Surgical management of extrahepatic portal vein obstruction in children: advantages of MesoRex shunt compared with distal splenorenal shunt.

PURPOSE: To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children's Hospital and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS). METHODS: This is a single-centre retrospective review documenting pre- and post-operative data in 21 children. Twenty-two shunts were performed, 15 MRS and 7 DSRS, over an 18-year period. Patients were followed up for a mean of 11 years (range 2-18). Data analysis included demographics, albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalised ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets before the operation and 2 years after shunt surgery. RESULTS: One MRS thrombosed immediately post-surgery and the child was salvaged with DSRS. Variceal bleeding was controlled in both groups. Significant improvements were seen amongst MRS cohort in serum albumin, PT, PTT, and platelets and there was a mild improvement in serum fibrinogen. The DSRS cohort showed only a significant improvement in the platelet count. Neonatal umbilic vein catheterization (UVC) was a major risk for Rex vein obliteration. CONCLUSION: In EHPVO, MRS is superior to DSRS and improves liver synthetic function. DSRS does control variceal bleeding but should only be considered when MRS is not technically feasible or as a salvage procedure when MRS fails.

Cross-cultural validation of the Itch Man Scale in pediatric burn survivors in a South African setting.

INTRODUCTION: Pruritus or itch is a common symptom after burn injuries. The Itch Man Scale has been recommended to assess itch severity in children. The aim of this prospective observational study was to perform a cross-cultural validation of the Itch Man Scale by comparing it with the Numeric Rating Scale (NRS) and the Toronto Pediatric Itch Scale. METHOD: At Red Cross War Memorial Children's Hospital in Cape Town, South Africa, parents of pediatric burn patients assessed their child's itch with the Itch Man Scale, NRS and Toronto Pediatric Itch Scale. Children from the age of 6years also rated the Itch Man Scale and NRS themselves. The Spearman rank order correlation between the different scales was calculated to determine construct validity. RESULTS: Over a two-month period, 255 pediatric burn survivors with a median age of 2.3years (IQR 1.4-4.0) were included; 35 of them were aged 6-13years. Parents' Itch Man Scale ratings correlated significantly with parents' NRS ratings (0.82, 95% CI 0.78-0.86) and with the Toronto Pediatric Itch Scale of the parent (0.80, 95% CI 0.75-0.84). The correlation between the older children's Itch Man Scale rating and those of their parents was 0.66 (95% CI 0.37-0.83). CONCLUSION: We concluded that the Itch Man Scale has promising validity and is a user-friendly tool to use in clinical practice to determine the itch intensity in children younger than 13years in a South African setting.

The Effect of Electrical Load Shedding on Pediatric Hospital Admissions in South Africa.

BACKGROUND: South Africa faced repeated episodes of temporary power shutdowns, or load shedding, in 2014/2015. The effect of load shedding on children's health is unknown. METHODS: We determined periods of load shedding using Twitter, Facebook, and data from the City of Cape Town. We obtained the number of unscheduled hospital admissions between June 2014 and May 2015 from Red Cross Children's Hospital, Cape Town, and weather data from the South African Weather Service. We used quasi-Poisson regression models to explore the relationship between number of hospital admissions and load shedding, adjusted for season, weather, and past admissions. Based on assumptions about the causal process leading to hospital admissions, we estimated the average treatment effect, that is, the difference in expected number of admissions per day had there been load shedding each day or on any of the preceding 2 days compared with if there had not been any load shedding. RESULTS: We found a 10% increase (95% confidence interval: 4%, 15%) in hospital admissions for days where load shedding was experienced on the same day, or no more than 2 days prior, compared with when there was no load shedding in the past 2 days. The increase was more pronounced during weekdays (12% [7%, 18%] vs. 1% [-9%, 11%]), and for specific diagnoses (e.g., respiratory system: 14% [2%, 26%]). The average treatment effect was estimated as 6.50 (5.12, 7.87) highlighting that about 6 additional admissions a day could be attributed to load shedding. CONCLUSIONS: The association we measured is consistent with our hypothesis that failures of the power infrastructure increase risk to children's health. See video abstract at, http://links.lww.com/EDE/B409.

Acceptability and functionality of the "Kettle Strap": An attempt to decrease kettle related burns in children.

BACKGROUND: Extensive hot water burns (HWB) are common at Red Cross War Memorial Children's Hospital (RCWMCH). The majority are caused by kettle scalds. These burn injuries usually affect toddlers living in poor socio-economic circumstances. The majority of these injuries are preventable. AIM: This trial aims to demonstrate the acceptability and functionality of the Kettle Strap as a kettle safety device. The feedback will be used for a public awareness program marketed by the Child Accident Prevention Foundation of Southern Africa and ChildSafe as part of their mandate to reduce kettle related thermal injuries. METHODS: 50 caregivers of children at RCWMCH were given a Kettle Strap for use in their homes, 25 with kettle related burns (Group I) and 25 who had no history of burns (Group II). All participants were instructed on Kettle Strap installation and use. Telephonic interviews on the acceptability and functionality of the strap occurred 1 month and 1 year later. RESULTS: The average age in Groups I and II was 25 and 22 months respectively. In Group I, the average burn surface area was 15%. Nineteen (76%) of the accidents occurred in the kitchen. Eighteen (72%) received immediate first aid. Twelve (48%) in Group I and 15 (60%) in Group II lived in formal housing. The majority of caregivers (90%) indicated that installation was quick and easy and thought that the Kettle Strap would prevent kettle burns. At 1 month follow-up, all the participants in Group I indicated that they would continue using the apparatus and felt greater protection compared to 84% of Group II. Only 40% indicated that use of the Kettle Strap raised awareness of other possible household dangers. Thirty participants were available telephonically after 1 year, 22 of these were still using the device, others had moved or lost their homes to fire. All participants had informed neighbors about the Kettle Strap and burn safety. The participants were prepared to pay ZAR 44 for the complete apparatus. CONCLUSION: The Kettle Strap is an acceptable, affordable device to improve kettle safety in the home.

The history of the formation of the Pan African paediatric surgical Association (PAPSA).

Political change in the 1990s in Southern Africa influenced the long awaited formation of a children's surgical association in Africa. Here, within is the historical account of the formation of the Pan African Association of Paediatric Surgeons (PAPSA). The basis of the argument for the formation of PAPSA was that paediatric surgeons from Africa have a wealth of experience and special knowledge of diseases affecting children in the African continent which differ substantially from those encountered in other regions of the world. This historical account is mainly from documentation by 2 of the organisations founding members.

Post burn pruritus in pediatric burn patients.

BACKGROUND: Pruritus is a common problem seen in the healing process of a burn wound and gives great discomfort for the patient. Most research in this field has been done in the adult population, so evidence in the pediatric population is still lacking PURPOSE: The aims of this study were to assess the incidence and severity of post-burn pruritus, identify predictors for pruritus and evaluate the pharmacological treatments in a pediatric setting. METHODS: Pruritus was assessed in this prospective observational study using a numeric rating scale and the Itch Man Scale applied by the patients' caregiver. The predictive values of candidate predictors for pruritus were compared using Fisher exact tests and Kruskal-Wallis tests. RESULTS: 413 patients were included in this study. Pruritus was reported in 71.7% of the patients. Complete symptom relief was only achieved in 29.8% of the patients who used medication. Time since burn (p<0.001), depth of the injury (p=0.017), TBSA burned (p=0.001) and skin grafting (p=0.001) were found to be significant predictors for post-burn pruritus. CONCLUSION: Post-burn pruritus is still a highly prevalent problem in pediatric burn care. Its intensity and frequency are higher especially in the first three months or with a deeper wound or a higher TBSA.

Can live music therapy reduce distress and pain in children with burns after wound care procedures? A randomized controlled trial.

OBJECTIVE: Burn wound care procedures are very painful and lead to distress. Live music therapy has shown beneficial effects on distress and pain in specific pediatric patient populations. In this study we measured whether live music therapy has beneficial effects in terms of less distress and pain in children with burns after wound care procedures. METHODS: This randomized assessor-blinded controlled trial (RCT) took place at the burns unit of the Red Cross War Memorial Children's Hospital, Cape Town, South Africa. It included newly admitted inpatients between the ages of 0 and 13 years undergoing their first or second wound care procedures. Excluded were children with a hearing impairment or low level of consciousness. The intervention group received one live music therapy session directly after wound care in addition to standard care. The control group received standard care only. The primary outcome was distress measured with the Observational Scale of Behavioral Distress-revised (OSBD-r). The secondary outcome was pain measured with the COMFORT-behavioral scale (COMFORT-B). In addition, in children older than 5 years self-reported distress with the validated Wong-Baker scale (FACES) and pain with the Faces Pain Scale-Revised (FPS-R) were measured. Patients in both groups were videotaped for three minutes before wound care; during the music therapy or the control condition; and for two minutes thereafter. Two researchers, blinded to the study condition, independently scored the OSBD-r and the COMFORT-B from the video footage before and after music therapy. RESULTS: We included 135 patients, median age 22.6 months (IQR 15.4-40.7 months). Change scores did not significantly differ between the intervention and the control groups for either distress (p=0.53; d=0.11; 95% CI -0.23 to 0.45) or pain (p=0.99; d=0.04; 95% CI -0.30 to 0.38). Self-reported distress in a small group of children (n=18) older than 5 years indicated a significant reduction in distress after live music therapy (p=0.05). CONCLUSIONS: Live music therapy was not found effective in reducing distress and pain in young children after burn wound care. Older children might be more responsive to this intervention.

Pediatric surgeon density in South Africa.

BACKGROUND: There are limited data regarding the available pediatric surgical workforce in South Africa and their employment prospects on completion of their specialist training. METHODS: This aim of this study was to quantify and analyze the pediatric surgical workforce in South Africa as well as to determine their geographic and sector distribution. This involved a quantitative descriptive analysis of all registered specialist as well as training pediatric surgeons in South Africa. RESULTS: The results showed 2.6 pediatric surgeons per one million population under 14 years. More than half (69%) were male and the median age was 46.8 years. There were however, more female surgical registrars currently in training. The majority of the pediatric surgical practitioners were found in Gauteng, followed by the Western Cape and Kwa-Zulu Natal. The majority of specialists reportedly worked in the public sector, however the number of public sector pediatric surgeons available to those without health insurance fell below those available to private patients. CONCLUSION: Interprovincial differences as well as intersectoral differences were marked indicating geographic and socioeconomic maldistribution of pediatric surgeons. Addressing this maldistribution requires concerted efforts to expand public sector specialist posts. STUDY TYPE: Descriptive audit LEVEL OF EVIDENCE: IV.

Massage has no observable effect on distress in children with burns: A randomized, observer-blinded trial.

IMPORTANCE: In a previous observational study we found that massage therapy reduced anxiety and stress in pediatric burn patients. We aimed to test this effect in a randomized controlled trial. OBJECTIVE: To determine whether (1) aromatherapy massage can provide relaxation to hospitalized children with burns; (2) massage with aromatherapy oil is more effective than without; and (3) massage sessions are more effective when repeated. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled clinical trial with 3 arms conducted in a burns unit from April 2013 to December 2014 in Cape Town, South Africa. INTERVENTIONS: Massage with carrier oil, massage with aromatherapy oil, and standard nursing care only. MAIN OUTCOMES AND MEASURES: Scores on the Muscle Tension Inventory (MTI) and Behavioral Relaxation Scale (BRS) to assess level of relaxation. Scores on the COMFORT behaviour scale and Numeric Rating Scale Distress to assess level of distress. Secondary outcomes were heart rate and oxygen saturation levels. Linear mixed models were used to determine the effect of condition and session number (1 to a maximum of 5 sessions per child) correcting for baseline outcomes of COMFORT behaviour scores and heart rates after sessions. Secondary analyses included the addition of sex, age, and total body surface area (TBSA) burned as covariates. RESULTS: We included 284 children aged 5 weeks to 13 years with TBSA burned between 10 and 45%. Two-thirds (65.5%) were under the age of 3 years. Mixed model analyses revealed no significant difference in reduction of COMFORT behavior scores (p=0.18), or heart rates (p=0.18) between the three study arms. These outcomes were also not associated with the session number (p=0.92 and p=0.13, respectively). Level of relaxation could not be reliably assessed with the MTI and BRS because 119 patients (41.9%) had bandages covering the larger part of the face, and in 40.1% of cases the child was not in the required position. CONCLUSION AND RELEVANCE: Massage therapy with or without essential oil was not effective in reducing distress behavior or heart rate in hospitalized children with burns. Evaluating the effectiveness of massage in terms of relaxation proved difficult in young children. TRIAL REGISTRATION: The Netherlands National Trial Registry: NRT3929.

Assessing and addressing the problem of pain and distress during wound care procedures in paediatric patients with burns.

OBJECTIVE: While the prevalence of burns in children is highest in low and middle-income countries, most research on burn-related pain intensity and distress is carried out in high-income countries. In this study we assessed pain intensity and distress in paediatric patients with burns undergoing wound care procedures without distraction and parental presence in a South-African children's hospital and sought to identify predictors for the outcomes. METHODS: This observational study, carried out as part of a randomized controlled trial, took place at a burns unit in Cape Town, South Africa and included patients between the ages of 0 and 13 years undergoing their first or second wound care procedure. We measured pain intensity and distress using the COMFORT Behavioural scale (COMFORT-B) across four distinct phases of wound care procedures: removal of bandage; washing the wound; administering wound care; putting on new dressings. COMFORT-B scores ≥21 indicate severe pain intensity and distress. RESULTS: 124 patients were included, median age 21.2 months (IQR 14.9-39.5 months), 90% suffered scalds, and median total body surface 8% (IQR 5-14%). Assessment scores for the majority of patients were indicative of severe pain intensity and distress during wound care procedures. Median COMFORT-B scores across the four phases were 24, 25, 25 and 22 respectively. Across the four phases respectively 76%; 89%; 81% and 62% of the patients were indicated with severe pain intensity and distress. Age was a predictor for pain intensity and distress as younger children were assigned higher scores than older children (Unstandardized B -.052; 95% CI -.071 to -.032 p<0.001). CONCLUSIONS: In this study children received wound care procedures without distraction or parental presence and were assessed to have high pain intensity and distress. There is a correlation between age and COMFORT-B scores: younger children show higher distress, indicating a great need for better pain and distress control during wound care procedures. It is difficult to identify whether pain or distress is the specific primary cause for the high COMFORT-B scores.

Adherence to Referral Criteria at Admission and Patient Management at a Specialized Burns Centre: The Case of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa.

Referral guidelines for burn care are meant to assist in decision-making as regards patient transfer and admissions to specialized units. Little is known, however, concerning how closely they are followed and whether they are linked to patient care. This is the object of the current study, focused on the paediatric burns centre of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. All patients admitted to the centre during the winters of 2011-2015 (n = 1165) were included. The patient files were scrutinized to clarify whether the referral criteria in place were identified (seven in total) and to compile data on patient and injury characteristics. A case was defined as adherent to the criteria when at least one criterion was fulfilled and adherence was expressed as a percentage with 95% confidence intervals, for all years aggregated as well as by year and by patient or injury characteristics. The association between adherence to any individual criterion and hospital care (surgery or longer length of stay) was measured using logistic regressions. The overall adherence was 93.4% (100% among children under 2 years of age and 86% among the others) and it did not vary remarkably over time. The two criteria of "injury sustained at a specific anatomical site" (85.2%) and "young age" (51.9%) were those most often identified. Children aged 2 years or older were more likely to undergo surgery or to stay longer than those of young age (although a referral criterion) and so were those with higher injury severity (a referral criterion). In this specialized paediatric burns centre, children are admitted mainly according to the guidelines. However, given the high prevalence of paediatric burns in the region and the limited resources at the burns centre, adherence to the guidelines need to be further studied at all healthcare levels in the province.

Total body and hand surface area: Measurements, calculations, and comparisons in ethnically diverse children in South Africa.

AIM: The aim was to investigate hand surface as a percentage of body surface area from infancy to 13 years of age using physical measurement and digital planimetry and establish the influence of age, gender, BMI for age and ethnicity, specifically in the South African population. A secondary aim included the development of a template for burn size measurement. METHODOLOGY: This was a cross-sectional observational study. Demographic information was obtained from each participant. Body mass index (BMI) and body surface area (BSA) were determined using several established formulas. The hand area was measured using a standard physical measurement method and a digital planimetry method. All data was presented in an Excel and SPSS spreadsheet and the calculations performed with SPSS 24.0. RESULTS: Three-hundred and sixty-eight burn patients and 150 children from a nearby primary school were enrolled. The age ranged from 1 month to 13 years. The hospital patient group was significantly younger, included more boys and had a lower BMI by age. Most patients (98.7%) were African or mixed race compared to the school children who were primarily Caucasian (p<0.001). The seven formulas to determine the BSA were highly comparable with Intraclass correlation coefficient (ICC) of 0.997 (95% CI 0.996-0.998). Actual hand surface area measured ranged from 22.44cm2 to 164.9cm2. The mean measured and digital percentage HSA of TBSA for all participants was 0.929% with a SD of 0.088. Male children, had a larger HSA as a proportion of TBSA by 0.036%. Generally, as the child gets older from toddler to late childhood, the hand becomes relatively smaller by a factor of approximately 0.08%. As the BMI increased, the hand got relatively smaller. CONCLUSION: The potential value of the physical measurement method is that it lends itself to direct measurement during examination of the burnt child. The study showed that there are minor differences between racial groups, gender, BMI and age variations. The clinical relevance of these variations is negligible.

'Getting under our skin': Introducing banked allograft skin to burn surgery in South Africa.

Deceased donor skin possesses many of the properties of the ideal biological dressing, and a well-stocked skin bank has become a critically important asset for the modern burn surgeon. Without it, managing patients with extensive burns and wounds becomes far more challenging, and outcomes are significantly worse. With the recent establishment of such a bank in South Africa, the challenge facing the medical fraternity is to facilitate tissue donation so that allograft skin supply can match the enormous demand.

Parent knowledge on paediatric burn prevention related to the home environment.

INTRODUCTION: Burns amongst children in South Africa are common and usually occur in the immediate home environment. In surveys many parents have requested ongoing educational burn prevention programs. This exploratory thematic parent orientation study assessed the level of parental knowledge on burn prevention strategies in the home. METHODS: Study populations included: Parent with a burned child admitted to hospital, parents of non-burnt hospital attenders and hospital naive parents unbiased by previous exposure to burns. Participants answered a burn prevention questionnaire consisting of five sections. In this, two pictures depicting the circumstances associated with paediatric burns sustained at home were used, one with 15 potential danger points and one sanitized. There was no educational intervention prior to parents viewing the pictures. RESULTS: There were 268 participants; 72 burnt inpatient, 97 non-burnt outpatients and 99 hospital naive participants. The inpatient population displayed the highest incidence of informal housing. A positive relationship was identified between the overall study population and burns general knowledge and prevention. Educated participants were more knowledgeable about burns and better at identifying risk factors. Knowledge about burns was higher in the outpatient population and the highest in the Naïve group when compared to the Inpatients group (p<0.01). The naïve group scored higher in prior knowledge about burns and burn prevention. Of the potential 15 danger points only four of 72 inpatients and three of 97 outpatients identified more than 80% of the potential danger points as compared to 43 of 99 of the naïve group. The dangling kettle cord, the use of a mug to pour paraffin into a lantern and the child pulling a tablecloth were the most common dangerous aspects identified. We demonstrated a positive correlation between participants' ability to identify potential dangers, identify safe practice and implementing safe practice. CONCLUSION: Our findings show that people living in environments optimal for burn incidents know relatively little about burn prevention strategies. Future intervention needs to not only target the population's behavior but most importantly needs to promote better education models.

The case of the exploding egg.

The vast majority of paediatric burns occur in developing countries, and many of these injuries are entirely preventable. In general, four paediatric injury patterns have been identified in toddlers and infants, who are at a significantly increased risk of burn injuries. Children <2 years of age are often innocent bystanders, but as they grow older physical mobility, social independence and gender-specific high-risk activities come into play.

Biofilms associated with bowel necrosis: A newly recognised phenomenon in infants.

BACKGROUND: A biofilm is defined as a collection of organisms attached to a surface and surrounded by a matrix. OBJECTIVE: To present three cases in which bowel necrosis coexisted with biofilm. METHODS: The medical records, bacteriological findings and tissue biopsies from three infants with bowel necrosis who subsequently died from sepsis were analysed. Tissue sent for histological evaluation was prepared for light microscopy. Haematoxylin and eosin (H&E), Sandiford and Alcian blue/periodic acid Schiff (ABPAS) stains were performed. Tissue samples were ex-waxed for electron microscopy in one case. RESULTS: The three patients described all had necrotic bowel at laparotomy, all cultured Klebsiella pneumoniae from peritoneal pus swabs, and all died despite appropriate antibiotics. All specimens showed varying degrees of bowel necrosis and an organising acute peritoneal reaction. In addition, all showed colonies of Gram-negative bacteria within a mucopolysaccharide matrix. CONCLUSIONS: The identification of biofilms in necrotic bowel has raised questions regarding their clinical implications. Further studies are needed to evaluate all resected necrotic bowel for biofilms and the clinical implications of this finding.

Burn surgeons in South Africa: A rare species.

BACKGROUND: The high burden of burn injuries in South Africa (SA) requires surgeons skilled in burn care. However, there are few dedicated burn surgeons and properly equipped units or centres. OBJECTIVES: To quantify the involvement of surgeons in burn care in SA hospitals, identify factors that attract surgeons to pursue burn care as a career and deter them from doing so, and understand the challenges of hospitals treating burn patients around the country. METHODS: This was a prospective, qualitative study. Questionnaires were handed out at the South African Burn Society Congress in September 2013 and a trade symposium in March 2014. RESULTS: One hundred questionnaires were handed out, and there was a 70% response rate. Twenty-six (39%) of the respondents had a specialist surgical qualification. Only half the units had registrars (48%) and interns (51%) on their staff. Only 30% of the respondents were dedicated to burn care alone, the majority being involved on a part-time basis. The most common factor respondents suggested was needed to recruit future burn care providers, cited by 76%, was better facilities and resources. Other factors included training and skills development (59%), subspecialist training (55%), development of a diploma in burn care (52%), development of research (52%) and healthcare worker psychological support (45%). DISCUSSION: We have demonstrated that current workforce resources for burn care are inadequate, the major deficit being lack of training and the resource-restricted environment. This survey provides basic information towards workforce planning, which can be used to inform the necessary strategic decisions.

Acticoat™ stimulates inflammation, but does not delay healing, in acute full-thickness excisional wounds.

Acticoat™ has antimicrobial and anti-inflammatory effects which aid wound healing. However, in vitro studies indicate that Acticoat™ is cytotoxic and clinical and in vivo studies suggest that it may delay healing in acute wounds. Therefore, this study investigated the effects of Acticoat™ on healing in acute full-thickness excisional wounds. Using a porcine model, healing was assessed on days 3, 6, 9 and 15 post-wounding. Five wounds dressed with Acticoat™ and five wounds dressed with polyurethane film (control) were assessed per day (n = 40 wounds). The rate of healing, inflammatory response, restoration of the epithelium and blood vessel and collagen formation were evaluated. No difference was found in the rate of healing between wounds treated with Acticoat™ and the control wounds. Inflammation was increased in Acticoat™-treated wounds on day 3 post-wounding compared to the control wounds. However, by day 15 post-wounding, the epithelium of the Acticoat™-treated wounds closely resembled normal epithelium. Acticoat™-treated wounds also contained a higher proportion of mature blood vessels, and differences in collagen deposition were apparent. Despite inducing an inflammatory response, Acticoat™ did not delay healing in acute wounds. Conversely, the improved quality of the epithelium and blood vessels within Acticoat™-treated wounds indicates that Acticoat™ has a beneficial effect on healing.