The effect of traditional healer intervention prior to allopathic care on pediatric burn mortality in Malawi.

INTRODUCTION: Burn injury is a significant contributor to mortality, especially in low and middle-income countries (LMICs). Patients in many communities throughout sub-Saharan Africa use traditional health practitioners for burn care prior to seeking evaluation at an allopathic burn center. The World Health Organization defines a traditional health practitioner as "a person who is recognized by the community where he or she lives as someone competent to provide health care by using plant, animal and mineral substances and other methods based on social, cultural and religious practices based on indigenous knowledge and belief system." The aim of this study is to determine the prevalence of prior traditional health practitioner treatment and assess its effect on burn injury mortality. METHODS: A retrospective analysis of the prospectively collected Kamuzu Central Hospital (KCH) Burn Surveillance Registry was performed from January 2009 through July 2017. Pediatric patients (<13 years) who were injured with flame or scald burns were included in the study and we compared groups based on patient or family reported use of traditional health practitioners prior to evaluation at Kamuzu Central Hospital. We used propensity score weighted multivariate logistic regression to identify the association with mortality after visiting a traditional healer prior to hospitalization. RESULTS: 1689 patients were included in the study with a mean age of 3.3 years (SD 2.7) and 55.9% were male. Mean percent total body surface area of burn was 16.4% (SD 12.5%) and most burns were related to scald injuries (72.4%). 184 patients (10.9%) used traditional medicine prior to presentation. Only a delay in presentation was associated with prior traditional health practitioner use. After propensity weighted score matching, the odds ratio of mortality after using a prior traditional health practitioner was 1.91 (95% CI 1.09, 3.33). CONCLUSION: The use of traditional health practitioners prior to presentation at a tertiary burn center is associated with an increased odds of mortality after burn injury. These effects may be independent of the potential harms associated with a delay in definitive care. Further work is needed to delineate strategies for integrating with local customs and building improved networks for burn care, especially in rural areas.

Correction to: Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

In the original article, Ziad C. Sifri's first and last names were interchanged. It is correct as reflected here.

Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

Global health is transitioning toward a focus on building strong and sustainable health systems in developing countries; however, resources, funding, and agendas continue to concentrate on "vertical" (disease-based) improvements in care. Surgical care in low- and middle-income countries (LMICs) requires the development of health systems infrastructure and can be considered an indicator of overall system readiness. Improving surgical care provides a scalable gateway to strengthen health systems in multiple domains. In this position paper by the Society of University Surgeons' Committee on Global Academic Surgery, we propose that health systems development appropriately falls within the purview of the academic surgeon. Partnerships between academic surgical institutions and societies from high-income and resource-constrained settings are needed to strengthen advocacy and funding efforts and support development of training and research in LMICs.

Efectividad de la tintura de propóleos al 10 % en pacientes con estomatitis subprótesis / Effectiveness of 10 % propolis tinction in patients with subprosthesis stomatitis

Se efectuó un estudio de intervención terapéutica en 50 pacientes con estomatitis subprótesis, quienes acudieron a la consulta de prótesis de la Clínica Estomatológica Ramón Guevara Montano de Baracoa, provincia de Guantánamo, desde abril del 2015 hasta junio del 2016, con vistas a determinar la efectividad del tratamiento con tintura de propóleos al 10 por ciento en los afectados. Se conformaron 2 grupos: uno de estudio (A) y otro de control (B), con 25 integrantes cada uno; el primero fue tratado con propóleos y el segundo con medicina alopática (nistatina en suspensión). La evaluación se realizó a los 4, 8 y 12 días. Al finalizar la terapia se observó que en 100,0 por ciento de los pacientes del grupo A se eliminó la lesión; por tanto, esta alternativa terapéutica resultó efectiva. Se recomendó extender dicha aplicación a otras afecciones bucales.

A study of therapeutic intervention was carried out in 50 patients with subprosthesis stomatitis who went to the Prosthesis department of "Ramón Guevara Montano" Stomatological Clinic in Baracoa, Guantánamo province, from April, 2015 to June, 2016, aimed at determining the effectiveness of the treatment with 10 percent propolis tinction in the affected patients. Two groups were formed: a study group (A) and a control group (B), with 25 members each; the first one was treated with propolis tinction and the second with allopathic medicine (nystatin in suspension). The evaluation was carried out at 4.8 and 12 days. When concluding the therapy it was observed that in 100.0 percent of the patients of the group A the lesion was eliminated; therefore, this therapeutic alternative was effective. It was recommended to extend this procedure to other oral disorders.

Analysis of 334 Cases of Pediatric Esophageal Foreign Body Removal Suggests that Traditional Methods Have Similar Outcomes Whereas a Magnetic Tip Orogastric Tube Appears to Be an Effective, Efficient, and Safe Technique for Disc Battery Removal.

Procedures and outcomes for pediatric esophageal foreign body removal were analyzed. Traditional methods of battery removal were compared with a magnetic tip orogastric tube (MtOGT). A single institution retrospective review from 1997 to 2014 of pediatric patients with esophageal foreign bodies was performed. Balloon extraction with fluoroscopy (performed in 173 patients with 91% success), flexible endoscopy (92% success in 102 patients), and rigid esophagoscopy (95% in 38 patients) had excellent success rates. A MtOGT had 100 per cent success in six disc battery patients, when other methods were more likely to fail, and was the fastest. Power analysis suggested 20 patients in the MtOGT group would be needed for significant savings in procedural time. Thirty-two per cent of all foreign bodies and 95 per cent of batteries had complications (P = 0.002) because of the foreign body. Overall, 1.2 per cent had severe complications, whereas 10 per cent of batteries had severe complications (P = 0.04). Each technique if applied appropriately can be a reasonable option for esophageal foreign body removal. Magnetic tip orogastric tubes used to extract ferromagnetic objects like disc batteries had the shortest procedure time and highest success rate although it was not statistically significant. Disc batteries require emergent removal and have a significant complication rate.

The Utility of Local Anesthesia for Neurosurgical Interventions in a Low-Resource Setting: A Case Series.

INTRODUCTION: Trauma is a major contributor to global morbidity and mortality, and injury to the central nervous system is the most common cause of death in these patients. While the provision of surgical services is being recognized as essential to global public health efforts, specialty areas such as neurosurgery remain overlooked. METHOD: This is a retrospective case review of patients with operable lesions, such as extra-axial hematomas and unstable depressed skull fractures that underwent neurosurgical interventions under local anesthesia. RESULTS: A total of 13 patients underwent neurosurgical intervention under local anesthesia. Two and three patients with burr hole decompression of epidural and subdural hematomas, respectively; seven patients had elevation of depressed skull fractures and lastly one patient had an aspiration of a brain abscess. All patients survived with and without residual neurological deficits. CONCLUSION: Access to resources and staff required to deliver general anesthesia is challenging in resource-poor settings. We have therefore begun performing emergent interventions under local anesthesia, with or without conscious sedation. While some patients had some minor residual weakness after the procedure, the degree of neurological deficit was improved from that observed before the procedure in all patients.

The effect of incentive spirometry on postoperative pulmonary function following laparotomy: a randomized clinical trial.

IMPORTANCE: Changes in pulmonary dynamics following laparotomy are well documented. Deep breathing exercises, with or without incentive spirometry, may help counteract postoperative decreased vital capacity; however, the evidence for the role of incentive spirometry in the prevention of postoperative atelectasis is inconclusive. Furthermore, data are scarce regarding the prevention of postoperative atelectasis in sub-Saharan Africa. OBJECTIVE: To determine the effect of the use of incentive spirometry on pulmonary function following exploratory laparotomy as measured by forced vital capacity (FVC). DESIGN, SETTING, AND PARTICIPANTS: This was a single-center, randomized clinical trial performed at Kamuzu Central Hospital, Lilongwe, Malawi. Study participants were adult patients who underwent exploratory laparotomy and were randomized into the intervention or control groups (standard of care) from February 1 to November 30, 2013. All patients received routine postoperative care, including instructions for deep breathing and early ambulation. We used bivariate analysis to compare outcomes between the intervention and control groups. INTERVENTION: Adult patients who underwent exploratory laparotomy participated in postoperative deep breathing exercises. Patients in the intervention group received incentive spirometers. MAIN OUTCOMES AND MEASURES: We assessed pulmonary function using a peak flow meter to measure FVC in both groups of patients. Secondary outcomes, such as hospital length of stay and mortality, were obtained from the medical records. RESULTS: A total of 150 patients were randomized (75 in each arm). The median age in the intervention and control groups was 35 years (interquartile range, 28-53 years) and 33 years (interquartile range, 23-46 years), respectively. Men predominated in both groups, and most patients underwent emergency procedures (78.7% in the intervention group and 84.0% in the control group). Mean initial FVC did not differ significantly between the intervention and control groups (0.92 and 0.90 L, respectively; P=.82 [95% CI, 0.52-2.29]). Although patients in the intervention group tended to have higher final FVC measurements, the change between the first and last measured FVC was not statistically significant (0.29 and 0.25 L, respectively; P=.68 [95% CI, 0.65-1.95]). Likewise, hospital length of stay did not differ significantly between groups. Overall postoperative mortality was 6.0%, with a higher mortality rate in the control group compared with the intervention group (10.7% and 1.3%, respectively; P=.02 [95% CI, 0.01-0.92]). CONCLUSIONS AND RELEVANCE: Education and provision of incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. We would not recommend the addition of incentive spirometry to the current standard of care in this resource-constrained environment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01789177.