Health spending, illicit financial flows and tax incentives in Malawi.

This analysis examines the gaps in health care financing in Malawi and how foregone taxes could fill these gaps. It begins with an assessment of the disease burden and government health expenditure. Then it analyses the tax revenues foregone by the government of Malawi by two main routes: Illicit financial flows (IFF) from the country, Tax incentives. We find that there are significant financing gaps in the health sector; for example, government expenditure is United States Dollars (USD) 177 million for 2013/2014 while projected donor contribution in 2013/2014 is USD 207 million and the total cost for the minimal health package is USD 535 million. Thus the funding gap between the government budget for health and the required spending to provide the minimal package for 2013/2014 is USD 358 million. On the other hand we estimate that almost USD 400 million is lost through IFF and corporate utilization of tax incentives each year. The revenues foregone plus the current government health spending would be sufficient to cover the minimal public health package for all Malawians and would help tackle Malawi's disease burden. Every effort must be made, including improving transparency and revising laws, to curtail IFF and moderate tax incentives.

Economics and ethics of paediatric respiratory extra corporeal life support.

Extra corporeal membrane oxygenation (ECMO) is a form of life support, which facilitates gas exchange outside the body via an oxygenator and a centrifugal pumping system. A paediatric cardiac ECMO programme was established in 2005 at Our Lady's Children's Hospital, Crumlin (OLCHC) and to date 75 patients have received ECMO, the majority being post operative cardiac patients. The outcome data compares favourably with international figures. ECMO has been most successful in the treatment of newborn infants with life threatening respiratory failure from conditions such as meconium aspiration, respiratory distress syndrome and respiratory infections. There is no formal paediatric respiratory ECMO programme at OLCHC, or anywhere else in Ireland. Currently, neonates requiring respiratory ECMO are transferred to centres in Sweden or the UK at an average cost of 133,000 Euros/infant, funded by the Health Service Executive E112 treatment abroad scheme. There is considerable morbidity associated with the transfer of critically ill infants, as well as significant psycho-social impact on families. OLCHC is not funded to provide respiratory ECMO, although the equipment and expertise required are similar to cardiac ECMO and are currently in place. The average cost of an ECMO run at OLCHC is 65,000 Euros. There is now a strong argument for a fully funded single national cardiac and respiratory paediatric ECMO centre, similar to that for adult patients.

Epidemiology of major paediatric trauma.

In Europe injury is the leading cause of death in those aged between 1 and 14 years. In Ireland over 800,000 people are aged less than 14 years. There is currently no national trauma register to collect data on the morbidity and mortality associated with major trauma in the paediatric population in Ireland. We prospectively collected data on 153 patients admitted to our hospital with major trauma. There were 99 males and 54 females. The majority of patients were transported by ambulance (n= 138). Road traffic accidents (n=69) and thermal injuries (n=49) represented the majority of admissions. 68% (n=47) of the vehicle occupants in this study were either unrestrained or incorrectly restrained. Most patients (n=133) had an in patient stay of <50 days, with only 4 patients staying >100 days. 14 patients died. A paediatric trauma register as well as a level 1 paediatric trauma centre are required in Ireland.

A pilot study to determine if nurses trained in basic neonatal resuscitation would impact the outcome of neonates delivered in Kampala, Uganda.

AIMS AND OBJECTIVES: To determine if a team dedicated to basic neonatal resuscitation in the delivery ward of a teaching hospital would impact the outcome of neonates delivered in Kampala, Uganda. METHODS: A five-member team of nurses, trained in basic neonatal resuscitation attended 1046 deliveries over a thirty-one day pilot period. They were available in the delivery ward twenty-four hours each day. Outcomes studied included the number of stillbirths recorded on the delivery ward, the number of neonates admitted to the special care baby unit (SCBU), the number of babies admitted to SCBU who died and the mortality in the different weight categories. APGAR scores before and after intervention was also compared. Admission diagnoses between the two groups were also compared. Outcome data collected during this pilot period was compared with historic controls from the previous 31 days in the same unit. PATIENTS AND SETTING: A delivery ward, 22,000 deliveries per year. RESULTS: The stillbirth rate and admission rate to the SCBU were unchanged. Basic neonatal resuscitation in this setting decreased the incidence of asphyxia (defined as failure to initiate and sustain breathing or an APGAR score of <7 at 5 min), improved APGARS and a decrease in the mortality of babies weighing more than 2 kg. CONCLUSION: The resuscitation team reduced the incidence of and mortality from asphyxia and improved the outcome of babies greater than 2 kg. This pilot study provides evidence of the beneficial effect of basic neonatal resuscitation in this setting.

Home-based care for orphaned children infected with HIV/AIDS in Uganda.

The primary aim of this paper is to describe an outreach programme from a main state hospital in sub-Saharan Africa, which has been running for three years. This programme is based in Mulago Hospital, Kampala, Uganda and cares for up to 200 children infected with HIV/AIDS in their home. We describe the clinic and how we meet the families and enrol them, the infrastructure of the programme and the personnel involved. Children and their families receive physical, psychological and social care and we describe each aspect of this. The knowledge base about older children with AIDS in Africa is scarce and the secondary aim of this paper is to publish observations that were made while providing care. This includes demographics and the health problems encountered among children living with HIV/AIDS in a resource-poor setting who do not receive antiretroviral medication. Finally, we discuss the strengths and weaknesses of this model of care and the prerequisites to setting up a similar model.

Paediatric near-drowning: mortality and outcome in a temperate climate.

The decision whether to continue to resuscitate the paediatric victim of near-drowning is influenced by potential poor neurological outcome. A low core body temperature at presentation is frequently cited as a reason to continue resuscitation. We report the case of an 11 month old infant admitted to the intensive care unit following near-drowning and a prolonged resuscitation. The infant's core body temperature was 29 degrees C. Cardiac output was restored, but the child remains in a persistent vegetative state. We present the results of a ten year review of near-drowning in a tertiary referral institution, to evaluate the mortality and outcome in a temperate climate. Thirteen patients were identified in the review. The mortality was 23%. The incidence of a persistent vegetative state was 15%. Asystole, immersion time greater than 15 minutes, resuscitation time longer than 30 minutes, the administration of epinephrine, and a low core body temperature were associated with a poor outcome.

Shoshin beri-beri precipitated by intravenous glucose.

A thiamine deficient patient presented to the emergency department with an acute confusional state, becoming unconscious and hypotensive following the administration of 32 g of intravenous glucose over 4 hr. A dramatic clinical improvement in his cardiovascular and neurological status followed a single intra-venous dose of 250 mg of thiamine. Profound thiamine deficiency was confirmed on biochemical testing. A substantial proportion of hospital patients are thiamine deficient and intravenous dextrose may precipitate cardiovascular collapse and lactic acidosis due to the development of 'shoshin' beriberi. A rapid response to intravenous thiamine may confirm the diagnosis. All patients presenting with acute neurological dysfunction should receive thiamine before glucose-containing solutions are administered.

A case of pneumomediastinum in paediatric ARDS: to oscillate or not?

An 18-month-old was transferred (intubated and ventilated) to our hospital with staphylococcal tracheitis, which progressed to a necrotizing pneumonitis, complicated by surgical emphysema and pneumomediastinum. Maximum conventional ventilation on a Servo 300 failed. Treatment with high frequency oscillatory ventilation (for 10 days) with a permissive hypercarbia and hypoxaemia strategy to limit mean airway pressure facilitated recovery in our patient.

Evaluation of the effects of levobupivacaine on clotting and fibrinolysis using thromboelastography.

Amide local anaesthetics inhibit platelet function. We hypothesized that residual anaesthetic in the epidural space could decrease efficacy of an epidural blood patch in preventing postdural puncture headache. Levobupivacaine has recently been approved for epidural anaesthesia. Its effects on coagulation have not previously been studied. The aim of this study was to determine the effects of levobupivacaine on clotting using thromboelastography. Ten ASA Class I volunteers were studied. Venous blood samples were analysed using a Haemoscope 2000D TEG analyser. Whole blood, a 50% saline control and two levobupivacaine solutions (2.5 mg mL(-1) and 2.5 microg mL(-1) in blood) were compared. The former reproduces that produced in the epidural space by blood (20 mL for an epidural blood patch) and levobupivacaine 0.5% (20 mL). The latter approximates plasma concentrations following epidural injection of levobupivacaine 0.5% (20 mL). P < 0.05 was considered significant. Maximum amplitude (MA), a measure of clot strength, is decreased by levobupivacaine 2.5 mg mL(-1). Levobupivacaine 2.5 mg mL(-1) decreases clot strength and may reduce efficacy of a prophylactic epidural blood patch.

Comparison of exogenous surfactant and positive end-expiratory pressure therapies in a model of human breast milk-induced acute lung injury in rabbits.

To evaluate surfactant and positive end-expiratory pressure (PEEP) as potential therapies for the acute lung injury after tracheal instillation of 0.8 ml kg-1 human breast milk (HBM) acidified to pH 1.8, adult white rabbits were anaesthetized, tracheostomized, ventilated and randomized to (six rabbits per treatment): (i) no treatment after HBM (control); (ii) exogenous Bovine surfactant (100 mg kg-1) 1 h after HBM; (iii) PEEP-pre (0.5 kPa PEEP) before and after HBM; or (iv) PEEP-post (0.5 kPa PEEP) after HBM. A fifth group of six rabbits received no tracheal instillate (no aspirate). The alveolar to arterial oxygen tension gradient (A-aDO2) and dynamic compliance were measured pre-injury and hourly for 4 h. At post-mortem, the lungs were examined histologically. A-aDO2 in all four HBM-injured groups increased to a maximum at 1 h post-injury; A-aDO2 then returned towards the baseline in the surfactant and PEEP-post groups, but remained increased in the PEEP-pre and control groups. Dynamic compliance decreased in all four HBM-injured groups. A-aDO2 and compliance were unchanged in the no aspirate group. Bronchoalveolar architecture after surfactant therapy was normal. We conclude that surfactant is a more effective therapy for HBM-induced lung injury than either 0.5 kPa PEEP-post or PEEP-pre injury.

The effects of ropivacaine hydrochloride on coagulation and fibrinolysis. An assessment using thromboelastography.

Amide local anaesthetics impair coagulation by inhibition of platelet function and enhanced fibrinolysis. The potential therefore exists that the presence of amide local anaesthetics in the epidural space could contribute to the therapeutic failure of an epidural autologous blood patch. Ropivacaine is an aminoamide local anaesthetic increasingly used for epidural analgesia and anaesthesia, particularly in obstetric practice. This study was undertaken to investigate whether concentrations of ropivacaine in blood, which could occur clinically in the epidural space, alter coagulation or fibrinolysis. Thromboelastography was used to assess clotting and fibrinolysis of blood to which ropivacaine had been added. Although modest alterations in maximum amplitude, coagulation time and alpha angle were observed, the effect of ropivacaine on clotting and fibrinolysis was not clinically significant. We conclude that it is unlikely that the presence of ropivacaine in the epidural space would reduce the efficacy of an early or prophylactic epidural blood patch.

Acute lung injury after instillation of human breast milk into rabbits' lungs: effects of pH and gastric juice.

BACKGROUND: The authors compared the lung injury in rabbits that occurred after tracheal instillation of human breast milk (HBM) acidified to pH 1.8 with hydrochloric acid (HCl), HBM at its native pH (7.0), and HBM acidified with gastric juice to pH 1.8 and 3.0. METHODS: The alveolar-to-arterial oxygen tension gradient and dynamic compliance were recorded before and hourly for 4 h after intratracheal instillation of 0.8 ml/kg HBM acidified with HCI (pH 1.8), HBM at its native pH (7.0), HBM acidified with gastric juice (pH 1.8 or 3.0), or 5% dextrose solution acidified with gastric juice (pH 1.8) as a control in 30 adult rabbits. The circulating neutrophil count and phagocyte oxidant activity were determined before and 1 and 4 h after instillation. RESULTS: The alveolar-to-arterial oxygen tension gradient increased and dynamic compliance decreased significantly in all groups after instillation of HBM compared with baseline values and those in the control group. The severity of the lung injury after instillation of HBM at all pH values (1.8, 3.0, and 7.0) and after acidification with gastric juice or HCl was similar. The circulating neutrophil count increased steadily for 4 h after instillation (P < 0.013), whereas spontaneous phagocyte oxidant burst activity peaked at 1 h (P < 0.007) and returned to baseline by 4 h after instillation. CONCLUSIONS: The severity of the lung injury after tracheal instillation of 0.8 ml/kg HBM in rabbits is similar at pH values between 1.8 and 7.0 after acidification with HCl or gastric juice. Tracheal instillation of HBM increases the circulating neutrophil count and phagocyte oxidant burst activity.

Intra-ocular pressure changes following laryngeal mask airway insertion: a comparative study.

We compared the effects of the Brain laryngeal mask airway with a tracheal tube on intra-ocular pressure. Propofol was used as induction agent and atracurium as relaxant. Twenty-six patients with normal intra-ocular pressure undergoing cataract surgery were randomly allocated to two groups. Group A (n = 13) had a laryngeal mask airway inserted and Group B (n = 13) had a tracheal tube inserted. Intra-ocular pressure was measured just before insertion of the airway, 20 s after insertion and at 2 min. In the laryngeal mask airway group there were no significant changes in mean intra-ocular pressure. In the tracheal tube group there was a significant rise in mean intra-ocular pressure at 20 s (p = 0.0056) which returned to pre-insertion levels at 2 min. We conclude that the laryngeal mask airway continues to have advantages over the tracheal tube for ophthalmic surgery despite the use of propofol and atracurium as anaesthetic agents.