Anorectoplasty in children in Papua New Guinea

The posterior sagittal anorectoplasty (PSARP) procedure for the definitive repair of children with imperforate anus was described in 1982. Unfortunately, surgeons in Papua New Guinea (PNG) have until recently not had the opportunity of being trained in the technique. Through the Medical Officer, Nursing and Allied Health Sciences Training Project (MONAHP) and Pacific Islands Project (PIP) of the Royal Australasian College of Surgeons, 65 Papua New Guinean children with an anorectal anomaly have undergone a repair, in conjunction with training of the surgical staff and medical students. A new technique for the management of a prolapsed colostomy has been developed and a protocol for management of PSARP patients postoperatively has been formulated. Patients referred to the paediatric surgical visiting teams were diagnosed and treated according to the stage their management had reached. Patients with a low anomaly were treated by a cutback procedure, those with a colostomy and a high lesion were managed by a PSARP and those with failed previous surgery were managed with a redo anorectoplasty, often without a covering colostomy. Data were collected on the patients treated and, where possible, the patients were followed during subsequent visits. 65 patients with an anorectal anomaly were treated, of whom 6 were treated with a cutback and 43 had a primary repair of a major anomaly. 5 of these 43 involved an abdominoperineal procedure. 19 children had redo surgery, 3 of whom had a second operation by the senior author, due to failure of initial postoperative management; 1 of these was for a failure to carry out the postoperative dilatations and 2 were due to poorly controlled constipation in the early postoperative period. A protocol for the postoperative dilatations was developed using shaped candles. Major complications were uncommon, in particular infections were rare despite the relative lack of facilities. However, difficulties with outpatient follow-up resulted in problems that could have been avoided. A large number of anorectal anomalies have been successfully treated as part of the MONAHP and PIP projects with local surgeons learning the technique. A protocol for follow-up and a technique for the management of colostomy prolapse have been developed.

The development of paediatric surgery in Papua New Guinea

Until 1993 complex surgery for children in Papua New Guinea (PNG) was usually conducted by general surgeons, or by overseas paediatric surgeons during ad hoc visits. There had been little coordination of these occasional international visits and no involvement in the surgical teaching program in the University Department of Surgery. Over eight years from July 1993 to July 2000, three Australian surgeons spent 33 weeks teaching paediatric surgery and paediatric urology, using lectures, tutorials and operative demonstration sessions. This paper is a report of the teaching and service provided by one surgeon (PAD) over 27 weeks in PNG and describes the development and training of the surgeon who will be the country's first qualified paediatric surgeon (MM). Other support given has been assistance with the publication of scientific papers, reviews of Masters' theses, the development of a proposal for investigation of the prevalence of renal tract anomalies and the development of protocols for the surgical management of anorectal anomalies and Hirschsprung's disease. In addition to this teaching, 311 children have had surgery during the 11 visits that form the basis of this report. The visits have been supported and funded by AusAID and the Royal Australasian College of Surgeons through the Medical Officer, Nursing and Allied Health Professional (MONAHP) and Pacific Islands Project (PIP) programs. An indication of the impact on the care of children with surgical diseases is evident from the improved skills and the changed referral patterns over the eight years.

Minimal stimulation protocol: a cheap and effective method of ovulation induction

OBJECTIVE

To determine the effectiveness and cost of Minimal Stimulation Protocol (MSP), a new combination of human menopausal gonadotrophin (hMG) and clomiphene citrate (CC), for controlled ovarian hyperstimulation.

METHOD

The ovulation rates, pregnancy rates, abortion rates and the cost of medication were assessed in respect of 67 women who underwent MSP.

RESULTS

Ovulation rate in the study group was 82%, pregnancy rate 21% and multiple pregnancies 7%. Spontaneous abortion occurred in 36% of the pregnancies. The average cost of MSP stimulation was one-third of hMG protocol.

CONCLUSION

MSP protocol, while substantially cheaper than hMG, gives comparable pregnancy rates with less need for monitoring and better patient comfort. These justify further evaluation of its role in the treatment of infertility.

Placental binding and transfer of radiopharmaceuticals: technetium-99m d, 1-HMPAO

Placental binding and transfer of 99mTc d, 1-hexamethyl propyleneamine oxime (HMPAO) was studied in vitro using human placenta and pregnant guinea pigs.

MATERIALS AND METHODS

Five pieces of human placenta were incubated in 50 ml Earle's solution containing 1.85 MBq 99mTc d, 1-HMPAO. The percent binding of the tracer to the placenta per 1 ml standard solution was calculated. Pregnant guinea pigs representing first, second and third trimesters were each injected with 74 MBq 99mTc d, 1-HMPAO through the jugular or femoral vein after sedation was induced with pentabarbital sodium. Static images were obtained, the guinea pigs were killed, and the fetuses were removed, weighed and imaged separately. The placentas, maternal and fetal brains, lungs, livers and kidneys also were removed, and the radioactivity was assayed in a dose calibrator for each organ. The percent radioactivity in each organ was calculated.

RESULTS

The binding of 99mTc d, 1-HMPAO to human placenta ranged from 2.95% +/- 1.5% to 5.82% +/- 0.3% per 1 ml standard solution. Both the binding of 99mTc d, 1-HMPAO to guinea pig placenta and its transfer to the fetus increased with gestational age. The percent binding ranged from 0.09% +/- 0.06% to 0.43% +/- 0.05%, whereas that of transfer to the fetus ranged from 0.05% +/- 0.03% to 2.19% +/- 0.64%. Of the amount transfered to the fetus, the order of accumulation in the fetal organs was liver > blood >> brain > lungs > kidneys > heart.

CONCLUSION

Technetium-99m d, 1-HMPAO binds to the placenta, and a minimal amount crosses the placental barrier and is transfered into the fetal circulation, mostly in the liver but a measurable amount is found in brain tissue.

Shigella and the fluorinated quinolones

Between July 1996 to June 1997 a total of 531 Stool samples from cases of acute diarrhoea, dysentry, colitis admitted to Kasturba Medical College Hospital, Manipal were investigated. Shigella were isolated from 29 samples (5.46%). Out of them, Shigella flexneri were 16 (55.17%), Shigella boydii 8 (27.58%), Shigella dysentriae 3 (10.34%) and Shigella sonnei 2 (6.89%). Five strains of Shigella flexneri and one strain of Shigella dysentriae were found to show resistance to Nalidixic acid and the newer fluoroquinolones viz., Ciprofloxacin, Norfloxacin and Ofloxacin. The in vitro 'R' factor transfer study showed that the resistance was not transferable.

Fine needle aspiration and frozen section diagnosis in the management of thyroid nodules

Fine needle aspiration (FNA) is a valuable technique in the evaluation of thyroid nodules. A total of 182 FNAs of the thyroid performed at the Sultan Qaboos University Hospital were reevaluated and 153 were found to be adequate (84%). The cytological results of FNA were divided into neoplastic and non-neoplastic groups. Subsequent histology was obtained in 53 patients with an intraoperative frozen actions (FS) in 27 patients. Papillary carcinoma was found to be the most common, accounting for 70% of these cases with histological follow-up in the neoplastic group. The utility of performing FNA in all thyroid nodules and an intraoperative frozen section only in selected cases is discussed.

Stability of piperacillin sodium in the presence of tazobactam sodium in 5% dextrose and normal saline injections

The stability of piperacillin sodium in the presence of tazobactam sodium in 5% dextrose and normal saline i.v. admixtures has been determined using a modified stability-indicating high performance liquid chromatography assay method reported in the literature. The solutions were stored at room and refrigerator temperatures in plastic bags. They remained clear throughout the study although the pH values decreased slightly during storage. The solutions were stable for 2 days at 25 degrees C and for 28 days at 5 degrees C. Tazobactam sodium appears to have a slight adverse effect on the stability of piperacillin sodium.

Stability of ciprofloxacin in 5% dextrose and normal saline injections

The stability of ciprofloxacin in 5% dextrose and normal saline i.v. admixtures have been determined using a stability-indicating high performance liquid chromatographic assay method reported in the literature. The solutions were stored in plastic bags, a procedure being used in hospitals for in or out-patient therapy. The solutions were stable for at least 3 months when stored at room or refrigerator temperatures. They remained clear throughout the study and their pH values did not change. The expiry date recommended by the manufacturer appears to be very conservative from a chemical viewpoint.

Stability of metronidazole benzoate in suspensions

A stability-indicating HPLC assay method has been developed to quantify metronidazole benzoate in suspensions. A study of the stabilities of two suspensions (16.0 mg/ml) of metronidazole benzoate in commercially available vehicles, Ora-Plus and a mixture of Ora-Plus and Ora-Sweet, showed that both suspensions were stable for at least 90 days at room temperature. The mobile phase required to elute metronidazole benzoate contained 40% acetonitrile versus approximately 10% for the free base. The solubility of the ester in water at 25 degrees C was found to be approximately 0.1 mg/ml versus 10 mg/ml for the free base. The ester did not hydrolyse significantly to the free base after storage for 8 h at 37 degrees C in simulated gastric fluid, and 5 h at 37 degrees C in simulated intestinal fluid. The bitter tasting metronidazole may not be satisfactorily substituted with its tasteless ester in the treatment of local gastrointestinal infections.

Stability of foscarnet sodium in 5% dextrose and 0.9% sodium chloride injections

The stability of foscarnet sodium injection in 5% dextrose and 0.9% sodium chloride injections was determined using a stability-indicating assay reported in the literature. The solutions were stable for at least 35 days when stored at 25 degrees or 5 degrees C. They remained clear throughout the study and pH values did not change. The solutions were stored in plastic bags as used by patients at home.

Stability of metronidazole in solutions and suspensions

Excellent stable oral liquid dosage forms of metronidazole can be prepared from tablets or powder using commercially available vehicle containing suspending agents. Liquid dosage forms (5 mg/ml) can be prepared without suspending agents. The four samples prepared (10 and 5 mg/ml) were stable for at least 90 days at room temperature. Their pH values and physical appearances did not change on storage. When metronidazole free base is prescribed it may not be substituted with the ester (metronidazole benzoate) as is common practice in the U.S.A. Metronidazole tablets with a labelled expired date of April 1986 still showed 99.3% potency when assayed in January 1993.

The development of oral liquid dosage forms of metronidazole

The stability of eight samples of metronidazole in aqueous vehicles was studied using a modified HPLC assay method. The samples were prepared using either metronidazole powder (5 mg/ml), metronidazole hydrochloride injection powder (10 mg/ml), or metronidazole powdered tablets (10 mg/ml). The samples prepared using metronidazole hydrochloride powder were stable and clear for at least 133 days at 25 degrees C. Their pH values were between 1.8 and 2.0. The samples prepared from metronidazole powder had pH values close to neutral and were stable for at least 45 days at room temperature (25 degrees C). However, to keep the drug in solution, the concentration of metronidazole powder was reduced to 5 mg/ml. The powdered tablets did not yield good uniform suspensions.

Midazolam for prolonged intravenous sedation in patients with tetanus

Midazolam was used for prolonged sedation in ten adult patients with severe tetanus in the Intensive Care Unit for periods ranging from 10 to 50 days. An infusion was started soon after induction and adjusted according to clinical needs. All the patients were intubated and ventilated and in addition received morphine 1-2 mg/hr and alcuronium or pancuronium infusion. Two patients died from complications of tetanus. Six patients recovered from the effects of midazolam within 24 hrs of the cessation of infusion. Recovery took 48 and 72 hrs respectively in the other two patients. Midazolam is a suitable drug for long-term sedation in patients with tetanus. However, dose requirements are variable and recovery may be delayed in some patients.