Delays in presentation of intussusception and development of gangrene in Zimbabwe.

INTRODUCTION: prompt diagnosis and treatment are considered key to successful management of intussusception. We examined pre-treatment delay among intussusception cases in Zimbabwe and conducted an exploratory analysis of factors associated with intraoperative finding of gangrene. METHODS: data were prospectively collected as part of the African Intussusception Network using a questionnaire administered on consecutive patients with intussusception managed at Harare Children´s Hospital. Delays were classified using the Three-Delays-Model: care-seeking delay (time from onset of symptoms to first presentation for health care), health-system delay (referral time from presentation to first facility to treatment facility) and treatment delay (time from presentation at treatment facility to treatment). RESULTS: ninety-two patients were enrolled from August 2014 to December 2016. The mean care-seeking interval was 1.9 days, the mean health-system interval was 1.5 days, and the mean treatment interval was 1.1 days. Mean total time from symptom onset to treatment was 4.4 days. Being transferred from another institution added 1.4 days to the patient journey. Gangrene was found in 2 (25%) of children who received treatment within 1 day, 13 (41%) of children who received treatment 2-3 days, and 26 (50%) of children who received treatment more than 3 days after symptom onset (p = 0.34). CONCLUSION: significant care-seeking and health-system delays are encountered by intussusception patients in Zimbabwe. Our findings highlight the need to explore approaches to improve the early diagnosis of intussusception and prompt referral of patients for treatment.

Risk Factors Associated With Increased Mortality From Intussusception in African Infants.

OBJECTIVES: Morbidity and mortality from intussusception, the leading cause of bowel obstruction in infants, is higher in Africa than in other regions of the world, but the reasons have not been well examined. We sought to identify risk and protective factors associated with death or intestinal resection following intussusception. METHODS: Infants with intussusception from 7 sub-Saharan African countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) were enrolled through active, hospital-based surveillance from February 2012 to December 2016. We examined demographic, clinical, and socioeconomic factors associated with death or intestinal resection following intussusception, using multivariable logistic regression. RESULTS: A total of 1017 infants <1 year of age with intussusception were enrolled. Overall, 13% of children (133/1017) died during the hospitalization, and 48% (467/966) required intestinal resection. In multivariable analyses, female sex [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.2-3.3], longer duration of symptoms before presentation (OR 1.1; 95% CI 1.0-1.2), and undergoing intestinal resection (OR 3.4; 95% CI 1.9-6.1) were associated with death after intussusception. Diagnosis by ultrasound or enema (OR 0.4; 95% CI 0.3-0.7), and employment of a household member (OR 0.7; 95% CI 0.4-1.0) were protective against intestinal resection. CONCLUSIONS: Delays in hospital presentation and female sex were significantly associated with death, whereas higher socioeconomic status and availability of radiologic diagnosis reduced likelihood of undergoing resection. Efforts should be intensified to improve the awareness, diagnosis, and management of intussusception in sub-Saharan African countries to reduce morbidity and mortality from intussusception in these resource-limited settings.

Intestinal Evisceration in Children From the Bite of the Domestic Pig, Sus scrofa domesticus: A Report of Two Cases.

Pig bite injuries are an infrequently described consequence of human-animal conflict. The domestic pig is thought to be a placid animal not given to unprovoked aggression. We report 2 separate cases of children managed at our institution who sustained abdominal injuries after attack by domestic pigs in rural Zimbabwe. Both incidents occurred at home in remote rural areas with long prehospital transport times. Initial resuscitative interventions were performed in both cases in the prehospital setting and at poorly resourced peripheral hospitals before referral. Prophylactic antibiotics were also given in both cases. Laparotomy was performed for both patients. Reduction of eviscerated bowel, exploratory laparotomy, and peritoneal lavage were performed with closure of the abdominal wounds. No surgical site infections were encountered, and patients were subsequently discharged after an uneventful convalescence. Prehospital care is the crucial phase of management of these injuries, which frequently take place in remote, rural settings and usually have a long time to definitive intervention. Expeditious laparotomy and exploration are indicated, as well as meticulous attention to techniques to avert infectious complications. Despite the generally placid temperament of the domestic pig, their bite can result in grave injuries, including abdominal evisceration necessitating prompt referral and emergency laparotomy.

Volvulus of the ascending colon due to failure of zygosis: A case report and review of the literature.

INTRODUCTION: Volvulus of the mobile ascending colon is a serious complication of a subtle embryological abnormality that frequently goes unrecognised. There has been renewed interest in the development of the mesentery because of its relevance to the contemporary management of surgical diseases. This case is presented to illustrate the dire consequences of missing this diagnosis and to review the fascinating embryology of the condition as well as its clinical implications. PRESENTATION OF CASE: We report on a 23-year-old male who presented with signs and symptoms of distal small bowel obstruction after a long prior history of intermittent right lower quadrant pain. At laparotomy, a 360-degree counter-clockwise volvulus of the entire right colon was noted as the result of an excessively long ascending mesocolon and unattached hepatic flexure. All gangrenous bowel was resected with primary ileocolic anastomosis performed thereafter. The patient did well post-operatively and was subsequently discharged. DISCUSSION: Interruption of the in-utero events of fixation known as peritoneal zygosis lead to a persistence of the mesocolon in parts of the bowel that ordinarily are retroperitoneal. The events that lead to this anomaly are poorly understood and have been subject to controversy for centuries. New insights have challenged surgical dogma and informed new surgical techniques. Its true incidence is probably underestimated because of its indolent clinical prodrome, and it requires a high index of suspicion. CONCLUSION: Failure of peritoneal zygosis is implicated in a myriad of clinical conditions. Expeditious recognition and intervention in the prodromal period can avert potentially disastrous complications.

Development of a Novel Global Surgery Course for Medical Schools.

OBJECTIVE: We endeavored to create a comprehensive course in global surgery involving multinational exchange. DESIGN: The course involved 2 weeks of didactics, 2 weeks of clinical rotations in a low-resource setting and 1 week for a capstone project. We evaluated our success through knowledge tests, surveys of the students, and surveys of our Zimbabwean hosts. SETTING: The didactic portions were held in Sweden, and the clinical portion was primarily in Harare with hospitals affiliated with the University of Zimbabwe. PARTICIPANTS: Final year medical students from Lund University in Sweden, Harvard Medical School in the USA and the University of Zimbabwe all participated in didactics in Sweden. The Swedish and American students then traveled to Zimbabwe for clinical work. The Zimbabwean students remained in Sweden for a clinical experience. RESULTS: The course has been taught for 3 consecutive years and is an established part of the curriculum at Lund University, with regular participation from Harvard Medical School and the University of Zimbabwe. Participants report significant improvements in their physical exam skills and their appreciation of the needs of underserved populations, as well as confidence with global surgical concepts. Our Zimbabwean hosts thought the visitors integrated well into the clinical teams, added value to their own students' experience and believe that the exchange should continue despite the burden associated with hosting visiting students. CONCLUSIONS: Here we detail the development of a course in global surgery for medical students that integrates didactic as well as clinical experiences in a low-resource setting. The course includes a true multilateral exchange with students from Sweden, the United States and Zimbabwe participating regularly. We hope that this course might serve as a model for other medical schools looking to establish courses in this burgeoning field.

Diagnostic and surgical challenges of a giant pheochromocytoma in a resource limited setting-A case report.

INTRODUCTION: Pheochromocytomas are catecholamine producing tumours which arise from chromaffin cells within the adrenal medulla. Patients with these tumours commonly present with a triad of headache, palpitations and hypertension. CASE PRESENTATION: We present a case of a 37-year-old male patient who presented with dull left sided abdominal pain and discomfort for 6 weeks. A preoperative Computed tomography (CT) scan showed a huge left suprarenal tumour but urinary vanillylmandelic acid (VMA) were negative. The patient underwent an open surgical resection via an extraperitoneal approach without untoward intraoperative and postoperative events. Histopathological evaluation of the specimen showed a pheochromocytoma with a PASS score of 9. The successful management of the patient highlights the good results of team work despite the limitations of preoperative diagnosis. DISCUSSION: Giant pheochromocytomas by definition are tumours more than 7 cm in size and are rare. They rarely secrete catecholamines and commonly present with vague abdominal symptoms. A computerized tomogram helps suggest the diagnosis whilst the biochemical workup for pheochromocytoma may be diagnostic. If the tumours are biochemically active, preoperative alpha-blockade is necessary and care must be taken at operation in handling the tumour. The surgical and anaesthetic team must be prepared to manage hypertensive crisis should it occur. CONCLUSION: This case brings to the attention of clinicians the need to have a high index of suspicion of a giant pheochromocytoma in a patient presenting with vague abdominal symptoms whose CT scan shows a large retroperitoneal tumour, even in the absence of clinical symptoms and negative or absent biochemical workup.

Development of a neonatal curriculum for medical students in Zimbabwe - a cross sectional survey.

BACKGROUND: Calls have been made to reassess the curricula of medical schools throughout the world to adopt competence-based programs that address the healthcare needs of society. Zimbabwe is a country characterized by a high neonatal mortality rate of 24 per 1000 live births. The current research sought to determine the content and appropriate teaching strategies needed to guide the development of an undergraduate neonatal curriculum map for medical students at the University of Zimbabwe College of Health Sciences. METHODS: We surveyed faculty (n = 8) and non-faculty pediatricians (n = 5), senior resident medical officers (N = 26) using a self-administered questionnaire, and completed one focus group discussion with midwives (n = 11). We asked respondents their expectations regarding knowledge, psychomotor skills, competencies, and teaching strategies in a basic newborn curriculum for medical students. Relevant policy and curricula documents were reviewed to assess newborn health needs and the current training. A group of faculty educationists (n = 11) collated and finalized the findings from the document review, survey, and focus group using descriptive statistics and thematic analysis. RESULTS: The document review revealed three key neonatal health objectives according to the current national maternal and neonatal health road map. These objectives are to be met using a four tier approach comprising (i) family planning (ii) focused antenatal care (iii) clean and safe delivery and (iv) basic and comprehensive emergency obstetric & neonatal care. Existing curriculum has 15 newborn topics taught in lecture style during the pediatric rotations, and five newborn care skills to be learned through observation. The existing curriculum is silent on desired competencies. In the current study 19 cognitive areas, 17 psychomotor skills and six competency domains were identified for an ideal neonatal curriculum for undergraduate students. A combination of teaching strategies including classroom, simulation and a clinical rotation were recommended. CONCLUSION: This study revealed a significant gap between the existing neonatal curriculum and the ideal curriculum as recommended by broad stakeholders in the context of national health care needs. Next steps are to complete the development and implementation of the proposed curriculum map to better align with the ideal state.

Evaluation of Intussusception after Monovalent Rotavirus Vaccination in Africa.

BACKGROUND: Postlicensure evaluations have identified an association between rotavirus vaccination and intussusception in several high- and middle-income countries. We assessed the association between monovalent human rotavirus vaccine and intussusception in lower-income sub-Saharan African countries. METHODS: Using active surveillance, we enrolled patients from seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) who had intussusception that met international (Brighton Collaboration level 1) criteria. Rotavirus vaccination status was confirmed by review of the vaccine card or clinic records. The risk of intussusception within 1 to 7 days and 8 to 21 days after vaccination among infants 28 to 245 days of age was assessed by means of the self-controlled case-series method. RESULTS: Data on 717 infants who had intussusception and confirmed vaccination status were analyzed. One case occurred in the 1 to 7 days after dose 1, and 6 cases occurred in the 8 to 21 days after dose 1. Five cases and 16 cases occurred in the 1 to 7 days and 8 to 21 days, respectively, after dose 2. The risk of intussusception in the 1 to 7 days after dose 1 was not higher than the background risk of intussusception (relative incidence [i.e., the incidence during the risk window vs. all other times], 0.25; 95% confidence interval [CI], <0.001 to 1.16); findings were similar for the 1 to 7 days after dose 2 (relative incidence, 0.76; 95% CI, 0.16 to 1.87). In addition, the risk of intussusception in the 8 to 21 days or 1 to 21 days after either dose was not found to be higher than the background risk. CONCLUSIONS: The risk of intussusception after administration of monovalent human rotavirus vaccine was not higher than the background risk of intussusception in seven lower-income sub-Saharan African countries. (Funded by the GAVI Alliance through the CDC Foundation.).

Infant, maternal, and geographic factors influencing gastroschisis related mortality in Zimbabwe.

INTRODUCTION: Survival for infants with gastroschisis in developed countries has improved dramatically in recent decades with reported mortality rates of 4-7%. Conversely, mortality rates for gastroschisis in sub-Saharan Africa remain as great as 60% in contemporary series. This study describes the burden of gastroschisis at the major pediatric hospital in Zimbabwe with the goal of identifying modifiable factors influencing gastroschisis-related infant mortality. METHODS: We performed a retrospective cohort study of all cases of gastroschisis admitted to Harare Children's Hospital in 2013. Univariate and multivariate analyses were performed to describe infant, maternal, and geographic factors influencing survival. RESULTS: A total of 5,585 neonatal unit admissions were identified including 95 (1.7%) infants born with gastroschisis. Gastroschisis-related mortality was 84% (n = 80). Of infants with gastroschisis, 96% (n = 91) were born outside Harare Hospital, 82% (n = 78) were born outside Harare Province, and 23% (n = 25) were home births. The unadjusted odds of survival for these neonates with gastroschisis were decreased for low birth weight infants (<2,500 grams; odds ratio [OR], 0.15; 95% CI, 0.05-0.51), preterm births (<37 weeks gestational age; OR, 0.06; 95% CI, 0.01-0.50), and for those born to teenage mothers (<20 years of age; OR, 0.05; 95% CI, 0.01-0.46). There was also a trend toward decreased odds of survival for home births (OR, 0.16; 95% CI, 0.02-1.34) and for those born outside Harare Province (OR, 0.35; 95% CI, 0.10-1.22). CONCLUSION: Gastroschisis-related infant mortality in Zimbabwe is associated with well-known risk factors, including low birth weight, prematurity, and teenage mothers. However, modifiable factors identified in this study signify potential opportunities for developing innovative approaches to perinatal care in such a resource-constrained environment.