acute asthma at an Accident and Emergency department over a three-month period. Clinical details were recorded for 1248 subjects with an estimated ascertainment rate of 54 percent. Of 1213 subjects with known age, there were 453 (37 percent) aged 0-11 years, 141 (12 percent) aged 12-17 years, and 619 (51 percent) aged 18 years or older. There were 846 (70 percent) Afro-Trinidadian; 751 (62 percent) had previous attacks; and 667 (55 percent) had previous hospital admissions. Indicators of the severity of the attack were recorded as follows; heart rate, 968 (80 percent). respiratory rate, 985 (81 percent), peak flow rate, 495 (41 percent). The patient's usual maintenance treatment included inhaled salbutamol in 767 (63 percent) and inhaled corticosteroid in 286 (24 percent). Inhaled corticosteroids were more often used by patients aged > 18 years or who had previous hospital admissions for asthma. The acute attack was treated with nebulized salbutamol in 1031 (85 percent), nebulized atrovent in 769 (63 percent), intravenous corticosteroids in 268 (22 percent) or oral corticosteroids in 370 (31 percent). Overall corticosteroids were given in the acute attack to 623 (51 percent), corticosteroids were more often given to those > 18 years and those with higher respiratory rates (OR 1.41, 95 percent CI 1.02 yo 1.96). Only 247 (20 percent) had planned follow up arrangements recorded. We conclude that asthma attacks are common and often recurrent. Prophylactic treatment with inhaled corticosteroids may be under-utilized. Acute attacks are mostly treated with bronchodilators. Planned follow-up is not usual. It is possible that morbidity might be reduced through greater use of prophylactic treatment in those with recurrent symptoms.(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)

A prospective analysis of 4,041 consecutive cases in a West Indian accident and emergency department - abstract

Information on arrival, attendance and discharge times, age, sex, diagnoses, outcome, trauma classification and procedures and investigations performed was recorded in a specially designed form in 4,041 consecutive cases attending the Port-of-Spain General Hospital Accident & Emergency (A & E) department over a two-week period and was prospectively analyzed; 468 patients were referred to health centres, 1, 397 (35 percent) were admitted, and 2,171 (54 percent) were seen and discharged; 83 percent of all cases were seen without prior referral. The average time before being seen by a doctor was 31 minutes and the maximum period spent by any patient (admission - discharge) was 5 hours and 42 minutes. Medical procedures (adult and paediatric), general and orthopaedic surgery accounted for 78.4 percent of all cases. The most commonly encountered diagnoses in these specialities were asthma, lacerations and upper limb fractures. Based on these findings, the efficiency of the A & E department may be improved by increasing screening at the primary care level, training A & E officers in high-volume specialities, supplementing casualty staff with a paediatrician during peak hours and providing 'ensuite' plaster room for minor orthopaedi trauma (AU)

The musculo-aponeurotic repair for midline ventral abdominal wall herniae - abstract

Recurrence-free repair of midline ventral abdominal wall herniae continues to challenge 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 recti and their sheath on either side of the hernial defect are directly brought together to obliterate the hernia, while the intervening linea alba and intact hernia sac are "keeled" into the abdominal cavity. Using this technique, 85 consecutive midline abdominal herniae were repaired over an 11 year period. The follow-up period was between 18 months and 12 years, and there was one recurrence (1.2 percent). On re-operation, technical error was judged the cause of recurrence and the patient remains well 18 months following the second operation. The rectus repair is recommended as a highly effective method of dealing with ventral midline wall herniae (AU)

Band ligation versus haemorrhoidectomy for piles - abstract

A prospective policy to treat 100 patients with haemorrhoids by rubber band ligation (RBL) was undertaken, and compared to 100 patients who previously had Milligan-Morgan haemorrhoidectomy (MMH). Of the 100 cases who presented for RBL, only 9 required MMH. None of the patients who had RBL lost time from work of required hospitalization, compared to the MMH group, 21 days and 1.3 days, respectively. No patient in the RBL group required anaesthesia or operating theatre time. None of the RBL group required narcotic analgesics but 17 used non-narcotics for one day. Patients who had MMH averaged 3.6 doses of narcotics, and used non-narcotic for an average of 16 days. Stool softners were used by all patients in the MMH group and by only 8 in the RBL group. In view of these considerable benefits, RBL should be adopted as the treatment of choice for haemorrhoids in the West Indies(AU)

Surgery for colon trauma without colostomy; the best option in a developing country - abstract

In addition to the specific disadvantages of colostomy, other limitations are experienced by the patient in a developing country. Colostomies are ill managed by the patient due to unreliable supply of collection devices, poor patient education and inadequate toilet facilities. Members of a largely outdoor population become social recluses, and prolonged absence from work is common, since stoma closure is delayed due to scarcity of operating time. There is greater cost to the health system from multiple hospitalizations, increased drug usage, multiple operations and greater demand on manpower resources. In view of these factors, a policy of primary repair for colon trauma has been undertaken prospectively since 1978. Seventy-six (76) consecutive cases of colon trauma were managed between 1978 and 1990. Seventy-one (93 per cent) of these underwent primary repair while, in five (5), colostomy was constructed. Emergency repair of the colon was performed regardless of the site of the injury, mode of injury, presence of hypotension or peritoneal contamination. There was one death unrelated to anastomotic complications and one anastomotic leakage. The resulting faecal fistula closed spontaneously in four (4) weeks. Superficial wound infection rate was 10 per cent; there were no deep wound disruptions or other major complications. In view of our data, we strongly recommend that colon repair without colostomy is the best surgical operation for trauma of the colon in a developing country (AU)

The advanced trauma life support course: can it benefit the region? - abstract

The advanced trauma life support (ATLS) course was introduced in Trinidad and Tobago in 1986. The cumulative injury to death ratios for the two years prior to the course (1984 & 1985) and the two years after the inauguration of the course (1987 & 1988) were 20.2 and 21.2, respectively. The temporal pattern of injuries and deaths (day of week and time of day) in both groups was similar; and most deaths occurred during periods when the onus of patient care rested with those physicians on whom the course was to have maximum impact. Any benefit from the ATLS course may only be realised if improvements in communication, transport and trained paramedical staff augment the existing health system (AU)

The Jaipur foot: the best option for the West Indian amputee - abstract

The amputation rate at the Port-of-Spain General Hospital has doubled over the last 10 years from 114 and 102 in 1979 and 1980 to 274 and 225 in 1988 and 1989. The majority of the amputees are not able to work again because of the unavailability of a suitable prosthesis and physical and psychological rehabilitation are severely compromised. In order to overcome this, we decided to carry out a programme of fitting of prostheses. Of 200 amputees who were assessed 92 were fitted with prostheses, 60 (65 percent) above and 32 (35 percent) below the knee. Most were diabetics ranging in age from 18 to 62 years with a M:F ratio of 1.2:1. The Jaipur foot prosthesis was chosen for its light weight (about 2 kg), low cost (US$8 - $18), and good features (waterproof, well ventilated, good grip, shock absorbent, flexible and cosmetic appearance). Four patients returned for minor adjustments to the stump/socket interface and 90 percent expressed extreme satisfaction with their prosthesis. The Jaipur foot prosthesis seems ideal for West Indian amputees and there is a strong case for an on-going well co-ordinated programme involving trained technicians, physiotheraptists and surgeons to address the needs of the large amputee population in Trinidad and Tobago (AU)_

The Trinidad and Tobago coup of July 1990: a surgeon's view - abstract

The Coup of July, 1990, was a unique disaster in Trinidad. It lasted six (6) days, most of the violent actions occurred in Port-of-Spain and resulted in an unprecedented number and variety of injuries being brought to the General Hospital, Port-of-Spain. This study examines the number and type of injuries seen, and the mortality and management aspects at the hospital during the diaster. Three doctors kept daily records of casualty attendance, admission, types of injuries, circumstances surrounding the injury and treatment. Over the 6 days, 560 patients were seen at the Accident and Emergency Department. Of these 302 were admitted, 250 were treated and discharged (of the 50 were coup-related), and 8 died. There were 187 surgical admissions of which 170 were coup-related and 107 injuries were due to gunshots. Of 231 persons injured as a result of the coup, 133 (58 percent) were looters. Extraordinary efforts were required to cope with the overwhelming demands on the staff and hospital facilities. The unique nature of the calamity exposed areas of weakness in our disaster plan. Special circumstances such as the curfew and catering for large numbers of staff over a prolonged period needed specific attention. Effective comunication between the disaster area and health care facilities has to be established. Hospital specialist should participate in the planning for such a disaster (AU)

Same day surgery: is this the direction West Indian surgery should take? - abstract

A free standing, separate, self-contained same day surgery with 2 operating theatres and a 12-bed recovery room at the Eric Williams Medical Sciences Complex came into use on August 20th, 1990. This paper describes the first 3 months' experience of this unit. General, paediatric, orthopaedic and plastic surgeons, together with anaesthetists, a head nurse, 5 registered nurses, 8 nursing assistants, 2 anaesthetic technicians, 2 clerks and 3 attendants comprise the personnel. Five hundred and eighteen (518) cases were done over a 3-month period for an average of 88 cases per theatre per month. The average for the gross operating time (from entry to exit of patient) was 74 minutes while the net operating time (from incision to final closure) was 37 minutes. Patients ranged in age from 4 months to 83 years with 135 (26 percent) under 11 years. General anaesthesia was used in 71 percent of cases, and local in 26.5 percent. Herniorrhaphy was the most common procedure (16 percent). The transfer rate was 2.8 percent but no major complications occurred post-operatively. Health care workers and patients have a high appreciation for same day surgery. It is strongly recommended as a possible solution to many of the problems facing patients and surgeons in the Caribbean region (AU)

Routine drainage in thyroid surgery: is this practice obsolete? - abstract

Thyroid surgery without drainage is thought by many surgeons to be a practice with potentially catastrophic consequences. This thinking which evolved from the late nineteenth century view of absolute prescription of thyroidectomy because of bleeding has been questioned in recent papers. Our experience at surgery also led us to doubt the necessity of routine drainage, and so, since 1976, we practised non-drainage prospectively in 248 consecutive thyroidectomies. Subtotal lobectomy was done in 56 cases, unilateral lobectomy in 115 and bilateral subtotal thyroidectomy in 77 cases. This is the largest such series reported to date. In only one case was drainage considered necessary, and the only complication attributable to non-drainage was minor subcutaneous fluid collection (2 cases). In thyroid surgery, following meticulous haemotasis, routine drainage is not necessary (AU)