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INTRODUCTION: This paper seeks to quantify the reliability of the assessment of students' answers to essay-type questions, in an attempt to define the role of such questions in University examinations. METHODS: The marks awarded for essay-type questions during three consecutive final undergraduate examinations in surgery were analyzed. The mean scores, 95% confidence intervals and the standard error of the mean were calculated to determine the distribution of the marks. Statistical analysis was used to determine the correlation of the marks awarded for the same answer by different markers and deduce the dependability of this method of testing. RESULTS: The marks awarded to 233 answer papers were available for analysis. The marks awarded by each pair of examiners for student answers to individual questions coincided on only 46.3% of occasions, but varied within just +/- 5% on 90.7% of occasions. Use of the kappa index to determine the agreement between markers produced a value of just 0.385, well short of the ideal of 1.0. Assessment of the overall reliability of this type of examination by Cronbach's reliability coefficent gave a value of 0.672. CONCLUSION: There was a significant variation among markers in the evaluation of answers to essay-type questions. However; the overall test reliability was acceptable enough to justify continuation of this type of assessment as a supplement to other methods.

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INTRODUCTION: This paper seeks to quantify the reliability of the assessment of students' answers to essay-type questions, in an attempt to define the role of such questions in University examinations. METHODS: The marks awarded for essay-type questions during three consecutive final undergraduate examinations in surgery were analyzed. The mean scores, 95% confidence intervals and the standard error of the mean were calculated to determine the distribution of the marks. Statistical analysis was used to determine the correlation of the marks awarded for the same answer by different markers and deduce the dependability of this method of testing. RESULTS: The marks awarded to 233 answer papers were available for analysis. The marks awarded by each pair of examiners for student answers to individual questions coincided on only 46.3% of occasions, but varied within just ± 5% on 90.7% of occasions. Use of the kappa index to determine the agreement between markers produced a value of just 0.385, well short of the ideal of 1.0. Assessment of the overall reliability of this type of examination by Cronbach's reliability coefficent gave a value of 0.672. CONCLUSION: There was a significant variation among markers in the evaluation of answers to essay-type questions. However, the overall test reliability was acceptable enough to justify continuation of this type of assessment as a supplement to other methods.

INTRODUCCIÓN: Este trabajo busca cuantificar la confiabilidad de la evaluación de las respuestas de los estudiantes a las preguntas de ensayo, en un intento por definir el papel de este tipo de preguntas en los exámenes de la Universidad. MÉTODOS: Se analizaron las notas otorgadas en cirugía a las preguntas de ensayo durante los tres exámenes finales consecutivos de pregrado. Se calcularon los puntajes promedio, intervalos de confianza de 95%, y el error estándar de la media, con el fin de determinar la distribución de las notas. Se usó el análisis estadístico para determinar la correlación de las notas dadas a las mismas respuestas por diferentes evaluadores, y para deducir la confiabilidad de este método de evaluación. RESULTADOS: Las notas otorgadas a 233 pruebas respondidas fueron puestas a disposición para su análisis. Las notas dadas por cada par de examinadores a las respuestas de los estudiantes a las preguntas individuales, coincidieron sólo en 46.3% de las ocasiones, pero variaron en justamente ± 5% en 90.7% de las ocasiones. El uso del índice de Kappa para determinar el acuerdo entre evaluadores, produjo un valor de sólo 0.385, bien lejos del ideal 1.0. La evaluación de la confiabilidad general de este tipo de examen, mediante el coeficiente de confiabilidad de Cronbach, arrojó un valor de 0.672. CONCLUSIÓN: Hubo una variación significativa entre los evaluadores a la hora de calificar las respuestas a las preguntas de ensayo. Sin embargo, la confiabilidad de la prueba en general fue suficientemente aceptable para justificar que se continúe con este tipo de evaluación como un complemento de otros métodos.

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OBJECTIVE: This study was carried out to compare the density of the interstitial cells of Cajal (ICCs) in the bowel wall of children with Hirschsprung's disease (HD), anorectal malformations (ARM) and normal controls in Trinidad and Tobago. SUBJECTS AND METHOD: Segments of bowel wall excised from eight children with HD, three controls and two children with ARM were immunostained with c-Kit primary antibody. Cells with features of ICCs were counted. RESULTS: All three controls and the two children with ARM had dense distribution of ICCs. Most children (6/8;75%) with HD had markedly reduced counts in aganglionic bowel. Two (25%) also had a decrease in ganglionic bowel. Possible influences were patient age and gender and the level of bowel sectioned. CONCLUSION: Analysis of this sample suggests that immunostaining for c-Kit positive cells might be a useful screening test in the assessment of bowel motility disorders. The possible effects of age, gender and the level of bowel sampled await determination.

OBJETIVO: Este estudio se llevó a cabo con el propósito de comparar la densidad de las células intersticiales de Cajal (CIC) en las paredes intestinales de niños con la enfermedad de Hirschprung (EH), y malformaciones anorectales (MAR), frente a controles normales en Trinidad Tobago. SUJETOS Y MÉTODOS: Segmentos de las paredes intestinales les fueron extirpados a ocho niños con EH; tres controles y dos niños con MAR fueron inmunoteñidos con anticuerpo primario c-kit. Se contaron las células con características de CIC. RESULTADOS: Los tres controles y los dos niños con MAR presentaban una distribución densa de CICs. La mayor parte de los niños (6/8; 75%) con EH tuvieron conteos marcadamente reducidos de intestino agangliónico. Dos niños (25%) también tuvieron una disminución de intestino gangliónico. Entre las influencias posibles se cuentan la edad y el género del paciente así como el nivel de intestino seccionado. CONCLUSIÓN: El análisis de esta muestra sugiere que la inmunotinción para células c-kit positivas podría ser un útil test de pesquisaje a la hora de evaluar desórdenes en la motilidad intestinal. Los efectos posibles de la edad, el género y el nivel de intestino muestreado, están pendientes de determinación.

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A case report is presented of an infant who developed a biloma over three months after major hepatic injury and after almost complete healing. A brief literature review is given to highlight unusual features of this case.

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OBJECTIVE: This study was carried out to compare the density of the interstitial cells of Cajal (ICCs) in the bowel wall of children with Hirschsprung's disease (HD), anorectal malformations (ARM) and normal controls in Trinidad and Tobago. SUBJECTS AND METHOD: Segments of bowel wall excised from eight children with HD, three controls and two children with ARM were immunostained with c-Kit primary antibody. Cells with features of ICCs were counted. RESULTS: All three controls and the two children with ARM had dense distribution of ICCs. Most children (6/8; 75%) with HD had markedly reduced counts in aganglionic bowel. Two (25%) also had a decrease in ganglionic bowel. Possible influences were patient age and gender and the level of bowel sectioned. CONCLUSION: Analysis of this sample suggests that immunostaining for c-Kit positive cells might be a useful screening test in the assessment of bowel motility disorders. The possible effects of age, gender and the level of bowel sampled await determination.

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A case report is presented of an infant who developed a large barium concretion proximal to a jejunal anastomosis. A brief literature review outlines the issues involved in the indications for, and choice of, contrast material for use in the precise radiological diagnosis of upper intestinal obstruction in infants.

Se presenta el reporte de un caso de un neonato que desarrolló una concreción grande de bario cercana a una anastomosis yeyunal. Una breve revisión de la literatura esboza los problemas involucrados en las indicaciones y selección del material de contraste para uso en un diagnóstico radiológico preciso de la obstrucción intestinal superior en los neonatos.

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A case report is presented of an infant who developed a large barium concretion proximal to a jejunal anastomosis. A brief literature review outlines the issues involved in the indications for, and choice of, contrast material for use in the precise radiological diagnosis of upper intestinal obstruction in infants.

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A case report is presented of a malignant rhabdoid tumour occurring in the kidney of a 23-month-old boy. Important differences between this and the conventional Wilms' tumour include the histological demonstration of sheets or cords of large cells resembling myoblasts, a tendency to frequent clinical relapse, and a high mortality rate despite multimodal therapy. In this child, an encouraging initial response to pre-operative chemotherapy, followed by surgical excision and postoperative triple chemotherapy, was not sustained. Recurrence of pulmonary metastases did not respond to further chemotherapy and whole lung irradiation.

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A case report is presented of a malignant rhabdoid tumour occurring in the kidney of a 23-month-old boy. Important differences between this and the conventional Wilms' tumour include the histological demonstration of sheets or cords of large cells resembling myoblasts, a tendency to frequent clinical relapse, and a high mortality rate despite multimodal therapy. In this child, an encouraging initial response to pre-operative chemotherapy, followed by surgical excision and postoperative triple chemotherapy, was not sustained. Recurrence of pulmonary metastases did not respond to further chemotherapy and whole lung irradiation.

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PURPOSE: To evaluate the relative effectiveness of three techniques of regional anaesthesia in the provision of postoperative analgesia in children. METHODS: Random assignment was made of 183 children scheduled for groin surgery to one of three groups. Bupivacaine 0.5% plain (2 mg.kg-1) was injected by the surgeon after skin incision. Group A received wound infiltration. Group B had regional nerve blockade. Group C had a combination of both methods. Postoperatively, pain was assessed using the CHEOPS behavioural scale at half hourly intervals until discharge home. Satisfactory pain control was arbitrarily defined as a CHEOPS score of < or = six. Potential differences among the groups were sought using graphical representation of mean pain scores, the frequencies of maximum pain scores, and the incidence of postoperative vomiting and oral analgesic consumption. RESULTS: Fifteen patients had to be excluded from analysis. This left 61 patients in Group A, 55 in Group B, and 52 in Group C. There were no demographic differences among the groups. No differences were demonstrated among the groups either in CHEOPS pain scores at any observation point (P = > 0.8), or in the incidence of vomiting or need for postoperative analgesia. (P = 0.52 and P = 0.41 respectively). Overall, 80% of the observations made (1,135/1,425) met our definition of satisfactory pain control. A post hoc calculation of the power of the study confirmed sufficient power to detect a 5% difference among groups. CONCLUSION: All three methods achieved analgesia with 80% of the pain scores meeting our definition of satisfactory pain control. None of the techniques enjoyed any apparent advantage.

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A prospective clinical trial was carried out to compare the effect, on wound healing, of the use of polyglactin, plain catgut sutures, or skin tapes, in the closure of 190 groin crease incisions in children. The final outcome variable analysed was uneventful healing, defined as the absence of wound erythema, induration, discharge, raw areas, stitch sinuses or extrusions, or spreading or thickening of the scar, at four successive observation periods, up to 11 months post-operatively. Wounds closed with polyglactin exhibited a significant advantage over either of the two other methods in the early postoperative period (P = < 0.5). This association diminished over subsequent observation periods. Skin tapes were cheapest and quickest to use, but gave rise to a high incidence of wound problems, particularly early separation of the skin edges. Patient age (P = < 0.01 to < 0.05) and sex (P < 0.01) also exercised an effect on wound outcome, particularly at the final observation point. The reason for this was not determined. The results of this trial favour the use of polyglactin sutures over plain catgut and skin tapes in the closure of groin crease incisions in the population studied.

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A prospective clinical trial was carried out to compare the effect, on wound healing, of the use of polyglactin, plain catgut sutures, or skin tapes, in the closure of 190 groin crease incisions in children. The final outcome variable analysed was uneventful healing, defined as the absence of wound erythema, four successive observation periods, up to 11 months post-operatively. Wounds closed with polyglactin (P=<0.5). This association diminished over subsequent observation periods. Skin tapes were cheapest of the skin edges. Patient age (P=<0.01 to <0.05) and sex (P<0.01) also exercised an effect on wound outcome, particularly at the final observation point. The reason for this was not determined. The results of this trial favour the use of polyglactin sutures over plain catgut and skin tapes in the closure of groin crease incisions in the population studied (AU)

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A statistical analysis was undertaken of 1158 children admitted to a surgical ward for the management of acute abdominal pain. Over two-thirds (40%) of the children had non-specific abdominal pain while 29.7% had appendicitis. The remainder were found to have had urinary tract infections (11.7%), constipation (7.5%), gastroenteritis (5.8%) or intussusception (5.3%). A stepwise discriminant analysis of the data collected during their evaluation was performed, using the BMDP statistical software package. Demographic and clinical features, as well as the results of ancillary investigations, were included in the data. The programme generated a classification function of a sub-set of 18 variables which best discriminated among the diagnostic groups. The coefficients of the classification functions were then combined with the rank order of selection of the variables to derive a scoring method for predicting the diagnosis. The results of urine culture were excluded since these would be unavailable during early clinical assessment. The scores for the diagnostic groups fell within the following ranges:-1-23 Non-specific abdominal pain; 20-48 appendicitis; 35-84 Gastroenteritis; 75-88 Constipation and 89-140 Intussusception. It is suggested that this scoring method be evaluated by a prospective study to test its validity.

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A case report is presented of a Wilms' tumour in a three-year-old child. Direct intravascular extension into the heart led to a fatal outcome. Though a rare complication, clinical suspicion, combined with appropriate investigation and management, should lead to salvage of such a patient.

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This is a multivariate analysis of the data recorded in assessing 1158 consecutive admissions presenting to a children's surgical ward with acute abdominal pain. There were 56 binary variables available for entry into the analysis. A statistical software package was used to perform a stepwise discriminant analysis on the data. The program selected 18 variables as having discriminating power in assigning patients to the six diagnostic groups. In order of discriminating power these were, mainly, a positive urine culture, the bowel history, the findings on rectal examination, the location of abdominal tenderness, the presence of a mass, and the white cell count. Lesser discriminating potential was assigned to the presence of dehydration; fluid levels on erect abdominal films, a rise in temperature, an increased pulse rate, the presence of urinary symptoms, and the general appearance of the child. Use of these data led to an overall correct classification of 80.7% of cases. It is concluded that these variables should be included in the assessment of children with acute abdominal pain.

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Fifty-one children under the age of 10 years admitted to a general hospital in Trinidad had a confirmed diagnosis of malrotation of the intestines. This was the primary diagnosis in 20 cases. Analysis of the records of these 20 revealed that one-half were less than 1 month of age at first presentation. Vomiting was a universal complaint, and nearly two-thirds were malnourished. Disturbed bowel habit, anorexia and abdominal pain were also reported. In 30% (six of 20) there were signs of dehydration; an equal number had features of intestinal obstruction. Radiological investigation provided the diagnosis in all but one child, who underwent surgical exploration with a provisional diagnosis of appendicitis. Although a volvulus was found in 35% of cases, no resections were necessary. A high rate of morbidity and a mortality rate of 15% highlight the problems involved in the surgical care of young infants.

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A review of 391 children in the first decade of life admitted to a surgical ward with soft tissue infections revealed predisposing factors in 38.4% of cases, mainly trauma and adjacent skin sepsis. Superficial abscess formation occurred in 90% of cases, muscle abscesses in 9.5%, and necrotizing fasciitis in less than 1%. The most frequent organism isolated was the staphylococcus aureus which was found in 52.8% of the available cultures. Coliform organisms were found in 14.6%, and haemolytic streptococci in just over 10%. A study of the culture and sensitivity profiles obtained made it possible to formulate a programme for the empirical treatment of soft tissue infections based on the region of the body involved.

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A review of 391 children in the first decade of life admitted to surgical ward with soft tissue infections revealed predisposing factors in 34.8 per cent of cases, mainly trauma and adjacent skin sepsis. Superficial abscess formation occurred in 90 per cent of cases, muscle abscess in 9.4 per cent, and necrotizing fascitis in less than 1 per cent. The most frequent organism isolated was the staphylococcus aureus which was found in 52.8 per cent of the available cultures. Coliform organisms were found in 14.6 per cent, and haemplytic streptococci in just over 10 per cent. A study of the culture and sensitivity profiles obtained made it possible to formulate a programme for the empirical treatment of soft tissue infections based on the region of the body involved.

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