The impact of helmets on motorcycle head trauma at a tertiary hospital in Jamaica.

BACKGROUND: Although the Jamaica road traffic act mandates motorcycle riders to wear approved helmets, opponents suggest that the local road conditions obviate any benefits from helmet use that have been proven in Developed countries. They suggest that the narrow, winding, poorly surfaced, congested local highways do not allow motorcyclists to sustain high velocity travel. The accidents then tend to occur at lower speeds and are accompanied by less severe injuries. This study was carried out to determine the impact of helmet use on traumatic brain injuries from motorcycle collisions in patients admitted to a tertiary referral hospital in Jamaica. METHODS: A prospectively collected trauma registry maintained by the Department of Surgery at the University Hospital of the West Indies in Jamaica was accessed to identify all motorcycle collision victims from January 2000 to January 2007. The therapeutic outcomes of traumatic brain injuries were compared between helmeted and un-helmeted riders. The data was analyzed using SPSS Version 12. RESULTS: Of 293 motorcycle collision victims, 143 sustained brain injuries. There were 9 females (6.3%) with an average age of 23 +/- 7.3 years and 134 males (93.7%) at an average age of 33.4 +/- 11.2 years (mean +/- SD). Only 49 (34.3%) patients wore a helmet at the time of a collision. Helmet use at the time of a collision significantly reduced the severity of head injuries (28.6% vs 46.8%, P = 0.028) and the likelihood of sustaining intra-cranial lesions (26.5% vs 44.7%, P = 0.03) from head injuries. CONCLUSION: Wearing a helmet at the time of a motorcycle collision reduces the severity of head injuries. However, the prevalence of helmet use at the time of a collision is unacceptably low.

Granulomatous lobular mastitis. A case report and review of the literature

Granulomatous labour mastitis is a rare, benign, inflammatory breast condition of unknown aetiology that can clinically mimic breast cancer. Awareness of this condition is important, as the appropriate specimens must be taken to confirm the diagnosis and to rule out an infectious aetiology. While surgical exclusion has been the traditional therapeutic modality, the most appropriate therapy seems to involve the use of corticosteriods, even in the case of recurrence. (AU)

Management of Hepatic cysts by percutaneous drainage and instillation of tetracycline hydrochloride

This paper reports two cases of benign hepatic cysts successfully treated by the instillation of tetracycline hydrochloride. The patients presented with solitary large symptomic hepatic cysts and underwent ultrasound guided needle aspiration followed by the instillation of tetracycline hydrochloride. The cyst size diminished without complication and the patients have remained symptom free. We review the treatment of this uncommon entity and propose that injection of tetracycline hydrochloride is an effective non-operative treatment of symptomatic solitary hepatic cysts. (AU)

Patterns of trauma injuries in rural versus urban Jamaica

Trauma admissions to St. Ann's Bay Hospital and the University Hospital of the West Indies (UHWI) in the capital city of Kingston are compared. Trauma accounted for 19 percent and 22 percent of surgical admissions to UHWI and the St. Ann's Bay Hospital, respectively. Sixty-three percent of trauma cases admitted to St. Ann's Bay Hospital and 56 percent to the UHWI were due to unintentional injuries (95 percent CI, -0.05, 0.19). The main cause of unintentional injuries at both hospitals was motor vehicle accidents, accounting for 43 percent and 37 percent at UHWI and St. Ann's Bay Hospital respectively (95 percent CI, -0.04, 0.17). The prevalence of falls was significantly higher in St. Ann's Bay hospital compared with UHWI, 41 percent and 26 percent respectively (95 percent CI, 0.10, 0.21). Intentional injuries accounted for 37 percent of cases in St. Ann's Bay Hospital and 44 percent at UHWI (95 percent CI, -0.20, 0.04). The prevalence of firearm injuries was significantly higher at the UHWI than in St. Ann's Bay Hospital, 55 percent and 18 percent respectively (95 percent CI, -0.15, -0.05). There was no significant difference in age and injury severity scores in the two hospitals but patients remained in hospital significantly longer at UHWI. (AU)

Colonic Lipomas at the University Hospital of the West Indies

Lipomas of the colon are uncommon but cause diagnostic difficulty when they are symptomatic. The clinical and pathological features of 17 cases of colonic lipomas diagnosed at the University Hospital of the West Indies between 1970 and 1999 are reported. Ten cases were symptomatic, two of these being diagnosed with adult intussusception. Six patients had incidental lipomas in bowel resected for other patholgoy while one lipomas was diagnosed an sigmoidoscopy. Increased awareness of these lesions will enhanced pre-operative diagnostic accuracy.(Au)

Cholecystectomy in Jamaican children with homozygous sicke-cell disease

Twenty-seven children aged 18 years and under with homozygous sickle-cell disease had open cholecystectomy for symptomatic gallstones over the 12 year period 1985-1997. Emergency procedures (done during period of acute exacerbation of symptoms) were performed on 16 patients. Four with haemoglobin levels greater than 1g/dl below their steady state received a simple blood transfusion preoperatively designed to raise haemoglobin levels to 10g/dl. All had acute or acute on chronic cholecystitis based on histological examination of gallbladder specimens. Twelve had common bile duct stones. In two patients calculi were missed intraoperatively but these subsequently passed into the duodenum after a period saline irrigation via an in-situ t-tube. Six developed the acute chest syndrome (aetiology not determined) and this progressed to multi system failure and death in one. This high level of postoperative mobility and mortality may in part be due to the high proportion of emergency procedures. (AU)

Chronic Relapsing Pancreatitis in a Child: Use of the Puestow Procedure to Achieve Ductal Drainage

A case of chronic relapsing pancreatitis presenting in an 8-year old African Jamaican girl is outlined. Aggressive supportive management failed to control pain and vomitting. The Puestow Procedure effectively aborted these symptoms. The use of the Puestow procedure should not be inordinately delayed in chronic relapsing pancreatitis if symptoms persist, since it may not only control pain but also halt declining pancreatic function.(Au)

Chronic relapsing pancreatitis in a child: use of the puestow procedure to achieve ductal drainage

A case of chronic relapsing pancreatitis presenting in an 8-year old African Jamaican girl is outlined. Aggressive supportive management failed to control pain and vomitting. The Puestow Procedure effectively aborted these symptoms. The use of the Puestow procedure should not be inordinately delayed in chronic relapsing pancreatitis if symptoms persist, since it may not only control pain but also halt declining pancreatic function.

Morbidity pattern of emergency room patients in Jamaica

OBJECTIVE: This study documents the morbidity pattern of diseases in patients presenting to the Accident and Emergency (A&E) Unit at the University Hospital of the West Indies in Jamaica. DESIGN and METHODS: Data were retrieved from a log book kept by the nursing staff in the A&E Unit at the UHWI. This SPSS software package was used to select 100 random days in 1997. All cases treated in the A&E Unit on those days were included in the study. Data collected included demographic data, discharge diagnosis and disposal. Diagnosis were coded and classified using the International Classification of Diseases - 9th edition coding system. RESULTS: In 1997, 16,798 patients were treated in the A&E Unit during the 100 random days selected, 4611 of these were seen. Twelve cases were excluded, as the diagnoses were unknown. Some patient had more than one diagnosis and therefore, 4762 diagnoses were made in 4599 patients. The mean age was 34ñ 24 (SD) years. The male to female ratio was 1.8:1. Injuries and poisoning accounted for 31 per cent of cases. Respiratory diseases were the next most prevalent (16.2 percent). Cardiovascular and digestive diseases accounted for 5.8 and 10.5 per cent of cases, respectively. Infectious diseases accounted for only 1.75 per cent of cases; 71.7 per cent of patients were discharged home, 23.5 per cent admitted and 4.2 per cent transferred to another institution. The mortality rate was 0.6 per cent. CONCLUSIONS: The pattern of diseases seen in this study demonstrates epidemiologic transition where injuries, cardiovascular and other chronic diseases are evolving as the most prevalent conditions seen. This is now seen frequently in the Caribbean and other developing countries. (Au)

Predictions and outcome of patients with skull fractures - Poster abstract

OBJECTIVE: To determine the clinical outcome of patients presenting to the University Hospital of the West Indies with head injuries including skull fractures. DESIGN AND METHODS: Data was retrieved from the Hospital trauma database for the period January 15, 1998 to October 9, 1999. RESULTS: Of 2126 injured patients admitted to the University Hospital of the West Indies over a 21 month period, 706 patients (32.2 percent) had head injuries, of whom 141 had skull fractures. The predominantly male group had an average age of 30 years. Overall, road traffic accidents were responsible for the majority of injuries, but intentional injuries were most common (48.2 percent) in those with skull fractures. A skull fracture was associated with a longer period of unconsciousness, a lower Glasgow coma scale, a higher injury severity score, longer hospital stay, higher probability of intracranial complications, a five times more frequent rate of operative intervention, and a worse outcome. Skull X-rays are readily available in most hospitals in the Caribbean compared to CT scanning for which access is often restricted due to cost and distance. CONCLUSIONS: The early identification of a skull fractue can identify patients at high risk for the development of intracanial complications after a head injury. These patients need urgent neurosurgical and neuroradiological assessment so that appropriate, prompt intervention can take place. Prevention of injury and early, effective assessment and treatment are the only ways in which this common problem can be mimimized.(AU)

Penetrating wounds to the torso: the University Hospital of the West Indies experience

OBJECTIVE: This study was done to determine the aetiology of penetrating torso injuries in patients presenting at the University Hospital of the West Indies (UHWI) as well as to document the organs frequently injured and to assess the outcome of these cases. DESIGN AND METHODS: Data were derived from the UHWI trauma registry. All patients presenting to the UHWI with penetrating torso injuries between January 1, 1998 and June 30, 1999 were studied. Biographic data, cause of injury, organs injured and procedures used in treatment were recorded. TRISS methodology was used to identify unexpected deaths. RESULTS: 1899 (42 percent) of the 4,496 admissions to the surgical services of the UHWI were due to trauma. Two hundred and twenty-nine (229) of these had torso injuries and 159 (8 percent) were due to penetrating injuries. Assaults accounted for 98 percent of cases. The male to female ratio was 7.4:1 and the mean age was 28 +or- 10 (SD) years. There were 92 (59 percent) stab wounds and 63 (41 percent) firearm injuries. Mean hospital stay was 8 +or- 15 (SD) days. Mortality rate was 10 percent. Small bowel (17), colon (15) and liver (15) were the abdominal organs most frequently injured. Pneumothorax or haemothorax was detected in 107 patients. All except 20 patients had a major surgical procedure done. There were seven non-therapeutic thoracotomies and 17 non-therapeutic laparotomies. Greater than 50 percent deaths were assessed as preventable. CONCLUSIONS: The wider use of imaging procedures in treatment protocols should reduce the number of non-therapeutic procedures. The preventable death rate may be decreased through training in ATLS protocols and improved equipment maintenance.(Au)

Alcohol, cannabis and cocaine usage in patients with trauma injuries

Sera from 111 patients with trauma injuries, who presented to the Accident and Emergency Unit (A&E), University Hospital of the West Indies, during a 3-month period, were screened for blood alcohol. Urine specimens were analysed for metabolites of cannabis and cocaine. Sixty-two percent (62 percent) of patients were positive for at least one substance and 20 percent for two or more. Positivity rates were as follows: cannabis (46 percent), alcohol (32 percent) with 71 percent of these having blood alcohol levels (BAC) greater than 80 mg per decilitre; cocaine (6 percent). Substance usage was most prevalent in the third decade of life. The patients who yielded a positive result were significantly younger than those who were negative. There was no significant difference in age or substance usage between the victims of interpersonal violence or road traffic accidents. In the group designated "other accidents", patients were significantly older and had a lower incidence of substance usage that the other two groups. Cannabis was the most prevalent substance in all groups. Fifty percent (50 percent) and fifty-five percent (55 percent) of victims of road accidents and interpersonal violence, respectively, were positive for cannabis compared with 43 percent and 27 percent for alcohol, respectively. There was no significant difference in Hospital Stay or Injury Severity Score between substance users and non-users.(AU)

Trauma aetiology and cost in the Accident and Emergency Unit of the University of the West Indies

Trauma accounted for 37 percent of 22,311 patients seen in the Accident and Emergency Unit (A&E) at the University Hospital of the West Indies (UHWI) during 1996. Thirty-nine percent of injuries were intentional and 18 percent were due to motor vehicle accidents. Knives, machetes and rocks accounted for 75 percent of the injuries compared with 5 percent for gunshot wounds. Passengers were injured in about 40 percent of motor vehicle accidents and pedestrians in 19 percent. The admission rate was 16 percent and the orthopaedic clinic received 75 percent of the patients referred to specialist clinics. Victims of motor vehicle accidents made up a greater proportion of admissions (24 percent) than those of unintentional violence (13 percent). The average cost of caring for each patient in the A&E Unit was US$70 resulting in an annual cost of US$578,000.(AU)

Normal ultrasound in abdominal trauma - clinical outcomes

Imaging plays an increasingly important role in trauma and the access to CT scans in more advanced centres has decreased the number of exploratory laparotomies. Ultrasound has not been given the status of CT scanning in trauma centres because it does not give a panoramic view of the abdomen, is operator dependent and surgeons are not as "comfortable" with the images generated. It is however cheaper and more readily available than CTs, especially in developing countries. The aim of this study is to determine the negative value of abdominal ultrasound in trauma. A retrospective study was done using data from the Ultrasound register of the Radiology Department and the Trauma Registry of the Department of Surgery for the period 1st August 1998 to 28th February 1999. Sixty-four (64) patients had normal abdominal ultrasounds: twenty-four (24) for penetrating and forty (40) for blunt trauma. Fifteen (15) patients were female and forty-nine (49) male. Fifty-five (55) patients were discharged from A&E. Nine (9) patients were admitted to the ward of which eight (8) were subsequently discharged without surgical intervention. One (1) patient had an exploratory laparotomy which was negative for injury. No patient developed problems on follow-up. In this preliminary study, normal ultrasound in blunt or penetrating trauma had a 100 percent negative predictive value. We conclude that in competent hands, ultra-sound is useful in decreasing both the number of admissions to hospitals and the need for exploratory laparotomies.(AU)

Postoperative acute chest syndrome in sickle cell disease

62 patients with homozygous sickle cell (SS) disease who were subjected to cholecystectomy for symptomatic gall stones were analysed to determine the frequency and outcome of postoperative acute chest syndrome (ACS). Patients were selectively transfused preoperatively where haemoglobin levels were found to be >1 g/dl below steady state values. All patients had open cholecystectomy. 11 patients developed postoperative ACS. Age range was 8 to 54 years among cholecystectomy patients and 10 to 38 years among ACS cases. Two of the 11 received preoperative simple transfusion and haemoglobin levels ranged from 5.6 to 8.6 g/dl among the 9 not transfused. ACS precipitated falls in O2 partial pressures below 70 mm Hg on room air in 10 of the 11 cases. All but one of the patients received therapeutic transfusion (3 exchange and 7 simple) during their phase of clinical deterioration culminating in multi-system failure. ACS remains the leading cause of post operative morbidity and mortality in sickle cell disease. Hydration attention to infection, oxygen therapy via mask or positive pressure ventilation, simple or exchange transfusion and chest physiotherapy remain standard treatment. The potential for multi-system failure makes patient outcome unpredictable.(AU)

Torsion of an intra-abdominal testicle in a neonate: case report and review of the literature

The thirty-ninth reported case of torsion of an intra-abdominal testicle is described in a neonate. The gonad was excised as is recommended because of the high incidence of malignancy (60 percent of 37 cases). Torsion of an intra-abdominal testicle should be considered where an abdominal mass with calcification is found in an infant with undescended testis. Ultrasonography improves the diagnostic accuracy in infants because of the cystic nature of these masses in this age group.(AU)

Setting up practice

Careful planning is essential for the setting up of a successful medical practice. After qualification there is need for further experience and training. The location of the practice and the preparation of the physical plant are discussed. Being a service industry, all the ingredients necessary for good quality service and patient care must be put in place from the start. Attention must be paid to establishing a proper accounting system and the ability to retrieve data for reporting one's experience must also be put in place.(AU)

Childhood injuries in Jamaica - abstract

Childhood (age < 10 years) injuries were the reason for 225 emergency admissions to the Bustamante Hospital for Children and the University Hospital of the West Indies over a six week period ending June 30, 1996. Intentional injuries numbered 21 (9.3 percent) and unintentional injuries 204 (90.7 percent). Male/Female distribution was 143 (63.5 percent) and 82 (36.5percent). The average age of patients was 4.9 years. Falls, burns and motor vehicle accidents were the common causes of injuries resulting in 125 (55.5 percent), 19 (8.4 percent) and 17 (7.5 percent) admissions respectively. Bony, head and soft tissue injuries numbered 79 (35 percent), 63 (28 percent) and 35 ( 15.5 percent) respectively. Injury severity was graded according to the Tepas trauma score with severe injuries receiving grade 8 and lower. These totalled 22 affecting head (9), bone (8), and multiple sites (5). There were two deaths: a severe head injury (Tepas score 5) and a case of 35 percent flame burns. (AU)

Cholecystectomy in sickle-cell disease: the Jamaican experience

Fifty-eight patients with homozygous sickle-cell disease had cholecystectomy for symptomatic gallstones between January 1986 and September 1995 at the University Hospital of the West Indies and the Bustamante Hospital for Children, Jamaica. Top-up blood transfusion was administered to 7 patients with haemoglobin levels > lgm/dl below their steady state values. Complications related to the presence of biliary calculi were cholecystitis (58), common bile duct (CBD) dilatation (20), gallbladder empyema (2), and gallstone ileus (1). Nine developed the acute chest syndrome post-operatively leading to death in two patients. Three had retained CBD stones, which passed into the duodenum after a trial of saline irrigation via an in-situ t-tube. Because pre-operative ultrasonography is an unrelialbe modality for detecting CBD stones and also because of the high presence of CBD stones in sickle-cell disease, routine operative cholangiography is recommended at the time of surgery (AU)

The prevalence of cannabis abuse in trauma patients presenting to the University Hospital of the West Indies

During a three-month period patients aged 16 years and over, admitted to the University Hospital of the West Indies (UHWI) via the emergency room, were screened for the metabolites of cannabis in the urine. Forty-six per cent were positive for cannabis. Patients testing positive were significantly younger than those who tested negative (p<0.001), the mean ages (95 percent confidence interval CF) being 28 (25-30) years and 35 (29-39) years, respectively. Patients were placed into one of three groups depending on whether they were victims of motor vehicle accidents, interpersonal violence or "other accidents". The prevalence of cannabis abuse was significantly less in the "other accidents" group compared with victims of motor vehicle accidents and interpersonal violence. Fifty per cent of the road traffic accident victims (95 percent CI, 35-52 percent), 55 per cent due to interpersonal violence (95 percent CI, 39-69 percent) and 16 per cent of the "other accidents" group (95 percent CI, 4-38 percent) tested positive for cannabis. There was no significant difference in hospital stay (HS), Revised Trauma Score (RTS) or Injury Severity Score (ISS) between cannabis abusers and nonusers. We conclude that there is a high incidence of cannabis abuse among trauma victims in Jamaica and postulate that it may play an important role in the aetiology of motor vehicle accidents and interpersonal violence (AU)