Surgically avertable burden of obstetric conditions in low- and middle-income regions: a modelled analysis.

OBJECTIVE: To quantify the burden of maternal and neonatal conditions in low- and middle-income countries (LMICs) that could be averted by full access to quality first-level obstetric surgical procedures. DESIGN: Burden of disease and epidemiological modelling. SETTING: LMICs from all global regions. POPULATION: The entire population in 2010. METHODS: We included five conditions in our analysis: maternal haemorrhage; obstructed labour; obstetric fistula; abortion(1) ; and neonatal encephalopathy. Demographic and epidemiological data were obtained from the Global Burden of Disease 2010 study. We split the disability-adjusted life years (DALYs) of these conditions into surgically 'avertable' and 'non-avertable' burdens. We applied the lowest age-specific fatality rates from all global regions to each LMIC region to estimate the avertable deaths, assuming that the differences of death rates between each region and the lowest rates reflect the gap in surgical care. MAIN OUTCOME MEASURES: Deaths and DALYs avertable. RESULTS: Of the estimated 56.6 million DALYs (i.e. 56.6 million years of healthy life lost) of the selected five conditions, 21.1 million DALYs (37%) are avertable by full coverage of quality obstetric surgery in LMICs. The avertable burden in absolute term is substantial given the size of burden of these conditions in LMICs. Neonatal encephalopathy constitutes the largest portion of avertable burden (16.2 million DALYs) among the five conditions, followed by abortion (2.1 million DALYs). CONCLUSIONS: Improving access to quality surgical care at first-level hospitals could reduce a tremendous burden of maternal and neonatal conditions in LMICs.

Meningococcal septicaemia complications involving skin and underlying deeper tissues--management considerations and outcome.

OBJECTIVE: To describe surgical experience with purpura fulminans related to meningococcaemia in a single institution, and to suggest a management protocol. METHODS: A retrospective review was done of patients admitted to the intensive care unit at Red Cross War Memorial Children's Hospital in Cape Town with the clinical diagnosis of purpura fulminans. RESULTS: During a 28-year period (1977-2005) 112 children (average age 3.4 years) were treated for meningococcaemia with purpura fulminans. Overall mortality was 10.7%. Local treatment consisted of measures to improve circulation, infection control and healing of necrotic tissue. Demarcation of necrotic areas was evident at 5.5 days and the average area of skin necrosis was 14% total body surface area (range 2-85%). The lower limbs were predominantly affected. Purpura fulminans resolved in 35 children (31.2%) without skin necrosis. Skin grafting was required in 77 children (68.8%). Factors associated with a poor outcome for peripheral extremity salvage were progressive irreversible skin changes, early disappearance of distal pulses, tense cold swollen extremities and intense pain on passive movement of the affected extremity. Amputations were performed proximal to the area of necrosis, on average 27 days after injury. CONCLUSIONS: Meningococcaemia is a disease with potentially devastating consequences. Early surgical consultation is essential. Skin- and soft-tissue-releasing incisions should be considered early to reduce the incidence of extremity necrosis. Small necrotic areas usually separate spontaneously with secondary healing or can be excised and sutured. Larger necrotic areas should be excised only after demarcation has been established, and can be covered with delayed skin grafting. Amputation should be conservative but may require revision.

Paediatric burn injuries in Sub Saharan Africa--an overview.

Paediatric burn injuries in Sub Saharan Africa are common and often lead to devastating consequences. Unfortunately relevant and accurate data regarding these injuries is sketchy and incomplete. This paper reviews the available information on the epidemiology of paediatric burns in Africa, associated health problems and contributing environmental factors responsible for these burns. The current status of burn care, the lack of infrastructure, and traditional methods of treatment, further contribute to the unsatisfactory status of overall burn management, prevention, and rehabilitation of burn survivors. A strategy for improving burn care in Africa has been formulated. The management of childhood burns will only be successful if educational, social, fiscal and infrastructure standards are improved. Traditional beliefs and methods cannot be discarded as they play an important role in the management of these children. It is furthermore essential that local and central government organisations support these initiatives. Clearly, the children of Africa deserve better burn care.

The effects of war on children in Africa.

There is no doubt that the effects of war extend to the most vulnerable members of society, including children. Although armed conflicts occur throughout the world, the African continent seems to be a particular background for civil and international wars. The aim of this study was to identify causes of conflict in Africa and to evaluate the effect of war on children and their health in order to make practical recommendations to health care workers dealing with children in the setting of war. All articles written in the past 5 years concerning "war" and "children" were identified by means of a literature search and internet review. Contrary to common belief, the causes of conflict are complicated and multi-factorial. The effects of war on childhood are disastrous and include severe negative effects on general paediatric health status. Short-term recommendations for health care workers working with children in war include supply of emergency medical infrastructures, basic health care, rehabilitation and education. Long-term recommendations include orchestrating the relief and support efforts from both national governments and international non-profit organisations and speeding up of economic recovery. The causes of conflict in Africa are complex and unlikely to be resolved soon. The effects of war on children are horrendous in many ways, but can be limited by providing timely and appropriate health care.

Surgical services for children in developing countries.

There is growing evidence that childhood surgical conditions, especially injuries, are common in developing countries and that poor care results in significant numbers of deaths and cases of disability. Unfortunately, however, surgical care is not considered an essential component of most child health programmes. Strategies for improving paediatric surgical care should be evidence-based and cost-effective and should aim to benefit the largest possible number of children. The most likely way of achieving policy change is to demonstrate that childhood surgical conditions are a significant public health problem. For paediatric purposes, special attention should also be given to defining a cost-effective package of surgical services, improving surgical care at the community level, and strengthening surgical education. Surgical care should be an essential component of child health programmes in developing countries.

Pediatric surgery in sub-Saharan Africa.

Pediatric surgery in sub-Saharan Africa is disadvantaged by the large number of sick children, disease patterns specific to the region, late presentation, and advanced pathology. In addition, it is practiced in an environment of limited resources and facilities and other health priorities. Obstacles to better pediatric-surgical care (PSC) include a general lack of interest in surgical conditions affecting African children, its poorly defined role, and a lack of political commitment by governments and international agencies to see surgical care of children improve. Pediatric-surgical practice in Africa must be cognizant of the factors that limit delivery of surgical services and work toward developing cost-effective strategies that benefit the largest number of children. Demonstrating that childhood surgical conditions are a significant public health-care problem is the most likely way to change health-care policy and to ensure adequate resources for PSC. Other priorities should be to define a cost-effective package of pediatric surgical services, improve PSC at the community level, and strengthen pediatric surgical-education.

Bone setter's gangrene.

BACKGROUND/PURPOSE: Little published data exist on the morbidity and mortality associated with poor trauma care in developing countries. This report highlights our experience with iatrogenic limb gangrene related to fracture management by traditional bone setters. METHODS: Children with "bone setter's" gangrene were identified from a prospectively recorded pediatric surgery database at the Royal Victoria Hospital in Banjul, The Gambia--the main government referral hospital. RESULTS: Nine children were treated for bone setter's gangrene during a 29-month period. The average age was 8.2 years (range, 5 to 14 years). Bone setter's gangrene was more common in boys (male to female ratio, 2:1) and occurred almost exclusively (89%) in children from rural areas where access to health care was limited. Five children (56%) underwent proximal extremity amputations. Complications included 1 death related to sepsis, a case of chronic osteomyelitis at an amputation site, and a contracted insensate hand in a child whose parents refused amputation. CONCLUSIONS: Bonesetter's gangrene is a preventable complication that results from a failure of child health planners to recognize the importance of basic trauma care. Management of fractures should be considered an essential component of child health programs in developing countries.

Non-communicable diseases: is their emergence in industrialized societies related to changes in neuroendocrine function?

This hypothesis suggests that industrialization alters the human neuroendocrine system. The neuroendocrine changes come about because of changes in environmental stimuli. It is further proposed that changes in neuroendocrine function can account for the contrasting pattern of non-communicable diseases in traditional and industrialized societies. The hypothesis is based on subtle clinical differences in traditional and industrialized societies, and the evolving concept of neuroendocrine regulation of physiological processes. Compared to traditional societies, individuals from industrialized communities tend to have lower pain tolerance, slower gastrointestinal transit-time, and a greater chance of having a calcified pineal gland. These changes parallel the increasing incidence of non-communicable diseases in industrialized societies. There is sufficient reason to suspect the variations in pain tolerance, gastrointestinal transit-time and pineal gland calcification represent changes in neuroendocrine function. Programming of the neuroendocrine system by environmental events early in life is one possible mechanism whereby these changes might be effected. Understanding the physiological changes that occur with industrialization, and how environmental stimuli interact with the developing neuroendocrine system might lead to new strategies for the prevention and treatment of non-communicable diseases.

Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia.

INTRODUCTION: There is a paucity of published data on the type of conditions that require surgery among children in sub-Saharan Africa. Such information is necessary for assessing the impact of such conditions on child health and for setting priorities to improve paediatric surgical care. METHODS: Described in the article is a 29-month prospective study of all children aged < 15 years who were admitted to a government referral hospital in the Gambia from January 1996 to May 1998. RESULTS: A total of 1726 children were admitted with surgical problems. Surgical patients accounted for 11.3% of paediatric admissions and 34,625 total inpatient days. The most common admission diagnoses were injuries (46.9%), congenital anomalies (24.3%), and infections requiring surgery (14.5%). The diagnoses that accounted for the greatest number of inpatient days were burns (18.8%), osteomyelitis (15.4%), fractures (12.7%), soft tissue injuries (3.9%), and head injuries (3.4%). Gambian children were rarely admitted for appendicitis and never admitted for hypertrophic pyloric stenosis. The leading causes of surgical deaths were burns, congenital anomalies, and injuries other than burns. DISCUSSION: Prevention of childhood injuries and better trauma management, especially at the primary and secondary health care levels, should be the priorities for improving paediatric surgical care in sub-Saharan Africa. Surgical care of children should be considered an essential component of child health programmes in developing countries.

The treatment of paediatric burns using topical papaya.

Due to the limited resources for the management of burns in most regions of Africa there is a significant role for many aspects of traditional African medicine. The active component of many traditional preparations is often of plant origin and more than 25 plants have been described as useful in relations to burns and wound healing. Carica papaya is currently used in The Gambia at the Royal Victoria Hospital, Banjul in the Paediatric Unit as the major component of burns dressings, where it is well tolerated by the children. Cheap and widely available, the pulp of the papaya fruit is mashed and applied daily to full thickness and infected burns. It appears to be effective in desloughing necrotic tissue, preventing burn wound infection, and providing a granulating wound suitable for the application of a split thickness skin graft. Possible mechanisms of action include the activity of proteolytic enzymes chymopapain and papain, as well as an antimicrobial activity, although further studies are required.

Balloon extraction of esophageal foreign bodies in children.

BACKGROUND: Whereas esophageal foreign bodies are commonly removed with rigid esophagoscopy under general anesthesia, selected foreign bodies also can be removed using a Foley catheter balloon under fluoroscopic control without anesthesia. The authors prefer to initially attempt removal of smooth, radiopaque esophageal foreign bodies using the balloon technique and then proceed to rigid esophagoscopy if unsuccessful. METHODS: The authors reviewed their 7-year experience with this approach in 276 children with esophageal foreign bodies. RESULTS: One hundred seventy-three children underwent attempted balloon extraction, and 146 of these underwent successful removal with this method. Fifteen remained lodged in the esophagus and were subsequently removed by esophagoscopy, and 12 passed into the stomach and were observed. The only complication was one episode of epistaxis that resolved. Success of the balloon method was not related to patient age, foreign body duration, location, or presenting symptoms. The use of more than 5 minutes of fluoroscopy time was associated with a low likelihood of successful extraction. CONCLUSION: The balloon extraction technique is a safe and effective alternative to rigid esophagoscopy for the removal of selected esophageal foreign bodies in children.

Esophageal duplication cyst with esophageal web and tracheoesophageal fistula.

The authors report the case of lower cervical/upper thoracic esophageal duplication associated with an obstructing esophageal web. This presented in the newborn period as an esophageal atresia. Initial resection of the web and closure of the fistula were performed. The duplication was excised electively at 2 months of age. Persistent symptomatic tracheomalacia required aortopexy, after which the child recovered uneventfully. There are only three other reports (four cases) in the literature of esophageal atresia (or variants) associated with esophageal duplication.

Thal fundoplication in neurologically impaired children.

Children with neurological impairment (NI) frequently require feeding gastrostomy, and this often aggravates or produces gastroesophageal reflux (GER). From 1976 to 1994, 141 children with severe NI underwent Thal fundoplication and gastrostomy (GT). GER was evident in 80%; in the rest, fundoplication was an adjunct to GT. Ph results were positive in 38 cases, and 57 children had reflux according to the barium studies. There were no major intraoperative complications. Disruption of the repair and/or recurrent GER was noted in 14 cases (10%); 8 were redone as Thals, and 6 were converted to Nissen procedures. Pyloroplasty was done later in 9 children (6%). Bowel obstruction was seen in 4 patients (3%). Clinical follow-up (mean, 54 months) showed improvement in 96%; only 5 of the 141 (3.2%) have residual symptoms. Of the patients with an intact Thal, 67% could burp or vomit. The ability to vomit may protect the Thal fundoplication and avoid disruption of the repair.

Common bile duct obstruction related to intestinal polyposis in a child with Peutz-Jeghers syndrome.

Peutz-Jeghers syndrome is characterized by hamartomatous polyposis of the small and large bowel and mucocutaneous pigmentation. The authors describe a 9-year-old girl with small bowel obstruction related to duodenal intussusception caused by polyposis in the fourth portion of the duodenum. Operative reduction of the intussusception and excision of the polyps were performed, at which time the pancreas appeared to have mild pancreatitis. A liver biopsy specimen showed mild portal fibrosis and ductal proliferation. The patient did well postoperatively, but later presented with symptoms consistent with biliary obstruction. Percutaneous transhepatic cholangiography showed pancreatic and biliary duct dilatation as well as obstruction of the common bile duct, which extended into the left upper quadrant. Exploration showed ampullary obstruction several centimeters proximal to the line of resection. Sphincteroplasty was performed. The postoperative course was uncomplicated. The authors conclude that Peutz-Jeghers syndrome with polyps in the duodenum can markedly distort duodenal and ductal anatomy and can lead to ampullary obstruction.