Fat embolism syndrome following long bone fractures

During the period August, 1979 to December, 1992, 14 patients with the fat embolism syndrome (FES) were admitted to the University Hospital of the West Indies (UHWI). Two were females and 12 males, their ages ranging from 18 to 78 years, with a median age of 23.5 years. All had lower limb long bone fractures. Clinical features included fever, tachypnoea, confusion and drowsiness. They were all hypoxaemic; 9 required Intensive Care Unit (ICU) admission and, of these 4 needed ventilatory support. Five patients became comatose, 4 of whom developed decerebrate posturing. There was one death from Klebsiella septicaemia, and 13 patients recovered fully. The FES is a serious life-threatening complication of long bone fractures whether simple or compound, usually occurring within 72 hours of the injury. A high index of suspicion is needed for its prompt detection, and early attempts at maintaining adequate tissue oxygenation most be instituted if serious neurological complications and death are to be avoided. (AU)

Fat embolism syndrome following long bone fractures

During the period August, 1979 to December, 1992, 14 patients with the fat embolism syndrome (FES) were admitted to the University Hospital of the West Indies (UHWI). Two were females and 12 males, their ages ranging from 18 to 78 years, with a median age of 23.5 years. All had lower limb long bone fractures. Clinical features included fever, tachypnoea, confusion and drowsiness. They were all hypoxaemic; 9 required Intensive Care Unit (ICU) admission and, of these 4 needed ventilatory support. Five patients became comatose, 4 of whom developed decerebrate posturing. There was one death from Klebsiella septicaemia, and 13 patients recovered fully. The FES is a serious life-threatening complication of long bone fractures whether simple or compound, usually occurring within 72 hours of the injury. A high index of suspicion is needed for its prompt detection, and early attempts at maintaining adequate tissue oxygenation most be instituted if serious neurological complications and death are to be avoided.

Thymectomy in myasthenia gravis: the Jamaican experience

Forty-five patients with myasthenia gravis (MG) were subjected to thymectomy by the median sternotomy technique and were followed up for 4,380 patient months. No operative deaths occurred and 93.3 percent of the patients benefited from surgery with 28.8 percent achieving remission. Forty patients (88.5 percent) showed improvement within one month, and 73 percent of those who achieved remission did so in the first 2 years. Outcome was not affected by thymic pathology except in one patient who had a thymoma removed. These results confirm the value of thymectomy in the management of MG patients with generalised disease and the efficacy of the simple median sternotomy procedure (AU)

Myasthenia gravis in Jamaica: clinical, immunological and genetic studies

Clinical, immunological and genetic parameters were studied in 73 Jamaican patients with myasthenia gravis (Mg). The reported biomodal clinical distribution of females with early onset of disease and males with late onset was not observed. The female to male ratio was 2:1. The most frequent manifestations of disease were ptosis (84.9 percent), general muscle weakness (68.5 percent), bulbar symptoms (41.1 percent) and diplopia (32.9 percent). Unusual presenting features such as unilateral ptosis, recurrent chest infection and stumbling while walking resulted in diagnosis being missed in 5.8 percent of cases. The sensitivity of radiommunoassay in detecting acetylcholine receptor antibody (AchR-Ab) in sera from a subgroup of 35 MG patients was 71.4 percent whilst that of the ELISA was only 14.2 percent. There was no correlation between HLA-type, thymic pathology and course of disease. HTLV-I could not be implicated in the pathogenesis of this disease. There was a paucity of other associated autoimmune conditions among MG patients. Thymectomy was an important therapeutic modality in that improvement was observered in 22 cases and remission in 11. (AU)

Closed mitral valve commissurotomy in West Indian patients results of operative palliation (1955 to 1985)

A retrospective study of all patients subjected to closed mitral valve commissurotomy from 1955 to 1985 at the University Hospital revealed low morbidity and mortality rates associated with surgery. Out-patient follow-up studies indicate adequate symptomatic relief over a period of 1 to 27 years. Patients with isolated significant mitral stenosis should, therefore, be considered for surgical palliation (AU)

Mitral stenosis in West Indian patients: results of closed mitral commissurotomy (1955-1985) at the University Hospital of the West Indies - abstract

Mitral stenosis (MS) is not infrequently seen in patients presenting at referral clinics in the University Hospital (UH). These patients are offered surgical palliation - Closed mitral commissurotomy (CMC) - as published reports indicate such therapy is quite satisfactory. A study of all patients subjected to CMC for MS at UH was undertaken to evaluate the results of this operation. There were 97 women and 23 men and their ages ranged from 9 to 57 years (mean 24.7). A clinical diagnosis of MS was made in all patients. Thirty-four and 28 patients were subjected to cardiac catheterisation and echocardiography respectively to confirm the clinical diagnosis and /or to exclude other cardio-vascular abnormalities. The operative procedures performed were as follows: CMC - 117, CMC + lung biopsy - 1, Thoracotomy - 1, Prosthetic aortic and mitral valve replacement (failed CMC) - 1, Total = 120; Subsequent operations performed were as follows:- CMC - 1, Homograft mitral valve replacement - 5, Porcine xenograft mitral valve replacement - 3, Tracheostomy - 1, Thoracotomy (tamponade2, no tamponade 2) - 4, Total = 14. There were 3 intra-operative deaths (left coronary embolus, bleeding, acute cardiac failure), a 2.5 per cent mortality. Five and 9 patients died in the early and late post-operative periods respectively (cardiac failure, systemic embolisation, re-stenosis, re-operative), 4.2 and 7.5 per cent mortality. Follow-up studies after CMC indicate adequate symptomatoic relief over a period of 1 to 27 years. The results of CMC at UH indicate that the techniques of anaesthesia and surgery are associated with low morbidity and mortality. Patients with MS should therefore be considered for surgical palliation (AU)

Left atrial myxoma: an unusual cause of acute pulmonary oedema

A case of left atrial myxoma presenting as acute pulmonary oedema is described. As far as we are aware, this is the report in the West Indian medical literature of accurate pre-operative diagnosis and successful surgical excision of such a tumour. Recent improvements in the accuracy of pre-operative diagnosis are discussed, and the present day availability of surgical excision, utilising cardio-pulmonary bypass with excellent post-operative results at low-risk, make response of this case of considerable importance. (AU)

Patent ductus arteriosus: result of operative intervention (1953-1984)

A retrospective study of all patients with patent ductus arteriosus treated surgically from 1953 to 1984 at the University and National Chest Hospitals revealed low morbidity and mortality rates associated with anaesthesia and surgical treatment. Patients with patent ductus arteriosus should, therefore, be considered for surgical correction. (AU)

Patent ductus arteriosus in West Indian children - abstract

Patent ductus arteriosus (PDA) is frequently seen in children presenting at referral clinics. These children are offered surgical correction as published reports indicate such therapy is quite satisfactory. This study reports the results of operative intervention (1953 to 1984) at the University Hospital (UH) and National Chest Hospital (NCH). A study of all children (<13 years) subjected to surgical correction of PDA was undertaken to evaluate the results of this operation. There were 140 females and 72 males and their ages ranged from a few weeks to 12 years (mean 4.6 years). A clinical diagnosis of PDA was made in all patients. Forty-two children were subjected to cardiac catheterisation to confirm the clinical diagnosis and/or to exclude other cardio-vascular abnormalities. Anaesthetic management included a balanced technique and induced moderate arterial hypotension to facilitate the great vessel surgery. The operative procedures performed were as follows:- PDA division + suture - 151; PDA ligitation - 48; PDA division + suture & coarctation repair - 5; PDA division + suture & sub-aortic stenosis repair (OHS) - 1; PDA aneurysm repair with LA-femoral bypass - 1; No PDA at thoracotomy - 6, --division of ligamentum arteriosum, --repair of aorto-pulmonary fistulae (OHS) -1, --subsequent repair of VSD (OHS). (OHS = open heart surgery with cardio-pulmonary bypass). There was 1 intra-operative death (<0.5 per cent mortality) due to bleeding from a torn ductus (in 1965) and 1 post-operative death (<0.5 per cent mortality) caused by digoxin toxicity which occurred on day 1 in the convalescent ward. The clinical diagnosis of PDA is accurate (96.5 per cent), and the techniques of anaesthesia and surgery are associated with low morbidity and mortality. Children with PDA should therefore be considered for surgical correction (AU)

Prevalence of liver abnormality in early syphilis

Hepatic structure and function of 22 unselected patients with early syphilis was assessed. In 20 (91 percent) routine hepatic tests or bromsulphalein retention showed mild non-specific abnormalties. Minor changes in hepatic structure were present in 12 (55 percent), in three of whom intrahepatic spirochaetes were found. The only patient who had hepatomegaly also had splenomegaly. Observed changes in hepatic structure correlated with neither physical signs nor results of biochemical tests. Hepatic changes in early syphilis are common but frequently subclinical (AU)

Mitral valve disease in West Indian children results of operative intervention at the University Hospital of the West Indies - abstract

Rheumatic carditis and its sequelae tend to run a severe course in West Indian children. The mitral valve is most commonly affected by the disease process, and children thus afflicted often need surgical intervention to provide adequate palliation. A retrospective study of all children under 13 years of age subjected to isolated mitral valve surgery at the University Hospital was undertaken to evaluate the results of the palliative operations performed. There were 15 males and 13 females in the study and their ages ranged from 6 to 12 years (mean 10 yrs.) The operations performed were closed mitral commissurotomy (1), open mitral commissurotomy (1), porcine xenograft mitral valve replacemnet (3), homograft mitral valve replacement 922) and failed porcine homograft (1). Eight patients died of acute cardiac failure within 4 weeks of operation (29 per cent mortality). Of the 20 children surviving operation, 8 died (29 per cent mortality) between 0.25 and 5 years, and the causes of death were congestive cardiac failure (2), following re-operation (3), and infective endocarditis (3). The remaining 12 patients are alive and well and their period of follow-up ranges from 1 to 8.3 years (mean 4.5 years). Clinical and investigative (electrocardiographic and echocardiographic) data indicates a satisfactory functional result following operation. Mitral valve disease complicating rheumatic carditis is frequently encountered at the University Hospital, and the results of surgical intervention have been shown to be satisfactory. Earlier re-operation, when indicated, and stricter criteria for operative intervention, could further improve the results of surgical palliation (AU)

Pregnancy in patients after homograft cardiac valve replacement

Thirteen pregnancies in ten patients with homograft cardiac valves resulted in 11 healthy infants, one spontaneous abortion, one elective termination of pregnancy, and the stillbirth of one member of a twin pregnancy. Two forceps deliveries and three cesarean section were performed and routine antibiotic prophylaxis at the time of delivery was utilized to prevent infective endocarditis in all patients. No hemorrhagic or teratogenic complications were observed, and this was considered directly related to the fact that anticoagulant therapy was rendered unnecessary with the homograft valve - a distinct advantage. A more permissive policy of allowing pregnancy in young women with homograft cardiac valves is suggested by the satisfactory outcome of the pregnancies reported here (AU)

Methodology and cost of cardiopulmonary by-pass for open-heart surgery at the University Hospital of the West Indies: review of a 14-year experience (1968-1982)

A 14-year microcomputer-assisted review of cardiopulmonary by-pass at the University Hospital of the West Indies is presented. A total of 436 cardiopulmonary by-pass operations was used for open-heart surgery in 417 patients. The results indicate that the by-pass methodology used was relatively uneventful and easy to manage. The costs of cardiopulmonary by-pass have been low. This procedure which is a necessary adjunct for open-heart surgery at the University Hospital is relatively cheap and safe and its methodology presents no problems in management (AU)

A prospective study of anaesthesia related morbidity and mortality - abstract

A 2-year (1981-82) prospective study was undertaken to determine the incidence of morbidity and mortality related to anaesthesia at the University Hospital of the West Indies. Data was obtained from all patients subjected to anaesthesia relating to their pre-operative, intra-operative and post-operative (recovery room or ICU) course and, in relevant instances, the convalescent ward. A total of 8,334 anaesthetics were administered and the ages of the patients ranged from 3 days to 96 years (mean 36 years). Three hundred and sixty patients (4.31 per cent) developed a complication as a result of anaesthesia and, of these, 12 patients (0.14 per cent of the total) died. Five patients died following post-operative cardio-respiratory arrest whereas 6 patients died of intra-operative arrhythmia and/or hypotension. One patient, a 1-year old child, died post-operatively of hypoxic brain damage. The incidence of various organ system involvement among non-fatal complications were as follows: respiratory (45 percent), cardiovascular (32 percent), musculo-skeletal (3 percent) central nervous (<1 percent). Respiratory complications included laryngospasm and/or bronchospasm (49 percent), post-operative respiratory obstruction (15 percent), post-operative respiratory insufficiency (19 percent), pulmonary oedema following aspiration (4 percent). Fifty-five patients needed post-operative mechanical ventilation in the ICU. Aspiration of stomach contents occurred in 6 instances and 5 of these patients involved anaesthesia for emergency caesarean section. All of these patients improved with supportive therapy (AU)

Post-cardiac arrest survival of patients following admission to the intensive care unit - abstract

A retrospective study of patients admitted to the Intensibe Care Unit (ICU) at the Uiversity Hospital of the West Indies following a cardiac arrest was undertaken to determine the early and late survival rates. Patient data was collected on forms and inserted in a patient data-base (ICU-DATA) utilising a SWTPC micro-computer system. Pertinent data was retrieved and analysed using the report-writer and sort/merge software programmes respectively. During the 2-year period (1/1/81 to 31/12/82), 51 patient were admitted to the ICU following successful resuscitation of cardiac arrest. There were 32 males and 19 females and their ages ranged from 1 day to 78 years (mean 38.3 years). The secondary diagnosis was as follows:- cardiovascular (10), postoperative (8), central nervous system (7), respiratory (6), diabetes (4), renal failure (3), shock (3), anaemia (2), systemic lupus (1), multiple myeloma (1), not recorded (6). Forty (40) patients, i.e 78.4 per cent, died in the ICU. Their duration of stay ranged from 1 hour to 8 days (mean 1.2). The remaining 11 patients who were discharged from the ICU, 5 died on the convalescent wards and 1 at home. Of the remaining 5 survivors, 2 were lost to follow-up. The other 3 patients are doing well. Hence the overall death rate was 90.1 per cent (AU)

Pregnancy after open-heart surgery

Thirty-eight pregnancies in 27 patients who had previous open heart surgery resulted in 32 healthy babies, 4 spontaneous abortions and 2 elective abortions. Seven forceps deliveries and 5 Caesarean sections were performed. Detailed information was available for 22 infants all of whom were healthy and were born at term without evidence of haemorrhagic or teratogenic complications (no anticoagulant therapy was used in the mothers). The gratifying outcome of the majority of these pregnancies suggests that a more liberal policy in allowing pregnancy in patients who have had successful open heart surgery shoud be pursued (AU)

Pericardial constriction after open-heart surgery

A case of pericardial constriction developing after open-heart surgery is described. As far as we are aware, this is the first such case to be reported in the West Indian medical literature. Possible aetiological influences are discussed, important differences from the clinical features of idiopathic constrictive pericarditis are stressed, and the great importance of considering this diagnosis in any post-operative cardiac surgical patient who develops apparent heart failure is emphasized (AU)

Central venous catheter tip position with peripheral vein insertion

A study of the success rate of central venous line placement in 100 catheter insertions is presented. The need for selection of peripheral superficial sites and for radiological confirmation of the position of the catheter tip is stressed. The overall success rate of correct placement in this series is 84 per cent. (AU)

Haemodynamic improvements after peritoneovenous shunting in nephrogenic ascites

A patient being treated by regular hemodyalisis for end-stage renal failure had nephrogenic ascites. Despite attempts at fluid removal by ultrafiltration, progressive hypotension and low cardiac output eventually reduced fistula flow so much that haemodylasis became almost impossible. The insertion of a peritoneovenus shunt resulted in reduction of ascites and 78 percent increase in cardiac output, with consequent correction of hypotension and improvement of fistula flow. Peritoneovenous shunting is a simple and beneficial form of treatment for nephrogenic ascites that does not respond to fluid removal by dialysis (Summary)