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In the Bahamas, a group of staff physicians, the Physician Alliance, proposed the privatization of selective health services in the public hospital, to provide universal access and availabiltiy of "modern" health care services at an affordable cost. The initial project outlined for the physician group to provide capital funds to establish and manage an Ultrasonic diganostic facility. Charges for procedures would reflect the government's subsidy of its public institution; reduced costs for procedures, differential fees for public patients and procedures, to be performed at no charge to the indigent patient. The hospital would provide the physical site, utilities and excise duties in the purchased equipment. Net profits were to be shared equally between the Hospital and the Physician group. The Physician Alliance provided an initial capital fund of US$86,000. The first year financial audit revealed fixed assets of $300,000. The one-year revenue of $270,000 yielded a 20 percent return to the physician share holders. The cost providing diagnostic services to indigent patients accounted for 7.4 percent of total revenues. The hospital, in addition to its profit share, collects 7 percent in management fees. Funds were allocated also for physicians to attend training courses in relevant diagnostic procedures and non-physicians to pursue certification courses to become ultrasound technicians. The privatization project is being expanded to include endoscopic equipment and an operating room surgical suite; capitalization projected - $800,000. We believe that selective privatization has advanced health care delivery in the public institution; simultaneously it has fostered physician involvement in the hospital's strategic planning and implementation of patient-related heath care services (AU)

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Acute renal failure (ARF) has had an unchanged mortality of greater than 50 percent for the past 30 years, despite advances in critical care management. The aetiologies, complications, and prognosis have been well described in the literature from developed countries. A 30-month prospective survey of all cases of ARF seen at the Princess Margaret Hospital since January 1986 was undertaken. Of a total of 1,014 cases, 98 were analyzed; and the principal findings were the following. Sepsis was the leading cause identified in 47 patients (48 percent); Hypoperfusion-related states occurred in 41 patients (42 percent); Nephrotoxins were identified in 18 patients (18 percent); Vasculatic disease accounted for 15 patients, and Obstructive uropathy was the major factor in 11 patients. Nearly 50 percent of the patients had non-oliguric ARF. The mortality was 36.1 percent, and 67.3 percent in the non-oliguric and oliguric groups, respectively. Seven patients were classified as having died due to renal failure, and the overall combined mortality of all the patients was 51 percent. Of the 98 patients, 21 had complete recovery (21 percent); 23 patients had renal insufficiency (24 percent); and 47 patients (48 percent) were classified as non-renal deaths. A new entity of Cocaine-induced Rhabdomyolysis is described in 2 patients and the pathogenesis discussed. This survey indicates that the mortality of 55 percent in this developing country is comparable to figures reported from more advanced metropolitan countries (AU)

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Penile gangrene is an uncommon clinical entity and invariably secondary to the spreading perineal necroticzing cellulitis, Fournier's gangrene. Penile gangrene as a primary event is exceedingly rare with less than 30 cases cited in the literature. From a 3-year urological practice in the Bahamas, I present a series of 13 cases of penile gangrene occurring as a primary event. In 3 cases the entire glans and proximal penile shaft underwent necrosis; in the other 10 cases the necrosis was confined to the prepuce and/or skin of the shaft of the penis. Clinical evidence supports the pathogenesis as a necrotizing balanoposthitis occurring in a previously uncircumcised phimotic glans with poor penile hygiene. With surgical debridement as the definitive mangement, 8 patients required circumcision only, 2 needed denuding the entire penile skin with subsequent skin grafting, 2 required partial penectomy and 1 a radical penectomy. The age group ranged from 23 to 86 years. Only one patient was a diabetic and another had an underlying urethral stricture. The bacteriology was a mixed perineal flora suggesting the bacterial synergistic event. From the literature review, this represents the largest series of primary penile gangrene to date; the pathogenesis argues in favour of the routine neonatal circumcision for penile hygiene in the tropics (AU)

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Over a 14 month period 20 Porta-A-Caths were implanted in 20 adults patients with a spectrum of malignancies requiring long term cyclic chemotherapy. The devices were inserted into the superior vena cava via a cephalic vein cutdown under local anaesthesia. The catheters were in situ for a total of 3,109 patient days, averaging 164 days per patient. The longest a catheter has remained indwelling is 385 days. Complications were minimal; 1 catheter was removed for sepsis, one revised for occlusion and 1 was associated with perficial thrombosis. We were impressed by the safe, simple catheter insertion, ease of establishing venous access, minimal morbidity and high patient acceptability. Its use is recommended in all patients requiring long term chemotherapy. (AU)

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This paper is a report of one year's experience with the PermCath central venous access dialysis catheter in the Bahamas. The PermCath was employed for temporary access in patients requiring chronic haemo-dialysis while awaiting permanent access sites. PermCaths were inserted via internal or external jugular vein cut-down under local anaesthesia. Fifteen catheters were inserted in 13 patients. One patient had three PermCaths. The 15 PermCaths were in situ for a total of 1,224 patient days and 385 dialysis episodes. The catheters were in situ for a range of 3 to 155 days, an average of 81.5 days per patient. Six patients had a catheter in situ longer than four months. Three PermCaths were removed because of sepsis and one for occlusion. There were no exit site infections or clinical thrombosis. It is concluded that PermCaths can be used safely for long term vascular access, with minimal morbidity and their use is recommended if temporary access is required for longer than four weeks (AU)

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We report our experience with the Shiley Double Lumen (SDL) and Permacath (PC) central venous access dialysis catheters during the period May 1986 to August 1988. The SDL Catheter study was confined to all patients selected for chronic dialysis and awaiting vascular access by a visiting access surgeon; patients receiving A-V shunts or peritoneal dialysis were excluded. PC was introduced in December, 1987 as an alternative to SDL. SDLs were inserted by standard percutaneous Seldinger technique in the dialysis unit, and PC via an internal jugular vein cutdown under local anaesthesia. Of the group of patients for chronic renal dialysis on temporary SDL access, the 21 patients who eventually had permanent vascular access were reviewed. No patients failing to achieve permanent vascular access died or were discontinued from dialysis due to complications of SDL cannulation. The 21 patients received 40 SDL cannulations (17 right subclavian vein, 21 left subclavian and 2 right femorals) for a total of 1,170 patient days and 393 haemodialysis episodes. SDLs were resited if there was sepsis, luminal thrombosis or clinical signs of subclavian vein thrombosis. One patient was carried for 215 days on SDL catheterizations. The longest site cannulated was 139 days. Seven patients received PC for a total of 720 patient days and 240 dialysis. Four catheters were removed after permanent access was established, 1 after sepsis and 2 remain in situ. We conclude that SDL and PC catheters can be safely used over an extended period for temporary dialysis on an outpatient basis without compromising future permanent access. This is particularly suited for geographical areas lacking a permanent vascular access surgeon (AU)

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